You're using an outdated browser. Please upgrade to a modern browser for the best experience.
Enhanced Recovery after Surgery
Edit
This entry is adapted from the peer-reviewed paper 10.3390/jcm10081634

Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care.

enhanced recovery

1. Introduction

Enhanced recovery after surgery (ERAS) programs aim to optimise pre-, intra- and post-operative care in order to improve the quality and speed of recovery in surgical patients. ERAS protocols are complex, requiring organised care from a multidisciplinary team to ensure strong patient outcomes and provide an elevated level of care. Enhanced recovery pathways reduce length of stay (LOS) by an average of 2.35 days and total cost by an average of $639.06 in comparison with conventional perioperative procedures, according to a 2020 meta-analysis of ERAS across multiple surgeries and surgical specialties [1]. Despite concerns, ERAS does not increase morbidity, mortality or readmission rates [2], having even been shown to decrease 30-day mortality rates following orthopedic surgery [1]. Since its beginnings as ‘fast-track’ surgery in 1997 [3], ERAS has been researched across a broad range of surgical subspecialties, from orthopedics to transplant surgery [4]. The ERAS Study Group (now the ERAS Society) formed in 2001 to develop consensus guidelines for perioperative care using the best available evidence [4], to encourage further research and to facilitate the discussion of enhanced recovery on an international scale.
Rapid advancements have been made in many areas of surgery, with some interventions having been accepted as beneficial across most, if not all fields. Mainstays of pre-operative care include patient education and counselling [5], while decisions regarding the use of mechanical bowel preparation, for example, remain controversial [6]. Recent years have seen major progression in intra-operative fluid management, with landmark studies beginning to suggest a shift away from conservative fluid administration to more specific goal-directed fluid therapy [7]. Finally, in post-operative care there is increasing evidence for early mobilization and enteral feeding of patients, owing to reductions in complications and LOS [8][9].
Despite marked progress in many subspecialties, the acceptance of ERAS has been slow in the field of solid-organ transplantation. Thus, there is limited existing literature in this area. Changes to USA organ allocation laws, which prioritise patients on the basis of pre-operative health, may disincentivise pre-surgical optimisation, an important aspect of many ERAS pathways [10]. Among other factors, this has played a key role in slowing the development in ERAS in liver transplantation (LT), though novel research is encouraging, as experts seek ways to optimise surgical pathways while working in accordance with updated regulations [11]. Recent years have also seen the first use of ERAS protocols in kidney transplants. Following successful feasibility trials in 2016 [12], research is currently focused on pain control and reduction in opioid requirements to improve patients’ experience and LOS [13].

2. History of Enhanced Recovery after Surgery

The concept of enhanced recovery after surgery (formerly ‘fast track surgery’) was introduced by Danish surgeon Professor Henrik Kehlet in 1997 [3]. Kehlet suggested that ‘while no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction’ and went on to suggest pre-, intra- and post-operative surgical risk factors that may be addressed through coordinated perioperative protocols [3]. Following this, Kehlet published a trial that reported a mean post-operative hospital stay of 48 h after elective sigmoid resection [14]. Though this study included just 16 patients, fast-track surgery reduced post-surgical hospitalisation by 3–8 days [14].
In 2001 came the formation of the Enhanced Recovery After Surgery (ERAS) Study Group—a group of six surgeons assembled by Professors Ken Fearon and Ollie Ljungqvist and including Professor Kehlet, which aimed to produce and interpret the best available evidence to fine-tune fast track surgery [15][16]. Operating on the notion that ‘there was a great discrepancy between the actual practices and what was already known to be best practice’ [4], the ERAS Study Group published a review of the patterns of perioperative care in five northern European countries, concluding that colorectal perioperative protocols were neither standardized nor evidence based [17]. This was corroborated by a larger trial (n = 46,539), which found that crude mortality from cardiac surgery varied from 1.2% to 21.5% across Europe [18].
Maintaining its focus on colorectal surgery, the ERAS Study Group published what are now seen as the first consensus guidelines for perioperative care, conducting a 2005 review of enhanced recovery protocols in colorectal resections [19]. Enhanced recovery was becoming better researched, and its efficacy in colorectal surgery was consolidated in a 2010 meta-analysis of six randomized controlled trials, which reported that ERAS reduced length of hospital stay by 2.5 days and significantly reduced complication rates [20]. Following this, the Dutch Institute for Health Care Improvement conducted a trial to assess the ease of implementing ERAS protocols on a wider scale [21]. They enrolled 33 hospitals in the study and trained staff in a standardized ERAS protocols for elective colonic surgery, reporting significantly decreased LOS associated with early mobilisation and discontinuation of IV fluids as well as post-operative laxative administration [21]. While successful, the study did identify that adherence to the ERAS protocol fell to just 56% (calculated as mean average adherence to all post-operative aspects of the protocol) in the post-operative phase, having been 80% pre-operatively and 92% intra-operatively [21]. Studies have since highlighted the correlation between compliance and efficacy of ERAS protocols in both the short and long term [22][23].
In 2010, the ERAS Study Group registered as a new non-profit organization in Sweden under the title ‘the ERAS Society’, with the hope of evolving to reach other countries and create an international collaborative effort to improve perioperative protocols. Since its inception, the ERAS Society has published continuous research and guidance, held multiple symposia, and taken a leading role in the expansion of ERAS protocols to many new surgical subspecialties. It has also created an interactive audit system to help hospitals comply with ERAS protocols, making it easier for new hospitals to begin improving perioperative care. The main events in the history of ERAS are presented in Table 1.
Table 1. Summary of key events in the history of ERAS.
Table
Advancement in Enhanced Recovery Year
Kehlet publishes paper introducing the concept of ‘fast track surgery’ [3]. 1997
Kehlet publishes first paper showing efficacy of ERAS in sigmoid resection [14]. 1999
ERAS Study Group is formed. 2001
Study shows that perioperative care is not consistent across Europe [17]. 2005
ERAS Study Group publish first consensus guidelines for colorectal surgery [19]. 2005
ERAS Society is formed. 2010
Meta-analysis shows efficacy of ERAS [20]. 2010
Study confirms findings that perioperative care is inconsistent across Europe [18]. 2012
Study assesses possibility of large-scale implementation of ERAS protocols [21]. 2013

3. Key Pre-Operative Advancements

Pre-operative optimisation of patients, an essential aspect of ERAS protocols, allows the patient to prepare both physiologically and psychologically for surgery. Pre-operative interventions that have been studied include a reduced fasting period, carbohydrate loading and various forms of counselling.

3.1. Carbohydrate Loading (CL)

Carbohydrate loading (CL) through pre-operative solutions containing complex carbohydrates such as maltodextrin is recommended by the ERAS Society as well as the European Society of Anaesthesiology [24][25]. The American Society of Anesthesiologists and the Canadian Anesthesiologists’ Society (CAS) also permit the consumption of clear liquids until 2 h prior to surgery, with the CAS going so far as to encourage it [24][25][26]. Fasting allows time for gastric emptying, thereby reducing the risk of intra-operative pulmonary aspiration [24][26]. The benefits of carbohydrate loading include metabolic optimisation, increased insulin sensitivity, reduced nausea and vomiting, reduced thirst, and reduced anxiety [24][25][26].
Pre-operative CL ensures that the body enters surgery in a fed state, which is preferable to the catabolic state that occurs in patients who fast for the standard 8 h pre-surgical period [24][25][26]. This catabolism results from the inhibition of insulin, which causes the release of glucagon and cortisol; however, CL has been shown to increase insulin sensitivity [24][25][26]. This negates these effects, reducing post-operative insulin resistance (mean increase in glucose infusion rate of 0.76 mg/kg/min), preserving glycogen and shortening LOS by 0.30 days compared with fasting [27][28]. CL also decreases the incidence of post-operative nausea and vomiting, as identified by Yilmaz et al., who reported significantly lower verbal descriptive scale scores (a measure of nausea) and antiemetic consumptions in carbohydrate-loaded patients following elective laparoscopic cholecystectomy [29]. CL has also been noted to reduce thirst, hunger, anxiety and malaise as well as increasing fitness when compared with patients who fasted from midnight the evening before surgery [30].
Despite these effects, CL appears to have no significant impact on rates of post-surgical complication [25]. CL also has yet to be researched in specific subspecialties, as conclusions are currently reliant on minimal data from studies in a small range of surgeries. Finally, the effect of CL in diabetic populations remains unclear, though experts feel it should be avoided due to its effects on insulin sensitivity [25].

3.2. Mechanical Bowel Preparation (MBP)

The role of MBP prior to elective colorectal surgery is well studied but controversial, owing to contradictory data from two reviews [6]. In 2009, Nelson et al. compared the efficacy of oral antibiotics (OA) in combination with MBP, intravenous (IV) antibiotics in combination with MBP, and OA and IV antibiotics together in combination with MBP [31]. They found that combined OA and IV antibiotics with MBP significantly reduced surgical wound infection compared to all other groups [31]. In 2011, Guenaga et al. assessed the need for MBP, judging that it was unnecessary as there was no significant difference in complication rates in the ‘no MBP group’ (n = 415) in comparison to ‘MBP group’ (n = 431) [32]. This led to confusion as there was no existing data regarding the use of OA and IV antibiotics without MBP; however, it was also clear that MBP was not necessary in colorectal surgery.
Subsequent trials in 2012 and 2015 found that OA plus MBP reduces the incidence of surgical wound infection by 40–57% (when compared with no OA or MBP), as well as reducing complications such as ileus and anastomotic leak [33][34]. Settling the issue, the American Society for Enhanced Recovery (ASER) and the Perioperative Quality Initiative (PQI) released a joint consensus statement in 2017 [6]. This statement included three recommendations for pre-operative MBP. These were as follows:
‘We recommend routine use of a combined isosmotic MBP with OA before elective colorectal surgery’.
‘We do not recommend use of MBP without concurrent oral antibiotics before elective colorectal surgery’.
‘We recommend against the use of hyperosmotic bowel prep solutions before elective colorectal surgery’.
The final recommendation concerns the use of hyperosmotic bowel preparation solutions. The reason for this is that hyperosmotic solutions cause changes in plasma osmolality as well as phosphate, urea, calcium and potassium concentrations and can lead to renal impairment [35].

3.3. Patient Education and Counselling

It is widely accepted that pre-operative patient education and counselling should be included in many if not all ERAS pathways. This allows the patient to manage their expectations before undergoing surgery [5], helps them to prepare psychologically, and can increase compliance to ensure a quick recovery. Forsmo et al. reported an average reduction in LOS of three days in colorectal surgical patients managed under an enhanced recovery pathway with a particular focus on counselling [36]. This research group also found that pre-operative stoma education reduces LOS without increasing the rate of readmission or early stoma-related complications [37], corroborating the findings of Younis et al. in 2012 [38]. This may be attributed to education on ‘independent stoma management’, which was identified as a limiting factor in the speedy recovery and discharge of patients [38].
Education and counselling have also been shown to improve pain control, especially in patients experiencing high levels of anxiety related to their surgery [19]. This effect appears to be consistent with all forms of patient education, from informal spoken information to leaflets [5], with one study advocating journaling on the grounds that it increases patient empowerment [39]. While the benefits seem clear, there is some evidence that providing excessive information to patients may actually reduce post-operative satisfaction. Barlesi et al. found that patients receiving both oral and written information were significantly dissatisfied following surgery in comparison to those receiving only oral information [40]. Overall, the ERAS Society and European Society of Thoracic Surgeons strongly recommend the inclusion of patient education and counselling in ERAS pathways, despite reporting ‘low’ levels of evidence [5].

4. Conclusions

ERAS pathways offer safe and cost-effective approaches to perioperative care, which improve patient outcomes without increasing rates of complication. Since the inception of ERAS in 1997, so-called ‘fast-track’ surgical pathways have become widely used in multiple specialties, and the standard of perioperative care has improved substantially, in no small part due to the work of the ERAS Society. Key advancements have been made, including pre-operative carbohydrate loading, patient education, GDFT and early enteral nutrition. However, the uptake of ERAS in transplantation surgeries has been slow, leading to a paucity of literature in the field. While recent years have seen some developments in ERAS relating to liver and kidney transplants, other areas of solid-organ transplantation—including lung, heart and pancreas transplantation—are yet to make notable progress. Future research should address the feasibility and efficacy of ERAS in these areas, and emphasis should be placed on the speedy incorporation of ERAS pathways into standard perioperative care for transplant surgeries.

References

  1. Zhang, X.; Yang, J.; Chen, X.; Du, L.; Li, K.; Zhou, Y. Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses. Medicine 2020, 99, e20983.
  2. Paton, F.; Chambers, D.; Wilson, P.; Eastwood, A.; Craig, D.; Fox, D.; Jayne, D.; McGinnes, E. Effectiveness and implementation of enhanced recovery after surgery programmes: A rapid evidence synthesis. BMJ Open 2014, 4, e005015.
  3. Kehlet, H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 1997, 78, 606–617.
  4. History—ERAS. Available online: (accessed on 20 January 2021).
  5. Batchelor, T.J.P.; Rasburn, N.J.; Abdelnour-Berchtold, E.; Brunelli, A.; Cerfolio, R.J.; Gonzalez, M.; Ljungqvist, O.; Petersen, R.H.; Popescu, W.M.; Slinger, P.D.; et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur. J. Cardio-Thorac. Surg. 2019, 55, 91–115.
  6. Holubar, S.D.; Hedrick, T.; Gupta, R.; Kellum, J.; Hamilton, M.; Gan, T.J.; Mythen, M.G.; Shaw, A.D.; Miller, T.E.; Mythen, M.G.; et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper. Med. 2017, 6, 4.
  7. Edwards, M.; Forbes, G.; MacDonald, N. Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: Study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery. BMJ Open 2021, 9, e023455.
  8. Hajibandeh, S.; Hajibandeh, S.; Bill, V.; Satyadas, T. Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery. World J. Surg. 2020, 44, 1336–1348.
  9. Willcutts, K.F.; Chung, M.C.; Erenberg, C.L.; Finn, K.L.; Schirmer, B.D.; Byham-Gray, L.D. Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery: A Systematic Review and Meta-analysis. Ann. Surg. 2016, 264, 54–63.
  10. Freeman, R.B., Jr.; Wiesner, R.H.; Harper, A.; McDiarmid, S.V.; Lake, J.; Edwards, E.; Merion, R.; Wolfe, R.; Turcotte, J.; Teperman, L. The new liver allocation system: Moving toward evidence-based transplantation policy. Liver Transpl. 2002, 8, 851–858.
  11. Brustia, R.; Monsel, A.; Conti, F.; Savier, E.; Rousseau, G.; Perdigao, F.; Bernard, D.; Eyraud, D.; Loncar, Y.; Langeron, O.; et al. Enhanced Recovery in Liver Transplantation: A Feasibility Study. World J. Surg. 2019, 43, 230–241.
  12. Kruszyna, T.; Niekowal, B.; Kraśnicka, M.; Sadowski, J. Enhanced Recovery After Kidney Transplantation Surgery. Transplant. Proc. 2016, 48, 1461–1465.
  13. Campsen, J.; Call, T.; Allen, C.M.; Presson, A.P.; Martinez, E.; Rofaiel, G.; Kim, R.D. Prospective, double-blind, randomized clinical trial comparing an ERAS pathway with ketorolac and pregabalin versus standard of care plus placebo during live donor nephrectomy for kidney transplant. Am. J. Transplant. 2019, 19, 1777–1781.
  14. Kehlet, H.; Mogensen, T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br. J. Surg. 1999, 86, 227–230.
  15. Ljungqvist, O. Enhanced Recovery After Surgery and the ERAS® Society. J. Pancreatol. 2019, 2, 65–68.
  16. Ljungqvist, O.; Young-Fadok, T.; Demartines, N. The History of Enhanced Recovery After Surgery and the ERAS Society. J. Laparoendosc. Adv. Surg. Tech. 2017, 27, 860–862.
  17. Lassen, K.; Hannemann, P.; Ljungqvist, O.; Fearon, K.; Dejong, C.H.C.; von Meyenfeldt, M.F.; Hausel, J.; Nygren, J.; Andersen, J.; Revhaug, A. Patterns in current perioperative practice: Survey of colorectal surgeons in five northern European countries. BMJ 2005, 330, 1420.
  18. Pearse, R.M.; Moreno, R.P.; Bauer, P.; Pelosi, P.; Metnitz, P.; Spies, C.; Vallet, B.; Vincent, J.-L.; Hoeft, A.; Rhodes, A. Mortality after surgery in Europe: A 7 day cohort study. Lancet 2012, 380, 1059–1065.
  19. Fearon, K.C.H.; Ljungqvist, O.; Von Meyenfeldt, M.; Revhaug, A.; Dejong, C.H.C.; Lassen, K.; Nygren, J.; Hausel, J.; Soop, M.; Andersen, J.; et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin. Nutr. 2005, 24, 466–477.
  20. Varadhan, K.K.; Neal, K.R.; Dejong, C.H.; Fearon, K.C.; Ljungqvist, O.; Lobo, D.N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin. Nutr. 2010, 29, 434–440.
  21. Gillissen, F.; Hoff, C.; Maessen, J.M.C.; Winkens, B.; Teeuwen, J.H.F.A.; von Meyenfeldt, M.F.; Dejong, C.H.C. Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands. World J. Surg. 2013, 37, 1082–1093.
  22. ERAS Compliance Groups. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Ann. Surg. 2015, 261, 1153–1159.
  23. Gustafsson, U.O.; Oppelstrup, H.; Thorell, A.; Nygren, J.; Ljungqvist, O. Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study. World J. Surg. 2016, 40, 1741–1747.
  24. Makaryus, R.; Miller, T.E.; Gan, T.J. Current concepts of fluid management in enhanced recovery pathways. Br. J. Anaesth. 2018, 120, 376–383.
  25. Ackerman, R.S.; Tufts, C.W.; DePinto, D.G.; Chen, J.; Altshuler, J.R.; Serdiuk, A.; Cohen, J.B.; Patel, S.Y. How Sweet Is This? A Review and Evaluation of Preoperative Carbohydrate Loading in the Enhanced Recovery After Surgery Model. Nutr. Clin. Pract. 2020, 35, 246–253.
  26. Manning, M.W.; Dunkman, W.J.; Miller, T.E. Perioperative fluid and hemodynamic management within an enhanced recovery pathway. J. Surg. Oncol. 2017, 116, 592–600.
  27. Feldheiser, A.; Aziz, O.; Baldini, G.; Cox, B.P.B.W.; Fearon, K.C.H.; Feldman, L.S.; Gan, T.J.; Kennedy, R.H.; Ljungqvist, O.; Lobo, D.N.; et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: Consensus statement for anaesthesia practice. Acta Anaesthesiol. Scand. 2016, 60, 289–334.
  28. Smith, M.D.; McCall, J.; Plank, L.; Herbison, G.P.; Soop, M.; Nygren, J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst. Rev. 2014.
  29. Yilmaz, N.; Cekmen, N.; Bilgin, F.; Erten, E.; Ozhan, M.Ö.; Coşar, A. Preoperative carbohydrate nutrition reduces postoperative nausea and vomiting compared to preoperative fasting. J. Res. Med Sci. Off. J. Isfahan Univ. Med. Sci. 2013, 18, 827–832.
  30. Hausel, J.; Nygren, J.; Lagerkranser, M.; Hellström, P.M.; Hammarqvist, F.; Almström, C.; Lindh, A.; Thorell, A.; Ljungqvist, O. A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients. Anesth. Analg. 2001, 93, 1344–1350.
  31. Nelson, R.L.; Glenny, A.M.; Song, F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst. Rev. 2009.
  32. Güenaga, K.F.; Matos, D.; Wille-Jørgensen, P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst. Rev. 2011.
  33. Cannon, J.A.; Altom, L.K.; Deierhoi, R.J.; Morris, M.; Richman, J.S.; Vick, C.C.; Itani, K.M.F.; Hawn, M.T. Preoperative Oral Antibiotics Reduce Surgical Site Infection Following Elective Colorectal Resections. Dis. Colon Rectum 2012, 55, 1160–1166.
  34. Kiran, R.P.; Murray, A.C.A.; Chiuzan, C.; Estrada, D.; Forde, K. Combined Preoperative Mechanical Bowel Preparation with Oral Antibiotics Significantly Reduces Surgical Site Infection, Anastomotic Leak, and Ileus After Colorectal Surgery. Ann. Surg. 2015, 262, 416–425.
  35. Holte, K.; Nielsen, K.G.; Madsen, J.L.; Kehlet, H. Physiologic Effects of Bowel Preparation. Dis. Colon Rectum 2004, 47, 1397–1402.
  36. Forsmo, H.M.; Pfeffer, F.; Rasdal, A.; Østgaard, G.; Mohn, A.C.; Körner, H.; Erichsen, C. Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: Results of a randomized controlled trial. Colorectal Dis. 2016, 18, 603–611.
  37. Forsmo, H.M.; Pfeffer, F.; Rasdal, A.; Sintonen, H.; Körner, H.; Erichsen, C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery. Int. J. Surg. 2016, 36, 121–126.
  38. Younis, J.; Salerno, G.; Fanto, D.; Hadjipavlou, M.; Chellar, D.; Trickett, J.P. Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme. Int. J. Colorectal Dis. 2012, 27, 43–47.
  39. Schmidt, M.; Eckardt, R.; Scholtz, K.; Neuner, B.; von Dossow-Hanfstingl, V.; Sehouli, J.; Stief, C.G.; Wernecke, K.-D.; Spies, C.D.; Group, P. Patient Empowerment Improved Perioperative Quality of Care in Cancer Patients Aged ≥65 Years—A Randomized Controlled Trial. PLoS ONE 2015, 10, e0137824.
  40. Barlési, F.; Barrau, K.; Loundou, A.; Doddoli, C.; Simeoni, M.-C.; Auquier, P.; Thomas, P. Impact of Information on Quality of Life and Satisfaction of Non-small Cell Lung Cancer Patients: A Randomized Study of Standardized versus Individualized Information before Thoracic Surgery. J. Thorac. Oncol. 2008, 3, 1146–1152.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.
Upload a video for this entry
Information
Subjects: Medicine, Research & Experimental
Contributor MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Henry Golder
View Times: 969
Revisions: 2 times (View History)
Update Date: 17 May 2021
Table of Contents
Academic Video Service
Feedback