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Abstract

Functional complications after gastrectomy: state and development of the problem.

Gastroenteroanastomosis problems

Drainage of organs of the pancreatoduodenal zone, extrahepatic bile ducts

Disadvantages of traditional methods of draining the hollow organs of the abdominal cavity and cavit

Problems of creating nutritional jejunostomy

References

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Review Article

Relevance of Prevention of Postoperative Refluxes

Kolchin Dmitry Germanovich ¹

Rulev Vitaliy Nikolaevich ²

Trukhalev Vadim Aleksandrovich ³

Kurilov Vadim Aleksandrovich ⁴

Martynov Vladimir Leonidovich ^1*

*Corresponding Author: Martynov Vladimir Leonidovich, associate professor, consultant of surgical unit of

Citation: Kolchin D. Germanovich , Rulev V. Nikolaevich , Trukhalev V. Aleksandrovich , Kurilov V. Aleksandrovich , Martynov V. Leonidovich (2022) Relevance of Prevention of Postoperative Refluxes. J. Gastroenterology Pancreatology and Hepatobilary Disorders 6(2) DOI:10.31579/2641-5194/056

Copyright: © 2022, Martynov Vladimir Leonidovich, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 15 November 2021 | Accepted: 22 December 2021 | Published: 12 January 2022

Keywords: postgastrectomy complications; apostolos; bile salts; trypsin; lysolecithin

Abstract

Gastrectomy is a complex operation for stomach diseases. Despite the successes to date, there are still no cardinal grounds to recognize the results of gastrectomy as satisfactory (Ruchkin D.V., 2019;

Functional complications after gastrectomy: state and development of the problem.

Yang Y.S. et al., 2013). So the median survival of these patients was 29.3 months, the overall and relapse-free 2-year survival was 74.4% and 69.5%, respectively (Moon D.H., 2017). However, in the absence of damage to regional lymph nodes, the three-year survival rate is more than 60% (Roman L.D., 2016).
After gastrectomy, new anatomical conditions are formed. In this case, both trunks of the vagus nerve, including motor, sensory and parasympathetic nerve fibers, are crossed, denervation of the gallbladder occurs, leading to the development of its motor dysfunction, exclusion from the digestive process, stagnation of bile and the formation of calculi, after lymphadenectomy, lymphatic drainage in the upper floor of the abdominal cavity is disturbed, elements of the celiac plexus, including sensory, parasympathetic and postganglionic sympathetic fibers, are injured or completely excised (Chaika A.V. et al., 2018; Chen X. et al., 2014; Ballas KD et al., 2015), various variants of mechanical intestinal obstruction in the form of torsion of intestinal loops or mesenteries, adhesions.
As a result, the components of intestinal contents - bile salts, trypsin, lysolecithin - enter the esophagus, which leads to the development of reflux esophagitis of varying severity (catarrhal, erosive), and in some cases to the emergence of Barrett's esophagus. The pathogenesis of the disease includes the direct damaging effect of these components of the esophageal mucosa (Tarbaev I.S., 2018) and depends on the duration and frequency of reflux (Bax D., 2007).
Gastrectomy in various modifications inevitably contributes to the occurrence of reflux esophagitis (Gumerov A.A., 2020; Xiong J.J. et al., 2013, Bogopol'skĳ P.M., 2014), which is manifested by the main clinical symptom - heartburn. Reflux esophagitis is an optional precancerous disease that can transform into adenocarcinoma of the esophagus (Korochanskaya N.V. et al., 2017).
Postgastrectomy complications occur in 30–86% of patients: dumping syndrome (14–82%), agastral asthenia (30–40%), hypoglycemic syndrome (7–13%), reflux esophagitis (7–18%), syndrome adductor gut (3.5-16%), stricture (3-7%) of the esophageal-intestinal anastomosis (Ishizuka M. et al., 2014).
To reduce the severity of postgastrectomy complications, more than 70 modifications of gastroplasty options have been developed, which can be conditionally divided into methods with the inclusion of 12-PC in the passage of food intake and without it. Such a large selection indicates a lack of unity of views, as well as unsatisfactory functional results of the proposed methods (Baryshev A.G. et al., 2018; Ruchkn D.V. et al., 2019; Analatos, Apostolos et all., 2018). Currently, at a fundamentally new stage of technological progress, surgeons are faced with the task of not only the technical perfection of the surgical procedure, but also the creation of favorable conditions in the body for compensating for digestion and improving the quality of life of operated patients (D.V. Ruchkin et al., 2019; Banki F . et all., 2017; Wilshire CL, et all., 2016). It was found that one of the reasons for the dysfunction of the digestive system after gastrectomy is the rapid passage of food in the jejunum (Baryshev A.G. et al., 2018). In patients without severe concomitant 
diseases with a low prevalence of the tumor process, the absence of 12-PC pathology, to improve functional results, it is recommended to use more physiological reconstruction techniques - according to the Ru method or jejunogastroplasty options (Chernyavsky A.A. et al., 2016; Sylvia, van der Horst, 2018).
The formation of the esophageal-intestinal anastomosis is the most crucial stage of the operation (Bazaev, A.A. et al., 2016), but their creation requires areflux, which helps to reduce the frequency and severity of manifestations of inflammation, but over time, its valve function weakens or cicatricial anastomotic stricture (Wang JD, 2016). In the absence of a sphincter, reflux occurs, and patients complain of heartburn, belching, regurgitation of food eaten (Ivashkin V.T. et al., 2019).
Vinnik Yu.A. et al. (2013) attach great importance to the blood supply of the intestinal area allocated for anastomosis with the esophagus. In their opinion, the Roux method is advisable to use with insufficient length of the intestinal mesentery, loose type of blood supply and insufficient local blood flow of the graft, which was mainly used after resection of the esophagus in the thoracic region (10% of observations). In 7.5% of cases with a short mesentery length, the technique of lengthening it by 4 - 5 cm by ligating 1 - 2 radial vessels was used, which made it possible to form an anastomosis without tension not only in the abdominal cavity, but also in the chest, giving preference to the manual method. With the loop reconstruction, the leakage of the esophageal-intestinal anastomosis was observed in 1.3% of patients, with the reconstruction by the Roux method - in 7.4% (Aliev S.A. et al., 2015).
Disorders of the motor function of the digestive system are the leading pathogenetic link in the development of many gastroenterological diseases (Trukhmanov A.S., Ivashkina N.Yu., 2019).
Thus, when performing gastrectomy in 31 - 96%, conditions are created for the occurrence of such a severe functional pathology as reflux esophagitis, leading in almost 25% of cases to permanent disability of patients (Rybachkov V.V. et al., 2016; Ahmadi N. , 2017).
Prevention of functional disorders after gastrectomy is assessed as an exceptional parameter for improving the quality of life of patients who have undergone an already complex surgical intervention (Gorchakova A., 2017; Yates R. B. et al., 2017).
The results obtained after gastrectomy are not always satisfactory, therefore, the search continues for a technique that will help to avoid or reduce mortality, the number of complications both in the early and late postoperative period, which prompts surgeons to develop new standards in the treatment of this disease (Arutyunyan K.V. et al. ., 2018).
The true prevalence of GERD is also important, which significantly exceeds the indicators of population studies, which do not include individuals with asymptomatic course or atypical (extraesophageal) manifestations of the disease, which affects oncoetiopathogenesis in the esophagus (Ivashkin V.T. et al., 2017; Hunt R. et al., 2018;). The most sensitive and accurate method for determining the functional state of the esophageal-gastric junction is high-resolution manometry (Van Hoeij FB, Bredenoord AJ., 2016).
As indications for surgical treatment of GERD, the development of the disease against the background of hernia of the esophageal opening and the ineffectiveness (intolerance) of drug therapy, which is noted in 10-15% of patients with GERD, are considered (Broeders J. A. et al., 2013; Kohn G. P., 2018). Reflux esophagitis is one of the most common and socially significant chronic diseases, which leads to a significant violation of the quality of life of patients. In 94% of patients in the long-term period, a positive result from the performed antireflux operations was demonstrated (Chernousov A.F., 2017; Bell R. C. W. et al., 2014). But a few years later, a wave of first failures and complications of antireflux interventions began. The unsatisfactory results of operations are, according to various authors, 6-25.7% (Durleshter V.M., 2019).
Currently, at a fundamentally new stage of technological progress, surgeons are faced with the task of not only the technical perfection of the surgical procedure, but also the creation of favorable conditions in the body for compensating digestion and improving the quality of life of operated patients.

Gastroenteroanastomosis problems

After distal resection of the stomach, the surgeon solves an important problem - carrying out a reconstructive stage (the formation of an anastomosis between the stump of the stomach and the small intestine). More than 100 variants of gastroenteroanastomosis have been described, their number is constantly growing, and the incidence of functional and organic post-gastro-resection disorders is, nevertheless, 15-65% (Fedorov I.V., 2015). The Billroth-2 method allows avoiding collisions in the detection of pronounced cicatricial-ulcerative deformity of the 12-PC bulb, although the Billroth-1 method determines low mortality rates (0.2 - 3%), on average 1 -2% (Ruchkin D.V., 2019; Tanaka S. et al, 2011).
Comparative analysis of the clinical and endoscopic picture of gastroesophageal reflux (GER) after resection of the stomach according to Billroth-2 in various modifications revealed significant differences. The manifestations of GER were observed much more often in patients who underwent resection in the modification according to Hofmeister - Finsterer (85%), since during the formation of gastroenteroanastomosis according to this technique, a wide anastomosis is formed, which gapes at the time of the passage of the peristaltic wave, unregulated reflux of intestinal contents from the adductor loop to a gastric stump, which contributes to the development of post-gastro-resection syndromes: reflux gastritis in 75 - 100%, reflux esophagitis - in 20 - 50%, dumping syndrome - in 20 - 30% of patients (Bashirov S.R. et al., 2017; Chernousov A.F. et al., 2016).
When resecting the stomach with the imposition of an areflux anastomosis, an artificial pulp or valve is created, which closes and functions as a gatekeeper and thereby prevents the reflux of duodenal contents into the stomach stump in 40% of patients (Antonyan S.V. et al., 2017; Chernousov A.F. et al., 2020).
The incidence of erosive reflux gastritis after distal gastric resection in modification B-1 was 28%, and according to Namikawa T. (2011) even 100%, but the preservation of the pylorus helps to prevent this process to some extent. Up to 17.8% of reflux gastritis also occurs after distal subtotal gastric resection according to B-2, especially when performing loop plastic surgery (Namikawa T. Et al., 2011).
In persons who underwent gastric resection according to Billroth - 2, all examined had chronic gastritis of varying degrees of activity. It has been demonstrated that the etiological basis of chronic gastritis after gastric resection is mutually reinforcing factors: bile reflux, absence of a gastrin-producing zone (Korochanskaya N.V. et al., 2017).
Against the background of GHD, a direct correlation was revealed between the combination of the frequency of gastritis and cancer of the body and the upper third of the stomach, erosions and acute ulcers in the body of the stomach, cancer of the distal stomach and mucosal hyperplasia, signs of intestinal metaplasia (Mikhailusov et al., 2018; Tolone S. et al., 2016).
The risk of developing cancer of the gastric stump against the background of GHD with an increase in the postoperative period after resection according to Billroth-2 increases to 22.1% (Krivigina E.V. et al., 2015).
It should be emphasized that interintestinal anastomosis during gastric resection according to Balfour reduces the frequency (30 - 75%) and severity of enterogastric reflux in comparison with those using the Hofmeister-Finsterer method, but does not completely prevent it (Birendra K. et all., 2009).
There is an opinion that the only variant of gastroenteroanastomosis that can prevent enterogastric biliary reflux is an anastomosis on the Ru-loop (Askerkhanov R.G., 2017; Hirao M. et all., 2013). According to A.V. Bazaeva et al. (2016) gastric resection according to Roux is not inferior in terms of the functional results of gastric resection according to Billroth-1, and in terms of such indicators as the quality of life and the incidence of diseases of the operated stomach, it exceeds the resection of the stomach according to Billroth-2 in the modification of Hofmeister-Finsterer and according to Billroth- 1. Although Namikawa T. et all. (2011) Tanaka S. et all. (2011) did not note a significant difference in the two groups of patients. The search for operations to prevent biliary reflux continues (Khitaryan A.G. et al., 2019).

Drainage of organs of the pancreatoduodenal zone, extrahepatic bile ducts

The number of patients with diseases of the organs of the hepatopancreatoduodenal zone, extrahepatic bile ducts increases every year (Okhotnkov O.I., 2018; N.M. Hogan et al, 2016).
With the introduction of minimally invasive technologies, the frequency of damage to the bile ducts during cholecystectomy remains high and does not correlate either with the experience of the operator, or with the duration of the disease, or with the degree of inflammatory changes in the operation area (Korolkov A.Yu., 2018; Viste, A. et al., 2015; Granados-Romero, J. et al., 2016), but depends on the failure to thoroughly dissect tissues in the area of the Calot triangle. (Khalidov O.Kh. et al., 2017).
The widespread introduction of minimally invasive cholecystectomy methods, even in the hands of experienced surgeons (Korolev M.P. et al., 2016; S. Halbert et all., 2016), led to a significant increase in damage to the extrahepatic bile ducts, the frequency of which reaches 3% (Ivanov S.V., 2018; Okhotnikov O.I., 2016) to 5.5%, which is at least 2 times more than with open intervention (Maistrenko N.A. et al., 2016).
But, of course, endovideosurgical technologies have clear advantages in the form of a short hospital stay, quick recovery of work capacity and excellent cosmetic results (Rystedt et al, 2016; J. Kohn et all., 2018).
Intraoperative damage to the bile ducts in 93 - 95% of cases is the cause of the development of high cicatricial strictures (Vorobey A.V., 2018). It is important to diagnose and correct "fresh" injuries of the bile ducts (Okhotnikov O.I., 2019; Tulin A.I. et al., 2016; Oh CH., 2016).
Postoperative mortality in the treatment of cicatricial strictures reaches 12 - 30%, the frequency of recurrence of strictures is 30%, in reducing the number of which the choice of a method for restoring the passage of bile into the gastrointestinal tract is of no small importance (Markov P.V., 2017; Atavov R.S. et al., 2017; Ankersmit M. et al, 2017). In reconstructive surgery of the extrahepatic bile ducts, it is important to prevent the development of ascending reflux cholangitis (Belokonev V.I. et al., 2016; Rainio et al, 2018). At the same time, in the overwhelming majority of cases, a loop of the small intestine cut out according to Roux is used (Kukosh M.V. et al., 2016; Pugaev A.V. et al., 2018), which is recognized as the "gold standard" (Shevchenko Yu.L. et al., 2015). But they did not completely abandon the loop interintestinal anastomosis according to Brown and the "plug" of A.A. Shalimova (Tokarenko E.V. et al., 2016; Kurbonov K.M., 2017).
The defeat of the pancreas by tumors is growing. In the European Union, pancreatic cancer is the seventh most common cause of death from malignant neoplasms (Shoda J et al, 2015). Obstructive jaundice is the most frequent manifestation of tumor diseases of this localization and is detected in 50-80% of patients (Jo J.H. et al, 2017). Despite the development of surgical techniques, the incidence of complications after radical surgery (pancreatoduodenal resection) remains high - 38-52% (Shamali A, et al., 2017). In case of contraindications to radical surgery in palliative surgery, a biliodigestive anastomosis on the Roux loop is formed (Kim SY et al., 2018), but the choice of the optimal method of biliary decompression for distal tumor blockade of the bile duct has not yet been fully resolved (Rasulov N.A. , 2017).
The question of choosing the optimal and rational therapeutic tactics for cystic pancreatitis is still relevant and one of the most difficult in modern pancreatology (Trace O.N. et al., 2016; Sokolov Yu.Yu.). The presence of intraductal hypertension in chronic pancreatitis in 40–45%, the presence of cysts in a third of patients determines the increasing surgical activity of this pathology, the emergence of new methods of operations. Longitudinal pancreatojejunostomy is considered the "gold standard" of surgical treatment of chronic pancreatitis: on a Brown loop (Dryazhenkov G.I. et al., 2016), with a plug on the adductor loop, or according to the Ru method (Mukhin A.S., 2016; Chu YC, 2008).
According to published data, of all cystodigestive anastomoses, preference is given to the formation of an anastomosis with the jejunum on a disconnected loop along Roux (Mukhin A.S., 2016; Sarvanov A.V., 2017; Markov P.V., 2017), on the loop of the jejunum with interintestinal anastomosis according to Brown and with the formation of a "plug" according to A.A. Shalimov Stepan E.V. et al., 2017).
But the imposition of a cystopancreatojejunostomy with a completely non-disconnected intestinal loop is unacceptable (Poluektov V.L. et al., 2016), which increases the risk of infection of the cyst cavity, progression of pancreatitis.
Thus, the complexity of early diagnosis and adequate surgical correction, a significant proportion of unsatisfactory results, as well as the low quality of life of patients after unsuccessful reconstructive and restorative surgeries on the extrahepatic bile ducts, pancreatic ducts require the search for new ways to solve the problem (Kozlov I.A., 2017; Benkabbou A. et al. 2013; Addeo P. et al, 2014).

Disadvantages of traditional methods of draining the hollow organs of the abdominal cavity and cavit

Scarring of formed bile-intestinal anastomoses occurs in 9.8 - 35% of cases (Markov P.V., 2017; Benkabbou A. et al., 2013). With repeated operations, the mortality rate was 8.3%, their implementation requires a high professionalism of the surgeon and the development of new, more effective methods with the passage of bile into the duodenum (Markov P.V., 2017).
Jejunoanastomosis with interintestinal anastomosis according to Brown does not allow to fully avoid the above complications even when using the "plug" by A. A. Shalimov (Shalimov A.A., 1993), which eventually undergoes recanalization (Atavov R.S. et al., 2017). The authors themselves point to the possible restoration of the patency of the intestinal canal due to bedsore ligatures and metal clips at the site of their imposition. Their intussusception also cannot always reliably prevent the restoration of the intestinal lumen. This outcome does not prevent the ingress of intestinal contents into the drained structures (Atavov R.S. et al., 2017).
According to Belekov Zh.O. et al. (2007) clinical and endoscopic manifestations of reflux esophagitis associated with recanalization of the “Shalimov AA plug” were found in 63.2% and 58.3% of patients, respectively. The use of a loop of the small intestine with a Brownian anastomosis for anastomosis with the esophagus after gastrectomy without a plug leads to the development of reflux esophagitis in the first three months after surgery in 90% of patients (Panibratz L.S., 2010). The use of even two Brownian anastomoses on the loop of the intestine brought into the gates of the liver does not exclude the throwing of intestinal contents into the ducts and, as an outcome, stricture (Dryazhenkov G.I., 2015).
Only sufficient in length, at least 80 cm according to Aliyev et al., 2015, the abduction segment of the intestine significantly reduces intestinal reflux, which reduces the likelihood of developing ascending cholangitis (Korolev M.P. et al., 2017).
In the European surgical school, preference is given to reconstruction with the Roux-off loop of the jejunum, the length of which should be at least 40 cm to avoid reflux of bile and intestinal contents into the stomach stump and esophagus (Wirtzfeld D., 2015).
Opponents of the anastomosis on the Roux loop declare the complexity of such operations, are dissatisfied with the exclusion of a significant portion of the small intestine from digestion, note a significant number (2 - 17.6%) of complications in the form of anastomotic leakage (Abdullaev A.A., 2019; Atavov R.S. ., 2017; Koroleva A.A., 2017; Kuchin D.M., 2017; Kotelnikova L.P., 2020), reflux of intestinal contents remains in the drained structure in 27% of patients (Kulezneva Yu.V., 2019).
Microcirculatory changes in the wall of the intestinal loop, cut out according to Roux, the intersection of nerve fibers in 9-50

Problems of creating nutritional jejunostomy

Eating disorders in the postoperative period significantly reduce the effectiveness of treatment, increase the risk of developing septic and infectious complications, increase the length of hospital stay, worsen the mortality rates (Zybin K.D., 2017; Rodoman G.V., et al., 2017).
Tumor stenoses and cicatricial strictures of the esophagus lead to obstruction of the proximal parts of the digestive tract with the development of nutritional insufficiency, depletion and extinction of the compensatory capabilities of the body, which causes the refusal of the simultaneous formation of an artificial esophagus in patients of this category. For this category of patients, more and more attention is paid to the use of enteral nutrition for a long time through the areflux stoma (Marco B. et al., 2001), as the most physiological, causing fewer complications and an economically justified method (Nicola W., 2003).
The incidence of purulent mediasthenitis with esophageal perforation reaches 80%, and the mortality rate is 40-45%. The main task is to stop the flow of the contents of the lumen of the esophagus into the mediastinum, which determines the relevance of a nutritious stoma in these patients (Stolyarov S.I., 2016).
The use of nasointestinal intubation entails formidable complications - the formation of acute gastric ulcers and 12-PC, including those complicated by bleeding. The leading method for preventing such complications is the appointment of proton pump blockers, which leads to a decrease in the production of hydrochloric acid. The negative side of this therapeutic effect is a significant increase in the degree of bacterial contamination of the upper gastrointestinal tract in combination with a change in the microbiological landscape. Under these conditions, the presence of a foreign body (probe) in the esophagus and oropharynx, as well as the impossibility of hermetically closing the esophageal sphincter, create favorable conditions for the translocation of pathogenic microorganisms into the trachea and bronchi. The result of the above pathological processes is an increase in the frequency of nosocomial pneumonia (Yates, R. B. et al., 2017).
In his operating work, the surgeon often uses the patient's tissue to solve practical problems. For our work, the data of Liebermann-Meffert D. and White H. (1989) on the greater omentum are of interest. Research shows that the "policeman of the abdominal cavity" - the great omentum in pathological conditions, acquires very special properties: plasticity; the ability to adhere to an injured and inflamed surface; the ability to hemostasis; the ability for ingrowth and revascularization; the ability to absorb liquids and microparticles from the abdominal cavity; the ability to phagocytosis and immunological response. Adhesions with the omentum are formed much faster than with other organs of the abdominal cavity. Even the freely transplanted omentum tissue without blood supply retains these properties. After 21 days, the omentum tissue is completely fused with the recipient organ (Loewy R., 1996; Thompson S.A., Pollock B., 1945).
Experimental studies on ingrowth of the omentum graft and its vessels are very indicative. Sections of the omentum of various thicknesses and sizes were separated from its bulk and fixed without revascularization to various organs and tissues of the same or another animal: stomach, small and large intestine, liver, spleen, kidney, bladder, lung, pleura, peritoneum, mesentery, aorta, inferior vena cava. Within a week, the graft is firmly attached to the tissues of the recipient organs, its separation is difficult, due to a decrease in the amount of fat, its thickness is reduced, necrobiotic processes and necrosis zones are reduced. After three weeks, the graft cannot be separated, when an attempt is made, bleeding occurs, the amount of fat decreases and is replaced by dense fibro- and angioplastic tissues so that its surface resembles the surface of the recipient tissue. After 12 weeks, it is difficult to distinguish the omentum tissue from the recipient tissue; the suture line serves as a reference point. The engraftment of free grafts did not depend on their size, but necrosis zones are more often formed in thick grafts. The graft remains viable when frozen for two weeks or even longer.
Stages of omentum graft engraftment: attachment - up to 4 hours, beginning of vascular ingrowth - 24 hours, tight fit - 48 hours, revascularization - 3 days, fat resorption - 3 weeks, fibrous degeneration - 24 weeks (Liebermann-Meffert D., White H. , 1989).
Such negative consequences of enterostomy as dehydration, electrolyte disturbances, as well as local parastomal manifestations limit the use of this operation (Ibatullin A.A. et al., 2017). These negative aspects in the formation of an enterostomy can be prevented by forming an areflux (Martynov V.L. et al., 2017) nutritious small intestinal stoma using a "plug".
The question of choosing a method of artificial nutrition for malnourished patients should be reduced to the rule: “If the intestines are working, it should be used” (Mosolkov V.Yu., 2009).
Thus, the development of inflammatory changes as a result of reflux of foreign contents in terms of chemical and bacteriological composition in the drained organs of the abdominal cavity and retroperitoneal space affects both the immediate results of surgery and the further quality of life of patients. Without taking into account the arising refluxes, postoperative reflux disease develops.
The development of measures for the prevention of postoperative reflux disease is an important task of surgical science and practice.

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"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

Luiz Sellmann

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