Home Ultrasound-guided lumbar plexus block versus transversus abdominis plane block for analgesia in children with hip dislocation: A double-blind, randomized trial
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Ultrasound-guided lumbar plexus block versus transversus abdominis plane block for analgesia in children with hip dislocation: A double-blind, randomized trial

  • Ke Sun , Mei Jin and Xiaoguang Zhang EMAIL logo
Published/Copyright: October 21, 2022
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Open Medicine
From the journal Open Medicine Volume 17 Issue 1

Abstract

Lumbar plexus block is often used as analgesia for adult hip surgery, but it is rarely used in pediatric patients. This study aimed to compare the efficacy and feasibility of ultrasound-guided lumbar plexus block versus transversus abdominis plane block for postoperative analgesia in children with hip dislocation. Eighty children undergoing unilateral hip dislocation surgeries at our hospital from October 2019 to February 2021 were randomized to the lumbar plexus block group (group L) and transversus abdominis plane block group (group T). Compared with group L, the regional block time in group T was lower (8.0 ± 2.5 vs 11.5 ± 2.3 min, P < 0.05), and the ultrasound image definition was better (P < 0.05). There were no significant differences in mean blood pressure and heart rate within 24 h (all P > 0.05). Children’s Hospital of Eastern Ontario Pain Scale scores were lower in group L than in group T at 18–24 h only (all P < 0.05). The satisfying analgesia rate in group L was higher than in group T (87.5 vs 65%, P < 0.05). No regional block-related complications were found in both groups. Ultrasound-guided lumbar plexus block showed a longer postoperative analgesic effect in children with hip dislocation compared with transversus abdominis plane block.

Keywords: transversus abdominis; ultrasound; analgesia; hip joint; pediatric

1 Introduction

What is known

Transversus abdominis plane block for analgesia after adult hip surgery can reduce the dosage of opioids.

The application of lumbar plexus block or transverse abdominis plane block in children has become more popular.

What is new

Ultrasound-guided lumbar plexus block has a longer postoperative analgesic effect in children with hip dislocation than transversus abdominis plane block. It provides a convenient anesthesia method for such children.

Developmental dysplasia of the hip (DDH) refers to a spectrum of developmental hip abnormalities ranging from a mildly dysplastic acetabulum and concentrically located femoral head to a severely dysplastic acetabulum and dislocated or dislocatable femoral head [1,2,3]. Although hip instability may affect 1–3% of newborns, DDH is only diagnosed in 0.1–0.5% overall [1,2,4]. It is 4–8 times more common in females [1,5]. The risk factors include breech presentation, oligohydramnios, female gender, and a family history of the condition. DDH is also seen more frequently in the presence of other musculoskeletal anomalies and underlying genetic syndromes [2,3,4,5,6,7].

Most children with DDH require surgical treatment such as pelvic and femoral osteotomy to achieve a concentric reduction of the hip [3,8,9]. Due to the long operation time and significant trauma, the children usually have severe postoperative pain, accompanied by severe stress reactions, leading to poor postoperative recovery outcomes [9].

Lumbar plexus block is often applied as analgesia for adult hip surgery and has a positive effect [10,11], but due to the necessity of using a neurostimulator, it was rarely used in pediatrics before. In recent years, with the development of ultrasound guidance technology, the accuracy of lumbar plexus block in children has been improved, complications can be effectively avoided [12,13,14,15], and its clinical application value has been recognized. Transversus abdominis plane block has been applied in children early, but it was mostly applied in surgeries in the groin area and abdominal wall [16,17]. Transversus abdominis plane block for analgesia after adult hip surgery can reduce the dosage of opioids [18], but its effect in pediatric orthopedics is yet to be verified. In recent years, based on the safety and technical advantages of an ultrasound-guided regional block, the application of lumbar plexus block or transverse abdominis plane block in children has become more popular [19].

Therefore, this trial aimed to compare the analgesic effect and feasibility of ultrasound-guided lumbar plexus block and transversus abdominis plane block in the early postoperative period of pediatric hip dislocation surgery.

2 Materials and methods

2.1 Study design

This study was a double-blind (evaluators and guardians of children) randomized parallel controlled pilot study. The children were equally divided into two groups receiving different anesthesia methods using the random number table method (without blocks), namely the lumbar plexus block group (group L) and the transverse abdominis plane block group (group T). The randomization sequence was generated by a third-party statistician in opaque, sequentially numbered envelopes. The anesthetist opened the envelopes in order once the patient had entered the operating room. There were no changes to the protocol once the study started.

  1. Ethics approval: This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was approved by the Ethics committee of Beijing Jishuitan Hospital (2017-2), and all participants provided written informed consent.

2.2 Participants

Child patients who underwent unilateral hip dislocation surgery and pelvic and femoral osteotomy in our hospital from October 2019 to February 2021 were recruited. The scope of surgery included proximal femoral osteotomy and acetabular (pelvic) osteotomy and extensive loosening of soft tissues around the hip joint. The inclusion criteria were (1) 1–6 years of age, (2) child’s height and weight were within ±20% of the standard value (calculation of standard value: child’s body height = age × 7 + 75 cm, weight = age × 2 + 8 kg) [20], (3) American Society of Anesthesiologists (ASA) physical status I or II, (4) children with total dislocation of the hip (degrees I–III) or failed previous closed treatment of acetabular dysplasia or hip subluxation that progressed to total dislocation of the hip and require surgery, (5) unilateral or bilateral hip dislocation, (6) normal nervous system development, and (7) no congenital or genetic diseases apart from DDH. The exclusion criteria were (1) variation, deformity, or local infection of the puncture position; (2) abnormal blood coagulation; (3) central or peripheral nervous system diseases; or (4) any other systemic diseases that can affect surgery or general anesthesia.

2.3 Diagnosis standard [8]

The clinical manifestations of DDH include unequal lengths of limbs, limp walking, or swinging gait. Physical examination showed tense adductor muscle, Allis tests positive, and Trendelenburg tests positive. On the pelvic front view, the caput femoris is in the upper outer or lower outer quadrant of the Pekin square, the acetabulum is shallow, and a false bulge is formed.

2.4 Anesthesia

The children were fasted and water-deprived for 6 h before the operation. Then, 0.01 mg/kg of atropine was injected intramuscularly 30 min before the operation. Before entering the operation room, 2 mg/kg of ketamine could be injected intramuscularly as basic anesthesia based on the child’s cooperation degree. After entering the operation room, venous access was opened, and ECG, heart rate (HR), non-invasive arterial pressure, pulse oxygen saturation, and respiratory rate were continuously monitored. Continuous mask oxygen inhalation at 2–3 L/min was given. General anesthesia was induced with 0.08 mg/kg of midazolam, 2 μg/kg of fentanyl, 0.1 mg/kg of vecuronium, and 3 mg/kg of propofol. After induction, endotracheal intubation was performed, with volume-controlled ventilation, tidal volume of 8–10 mL/kg, and respiratory rate of 14–18 times/min, which could be adjusted according to the amount of carbon dioxide in exhaled air (ETCO2) during the operation. The child was placed in the knee-chest side-lying position, with the surgical side on top.

Ultrasound guidance was performed using the neuroimaging mode of the M-Turbo ultrasound system (SonoSite, Fujifilm, Bothell, WA, USA), with the transducer connected to the HFL38x/13-6 MHz linear array probe. In group L, the probe was placed above the mid-axillary line iliac crest to identify the shamrock-shaped image composed of the lumbar transverse process, psoas major, erector spinae, and quadratus lumborum, and the position of the L3 nerve root was confirmed. The puncture point was located by Winnie’s method, and a local anesthetic was injected into the L3–4 gap with an in-plane needle. In group T, the probe was placed between the mid-axillary iliac crest and the costal margin to identify the structure of the musculus obliquus externus abdominis, musculus obliquus internus abdominis, and musculus transversus abdominis. The probe was moved backward until the quadratus lumborum was on the superficial surface of the musculus transversus abdominis. The local anesthetic was injected into between the lateral abdominal wall muscles and the quadratus lumborum muscles with an in-plane needle (Figure 1).

Figure 1 Ultrasound images during local anesthesia. (a–c) Transversus abdominis plane block group (group T). (d–f) Lumbar plexus block group (group L). a/d, b/e, and c/f are representative images for positioning, puncture, and 3 min after drug injection, respectively. The yellow arrows show the position of puncture needles.
Figure 1

Ultrasound images during local anesthesia. (a–c) Transversus abdominis plane block group (group T). (d–f) Lumbar plexus block group (group L). a/d, b/e, and c/f are representative images for positioning, puncture, and 3 min after drug injection, respectively. The yellow arrows show the position of puncture needles.

Block was performed in the two groups by anesthesiologists with >3 years of ultrasound experience, who strictly abided by the principle of sterility. The puncture needle was a 22 G, 80 mm nerve stimulation needle (Stimuplex D Plus, B. Braun, Melsungen, Germany), and the local anesthetic was 0.3% ropivacaine hydrochloride (batch number: NBFD, AstraZeneca, London, UK) at 1 mL/kg. A 1- to 2-mL test dose was given before injection to confirm the needle tip position, and withdrawals were repeated during the injection to confirm that blood vessels or the peritoneum had not been punctured by mistake. Surgery started 30 min after the regional block. During the operation, narcosis was maintained with sevoflurane and propofol. The inhalation concentration of sevoflurane was 1–2%, and propofol was infused continuously at 3–5 mg/kg/h. After the operation, the children were moved to the postanesthesia care unit and extubated when becoming awake.

The postoperative evaluation was completed by another anesthesiologist with the same seniority who was not involved in the block.

2.5 Osteotomy

After general anesthesia, the child was placed in the supine position, and routine orthopedic disinfection was performed. Open reduction of the hip joint was performed using an anterolateral S-P or Bikini incision. After full exposure and loosening, a T-shaped cut was made to open the joint capsule and clear the contents of the acetabulum. The caput femoris was incorporated into the true acetabulum to achieve a concentric hip after reduction, and a V-shaped posterior capsulorrhaphy was performed. After concentric circle reduction was achieved, pelvic osteotomy was performed to reconstruct the acetabulum. For those who need a change of direction of the acetabulum, a triple osteotomy or Salter osteotomy was performed. For those who need a change of form of the acetabulum, Pemberton osteotomy was performed. The aforementioned steps were performed with the same surgical incision (S-P or Bikini). The surgical field was in the groin area, including the caput femoris, acetabulum, surrounding soft tissues, and pelvis. Osteotomy was performed on the proximal femur, with internal fixation with a steel plate, and an incision was made on the outside of the thigh. Proximal femur shortening osteotomy was performed to reduce the pressure on the acetabular head (caput femoris and acetabulum), or varus rotational osteotomy was performed to correct an excessive anteversion angle and cervical shaft angle (collum femoris and femoral shaft). The surgical field was in the proximal femur and surrounding soft tissues.

2.6 Postoperative cares

General care: After returning to the ward, the children were not fully awake. They laid down with their head tilted to one side. Continuous low-flow oxygen inhalation (3 L/min) was maintained. Body temperature, HR, non-invasive blood pressure, and respiratory rate were monitored. The color of the limb end, skin temperature, sensation, and movement were observed. Whether there was blood oozing at the incision was observed. Sleep and bowel movements were recorded.

Orthopedic care: After the operation, the child was plastered or fixed with limb support to keep the affected limb in position and avoid flexing the affected limb. The part under pressure was observed to avoid pressure sores.

2.7 Data collection and observation indicators

There were no changes to the outcomes after the trial started. The baseline data and clinical indicators of the two groups of children were recorded, including ASA grade, operation time, and regional block time. The mean blood pressure (MBP), HR, and Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) scores [21] of the children were recorded at 2, 6, 12, 18, and 24 h after surgery. The CHEOPS pain score uses six behavioral indicators: crying, facial expressions, speech, leg activity, physical activity, and wound touchability. Each item is defined as 0–2 points or 1–3 points, and the total score is 4–13 points. CHEOPS pain scores <6 were defined as analgesic satisfied, and the satisfying analgesia rate was calculated.

The regional block time was defined as the time taken from the start of the ultrasound scan to the completion of the local anesthetic injection. The ultrasound images were evaluated with a 4-point method [22]: 0 points, unable to display; 1 point, the anatomical structure and injection target position are not clear, and the puncture needle is partially developed; 2 points, the anatomical structure, and injection target position are clear, but the puncture needle tip is poorly developed, and local anesthetic diffusion is limited; 3 points, typical anatomical structure, and injection target position, the puncture needle tip can be accurately identified, and local anesthetic diffusion is complete. Images with ≥2 points meant that local anesthetics could be injected.

Whether there were local anesthetic toxic reactions, bleeding, or hematoma at the puncture position; whether there was a bilateral block or kidney injury in group L; and whether there were complications such as peritoneal puncture and intestinal injury in group T were observed.

2.8 Statistical analysis

As it was an exploratory study, no sample size was calculated. All children matching the eligibility criteria during the study period were asked to participate. SPSS 16.0 (SPSS, Chicago, IL, USA) was used for data analysis. The continuous data were tested for normal distribution using the Wilk–Shapiro test. Those conforming to the normal distribution were presented as mean ± standard deviation and were analyzed using Student’s t-test (between-group comparisons) and two-way ANOVA with the post hoc Student-Newman-Keuls test (for within-group comparisons among time points). Data that were not in a normal distribution were analyzed using the non-parametric Friedman test, and if the test results were statistically significant, the P-value was further adjusted using the Bonferroni method, and then, multiple comparisons were made using the Wilcoxon matched-pairs signed-rank test. Categorical data were expressed as n (%) and analyzed using the chi-square test or Fisher’s exact test. P-Values <0.05 were considered statistically significant.

3 Results

3.1 Baseline characteristics of the participants

From October 2019 to February 2021, 80 child patients who underwent unilateral hip dislocation and pelvic osteotomy and orthopedic surgeries were enrolled, aged 1–6 years, ASA physical status I or II, and weighting 8–25 kg. There were no significant differences in age, sex composition, height, weight, ASA grading, and operation time between the two groups (all P > 0.05; Table 1).

Table 1

Characteristics of the participants

L group (n = 40) T group (n = 40)
Age (years) 3.0 ± 1.2 3.2 ± 1.3
Sex n (%)
 Male 7 (17.5) 5 (12.5)
 Female 33 (82.5) 35 (87.5)
Height (cm) 89.6 ± 12.5 87.5 ± 14.2
Weight (kg) 14.9 ± 3.5 15.0 ± 3.5
ASA grade, n (%)
 I 39 (97.5) 38 (95)
 II 1 (2.5) 2 (5)
Operation time (min) 188.0 ± 23.0 186.5 ± 27.2

The data are displayed using mean ± standard deviation or n (%).

Group L: lumbar plexus block group; Group T: transverse abdominal muscle plane block group; ASA: American Society of Anesthesiologists.

3.2 Regional block and pain

All patients completed the regional block. Compared with group L, group T had a lower regional block time (8.0 ± 2.5 vs 11.5 ± 2.3 min, P < 0.05), and ultrasound image clarity was better (P < 0.05; Table 2). MBP and HR within 24 h after operation between the two groups were compared (Tables A1 and A2), and the differences were not statistically significant (all P > 0.05).

Table 2

Comparison of the regional block between the two groups

L group (n = 40) T group (n = 40)
Regional blocking time (min) 11.5 ± 2.3 8.0 ± 2.5a
Ultrasound image scoring
 2 Points 9 (22.5) 2 (5)a
 3 Points 31 (77.5) 38 (95)a

a P < 0.05 vs group L.

The data are displayed using mean ± standard deviation (SD) or n (%).

Group L: lumbar plexus block group; Group T: transverse abdominal muscle plane block group.

Anesthesia injection was performed when the ultrasound image score was ≥2 points.

There were no significant differences in the CHEOPS pain scores within 12 h after surgery between the two groups (all P > 0.05). Group L had lower scores than group T at 18–24 h (T18: 5 (4, 8) vs 5 (4.9), P = 0.01; T24: 5 (4, 9) vs 5 (4, 9), P = 0.01). Pain scores were significantly higher in the T group at 18 and 24 h postoperatively compared to 2 h postoperatively (T2 vs T18: 5 (4,6) vs 5 (4,9), P < 0.01; T2 vs T24: 5 (4,6) vs 5 (4,9), P < 0.01), but no significant differences were found in the L group (all P > 0.05). The satisfying analgesia rate of group L was higher than that of group T (87.5% vs 65%, P < 0.05; Table 3).

Table 3

Comparison of the analgesic effects in the two groups within 24 h after surgery

L group (n = 40) T group (n = 40)
CHEOPS pain score
 T2 5 (4,6) 5 (4,6)
 T6 5 (4,6) 5 (4,6)
 T12 5 (4,6) 5 (4,6)
 T18 5 (4,8) 5 (4,9)a,b
 T24 5 (4,9) 5 (4,9)a,b
Satisfying analgesia rate (%) 87.5 65a

The data are displayed using median (range).

a P < 0.05 vs group L; b P < 0.05 vs T2, using Friedman test.

Group L: lumbar plexus block group; Group T: transverse abdominal muscle plane block group; CHEOPS: Children’s Hospital of Eastern Ontario Pain Scale; T2, T6, T12, T18, and T24 represent postoperative 2, 6, 12, 18, and 24 h.

3.3 Safety

There were no local anesthetic toxic reactions, bleeding or hematoma at the puncture position, or complications related to regional block in the two groups.

4 Discussion

This trial aimed to compare the effect and feasibility of ultrasound-guided lumbar plexus block and transversus abdominis plane block for early postoperative analgesia in children with hip dislocation surgery. The results suggest that ultrasound-guided lumbar plexus block has a longer postoperative analgesic effect in children with hip dislocation than transversus abdominis plane block.

During hip surgery, a part of the abdominal wall and inguinal ligaments are separated from the iliac crest and reattached before closing the wound. Part of the postoperative pain is due to this soft tissue manipulation and the aponeurosis pulling on the iliac crest. Transverse abdominal block effectively anesthetizes the entire surgical area, including the incision, iliac crest, and groin. At the same time, local anesthetics can temporarily paralyze the abdominal muscles and reduce the tension of the abdominal wall on the iliac crest, thus reducing the degree of postoperative pain and reducing the need for opioids [18]. The pain stimulation caused by hip surgery in children is often stronger and lasts longer than in adults, and even causes long-term adverse effects, such as reduced pain tolerance, conversion to chronic pain, fear of reoperation, and psychological or behavioral changes [23]. A regional block is an important analgesic method in the perioperative period of rapid rehabilitation surgery. It can reduce the dosage of opioids after surgery and lower the incidence of adverse events, but it also has a regulatory effect on the body’s immune function and avoids excessive stress reactions [12,13,14,15,16,17]. Ultrasound-guidance technology has improved the safety and effectiveness of regional blocks in children, enabling the implementation of lumbar plexus block or transverse abdominis plane block, which was difficult to perform on children in the past. Still, the operation depends on factors such as the experience of the anesthesiologist, ultrasound equipment, and puncture needles; thus, the clinical applications are still limited. Ropivacaine is a long-acting local anesthetic of amide-type [24]. Increasing the dose can prolong the time of regional block analgesia, but the risks of toxic reaction and nerve damage also increase accordingly [24]. The 0.3% ropivacaine 1-mL/kg dose used in this experiment is currently the most commonly used dose for pediatric regional block in China, and it is within the range of pediatric safe medication [25].

Ultrasound-guided transversus abdominis plane block has a variety of needle access methods. According to the block range, the subcostal method, lateral approach, or posterior approach can be selected [26]. The advantages of the posterior approach include a long-acting time and wide block range [26,27]. Lochel et al. [18] found that posterior transversus abdominis plane block can be used for early analgesia in adult hip surgery. After the local anesthetic is injected into the potential fascial space, a part of the local anesthetic directly acts on the anterior branch of the spinal nerve. There are extensive communicating branches between the nerves in the transverse abdominis plane to form the musculus transversus abdominis nerve plexus so that a single injection can block multiple segments [26,27]. The rest of the local anesthetic reaches the paravertebral space through the quadratus lumborum muscle and expands the range of the block [26,27]. Children have loose tissues, and thus, local anesthetic diffuses more easily than in adults. It has been reported that with a larger dose of local anesthetics, even the femoral nerve can be blocked [26]. The block of nervus iliohypogastricus from T12 and L1 and nervus ilioinguinalis from L1 has an analgesic effect on pediatric hip surgery [26].

Compared with transversus abdominis plane block, ultrasound-guided lumbar plexus block with the “shamrock” method has been widely used for analgesia of adult hip and lower extremity surgeries [28,29]. A local anesthetic is usually injected at the L3 level. The blocking range can reach the innervation area of T12–L4. With its diffusion downward, part of the sacral plexus nerve can also be blocked [30]. Under ultrasound guidance, a local anesthetic can be accurately injected around the lumbar plexus. When the diffusion is good, the “donut sign” can be seen in the image, and the local anesthetic is in full contact with the nerve fiber to ensure the best blocking effect [19]. It can explain the longer analgesia time and more complete effect in group L than in group T.

Children have poor expression and communication skills, and their pain tolerance performance is also different from that of adults [31,32]. Behavioral scores are often used to evaluate analgesic effects [31,32]. The children in this trial had lower CHEOPS pain scores. In addition to the regional block to reduce the pain, the application of external fixation with a cast after the operation and the immobilization of the surgical site also reduced the pain caused by movement.

In this trial, a high-frequency linear array probe was selected for scanning, which can identify the echo difference more precisely. The nerve stimulation needle used was coated with high molecular polymer on the surface. Its porous microstructure can lock air microbubbles and enhance the reflection effect of ultrasound, facilitating the development of the needle tip. The anatomical structure of children is shallower than that of adults, the muscle thickness is not large, and the distance from the skin to the peritoneum is about 1–2 cm. However, the nerve fibers of the lumbar plexus in children are slender and difficult to distinguish from the psoas major muscle. Deep needle insertion may cause damage to the vertebral artery and bilateral blockage, which would introduce a large dosage of local anesthetics into the blood vessel or spinal canal, causing serious consequences [33,34]. Therefore, the unclear ultrasound images of some children in group L resulted in a longer block time. When the transversus abdominis plane is blocked, the injection target position is far from the nerves and blood vessels, and the peritoneum is highly recognizable under ultrasound. Thus, it is safer and more convenient.

Compared with adults, the anatomical structure of children is more delicate. The lumbar plexus is in the deep tissues, and the surrounding anatomical structure is complex, but the nerves, blood vessels, muscles, and bones have completely different acoustic characteristics. Ultrasound can provide clear imaging of the tissue structure of the local cross-section due to the different echoes. In children, because the subcutaneous tissue and muscle layers are thinner than in adults and the lumbar plexus is closer to the body surface, a high-frequency probe can be selected to improve the recognition of the lumbar plexus and surrounding tissues to timely guide the needle to reach the desired position. In addition, local anesthetics diffusion can be observed in real-time, allowing the dynamic fine adjustment of the tip position, improving the accuracy of injection, avoiding retroperitoneal hematoma due to a too deep puncture, kidney damage, or diffusion of the anesthetics in the spinal canal, thereby improving the safety of the procedure.

This study has limitations. Because children are not good at expression and communication, and the performance of pain tolerance is different from adults, behavioral indicators are usually used to evaluate the effect of postoperative analgesia in children. Although the five indicators used by CHEOPS are all objective behaviors, they depend on the subjective judgment of the rater [21]. In order to reduce interference, parents are required to guide the children not to focus on the surgical site. The rater was blind to the grouping of the children and had to try to avoid whitecoats, which caused fear in children during the follow-up visits. In addition, this trial was performed at a single center, and the sample size was small. There are subjective factors in the judgment of ultrasound images and postoperative scoring which interfere with the experimental results.

In summary, compared with transverse abdominis plane block, ultrasound-guided lumbar plexus block is better for early analgesia after hip dislocation surgery in children, with a longer analgesic time. Ultrasound-guided transversus abdominis plane block is relatively easy to operate and can be used as an alternative to lumbar plexus block. Future studies should explore different strategies for blocking, different drugs and dosages, and in different age groups in order to improve patient outcomes.

Abbreviations

CHEOPS

Children’s Hospital of Eastern Ontario Pain Scale

DDH

developmental dysplasia of the hip

HR

heart rate

MBP

mean blood pressure

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Acknowledgments

The authors acknowledge the help of the doctors in the pediatric orthopedics department of Beijing Jishuitan Hospital, Beijing, China. They put forward a lot of suggestions on orthopedic expertise and experimental design.

  1. Funding information: This trial was completely supported by the Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China.

  2. Author contributions: Mei Jin contributed to postoperative observation and evaluation. Ke Sun contributed to the design of the study, analysis of data, and drafted the manuscript. Xiaoguang Zhang performed the experiments. All authors contributed to the analysis and revised the manuscript. All authors have read and approved the final manuscript.

  3. Conflict of interest: The authors have no conflict of interest to declare.

  4. Data availability statement: The dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Appendix

Table A1

Comparison of MBP between the two groups within 24 hours after surgery

L group (n = 40) T group (n = 40)
MBP (mmHg)
 T2 63.0 ± 5.8 64.2 ± 5.5
 T6 61.3 ± 5.9 63.5 ± 4.4
 T12 62.1 ± 5.9 64.3 ± 4.3
 T18 65.4 ± 5.7 66.2 ± 4.8
 T24 65.5 ± 5.2 66.8 ± 4.6

The data is displayed using mean ± standard deviation (SD).

MBP: mean arterial pressure; Group L: lumbar plexus block group; Group T: transverse abdominal muscle plane block group. T2, T6, T12, T18, and T24 represent postoperative 2, 6, 12, 18, and 24 h.

Table A2

Comparison of HR in the two groups within 24 h after operation

L group (n = 40) T group (n = 40)
HR (beats/min)
T2 105.8 ± 13.5 107.5 ± 12.9
T6 103.7 ± 13.2 107.8 ± 10.5
T12 104.6 ± 11.7 107.9 ± 11.9
T18 107.3 ± 14.4 112.8 ± 12.8
T24 110.1 ± 14.2 115.4 ± 11.7

The data is displayed using mean ± standard deviation (SD).

HR: heart rate; Group L: lumbar plexus block group; Group T: transverse abdominal muscle plane block group. T2, T6, T12, T18, and T24 represent postoperative 2, 6, 12, 18, and 24 h.

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Received: 2022-04-19
Revised: 2022-09-22
Accepted: 2022-09-22
Published Online: 2022-10-21

© 2022 Ke Sun et al., published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/med-2022-0581
Keywords for this article
transversus abdominis; ultrasound; analgesia; hip joint; pediatric
Creative Commons
BY 4.0

Articles in the same Issue

  1. Research Articles
  2. AMBRA1 attenuates the proliferation of uveal melanoma cells
  3. A ceRNA network mediated by LINC00475 in papillary thyroid carcinoma
  4. Differences in complications between hepatitis B-related cirrhosis and alcohol-related cirrhosis
  5. Effect of gestational diabetes mellitus on lipid profile: A systematic review and meta-analysis
  6. Long noncoding RNA NR2F1-AS1 stimulates the tumorigenic behavior of non-small cell lung cancer cells by sponging miR-363-3p to increase SOX4
  7. Promising novel biomarkers and candidate small-molecule drugs for lung adenocarcinoma: Evidence from bioinformatics analysis of high-throughput data
  8. Plasmapheresis: Is it a potential alternative treatment for chronic urticaria?
  9. The biomarkers of key miRNAs and gene targets associated with extranodal NK/T-cell lymphoma
  10. Gene signature to predict prognostic survival of hepatocellular carcinoma
  11. Effects of miRNA-199a-5p on cell proliferation and apoptosis of uterine leiomyoma by targeting MED12
  12. Does diabetes affect paraneoplastic thrombocytosis in colorectal cancer?
  13. Is there any effect on imprinted genes H19, PEG3, and SNRPN during AOA?
  14. Leptin and PCSK9 concentrations are associated with vascular endothelial cytokines in patients with stable coronary heart disease
  15. Pericentric inversion of chromosome 6 and male fertility problems
  16. Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study
  17. Retrospective analysis of crescent score in clinical prognosis of IgA nephropathy
  18. Expression of DNM3 is associated with good outcome in colorectal cancer
  19. Activation of SphK2 contributes to adipocyte-induced EOC cell proliferation
  20. CRRT influences PICCO measurements in febrile critically ill patients
  21. SLCO4A1-AS1 mediates pancreatic cancer development via miR-4673/KIF21B axis
  22. lncRNA ACTA2-AS1 inhibits malignant phenotypes of gastric cancer cells
  23. circ_AKT3 knockdown suppresses cisplatin resistance in gastric cancer
  24. Prognostic value of nicotinamide N-methyltransferase in human cancers: Evidence from a meta-analysis and database validation
  25. GPC2 deficiency inhibits cell growth and metastasis in colon adenocarcinoma
  26. A pan-cancer analysis of the oncogenic role of Holliday junction recognition protein in human tumors
  27. Radiation increases COL1A1, COL3A1, and COL1A2 expression in breast cancer
  28. Association between preventable risk factors and metabolic syndrome
  29. miR-29c-5p knockdown reduces inflammation and blood–brain barrier disruption by upregulating LRP6
  30. Cardiac contractility modulation ameliorates myocardial metabolic remodeling in a rabbit model of chronic heart failure through activation of AMPK and PPAR-α pathway
  31. Quercitrin protects human bronchial epithelial cells from oxidative damage
  32. Smurf2 suppresses the metastasis of hepatocellular carcinoma via ubiquitin degradation of Smad2
  33. circRNA_0001679/miR-338-3p/DUSP16 axis aggravates acute lung injury
  34. Sonoclot’s usefulness in prediction of cardiopulmonary arrest prognosis: A proof of concept study
  35. Four drug metabolism-related subgroups of pancreatic adenocarcinoma in prognosis, immune infiltration, and gene mutation
  36. Decreased expression of miR-195 mediated by hypermethylation promotes osteosarcoma
  37. LMO3 promotes proliferation and metastasis of papillary thyroid carcinoma cells by regulating LIMK1-mediated cofilin and the β-catenin pathway
  38. Cx43 upregulation in HUVECs under stretch via TGF-β1 and cytoskeletal network
  39. Evaluation of menstrual irregularities after COVID-19 vaccination: Results of the MECOVAC survey
  40. Histopathologic findings on removed stomach after sleeve gastrectomy. Do they influence the outcome?
  41. Analysis of the expression and prognostic value of MT1-MMP, β1-integrin and YAP1 in glioma
  42. Optimal diagnosis of the skin cancer using a hybrid deep neural network and grasshopper optimization algorithm
  43. miR-223-3p alleviates TGF-β-induced epithelial-mesenchymal transition and extracellular matrix deposition by targeting SP3 in endometrial epithelial cells
  44. Clinical value of SIRT1 as a prognostic biomarker in esophageal squamous cell carcinoma, a systematic meta-analysis
  45. circ_0020123 promotes cell proliferation and migration in lung adenocarcinoma via PDZD8
  46. miR-22-5p regulates the self-renewal of spermatogonial stem cells by targeting EZH2
  47. hsa-miR-340-5p inhibits epithelial–mesenchymal transition in endometriosis by targeting MAP3K2 and inactivating MAPK/ERK signaling
  48. circ_0085296 inhibits the biological functions of trophoblast cells to promote the progression of preeclampsia via the miR-942-5p/THBS2 network
  49. TCD hemodynamics findings in the subacute phase of anterior circulation stroke patients treated with mechanical thrombectomy
  50. Development of a risk-stratification scoring system for predicting risk of breast cancer based on non-alcoholic fatty liver disease, non-alcoholic fatty pancreas disease, and uric acid
  51. Tollip promotes hepatocellular carcinoma progression via PI3K/AKT pathway
  52. circ_0062491 alleviates periodontitis via the miR-142-5p/IGF1 axis
  53. Human amniotic fluid as a source of stem cells
  54. lncRNA NONRATT013819.2 promotes transforming growth factor-β1-induced myofibroblastic transition of hepatic stellate cells by miR24-3p/lox
  55. NORAD modulates miR-30c-5p-LDHA to protect lung endothelial cells damage
  56. Idiopathic pulmonary fibrosis telemedicine management during COVID-19 outbreak
  57. Risk factors for adverse drug reactions associated with clopidogrel therapy
  58. Serum zinc associated with immunity and inflammatory markers in Covid-19
  59. The relationship between night shift work and breast cancer incidence: A systematic review and meta-analysis of observational studies
  60. LncRNA expression in idiopathic achalasia: New insight and preliminary exploration into pathogenesis
  61. Notoginsenoside R1 alleviates spinal cord injury through the miR-301a/KLF7 axis to activate Wnt/β-catenin pathway
  62. Moscatilin suppresses the inflammation from macrophages and T cells
  63. Zoledronate promotes ECM degradation and apoptosis via Wnt/β-catenin
  64. Epithelial-mesenchymal transition-related genes in coronary artery disease
  65. The effect evaluation of traditional vaginal surgery and transvaginal mesh surgery for severe pelvic organ prolapse: 5 years follow-up
  66. Repeated partial splenic artery embolization for hypersplenism improves platelet count
  67. Low expression of miR-27b in serum exosomes of non-small cell lung cancer facilitates its progression by affecting EGFR
  68. Exosomal hsa_circ_0000519 modulates the NSCLC cell growth and metastasis via miR-1258/RHOV axis
  69. miR-455-5p enhances 5-fluorouracil sensitivity in colorectal cancer cells by targeting PIK3R1 and DEPDC1
  70. The effect of tranexamic acid on the reduction of intraoperative and postoperative blood loss and thromboembolic risk in patients with hip fracture
  71. Isocitrate dehydrogenase 1 mutation in cholangiocarcinoma impairs tumor progression by sensitizing cells to ferroptosis
  72. Artemisinin protects against cerebral ischemia and reperfusion injury via inhibiting the NF-κB pathway
  73. A 16-gene signature associated with homologous recombination deficiency for prognosis prediction in patients with triple-negative breast cancer
  74. Lidocaine ameliorates chronic constriction injury-induced neuropathic pain through regulating M1/M2 microglia polarization
  75. MicroRNA 322-5p reduced neuronal inflammation via the TLR4/TRAF6/NF-κB axis in a rat epilepsy model
  76. miR-1273h-5p suppresses CXCL12 expression and inhibits gastric cancer cell invasion and metastasis
  77. Clinical characteristics of pneumonia patients of long course of illness infected with SARS-CoV-2
  78. circRNF20 aggravates the malignancy of retinoblastoma depending on the regulation of miR-132-3p/PAX6 axis
  79. Linezolid for resistant Gram-positive bacterial infections in children under 12 years: A meta-analysis
  80. Rack1 regulates pro-inflammatory cytokines by NF-κB in diabetic nephropathy
  81. Comprehensive analysis of molecular mechanism and a novel prognostic signature based on small nuclear RNA biomarkers in gastric cancer patients
  82. Smog and risk of maternal and fetal birth outcomes: A retrospective study in Baoding, China
  83. Let-7i-3p inhibits the cell cycle, proliferation, invasion, and migration of colorectal cancer cells via downregulating CCND1
  84. β2-Adrenergic receptor expression in subchondral bone of patients with varus knee osteoarthritis
  85. Possible impact of COVID-19 pandemic and lockdown on suicide behavior among patients in Southeast Serbia
  86. In vitro antimicrobial activity of ozonated oil in liposome eyedrop against multidrug-resistant bacteria
  87. Potential biomarkers for inflammatory response in acute lung injury
  88. A low serum uric acid concentration predicts a poor prognosis in adult patients with candidemia
  89. Antitumor activity of recombinant oncolytic vaccinia virus with human IL2
  90. ALKBH5 inhibits TNF-α-induced apoptosis of HUVECs through Bcl-2 pathway
  91. Risk prediction of cardiovascular disease using machine learning classifiers
  92. Value of ultrasonography parameters in diagnosing polycystic ovary syndrome
  93. Bioinformatics analysis reveals three key genes and four survival genes associated with youth-onset NSCLC
  94. Identification of autophagy-related biomarkers in patients with pulmonary arterial hypertension based on bioinformatics analysis
  95. Protective effects of glaucocalyxin A on the airway of asthmatic mice
  96. Overexpression of miR-100-5p inhibits papillary thyroid cancer progression via targeting FZD8
  97. Bioinformatics-based analysis of SUMOylation-related genes in hepatocellular carcinoma reveals a role of upregulated SAE1 in promoting cell proliferation
  98. Effectiveness and clinical benefits of new anti-diabetic drugs: A real life experience
  99. Identification of osteoporosis based on gene biomarkers using support vector machine
  100. Tanshinone IIA reverses oxaliplatin resistance in colorectal cancer through microRNA-30b-5p/AVEN axis
  101. miR-212-5p inhibits nasopharyngeal carcinoma progression by targeting METTL3
  102. Association of ST-T changes with all-cause mortality among patients with peripheral T-cell lymphomas
  103. LINC00665/miRNAs axis-mediated collagen type XI alpha 1 correlates with immune infiltration and malignant phenotypes in lung adenocarcinoma
  104. The perinatal factors that influence the excretion of fecal calprotectin in premature-born children
  105. Effect of femoral head necrosis cystic area on femoral head collapse and stress distribution in femoral head: A clinical and finite element study
  106. Does the use of 3D-printed cones give a chance to postpone the use of megaprostheses in patients with large bone defects in the knee joint?
  107. lncRNA HAGLR modulates myocardial ischemia–reperfusion injury in mice through regulating miR-133a-3p/MAPK1 axis
  108. Protective effect of ghrelin on intestinal I/R injury in rats
  109. In vivo knee kinematics of an innovative prosthesis design
  110. Relationship between the height of fibular head and the incidence and severity of knee osteoarthritis
  111. lncRNA WT1-AS attenuates hypoxia/ischemia-induced neuronal injury during cerebral ischemic stroke via miR-186-5p/XIAP axis
  112. Correlation of cardiac troponin T and APACHE III score with all-cause in-hospital mortality in critically ill patients with acute pulmonary embolism
  113. LncRNA LINC01857 reduces metastasis and angiogenesis in breast cancer cells via regulating miR-2052/CENPQ axis
  114. Endothelial cell-specific molecule 1 (ESM1) promoted by transcription factor SPI1 acts as an oncogene to modulate the malignant phenotype of endometrial cancer
  115. SELENBP1 inhibits progression of colorectal cancer by suppressing epithelial–mesenchymal transition
  116. Visfatin is negatively associated with coronary artery lesions in subjects with impaired fasting glucose
  117. Treatment and outcomes of mechanical complications of acute myocardial infarction during the Covid-19 era: A comparison with the pre-Covid-19 period. A systematic review and meta-analysis
  118. Neonatal stroke surveillance study protocol in the United Kingdom and Republic of Ireland
  119. Oncogenic role of TWF2 in human tumors: A pan-cancer analysis
  120. Mean corpuscular hemoglobin predicts the length of hospital stay independent of severity classification in patients with acute pancreatitis
  121. Association of gallstone and polymorphisms of UGT1A1*27 and UGT1A1*28 in patients with hepatitis B virus-related liver failure
  122. TGF-β1 upregulates Sar1a expression and induces procollagen-I secretion in hypertrophic scarring fibroblasts
  123. Antisense lncRNA PCNA-AS1 promotes esophageal squamous cell carcinoma progression through the miR-2467-3p/PCNA axis
  124. NK-cell dysfunction of acute myeloid leukemia in relation to the renin–angiotensin system and neurotransmitter genes
  125. The effect of dilution with glucose and prolonged injection time on dexamethasone-induced perineal irritation – A randomized controlled trial
  126. miR-146-5p restrains calcification of vascular smooth muscle cells by suppressing TRAF6
  127. Role of lncRNA MIAT/miR-361-3p/CCAR2 in prostate cancer cells
  128. lncRNA NORAD promotes lung cancer progression by competitively binding to miR-28-3p with E2F2
  129. Noninvasive diagnosis of AIH/PBC overlap syndrome based on prediction models
  130. lncRNA FAM230B is highly expressed in colorectal cancer and suppresses the maturation of miR-1182 to increase cell proliferation
  131. circ-LIMK1 regulates cisplatin resistance in lung adenocarcinoma by targeting miR-512-5p/HMGA1 axis
  132. LncRNA SNHG3 promoted cell proliferation, migration, and metastasis of esophageal squamous cell carcinoma via regulating miR-151a-3p/PFN2 axis
  133. Risk perception and affective state on work exhaustion in obstetrics during the COVID-19 pandemic
  134. lncRNA-AC130710/miR-129-5p/mGluR1 axis promote migration and invasion by activating PKCα-MAPK signal pathway in melanoma
  135. SNRPB promotes cell cycle progression in thyroid carcinoma via inhibiting p53
  136. Xylooligosaccharides and aerobic training regulate metabolism and behavior in rats with streptozotocin-induced type 1 diabetes
  137. Serpin family A member 1 is an oncogene in glioma and its translation is enhanced by NAD(P)H quinone dehydrogenase 1 through RNA-binding activity
  138. Silencing of CPSF7 inhibits the proliferation, migration, and invasion of lung adenocarcinoma cells by blocking the AKT/mTOR signaling pathway
  139. Ultrasound-guided lumbar plexus block versus transversus abdominis plane block for analgesia in children with hip dislocation: A double-blind, randomized trial
  140. Relationship of plasma MBP and 8-oxo-dG with brain damage in preterm
  141. Identification of a novel necroptosis-associated miRNA signature for predicting the prognosis in head and neck squamous cell carcinoma
  142. Delayed femoral vein ligation reduces operative time and blood loss during hip disarticulation in patients with extremity tumors
  143. The expression of ASAP3 and NOTCH3 and the clinicopathological characteristics of adult glioma patients
  144. Longitudinal analysis of factors related to Helicobacter pylori infection in Chinese adults
  145. HOXA10 enhances cell proliferation and suppresses apoptosis in esophageal cancer via activating p38/ERK signaling pathway
  146. Meta-analysis of early-life antibiotic use and allergic rhinitis
  147. Marital status and its correlation with age, race, and gender in prognosis of tonsil squamous cell carcinomas
  148. HPV16 E6E7 up-regulates KIF2A expression by activating JNK/c-Jun signal, is beneficial to migration and invasion of cervical cancer cells
  149. Amino acid profiles in the tissue and serum of patients with liver cancer
  150. Pain in critically ill COVID-19 patients: An Italian retrospective study
  151. Immunohistochemical distribution of Bcl-2 and p53 apoptotic markers in acetamiprid-induced nephrotoxicity
  152. Estradiol pretreatment in GnRH antagonist protocol for IVF/ICSI treatment
  153. Long non-coding RNAs LINC00689 inhibits the apoptosis of human nucleus pulposus cells via miR-3127-5p/ATG7 axis-mediated autophagy
  154. The relationship between oxygen therapy, drug therapy, and COVID-19 mortality
  155. Monitoring hypertensive disorders in pregnancy to prevent preeclampsia in pregnant women of advanced maternal age: Trial mimicking with retrospective data
  156. SETD1A promotes the proliferation and glycolysis of nasopharyngeal carcinoma cells by activating the PI3K/Akt pathway
  157. The role of Shunaoxin pills in the treatment of chronic cerebral hypoperfusion and its main pharmacodynamic components
  158. TET3 governs malignant behaviors and unfavorable prognosis of esophageal squamous cell carcinoma by activating the PI3K/AKT/GSK3β/β-catenin pathway
  159. Associations between morphokinetic parameters of temporary-arrest embryos and the clinical prognosis in FET cycles
  160. Long noncoding RNA WT1-AS regulates trophoblast proliferation, migration, and invasion via the microRNA-186-5p/CADM2 axis
  161. The incidence of bronchiectasis in chronic obstructive pulmonary disease
  162. Integrated bioinformatics analysis shows integrin alpha 3 is a prognostic biomarker for pancreatic cancer
  163. Inhibition of miR-21 improves pulmonary vascular responses in bronchopulmonary dysplasia by targeting the DDAH1/ADMA/NO pathway
  164. Comparison of hospitalized patients with severe pneumonia caused by COVID-19 and influenza A (H7N9 and H1N1): A retrospective study from a designated hospital
  165. lncRNA ZFAS1 promotes intervertebral disc degeneration by upregulating AAK1
  166. Pathological characteristics of liver injury induced by N,N-dimethylformamide: From humans to animal models
  167. lncRNA ELFN1-AS1 enhances the progression of colon cancer by targeting miR-4270 to upregulate AURKB
  168. DARS-AS1 modulates cell proliferation and migration of gastric cancer cells by regulating miR-330-3p/NAT10 axis
  169. Dezocine inhibits cell proliferation, migration, and invasion by targeting CRABP2 in ovarian cancer
  170. MGST1 alleviates the oxidative stress of trophoblast cells induced by hypoxia/reoxygenation and promotes cell proliferation, migration, and invasion by activating the PI3K/AKT/mTOR pathway
  171. Bifidobacterium lactis Probio-M8 ameliorated the symptoms of type 2 diabetes mellitus mice by changing ileum FXR-CYP7A1
  172. circRNA DENND1B inhibits tumorigenicity of clear cell renal cell carcinoma via miR-122-5p/TIMP2 axis
  173. EphA3 targeted by miR-3666 contributes to melanoma malignancy via activating ERK1/2 and p38 MAPK pathways
  174. Pacemakers and methylprednisolone pulse therapy in immune-related myocarditis concomitant with complete heart block
  175. miRNA-130a-3p targets sphingosine-1-phosphate receptor 1 to activate the microglial and astrocytes and to promote neural injury under the high glucose condition
  176. Review Articles
  177. Current management of cancer pain in Italy: Expert opinion paper
  178. Hearing loss and brain disorders: A review of multiple pathologies
  179. The rationale for using low-molecular weight heparin in the therapy of symptomatic COVID-19 patients
  180. Amyotrophic lateral sclerosis and delayed onset muscle soreness in light of the impaired blink and stretch reflexes – watch out for Piezo2
  181. Interleukin-35 in autoimmune dermatoses: Current concepts
  182. Recent discoveries in microbiota dysbiosis, cholangiocytic factors, and models for studying the pathogenesis of primary sclerosing cholangitis
  183. Advantages of ketamine in pediatric anesthesia
  184. Congenital adrenal hyperplasia. Role of dentist in early diagnosis
  185. Migraine management: Non-pharmacological points for patients and health care professionals
  186. Atherogenic index of plasma and coronary artery disease: A systematic review
  187. Physiological and modulatory role of thioredoxins in the cellular function
  188. Case Reports
  189. Intrauterine Bakri balloon tamponade plus cervical cerclage for the prevention and treatment of postpartum haemorrhage in late pregnancy complicated with acute aortic dissection: Case series
  190. A case of successful pembrolizumab monotherapy in a patient with advanced lung adenocarcinoma: Use of multiple biomarkers in combination for clinical practice
  191. Unusual neurological manifestations of bilateral medial medullary infarction: A case report
  192. Atypical symptoms of malignant hyperthermia: A rare causative mutation in the RYR1 gene
  193. A case report of dermatomyositis with the missed diagnosis of non-small cell lung cancer and concurrence of pulmonary tuberculosis
  194. A rare case of endometrial polyp complicated with uterine inversion: A case report and clinical management
  195. Spontaneous rupturing of splenic artery aneurysm: Another reason for fatal syncope and shock (Case report and literature review)
  196. Fungal infection mimicking COVID-19 infection – A case report
  197. Concurrent aspergillosis and cystic pulmonary metastases in a patient with tongue squamous cell carcinoma
  198. Paraganglioma-induced inverted takotsubo-like cardiomyopathy leading to cardiogenic shock successfully treated with extracorporeal membrane oxygenation
  199. Lineage switch from lymphoma to myeloid neoplasms: First case series from a single institution
  200. Trismus during tracheal extubation as a complication of general anaesthesia – A case report
  201. Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature
  202. Two case reports of skin vasculitis following the COVID-19 immunization
  203. Ureteroiliac fistula after oncological surgery: Case report and review of the literature
  204. Synchronous triple primary malignant tumours in the bladder, prostate, and lung harbouring TP53 and MEK1 mutations accompanied with severe cardiovascular diseases: A case report
  205. Huge mucinous cystic neoplasms with adhesion to the left colon: A case report and literature review
  206. Commentary
  207. Commentary on “Clinicopathological features of programmed cell death-ligand 1 expression in patients with oral squamous cell carcinoma”
  208. Rapid Communication
  209. COVID-19 fear, post-traumatic stress, growth, and the role of resilience
  210. Erratum
  211. Erratum to “Tollip promotes hepatocellular carcinoma progression via PI3K/AKT pathway”
  212. Erratum to “Effect of femoral head necrosis cystic area on femoral head collapse and stress distribution in femoral head: A clinical and finite element study”
  213. Erratum to “lncRNA NORAD promotes lung cancer progression by competitively binding to miR-28-3p with E2F2”
  214. Retraction
  215. Expression and role of ABIN1 in sepsis: In vitro and in vivo studies
  216. Retraction to “miR-519d downregulates LEP expression to inhibit preeclampsia development”
  217. Special Issue Computational Intelligence Methodologies Meets Recurrent Cancers - Part II
  218. Usefulness of close surveillance for rectal cancer patients after neoadjuvant chemoradiotherapy
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