nach oben

01.04.2014 | Special Report

Guidelines on the use of gelatin sponge particles in embolotherapy

Erschienen in: Japanese Journal of Radiology | Ausgabe 4/2014

Einloggen, um Zugang zu erhalten

Abstract

Gelatin sponge (GS) is one of the most widely used embolic agents in interventional procedures. There are four commercially available GS products in Japan; however, the endovascular use of Gelfoam and Spongel is off-label, and Gelpart can only be used for hepatic artery embolization and Serescue can only be used for hemostasis of arterial bleeding. GS has been used for a variety of clinical indications, mainly tumor embolization and stopping massive arterial bleeding. The optimal size and preparation procedure of GS particles differs slightly for each clinical indication. In addition, there is a risk of ischemic and/or infectious complications associated with GS embolization in various situations. Therefore, radiologists should be familiar with not only the preparation and handling of GS particles, but also the disadvantages and potential risks, in order to perform GS embolization safely and effectively.

Loffroy R, Guiu B, Cercueil JP, Krausé D. Endovascular therapeutic embolization: an overview of occluding agents and their effects on embolised tissues. Curr Vasc Pharmacol. 2009;7:250–63.PubMedCrossRef

Jenkins HP, Janda R. Studies on the use of gelatin sponge or foam as an hemostatic agent in experimental liver resections and injuries to large veins. Ann Surg. 1946;124:952–61.PubMedCentralCrossRef

Ishimori S, Hattori M, Shibata Y, Shizawa H, Fujinaga R. Treatment of carotid-cavernous fistula by gelfoam embolization. J Neurosurg. 1967;27:315–9.PubMedCrossRef

Yamada R, Sato M, Kawabata M, Nakatsuka H, Nakamura K, Takashima S. Hepatic artery embolization in 120 patients with unresectable hepatoma. Radiology. 1983;148:397–401.PubMed

Uchida H, Ohishi H, Matsuo N, Nishimine K, Ohue S, Nishimura Y, et al. Transcatheter hepatic segmental arterial embolization using Lipiodol mixed with an anticancer drug and Gelfoam particles for hepatocellular carcinoma. Cardiovasc Intervent Radiol. 1990;13:140–5.PubMedCrossRef

Matsui O, Kadoya M, Yoshikawa J, Gabata T, Arai K, Demachi H, et al. Small hepatocellular carcinoma: treatment with subsegmental transcatheter arterial embolization. Radiology. 1993;188:79–83.PubMed

Lo CM, Ngan H, Tso WK, Liu CL, Lam CM, Poon RT, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35:1164–71.PubMedCrossRef

Llovet JM, Real MI, Montaña X, Planas R, Coll S, Aponte J, Barcelona Liver Cancer Group, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. 2002;359:1734–9.PubMedCrossRef

Marelli L, Stigliano R, Triantos C, Senzolo M, Cholongitas E, Davies N, et al. Transarterial therapy for hepatocellular carcinoma: which technique is more effective? A systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol. 2007;30:6–25.PubMedCrossRef

10.

Cammà C, Schepis F, Orlando A, Albanese M, Shahied L, Trevisani F, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology. 2002;224:47–54.PubMedCrossRef

11.

Miyayama S, Matsui O, Yamashiro M, Ryu Y, Kaito K, Ozaki K, et al. Ultraselective transcatheter arterial chemoembolization with a 2-F tip microcatheter for small hepatocellular carcinomas: relationship between local tumor recurrence and visualization of the portal vein with iodized oil. J Vasc Interv Radiol. 2007;18:365–76.PubMedCrossRef

12.

Katsumori T, Nakajima K, Mihara T, Tokuhiro M. Uterine artery embolization using gelatin sponge particles alone for symptomatic uterine fibroids. AJR Am J Roentgenol. 2002;178:135–9.PubMedCrossRef

13.

Katsumori T, Kasahara T, Akazawa K. Long-term outcomes of uterine artery embolization using gelatin sponge particles alone for symptomatic fibroids. AJR Am J Roentgenol. 2006;186:848–54.PubMedCrossRef

14.

Katsumori T, Kasahara T, Kin Y, Nozaki T. Infarction of uterine fibroids after embolization: relationship between postprocedural enhanced MRI findings and long-term clinical outcomes. Cardiovasc Intervent Radiol. 2008;31:66–72.PubMedCrossRef

15.

Sone M, Arai Y, Shimizu T, Takeuchi Y, Higashihara H, Ohgi S, et al. Phase I/II multiinstitutional study of uterine artery embolization with gelatin sponge for symptomatic uterine leiomyomata: Japan Interventional Radiology in Oncology Study Group study. J Vasc Interv Radiol. 2010;21:1665–71.PubMedCrossRef

16.

Jander HP, Russinovich NA. Transcatheter gelfoam embolization in abdominal, retroperitoneal, and pelvic hemorrhage. Radiology. 1980;136:337–44.PubMed

17.

Velmahos GC, Demetriades D, Chahwan S, Gomez H, Hanks SE, Murray JA, et al. Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen. Am J Surg. 1999;178:367–73.PubMedCrossRef

18.

Borsa JJ, Fontaine AB, Eskridge JM, Song JK, Hoffer EK, Aoki AA. Transcatheter arterial embolization for intractable epistaxis secondary to gunshot wounds. J Vasc Interv Radiol. 1999;10:297–302.PubMedCrossRef

19.

Schwartz RA, Teitelbaum GP, Katz MD, Pentecost MJ. Effectiveness of transcatheter embolization in the control of hepatic vascular injuries. J Vasc Interv Radiol. 1993;4:359–65.PubMedCrossRef

20.

Hagiwara A, Yukioka T, Ohta S, Tokunaga T, Ohta S, Matsuda H, et al. Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization. AJR Am J Roentgenol. 1997;169:1151–6.PubMedCrossRef

21.

Velmahos GC, Chahwan S, Hanks SE, Murray JA, Berne TV, Asensio J, et al. Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt trauma to the pelvis. Am Surg. 2000;66:858–62.PubMed

22.

Panetta T, Sclafani SJ, Goldstein AS, Phillips TF. Percutaneous transcatheter embolization for arterial trauma. J Vasc Surg. 1985;2:54–64.PubMedCrossRef

23.

Blaine G. Absorbable gelatin sponge in experimental surgery. Lancet. 1951;2:427–79.PubMedCrossRef

24.

Kawano H, Arakawa S, Satoh O, Matsumoto Y, Hayano M, Miyabara S. Foreign body granulomatous change from absorbable gelatin sponge and microcoil embolization after a guidewire-induced perforation in the distal coronary artery. Intern Med. 2010;49:1871–4.PubMedCrossRef

25.

Sato M, Yamada R. Experimental and clinical studies on the hepatic artery embolization for treatment of hepatoma. Nippon Acta Radiologica. 1983;43:977–1005.

26.

Abada HT, Golzarian J. Gelatine sponge particles: handling characteristics for endovascular use. Tech Vasc Interv Rad. 2007;10:257–60.CrossRef

27.

Zielinski H, Szmigielski S, Petrovich Z. Comparison of preoperative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma. Am J Clin Oncol. 2000;23:6–12.PubMedCrossRef

28.

Schwartz MJ, Smith EB, Trost DW, Vaughan ED Jr. Renal artery embolization: clinical indications and experience from over 100 cases. BJU Int. 2007;99:881–6.PubMedCrossRef

29.

Boulleret C, Chahid T, Gallot D, Mofid R, Tran Hai D, Ravel A, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol. 2004;27:344–8.PubMedCrossRef

30.

Maassen MS, Lambers MDA. Tutein Nolthenius RP, van der Valk PHM, Elgersma OE. Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. BJOG. 2009;116:55–61.PubMedCrossRef

31.

Yamashita Y, Takahashi M, Ito M, Okamura H. Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury. Obstet Gynecol. 1991;77:160–3.PubMed

32.

Hirai K, Kawazoe Y, Yamashita K, Kumagai M, Nagata K, Kawaguchi S, et al. Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Am J Gastroenterol. 1986;81:275–9.PubMed

33.

Yonemitsu T, Kawai N, Sato M, Tanihata H, Takasaka I, Nakai M, et al. Evaluation of transcatheter arterial embolization with gelatin sponge particles, microcoils, and n-butyl cyanoacrylate for acute arterial bleeding in a coagulopathic condition. J Vasc Interv Radiol. 2009;20:1176–87.PubMedCrossRef

34.

Yonemitsu T, Kawai N, Sato M, Sonomura T, Takasaka I, Nakai M, et al. Comparison of hemostatic durability between N-butyl cyanoacrylate and gelatin sponge particles in transcatheter arterial embolization for acute arterial hemorrhage in a coagulopathic condition in a swine model. Cardiovasc Intervent Radiol. 2010;33:1192–7.PubMedCrossRef

35.

Phadke RV, Sawlani V, Rastogi H, Kumar S, Roy S, Baijal SS, et al. Iatrogenic renal vascular injuries and their radiological management. Clin Radiol. 1997;52:119–23.PubMedCrossRef

36.

Chun JY, Morgan R, Belli AM. Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol. 2010;33:240–50.PubMedCrossRef

37.

Hahn S, Kim YJ, Kwon W, Cha SW, Lee WY. Comparison of the effectiveness of embolic agents for bronchial artery embolization: gelfoam versus polyvinyl alcohol. Korean J Radiol. 2010;11:542–6.PubMedCentralPubMedCrossRef

38.

Kobayashi S, Sakaguchi H, Takatsuka M, Suekane T, Iwai S, Morikawa H, et al. Two cases of hepatocellular adenomatosis treated with transcatheter arterial embolization. Hepatol Int. 2009;3:416–20.PubMedCentralPubMedCrossRef

39.

Igarashi A, Masuyama T, Watanabe K, Higaki Y, Kuramoto N, Suzuki K, et al. Long-term result of the transcatheter arterial embolization for ruptured renal angiomyolipoma. Nippon Hinyokika Gakkai Zasshi. 2002;93:702–6.PubMed

40.

Han YM, Kim JK, Roh BS, Song HY, Lee JM, Lee YH, et al. Renal angiomyolipoma: selective arterial embolization—effectiveness and changes in angiomyogenic components in long-term follow-up. Radiology. 1997;204:65–70.PubMed

41.

Green JA, Bellemore MC, Marsden FW. Embolization in the treatment of aneurysmal bone cysts. J Pediatr Orthop. 1997;17:440–3.PubMed

42.

Kwon JH, Shin JH, Kim JH, Gwon DI, Yoon HK, Ko GY, et al. Preoperative transcatheter arterial embolization of hypervascular metastatic tumors of long bones. Acta Radiol. 2010;51:396–401.PubMedCrossRef

43.

Shi HB, Suh DC, Lee HK, Lim SM, Kim DH, Choi CG, et al. Preoperative transarterial embolization of spinal tumor: embolization techniques and results. AJNR Am J Neuroradiol. 1999;20:2009–15.PubMed

44.

Chu JP, Chen W, Li JP, Zhuang WQ, Huang YH, Huang ZM, et al. Clinicopathologic features and results of transcatheter arterial chemoembolization for osteosarcoma. Cardiovasc Intervent Radiol. 2007;30:201–6.PubMedCrossRef

45.

Nagata Y, Mitsumori M, Okajima K, Mizowaki T, Fujiwara K, Sasai K, et al. Transcatheter arterial embolization for malignant osseous and soft tissue sarcomas. II. Clinical results. Cardiovasc Intervent Radiol. 1998;21:208–13.PubMedCrossRef

46.

Butori N, Tixier H, Filipuzzi L, Mutamba W, Guiu B, Cercueil JP, et al. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids. Eur J Radiol. 2011;79:1–6.PubMedCrossRef

47.

Iaccarino V, Sodano A, Belfiore G, Matacena G, Porta E. Embolization of glomus tumors of the carotid: temporary or definitive? Cardiovasc Intervent Radiol. 1985;8:206–10.PubMedCrossRef

48.

Hrabovsky EE, McLellan D, Horton JA, Klingberg WG. Catheter embolization: preparation of patient with pheochromocytoma. J Pediatr Surg. 1982;17:849–50.PubMedCrossRef

49.

Bunuan HD, Alltree M, Merendino KA. Gel foam embolization of a functioning pheochromocytoma. Am J Surg. 1978;136:395–8.PubMedCrossRef

50.

Yamasaki S, Hasegawa H, Kinoshita H, Furukawa M, Imaoka S, Takasaki K, et al. A prospective randomized trial of the preventive effect of pre-operative transcatheter arterial embolization against recurrence of hepatocellular carcinoma. Jpn J Cancer Res. 1996;87:206–11.PubMedCrossRef

51.

Paye F, Jagot P, Vilgrain V, Farges O, Borie D, Belghiti J. Preoperative chemoembolization of hepatocellular carcinoma: a comparative study. Arch Surg. 1998;133:767–72.PubMedCrossRef

52.

Harada T, Matsuo K, Inoue T, Tamesue S, Inoue T, Nakamura H. Is preoperative hepatic arterial chemoembolization safe and effective for hepatocellular carcinoma? Ann Surg. 1996;224:4–9.PubMedCentralPubMedCrossRef

53.

Lu CD, Peng SY, Jiang XC, Chiba Y, Tanigawa N. Preoperative transcatheter arterial chemoembolization and prognosis of patients with hepatocellular carcinomas: retrospective analysis of 120 cases. World J Surg. 1999;23:293–300.PubMedCrossRef

54.

Zhu K, Meng X, Li Z, Huang M, Guan S, Jiang Z, et al. Partial splenic embolization using polyvinyl alcohol particles for hypersplenism in cirrhosis: a prospective randomized study. Eur J Radiol. 2008;66:100–6.PubMedCrossRef

55.

Sangro B, Bilbao I, Herrero I, Corella C, Longo J, Beloqui O, et al. Partial splenic embolization for the treatment of hypersplenism in cirrhosis. Hepatology. 1993;18:309–14.PubMedCrossRef

56.

Owman T, Lunderquist A, Alwmark A, Borjesson B. Embolization of the spleen for treatment of splenomegaly and hypersplenism in patients with portal hypertension. Invest Radiol. 1979;14:457–64.PubMedCrossRef

57.

Bilbao JI, Sangro B, Longo JM, Zozaya JM, Fernández-Virgós A, Aquerreta JD, et al. Splenic embolization prior to myelosuppressive treatment in hepatocarcinoma and active chronic hepatitis. Eur J Radiol. 1992;15:211–4.PubMedCrossRef

58.

Miyazaki M, Itoh H, Kaiho T, Ohtawa S, Ambiru S, Hayashi S, et al. Partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura. AJR Am J Roentgenol. 1994;163:123–6.PubMedCrossRef

59.

Hirota S, Ichikawa S, Matsumoto S, Motohara T, Fukuda T, Yoshikawa T. Interventional radiologic treatment for idiopathic portal hypertension. Cardiovasc Intervent Radiol. 1999;22:311–4.PubMedCrossRef

60.

Romano M, Giojelli A, Capuano G, Pomponi D, Salvatore M. Partial splenic embolization in patients with idiopathic portal hypertension. Eur J Radiol. 2004;49:268–73.PubMedCrossRef

61.

Gu JJ, He XH, Li WT, Ji J, Peng WJ, Li GD, et al. Safety and efficacy of splenic artery coil embolization for hypersplenism in liver cirrhosis. Acta Radiol. 2012;53:862–7.PubMedCrossRef

62.

Kaneko T, Nakao A, Takagi H. Clinical studies of new material for portal vein embolization: comparison of embolic effect with different agents. Hepatogastroenterology. 2002;49:472–7.PubMed

63.

Ohkawa M, Hino I, Nakano S, Kimura N, Kojima K, Satoh K, et al. Portal vein embolization using lipiodol-gelatin sponge. Nippon Acta Radiologica. 1996;56:323–4.

64.

Kakizawa H, Toyota N, Arihiro K, Naito A, Fujimura Y, Hieda M, et al. Preoperative portal vein embolization with a mixture of gelatin sponge and iodized oil: efficacy and safety. Acta Radiol. 2006;47:1022–8.PubMedCrossRef

65.

Imamura H, Shimada R, Kubota M, Matsuyama Y, Nakayama A, Miyagawa S, et al. Preoperative portal vein embolization: an audit of 84 patients. Hepatology. 1999;29:1099–105.PubMedCrossRef

66.

Spencer HT, Hsu JT, McDonald DR, Karlin LI. Intraoperative anaphylaxis to gelatin in topical hemostatic agents during anterior spinal fusion: a case report. Spine J. 2012;12:e1–6.PubMedCrossRef

67.

Khoriaty E, McClain CD, Permaul P, Smith ER, Rachid R. Intraoperative anaphylaxis induced by the gelatin component of thrombin-soaked gelfoam in a pediatric patient. Ann Allergy Asthma Immunol. 2012;108:209–10.PubMedCrossRef

68.

Ishikura H, Sotozaki Y, Adachi H, Sato M, Yoshiki T. Granulomatous arteritis with massive eosinophilic leukocyte infiltration and transient peripheral eosinophilia subsequent to transarterial embolization therapy with a gelatin sponge. Acta Pathol Jpn. 1991;41:618–22.PubMed

69.

Sakamoto I, Aso N, Nagaoki K, Matsuoka Y, Uetani M, Ashizawa K, et al. Complications associated with transcatheter arterial embolization for hepatic tumors. Radiographics. 1998;18:605–19.PubMedCrossRef

70.

Tarazov PG, Polysalov VN, Prozorovskij KV, Grishchenkova IV, Rozengauz EV. Ischemic complications of transcatheter arterial chemoembolization in liver malignancies. Acta Radiol. 2000;41:156–60.PubMedCrossRef

71.

Miyayama S, Yamashiro M, Okuda M, Yoshie Y, Sugimori N, Igarashi S, et al. Chemoembolization for the treatment of large hepatocellular carcinoma. J Vasc Interv Radiol. 2010;21:1226–34.PubMedCrossRef

72.

Kim HK, Chung YH, Song BC, Yang SH, Yoon HK, Yu E, et al. Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma. J Clin Gastroenterol. 2001;32:423–7.PubMedCrossRef

73.

Takayasu K, Moriyama N, Muramatsu Y, Shima Y, Ushio K, Yamada T, et al. Gallbladder infarction after hepatic artery embolization. AJR Am J Roentgenol. 1985;144:135–8.PubMedCrossRef

74.

Makuuchi M, Sukigara M, Mori T, Kobayashi J, Yamazaki S, Hasegawa H, et al. Bile duct necrosis: complication of transcatheter hepatic arterial embolization. Radiology. 1985;156:331–4.PubMed

75.

Tsuda M, Kurihara N, Saito H, Yamaki T, Shimamura H, Narushima Y, et al. Ipsilateral percutaneous transhepatic portal vein embolization with gelatin sponge particles and coils in preparation for extended right hepatectomy for hilar cholangiocarcinoma. J Vasc Interv Radiol. 2006;17:989–94.PubMedCrossRef

76.

Kuribayashi S, Phillips DA, Harrington DP, Bettmann MA, Garnic JD, Come SE, et al. Therapeutic embolization of the gastroduodenal artery in hepatic artery infusion chemotherapy. AJR Am J Roentgenol. 1981;137:1169–72.PubMedCrossRef

77.

Kishimoto W, Nakao A, Takagi H, Hayakawa T. Acute pancreatitis after transcatheter arterial embolization (TAE) for hepatocellular carcinoma. Am J Gastroenterol. 1989;84:1396–9.PubMed

78.

Sonomura T, Yamada R, Kishi K, Nishida N, Yang RJ, Sato M. Dependency of tissue necrosis of gelatin sponge particle size after canine hepatic artery embolization. Cardiovasc Intervent Radiol. 1997;20:50–3.PubMedCrossRef

79.

Bonomo G, Pedicini V, Monfardini L, Della Vigna P, Poretti D, Orgera G, et al. Bland embolization in patients with unresectable hepatocellular carcinoma using precise, tightly size-calibrated, anti-inflammatory microparticles: first clinical experience and 1-year follow-up. Cardiovasc Intervent Radiol. 2009;33:552–9.PubMedCrossRef

80.

Sone M, Osuga K, Shimazu K, Higashihara H, Nakazawa T, Kato K, et al. Porous gelatin particles for uterine artery embolization: an experimental study of intra-arterial distribution, uterine necrosis, and inflammation in a porcine model. Cardiovasc Intervent Radiol. 2010;33:1001–8.PubMedCrossRef

81.

Katsumori T, Kasahara T. The size of gelatin sponge particles: differences with preparation method. Cardiovasc Intervent Radiol. 2006;29:1077–83.PubMedCrossRef

82.

Mori H, Saida Y, Watanabe Y, Irie T, Itai Y. Rapid production of gelatin sponge particles for transcatheter arterial embolization: pumping method. Nippon Acta Radiologica. 2000;60:702–4.

83.

Irie T, Kuramochi M, Takahashi N. Dense accumulation of Lipiodol emulsion in hepatocellular carcinoma nodule during selective balloon-occluded transarterial chemoembolization: measurement of balloon-occluded arterial stump pressure. Cardiovasc Intervent Radiol. 2013;36:706–13.PubMedCrossRef

84.

Katsumori T. The size distribution of porous gelatin particles (Gelpart^®). Jpn J Intervent Radiol. 2007;22:469–71.

85.

Nishida H. Development of transcatheter arterial embolization for the small intestine: experimental study of intra-arterial dynamics and embolic effects of various embolic materials. J Juzen Med Soc. 2002;111:82–97.

86.

Zhou B, Wang J, Yan Z, Shi P, Kan Z. Liver cancer: effects, safety, and cost-effectiveness of controlled-release oxycodone for pain control after TACE. Radiology. 2012;262:1014–21.PubMedCrossRef

87.

Lee SH, Hahn ST, Park SH. Intraarterial lidocaine administration for relief of pain resulting from transarterial chemoembolization of hepatocellular carcinoma: its effectiveness and optimal timing of administration. Cardiovasc Intervent Radiol. 2001;24:368–71.PubMedCrossRef

Titel: Guidelines on the use of gelatin sponge particles in embolotherapy
Publikationsdatum: 01.04.2014
Erschienen in: Japanese Journal of Radiology / Ausgabe 4/2014
Print ISSN: 1867-1071
Elektronische ISSN: 1867-108X
DOI: https://doi.org/10.1007/s11604-014-0292-2

Update Radiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Guidelines on the use of gelatin sponge particles in embolotherapy

Abstract

Neu im Fachgebiet Radiologie

Screening-Mammografie offenbart erhöhtes Herz-Kreislauf-Risiko

S3-Leitlinie zu Pankreaskrebs aktualisiert

Fünf Dinge, die im Kindernotfall besser zu unterlassen sind

„Nur wer sich gut aufgehoben fühlt, kann auch für Patientensicherheit sorgen“

Update Radiologie

Springer Medizin

Abstract

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Neu im Fachgebiet Radiologie

Screening-Mammografie offenbart erhöhtes Herz-Kreislauf-Risiko

S3-Leitlinie zu Pankreaskrebs aktualisiert

Fünf Dinge, die im Kindernotfall besser zu unterlassen sind

„Nur wer sich gut aufgehoben fühlt, kann auch für Patientensicherheit sorgen“

Update Radiologie