Loading

JSM Gastroenterology and Hepatology

The Use of High Resolution Manometry in the Management of a Patient with Dysphagia Secondary to Laparoscopic Adjustable Gastric Band - A Case Study

Case Report | Open Access

  • 1. GI Physiology Unit, St James’s Hospital, Ireland
+ Show More - Show Less
Corresponding Authors
Tracey Moran Brennan, GI Physiology Unit, St James’s Hospital, Dublin 8, Ireland, Tel: 00353-1-4162888; Email: tmoran@stjames.ie
Abstract

A 46-year-old obese woman presented to the Gastroenterology clinic with symptoms of dysphagia, odynophagia, regurgitation and vomiting. She had a laparoscopic adjustable gastric band in situ for a period of 10 years and this was believed to be causing her troublesome symptoms. Barium swallow indicated a hold up of contrast at the esophago-gastric junction and in the gastric reservoir between the junction and the band. High Resolution Manometry could confirm the placement of the band and the dual high pressure zones of the esophago-gastric junction and the gastric band. An elevated Integrated Resting Pressure and intra-bolus pressure indicated a hold up of bolus and resistance to flow across the esophago- gastric junction and in the gastric reservoir. 12 months post laparoscopic band removal, High Resolution Manometry was repeated. This revealed normal esophageal motility, a relaxing esophago-gastric junction and normal bolus transit. The patient’s symptoms improved greatly however her weight gain continued to be the cause of much stress to her and her options are under review. High Resolution Manometry is a useful tool in the assessment of patients with complicated gastric bands and is recommended both pre and post band placement or removal.

Keywords

Laparoscopic adjustable gastric, Band high resolution manometry, Esophago-gastric junction

ABBREVIATIONS

LAGB: Laparoscopic Adjustable Gastric Ban; HRM: High Resolution Manometry; EGJ: Esophago-Gastric Junction

INTRODUCTION

The laparoscopic adjustable gastric band (LAGB) has been used in the treatment of morbid obesity for over 20 years. In the early days of its inception it seemed like the ideal surgical technique, as other bariatric surgeries for obesity at the time such as the Vertical Banded Gastroplasty and Roux-en-Y gastric bypass were open procedures that were seen as quite complicated. The LAGB was both adjustable and easily reversible and relied on the technique of inducing a sensation of fullness and thus forcing the patient to feel less and less hungry. However, over the years the gastric band has fallen out of favor. This is due to the high complication rates that accompany this technique [1]. Complications such as band slippage and erosion, esophageal dilatation and the effect on esophago-gastric junction (EGJ) function, have become more apparent, especially in patients who have had the gastric band in situ for many years.

There has been much controversy in the literature regarding the overall effect of the band on the physiology of the esophagus and the EGJ. With some authors arguing that there is a profound effect on function, others concluded that there was no real significant effect. However these studies based their findings on radiology alone or on stationary pull through manometry [2- 4]. Stationary or conventional manometry was a four channel solid state or water perfused manometry technique which by todays standard does not give much information regarding EGJ morphology or bolus transit. Each channel is positioned 5cms apart and prone to axial displacement during swallow, which can often miss important information regarding LES relaxation.

High Resolution Manometry (HRM) is now considered the gold-standard in the assessment of esophageal motility. This technique utilizes 36 closely spaced recording sites that allow for a more detailed and dynamic assessment of esophageal and EGJ function. The data is displayed in the form of an isobaric contour plot which allows for a detailed assessment of the pressure dynamics across the EGJ taking into account esophageal shortening and the effect of crural diaphragm position relative to the lower esophageal sphincter high pressure zone [5-8].

In this case study I would like to demonstrate the clinical utility of HRM in the assessment and management of a patient with complications arising from a gastric band in situ for 10 years.

CASE PRESENTATION

A 46-year-old obese women with a BMI of >45kg/m3 , presented to the hospital with a 6-month history of severe dysphagia, odynophagia, post prandial regurgitation and vomiting. She was a non-smoker, drank alcohol occasionally and was in full time employment.

Medical history included pyloric stenosis as an infant, acid reflux, endometriosis and mild atrial regurgitation. The patient’s surgical history included a LAGB and cystectomy for ovarian cysts. The patient’s gastric band was in situ for 10 years prior to this presentation and needed revision after the first year of insertion. Over the course of 9 years post revision the patient did admit to bouts of intermittent dysphagia. During the last 12 months this began to increase, with symptoms becoming so severe in the last 6 months, that she felt food and liquid holding and regurgitating every time she ate.

She described bouts of being unable to swallow her own saliva. Her acid reflux was well controlled symptomatically with 40mg bd of Esomeprazole, prescribed by her GP. She was unsure about how long she had symptoms of reflux. There was no history of hematemesis. Physical exam revealed soft abdomen, with normal bowel sounds. There was weight loss of 22kg in 12 months, but she has, in general, struggled to lose weight with the Gastric Band.

Four months before her outpatient appointment the patient had an endoscopy which was ordered by her GP. Endoscopy at the time revealed the gastric band in situ with two small tongues of Barrett’s mucosa at 1 and 3 o’clock with no circumferential involvement, Prague score C0M2. Bloods and abdominal ultrasound were normal. A barium swallow was ordered and HRM was suggested depending on the outcome of the barium.

Barium showed a hold up of contrast at the EGJ and into the gastric reservoir. The esophagus was dilated throughout its length and a delay in gastric emptying was noted (Figure 1).

High Resolution Manometry with Impedance, revealed essentially normal esophageal body peristalsis with dual high pressure zone (HPZ) at the level of the EGJ. In this case the dual HPZ indicated the separation between the EGJ and the gastric band. The patient had an Integrated Relaxation Pressure (IRP) of 22.5mmHg. (Normal IRP for Manoscan™ HRM <15mmHg). This elevated IRP indicated an outflow obstruction at the EGJ. The impedance signal showed poor bolus clearance and bolus entrapment which was due to the failure of the gastric band to open to allow the bolus to transit (Figure 2). Both multiple rapid swallow and bread bolus provocation studies confirmed bolus hold up. After consultation with the patient, the gastroenterology and surgical teams it was decided that the best treatment was to remove the gastric band and port to help preserve the motility of the esophagus.

Repeat manometry was carried out 12 months post operatively and this indicated a return to normal EGJ function with no evidence of outflow obstruction and preserved esophageal body peristalsis (Figure 3). The patient’s last endoscopy did not indicate Barrett’s but revealed a 2 cm Hiatus Hernia. The patient was advised to continue on PPI’s and declined the offer of a 24 pH study to assess her reflux status. At her last outpatient appointment, the patient was feeling well with no melena or hematemesis, some dysphagia but very infrequently. Although the patient was given lifestyle advice she had gained 20kg since the surgery and now wanted to explore the option of gastric bypass surgery. A table of the timeline of the patient’s care pathway is provided in the appendices (Table 1).

DISCUSSION

It has been recognized that the LAGB can lead to various complications particularly on esophageal and EGJ function. In this case a middle aged female patient, with a gastric band in situ for 10 years, presented with symptoms of dysphagia, odynophagia, postprandial regurgitation and vomiting. The patient was obese with a BMI of >45kg/cm and had a history of acid reflux. Though complications of the gastric band may appear to be the main cause, other differential diagnosis needed to be ruled out. Reflux related complications such as peptic stricture, adenocarcinoma of the esophagus or gastric cardia, would have to be considered. Or possibly an underlying esophageal motility disturbance not identified pre LAGB. Many studies have shown a strong link between obesity and gastrointestinal disease from gastro esophageal reflux disease and motility disturbance to esophageal and gastric cancers [5,6].

Endoscopy with histology and a full blood work helped to rule out any sinister complications. Further testing with barium did indeed show a hold up of contrast at the EGJ and into the gastric reservoir.

However, barium did not give a lot of detail other than show that the flow of contrast was impeded and the esophagus dilated. With HRM however we can appreciate in more detail, the location of the gastric band, where it is relative to the EGJ and the overall effect it is having on motility.

High Resolution Manometry is a relatively new manometric technique used to assess esophageal motility and the function of the EGJ. In contrast to conventional manometry, HRM can record intraluminal esophageal pressures at much more closely spaced intervals with sensors spanning the length of the esophagus from pharynx to stomach. This arrangement of closely spaced sensors allows for more accurate data acquisition and generation of pressure topography plots. These pressure plots allow for the identification of the EGJ and clear assessment of esophageal function [7,8].

Esophageal pressure topography metrics are used in HRM as a means of measuring physiological function of the esophagus and the degree of relaxation of the EGJ. The IRP is a measure of mean EGJ pressure within a period of 4 seconds of maximal relaxation, in the 10-seconds after relaxation of the upper esophageal sphincter. The Distal Contractile Integral (DCI) is a measure of the amplitude x duration x length of the distal contractile segment and allows us to measure overall strength of the esophageal contraction. The Intra-bolus pressure (IBP) represents the degree of resistance to flow across the EGJ. This is assessed in conjunction with the IRP as an indicator of holdup in the distal esophagus. The addition of impedance sensors to the HRM assembly can provide additional information on bolustransit and regurgitation [7].

Though much research has been done on the effect of LAGB on esophageal motility, most of the findings have been based upon radiological studies alone or conventional manometry. Both of these techniques used alone have their limitations. With barium alone esophageal dilatation can be seen, as well as any hold up or aspiration of barium, but esophageal function, Lower Esophageal Sphincter (LES) attenuation or band pressure cannot be measured. As for conventional manometry alone, because these measurements produce a rudimentary line tracing it can be very difficult to distinguish the high pressure zone of the gastric band from the pressure zone of the LES. Also incomplete relaxation at the EGJ can be missed with standard manometry.

HRM results for this patient prior to band removal showed a dual high pressure zone. (Fig 2) The position of the gastric band in this case is distal to the EGJ and shows a prominent gap between the EGJ and the band. This sub-diaphragmatic enlargement of a gastric pouch between these two high pressure zones has been identified before in studies by Barton et al., [9]. The patient’s barium study also confirmed this pouch formation. The tightness of the band would significantly affect the ability of this pouch to empty and also affect the flow across the EGJ. This was reflected in the high IRP and IBP values obtained in this study. Provocation studies using saline soaked bread, multiple rapid swallows and free drinking techniques all supported the diagnosis of hold up of bolus in the pouch area. The patient still had reasonably good esophageal function with only 40% of her swallows showing a DCI <450mmHg. The HRM trace after removal of the gastric band (Figure 3) shows a vast improvement to the patient’s esophageal function with complete relaxation of EGJ, normal intra-bolus pressures and an improvement to esophageal body function with now only one swallow with DCI <450mmHg. A table of HRM results pre and post removal is supplied in the appendices (Table 1)

With this case study I wanted to highlight the importance of High Resolution Manometry in the investigation of patients who have had previous gastric banding. In this case HRM was only considered as an afterthought to the barium. Studies have shown that conventional contrast studies alone had missed abnormalities that manometry identified [9], therefore a combination of both should always be used to assess these patients [8].

Pre-operative assessment of esophageal function prior to placement of a gastric band has long been argued as essential and I would agree with this analysis [10]. Though gastric banding has fallen out of favor, some centers still provide this service and a preoperative assessment using HRM and if possible 24 hour pH studies, will help to ascertain if a patient has any

Table 1: High Resolution Manometry results pre and post band removal.

HRM Metrics Pre LAGB Removal Post LAGB Removal Normal Ranges for the Manoscan™ HRM system
IRP (mmHg 22.5 12.4 N < 15mmHg
IBP (mmHg) 27.8 19.9 N <17mmHg
% Contractions DCI<450mmHg-cm-s 40 20

DCI <450 ineffective

<100 failed

Mean DCI mmHg-cm-s 722.3 1177.8 450-8000
% Incomplete Bolus Transit 100 0 n/a
Abbreviations: IRP: Integrated Relaxation Pressure, IBP: Intra-Bolus Pressure, DCI: Distal Contractile Integral.

underlying motility disturbance or GERD. Studies have shown a correlation between obesity and the presence of GERD and motility disturbances, generally ineffective motility. Obesity is also associated with an increase in separation between the crural diaphragm and the LES i.e. Hiatus Hernia, making these patients more susceptible to reflux [11,12]. As with any esophageal surgery whether for anti-reflux purposes, Heller’s Myotomy or Peroral Endoscopic Myotomy (POEM), pre-operative High Resolution Manometry is an essential requirement for any procedure with a direct impact on esophageal motility. Though it is essential that HRM is carried out pre-operatively a limitation with the technique is that it is invasive and not available in all centers so access may be difficult, though I think every effort should be made to avail of the test.

Studies have shown the negative long term effects of LAGB on esophageal function, therefore I feel, we will over time be presented with more and more complicated cases [10]. HRM has an important role to play and every effort should be made to offer the patient an esophageal motility assessment as part of their work up.

There is a paucity of studies on this group of patients using HRM so with this case I hope to add to the growing appreciation for the diagnostic utility of High Resolution Manometry in these interesting cases.

It has long been demonstrated in other work that obesity is associated with upper GI disease therefore HRM should be considered for pre and post gastric band placement and when patients present with complications arising with the gastric band. This is even more essential if this patient is being considered for further surgical options. It ensures that any upper GI morbidities are ruled out before the patient even considers further bariatric surgery.

ACKNOWLEDGEMENTS

Thank you to Ms P Lawlor, Chief II GI Physiologist at St James’s Hospital and Prof. N Ravi, Esophageal Surgeon, Surgical Department, St James’s Hospital, Dublin for their ongoing support.

REFERENCES

1. Dargent J. Laparoscopic Gastric Banding: Game Over? Obes Surg. 2017; 27: 1914-1916.

2. Khan A, Ren-Fielding C, Traube M. Potentially Reversible Pseudoachalasia after Laparoscopic Adjustable Gastric Banding. J Clin Gastroenterol. 2011; 45: 775-779.

3. Naef M, Mouton WG, Naef U, van der Weg B, Maddern GJ, Wagner HE. Esophageal Dysmotility Disorders After Laparoscopic Gastric Banding-An Underestimated Complication. Ann Surg. 2011; 253: 285- 290.

4. Korenkov M, Kohler L, Yucel N, Grass G, Sauerland S, Lempa M, et al. Esophageal motility and reflux symptoms before and after bariatric surgery. Obes Surg. 2002; 12: 72-76.

5. Tolone S, Limongelli P, del Genio G, Brusciano L, Rossetti G, Amoroso V, et al. Gastroesophageal reflux disease and obesity: Do we need to perform reflux testing in all candidates to bariatric surgery? Int J Surg. 2014; 12: S173-S177.

6. Olefson S, Moss SF. Obesity and related risk factors in gastric cardia adenocarcinoma. Gastric Cancer. 2015; 18: 23-32.

7. Fox M, Kahrilas PJ, Pandolfino JE, Zerbib F. Manual of High Resolution Esophageal Manometry. Ist Edition-Bremen; UNI-MED. 2014 edn: SCIENCE U-M. Editor. Europe: International Medical publishers. 2014. 1-171.

8. Cruiziat C, Roman S, Robert M, Espalieu P, Laville M, Poncet G, et al. High resolution esophageal manometry evaluation in symptomatic patients after gastric banding for morbid obesity. Dig Liver Dis. 2011; 43: 116-20.

9. Burton PR, Brown WA, Laurie C, Korin A, Yap K, Richards M, et al. Pathophysiology of Laparoscopic Adjustable Gastric Bands: Analysis and Classification Using High-Resolution Video Manometry and a Stress Barium Protocol. Obes Surg. 2010; 20: 19-29.

10.Tchokouani L, Jayaram A, Alenazi N, Ranvier GF, Sam G, Kini S. The Long-Term Effects of the Adjustable Gastric Band on Esophageal Motility in Patients Who Present for Band Removal. Obes Surg. 2018; 28: 333-7.

11.Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ. Obesity: A challenge to esophagogastric junction integrity. Gastroenterology. 2006; 130: 639-49.

12.Tolone S, Savarino E, de Bortoli N, Frazzoni M, Furnari M, d’Alessandro A, et al. Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery. Int J Surg. 2016; 28: S109-S13.

Brennan TM (2022) The Use of High Resolution Manometry in the Management of a Patient with Dysphagia Secondary to Laparoscopic Adjust-able Gastric Band - A Case Study. JSM Gastroenterol Hepatol 9(1): 1107

Received : 19 May 2022
Accepted : 17 Jun 2022
Published : 18 Jun 2022
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X