Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: ORIGINAL RESEARCH
Abdominal Cerrahi Sonrası Kronik Ağrı Sendromlu Hastaların Retrospektif Değerlendirilmesi: 3 Yıllık Deneyimimiz
Retrospective Evaluation of Patients with Chronic Pain Syndrome After Abdominal Surgery: Our 3 Years Experience
Dostali ALİYEVa, Süheyla KARADAĞ ERKOÇb, Keziban Sanem ÇAKAR TURHANb, Fatma Feyhan ÖKTENb
aAnkara Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Renimasyon ABD, Algoloji BD, Ankara, TÜRKİYE
bAnkara Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Renimasyon ABD, Ankara, TÜRKİYE
Turkiye Klinikleri J Anest Reanim. 2021;19(1):17-25
doi: 10.5336/anesthe.2021-82607
Article Language: TR
ÖZET
Amaç: Kronik postoperatif ağrı (KPA) hayat kalitesini olumsuz etkileyen, iş gücü kaybı ile sağlık sistemlerine büyük bir yük getiren, yönetimi zor ve multimodal yaklaşım gerektiren önemli bir problemdir. Preoperatif ağrı, operasyon tipi, postoperatif akut ağrı ve psikososyal etkenler KPA için risk faktörleri olarak tanımlanmıştır. Bu çalışmada, hastanemizde abdominal cerrahi sonrası KPA ile algoloji servisine başvuran hastalar, retrospektif olarak incelenip risk faktörleri ortaya konmaya çalışılmıştır. Gereç ve Yöntemler: Üç yıl içinde 1.250 abdominal cerrahi geçirmiş hasta arasından, KPA nedeni ile algoloji kliniğimize baş vurmuş 50 hasta retrospektif olarak incelendi. KPA gelişmesinde etkisi olan risk faktörlerini belirlenmeye çalışıldı. Bulgular: Çalışma hastalarının %70'de (35 hasta) her şeyi felaketleştirme yani 'catastrophizing' hasta yapısı, anksiyete ve depresyon bulgularının mevcut olduğu görüldü (p0,05). Sonuç: Abdominal cerrahi sonrası KPA gelişmesinde; hastanın psikososyal yapısı, geçirilmiş ameliyat sayısı, yaşam tarzı önemli risk faktörleridir.

Anahtar Kelimeler: Kronik ağrı; laparotomi; tekrarlayan cerrahi; her şeyi felaketleştirme; anksiyete
ABSTRACT
Objective: Chronic postoperative pain is a condition that negatively affects the quality of life, puts a huge burden on health systems with loss of work force, is difficult to treat and requires a multimodal approach. Preoperative pain, type of operation and anesthetic approach, postoperative acute pain and psychosocial factors have been identified as risk factors for chronic postoperative pain. In this study, patients who applied to the algology service with chronic postoperative pain after abdominal surgery in our hospital were retrospectively analyzed and the risk factors were tried to be revealed. Material and Methods: Among 1,250 patients who had undergone abdominal surgery in 3 years, 50 patients who applied to our algology clinic due to chronic postoperative pain were retrospectively analyzed. It was tried to determine the risk factors affecting the development of chronic postoperative pain. Results: We found that 70% of the study patients (35 patients) had catastrophizing symptoms, anxiety and depression (p0.05). Conclusion: Psychosocial structure of the patient, number of previous surgeries and lifestyle are important risk factors in the development of chronic postoperative pain after abdominal surgery.

Keywords: Chronic pain; laparotomy; reoperation; catastrophization; anxiety
REFERENCES:
  1. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-25.[Crossref] [PubMed] 
  2. Wylde V, Dennis J, Beswick AD, Bruce J, Eccleston C, Howells N, et al. Systematic review of management of chronic pain after surgery. Br J Surg. 2017;104(10):1293-1306.[Crossref] [PubMed] [PMC] 
  3. Martucci KT, Mackey SC. Neuroimaging of pain: human evidence and clinical relevance of central nervous system processes and modulation. Anesthesiology. 2018;128(6):1241-54.[Crossref] [PubMed] [PMC] 
  4. Yang S, Chang MC. Chronic Pain: Structural and Functional Changes in Brain Structures and Associated Negative Affective States. Int J Mol Sci. 2019;20(13):3130.[Crossref] [PubMed] [PMC] 
  5. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):50-5.[Crossref] [PubMed] 
  6. Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999;86(12):1528-31.[Crossref] [PubMed] 
  7. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1-226.[PubMed] 
  8. Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41(4):576-88.[Crossref] [PubMed] 
  9. Pinto PR, McIntyre T, Ferrero R, Almeida A, Araújo-Soares V. Risk factors for moderate and severe persistent pain in patients undergoing total knee and hip arthroplasty: A prospective predictive study. PLoS One. 2013;8(9):e73917.[Crossref] [PubMed] [PMC] 
  10. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-98.[Crossref] [PubMed] [PMC] 
  11. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain. 2016;17(9Suppl):T70-92.[Crossref] [PubMed] [PMC] 
  12. Kuusniemi K, Pöyhiä R. Present-day challenges and future solutions in postoperative pain management: results from PainForum 2014. J Pain Res. 2016;9:25-36.[Crossref] [PubMed] [PMC] 
  13. Yang MMH, Hartley RL, Leung AA, Ronksley PE, Jetté N, Casha S, et al. Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ Open. 2019;9(4):e025091.[Crossref] [PubMed] [PMC] 
  14. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93(4):1123-33.[Crossref] [PubMed] 
  15. Crombie IK, Davies HT, Macrae WA. Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic. Pain. 1998;76(1-2):167-71.[Crossref] [PubMed] 
  16. Correll D. Chronic postoperative pain: recent findings in understanding and management. F1000Res. 2017;6:1054.[Crossref] [PubMed] [PMC] 
  17. Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 2015;114(4):551-61.[Crossref] [PubMed] 
  18. Gupta A, Gandhi K, Viscusi ER. Persistent postsurgical pain after abdominal surgery. Techniques in Regional Anesthesia and Pain Management. 2011:15(3);140-6.[Crossref] 
  19. Strik C, van den Beukel B, van Rijckevorsel D, Stommel MWJ, Ten Broek RPG, van Goor H. Risk of pain and gastrointestinal complaints at 6 months after elective abdominal surgery. J Pain. 2019;20(1):38-46.[Crossref] [PubMed] 
  20. Werner MU, Kongsgaard UE. I. Defining persistent post-surgical pain: is an update required? Br J Anaesth. 2014;113(1):1-4.[Crossref] [PubMed] 
  21. Sullivan MJL, Bishop SB, Jayne P. The pain catastrophizing scale: development and validation. Psychological Assessment. 1995;7(4):524-32.[Crossref] 
  22. Robert S, Nicholas M. Chronic Pain: The peri-operative management of chronic pain patients and chronic pain after abdominal surgery. Anton K, Michael JPS eds. Analgesia in Major Abdominal Surgery. 1st ed. Cham, Switzerland: Springer International Publishing AG; 2018. p. 249-51.[Crossref] 
  23. Thomazeau J, Rouquette A, Martinez V, Rabuel C, Prince N, Laplanche JL, et al. Predictive factors of chronic post-surgical pain at 6 months following knee replacement: influence of postoperative pain trajectory and genetics. Pain Physician. 2016;19(5):E729-41.[Crossref] [PubMed] 
  24. Wylde V, Sayers A, Lenguerrand E, Gooberman-Hill R, Pyke M, Beswick AD, et al. Preoperative widespread pain sensitization and chronic pain after hip and knee replacement: a cohort analysis. Pain. 2015;156(1):47-54. Erratum in: Pain. 2015;156(12):2636-7.[Crossref] [PubMed] [PMC] 
  25. Joris JL, Georges MJ, Medjahed K, Ledoux D, Damilot G, Ramquet CC, et al. Prevalence, characteristics and risk factors of chronic postsurgical pain after laparoscopic colorectal surgery: Retrospective analysis. Eur J Anaesthesiol. 2015;32(10):712-7.[Crossref] [PubMed] 
  26. Holtzman S, Clarke HA, McCluskey SA, Turcotte K, Grant D, Katz J. Acute and chronic postsurgical pain after living liver donation: Incidence and predictors. Liver Transpl. 2014;20(11):1336-46.[Crossref] [PubMed] 
  27. Guimarães-Pereira L, Farinha F, Azevedo L, Abelha F, Castro-Lopes J. Persistent postoperative pain after cardiac surgery: Incidence, characterization, associated factors and its impact in quality of life. Eur J Pain. 2016;20(9):1433-42.[Crossref] [PubMed] 
  28. Bayman EO, Parekh KR, Keech J, Larson N, Vander Weg M, Brennan TJ. Preoperative Patient Expectations of Postoperative Pain Are Associated with Moderate to Severe Acute Pain After VATS. Pain Med. 2019;20(3):543-54.[Crossref] [PubMed] [PMC] 
  29. Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J, et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology. 2010;112(4):957-69.[Crossref] [PubMed] 
  30. Lange JF, Meyer VM, Voropai DA, Keus E, Wijsmuller AR, Ploeg RJ, et al. The role of surgical expertise with regard to chronic postoperative inguinal pain (CPIP) after Lichtenstein correction of inguinal hernia: a systematic review. Hernia. 2016;20(3):349-56.[Crossref] [PubMed] [PMC] 
  31. Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259-65.[Crossref] [PubMed] [PMC] 
  32. Malafoglia V, Celi M, Muscoli C, Ilari S, Lauro F, Giancotti LA, et al. Lymphocyte opioid receptors as innovative biomarkers of osteoarthritic pain, for the assessment and risk management of opioid tailored therapy, before hip surgery, to prevent chronic pain and opioid tolerance/addiction development: OpMarkArt (Opioids-Markers-Arthroprosthesis) study protocol for a randomized controlled trial. Trials. 2017;18(1):605.[Crossref] [PubMed] [PMC] 
  33. Hinrichs-Rocker A, Schulz K, Järvinen I, Lefering R, Simanski C, Neugebauer EA. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) - a systematic review. Eur J Pain. 2009 ;13(7):719-30.[Crossref] [PubMed] 
  34. Kolesnikov Y, Gabovits B, Levin A, Veske A, Qin L, Dai F, et al. Chronic pain after lower abdominal surgery: do catechol-O-methyl transferase/opioid receptor μ-1 polymorphisms contribute? Mol Pain. 2013;9:19.[Crossref] [PubMed] [PMC] 
  35. Dimova V, Lötsch J, Hühne K, Winterpacht A, Heesen M, Parthum A, et al. Association of genetic and psychological factors with persistent pain after cosmetic thoracic surgery. J Pain Res. 2015;8:829-44.[Crossref] [PubMed] [PMC] 

Login



Contact


Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 119 - 123
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com