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Adam MA, Zhou H, Byrd J, Greenberg AL, Kelly YM, Hall L, Jones HL, Pingpank JF, Lipton ZC, Bartlett DL, Choudry HM. Predicting Severe Complications from Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Data-Driven, Machine Learning Approach to Augment Clinical Judgment. Ann Surg Oncol 2023; 30:5433-5442. [PMID: 37266808 DOI: 10.1245/s10434-023-13657-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND CRS-HIPEC provides oncologic benefit in well-selected patients with peritoneal carcinomatosis; however, it is a morbid procedure. Decision tools for preoperative patient selection are limited. We developed a risk score to predict severity of 90 day complications for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). PATIENTS AND METHODS Adults who underwent CRS-HIPEC at the University of Pittsburgh Medical Center (March 2001-April 2020) were analyzed as part of this study. Primary endpoint was severe complications within 90 days following CRS-HIPEC, defined using Comprehensive Complication Index (CCI) scores as a dichotomous (determined using restricted cubic splines) and continuous variable. Data were divided into training and test sets. Several machine learning and traditional algorithms were considered. RESULTS For the 1959 CRS-HIPEC procedures included, CCI ranged from 0 to 100 (median 32.0). Adjusted restricted cubic splines model defined severe complications as CCI > 61. A minimum of 20 variables achieved optimal performance of any of the models. Linear regression achieved the highest area under the receiving operator characteristic curve (AUC, 0.74) and outperformed the NSQIP Surgical Risk calculator (AUC 0.80 vs. 0.66). Factors most positively associated with severe complications included peritoneal carcinomatosis index score, symptomatic status, and undergoing pancreatectomy, while American Society of Anesthesiologists 2 class, appendiceal diagnosis, and preoperative albumin were most negatively associated with severe complications. CONCLUSIONS This study refines our ability to predict severe complications within 90 days of discharge from a hospitalization in which CRS-HIPEC was performed. This advancement is timely and relevant given the growing interest in this procedure and may have implications for patient selection, patient and referring provider comfort, and survival.
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Affiliation(s)
| | - Helen Zhou
- Carnegie Mellon University, Pittsburgh, PA, USA
| | | | | | | | - Lauren Hall
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heather L Jones
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in patients with peritoneal surface malignancies (PSM): a prospective single-center registry study. J Cancer Res Clin Oncol 2023; 149:1331-1341. [PMID: 36513815 PMCID: PMC9984350 DOI: 10.1007/s00432-022-04517-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/03/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new, palliative approach for patients with peritoneal surface malignancies (PSMs). Its main goals are to control symptoms and ascites. For this experimental procedure, treatment efficacy and patient safety need to be closely monitored. METHODS We performed a prospective registry study for patients with PSMs. Cisplatin (C) (7.5 mg/m2 body surface) and doxorubicin (D) (1.5 mg/m2) were administered laparoscopically via PIPAC. RESULTS Between November 2015 and June 2020, we recorded data from 108 patients and 230 scheduled procedures. Tumor burden, patient fitness, quality of life, operating time and in-hospital stay remained stable over consecutive procedures. We recorded 21 non-access situations and 14 intraoperative complications (11 intestinal injuries, and three aspirations while inducing anesthesia). Three or more previous abdominal surgeries or cytoreductive surgery (CRS) with intraperitoneal hyperthermic chemoperfusion (HIPEC) were risk factors for non-access and intestinal injuries (χ2, p ≤ 0.01). Five Grade IV and three Grade V postoperative complications according to the Clavien-Dindo Classification (CDC) occurred. Median overall survival was 264 days (interquartile range 108-586). Therapies were primarily discontinued because of death (34%), progressive (26%), or regressive (16%) disease. CONCLUSION PIPAC is effective in stabilizing PSMs and retaining quality of life in selected patients. Earlier abdominal surgeries and CRS with HIPEC should be considered when determining the indication for PIPAC. Randomized controlled studies are needed to evaluate PIPAC's therapeutic benefits compared to systemic chemotherapy (sCHT) alone. TRIAL REGISTRATION NCT03100708 (April 2017).
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Batista TP, Carneiro VCG, Tancredi R, Badiglian Filho L, Rangel RLC, Lopes A, Sarmento BJQ, Leão CS. A phase 2 trial of short-course Hyperthermic IntraPeritoneal Chemotherapy (HIPEC) at interval cytoreductive surgery (iCRS) for advanced ovarian cancer. Rev Col Bras Cir 2022; 49:e20223135. [PMID: 35239855 PMCID: PMC10578806 DOI: 10.1590/0100-6991e-20223135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to report the final analysis of a phase 2 trial assessing the efficacy and safety of short-course hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with advanced epithelial ovarian cancer (EOC). METHODS this was an open-label, multicenter, single-arm trial of HIPEC in patients with advanced EOC who underwent interval cytoreductive surgery (iCRS) after neoadjuvant chemotherapy (NACT). HIPEC was performed as a concentration-based regimen of platinum-based chemotherapy for 30 minutes. Primary endpoint was the rate of disease progression occurring at nine months following iCRS plus HIPEC (PD9). Secondary endpoints were postoperative complications, time to start adjuvant chemotherapy, length of hospital and ICU stay, quality of life (QoL) over treatment, and ultimately 2-year progression-free survival (PFS) and overall survival (OS). Analysis was by intention-to-treat with final database lock for survival outcomes on February 23, 2021. RESULTS fifteen patients with stage III EOC were enrolled between February 2015 and July 2019, in four centers. The intention to treat PD9 was 6.7%. With a median follow-up of 33 months (IQR, 24.3-46.5), the median PFS was 18.1 months and corresponding 2-year rates of PFS and OS was 33.3% and 93.3%, respectively. Three patients (20%) experienced graded III complications. Median length of hospital and ICU stay was 5 (IQR, 4-6.5) and 1 (IQR, 1-1) days, respectively. Time to restart systemic chemotherapy was 39 (IQR, 35-49.3) days and no significant difference over time in QoL was observed. CONCLUSIONS we demonstrate preliminary efficacy and safety of short-course HIPEC in patient with advanced EOC.
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Affiliation(s)
- Thales Paulo Batista
- - IMIP - Instituto de Medicina Integral Professor Fernando Figueira, Department of Surgery/Oncology - Recife - PE - Brasil
- - UFPE - Universidade Federal de Pernambuco, Center of Medical Science - Recife - PE - Brasil
| | - Vandré Cabral Gomes Carneiro
- - IMIP - Instituto de Medicina Integral Professor Fernando Figueira, Department of Surgery/Oncology - Recife - PE - Brasil
- - HCP - Hospital de Câncer de Pernambuco, Department of Gynecology - Recife - PE - Brasil
| | - Rodrigo Tancredi
- - IMIP - Instituto de Medicina Integral Professor Fernando Figueira, Department of Clinical Oncology - Recife - PE - Brasil
- - HCP - Hospital de Câncer de Pernambuco, Department of Clinical Oncology - Recife - PE - Brasil
| | | | | | - André Lopes
- - IBCC - Instituto Brasileiro de Controle do Câncer, Department of Gynecology - São Paulo - SP - Brasil
| | - Bruno José Queiroz Sarmento
- - IHBDF - Instituto Hospital de Base do Distrito Federal, Serviço de Oncologia Cirúrgica - Brasília - DF - Brasil
| | - Cristiano Souza Leão
- - IMIP - Instituto de Medicina Integral Professor Fernando Figueira, Departamento de Cirurgia - Recife - PE - Brasil
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Eshmuminov D, Karpovich I, Kapp J, Töpfer A, Endhardt K, Oberkofler C, Petrowsky H, Lenggenhager D, Tschuor C, Clavien PA. Pancreatic fistulas following distal pancreatectomy are unrelated to the texture quality of the pancreas. Langenbecks Arch Surg 2021; 406:729-734. [PMID: 33420516 DOI: 10.1007/s00423-020-02071-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The relevance of pancreatic texture for pancreatic fistula (POPF) formation after distal pancreatectomy (DP) remains ill defined. Recent POPF definition adjustments and common subjective pancreatic texture assessment are further drawbacks in the investigation of pancreatic texture as a factor for POPF development after DP. METHODS The predictive value of pancreatic texture by histologic assessment was investigated for POPF formation after DP, respecting the updated 2016 fistula definition. Histologic evaluation at the resection margin included amount of steatosis, degree of fibrosis, and pancreatic duct size. RESULTS A total of 102 patients who underwent DP were included. Thirty-six patients developed POPF. There was no difference in histologic variables in patients with and without POPF. In the univariate analysis, none of the three histologic features showed significant correlation with POPF formation. The ROC (receiver operating characteristic) curve demonstrated poor utility for the grade of steatosis 0.481 ± 0.058 (p = 0.75) and grade of fibrosis 0.466 ± 0.058 (p = 0.57) as predictive factors for POPF formation. CONCLUSION Results indicate that pancreatic texture does not predict POPF formation following DP. This is particularly relevant in the context of the increasing use of robotic and laparoscopic approaches for DPs with limited clinical pancreatic texture assessment by palpation.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | | | - Joshua Kapp
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Antonia Töpfer
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Katharina Endhardt
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Daniela Lenggenhager
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Ploug M, Graversen M, Pfeiffer P, Mortensen MB. Bidirectional treatment of peritoneal metastasis with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) and systemic chemotherapy: a systematic review. BMC Cancer 2020; 20:105. [PMID: 32041558 PMCID: PMC7011374 DOI: 10.1186/s12885-020-6572-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 01/23/2020] [Indexed: 02/08/2023] Open
Abstract
Background Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is used in the palliative treatment of peritoneal metastasis. The combination of intraperitoneal and systemic chemotherapy seems rational, and the aim of this systematic review was to compare PIPAC directed monotherapy with a bidirectional treatment approach (PIPAC in combination with systemic chemotherapy). Main outcomes were survival and quality of life. Methods A systematic literature search in Medline, Embase, Cochrane and the “Pleura and Peritoneum” was conducted and analyzed according to PRISMA guidelines. Studies in English reporting on bidirectional treatment with PIPAC and systemic chemotherapy and published before April 2019 were included. Results Twelve studies with a total of 386 patients were included. None were specifically designed to compare mono- versus bidirectional treatment, but 44% of the patients received bidirectional treatment. This was more frequent in women (non-gynecological cancers) and one-third of the bidirectional treated patients had received no prior chemotherapy. Data from the included studies provided no conclusions regarding survival or quality of life. Conclusion Bidirectional treatment with PIPAC and systemic chemotherapy is practised and feasible, and some patients are enrolled having received no prior systemic chemotherapy for their PM. The difficulty in drawing any conclusions based on this systematic review has highlighted the urgent need to improve and standardize reports on PIPAC directed therapy. We have, therefore, constructed a list of items to be considered when reporting on clinical PIPAC research. Trial registration International Prospective Register of Systematic Reviews, PROSPERO. Registration number: 90352, March 5, 2018.
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Affiliation(s)
- Magnus Ploug
- Odense PIPAC Center (OPC) and Odense Pancreas Center (OPAC), Upper GI and HPB Section, Department of Surgery, Odense University Hospital, J.B.Winsløvs Vej 4, 5000, Odense C, Denmark.
| | - Martin Graversen
- Odense PIPAC Center (OPC) and Odense Pancreas Center (OPAC), Upper GI and HPB Section, Department of Surgery, Odense University Hospital, J.B.Winsløvs Vej 4, 5000, Odense C, Denmark
| | - Per Pfeiffer
- Odense PIPAC Center (OPC) and Odense Pancreas Center (OPAC), Upper GI and HPB Section, Department of Surgery, Odense University Hospital, J.B.Winsløvs Vej 4, 5000, Odense C, Denmark
| | - Michael Bau Mortensen
- Odense PIPAC Center (OPC) and Odense Pancreas Center (OPAC), Upper GI and HPB Section, Department of Surgery, Odense University Hospital, J.B.Winsløvs Vej 4, 5000, Odense C, Denmark
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Roth L, Eshmuminov D, Laminger F, Koppitsch C, Schneider M, Graf TR, Gupta A, Kober F, Roka S, Gertsch P, Lehmann K. Systemic inflammatory response after hyperthermic intraperitoneal chemotherapy (HIPEC): The perfusion protocol matters! Eur J Surg Oncol 2019; 45:1734-1739. [DOI: 10.1016/j.ejso.2019.03.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
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Mutations of RAS/RAF Proto-oncogenes Impair Survival After Cytoreductive Surgery and HIPEC for Peritoneal Metastasis of Colorectal Origin. Ann Surg 2019; 268:845-853. [PMID: 30303876 DOI: 10.1097/sla.0000000000002899] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adequate selection of patients with peritoneal metastasis (PM) for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains critical for successful long-term outcomes. Factors reflecting tumor biology are currently poorly represented in the selection process. The prognostic relevance of RAS/RAF mutations in patients with PM remains unclear. METHODS Survival data of patients with colorectal PM operated in 6 European tertiary centers were retrospectively collected and predictive factors for survival identified by Cox regression analyses. A simple point-based risk score was developed to allow patient selection and outcome prediction. RESULTS Data of 524 patients with a median age of 59 years and a median peritoneal cancer index of 7 (interquartile range: 3-12) were collected. A complete resection was possible in 505 patients; overall morbidity and 90-day mortality were 50.9% and 2.1%, respectively. PCI [hazard ratio (HR): 1.08], N1 stage (HR: 2.15), N2 stage (HR: 2.57), G3 stage (HR: 1.80) as well as KRAS (HR: 1.46) and BRAF (HR: 3.97) mutations were found to significantly impair survival after CRS/HIPEC on multivariate analyses. Mutations of RAS/RAF impaired survival independently of targeted treatment against EGFR. Consequently, a simple point-based risk score termed BIOSCOPE (BIOlogical Score of COlorectal PEritoneal metastasis) based on PCI, N-, G-, and RAS/RAF status was developed, which showed good discrimination [development area under the curve (AUC) = 0.72, validation AUC = 0.70], calibration (P = 0.401) and allowed categorization of patients into 4 groups with strongly divergent survival outcomes. CONCLUSION RAS/RAF mutations impair survival after CRS/HIPEC. The novel BIOSCOPE score reflects tumor biology, adequately stratifies long-term outcomes, and improves patient assessment and selection.
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Bonnot PE, Piessen G, Kepenekian V, Decullier E, Pocard M, Meunier B, Bereder JM, Abboud K, Marchal F, Quenet F, Goere D, Msika S, Arvieux C, Pirro N, Wernert R, Rat P, Gagnière J, Lefevre JH, Courvoisier T, Kianmanesh R, Vaudoyer D, Rivoire M, Meeus P, Passot G, Glehen O. Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer With Peritoneal Metastases (CYTO-CHIP study): A Propensity Score Analysis. J Clin Oncol 2019; 37:2028-2040. [DOI: 10.1200/jco.18.01688] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Gastric cancer (GC) with peritoneal metastases (PMs) is a poor prognostic evolution. Cytoreductive surgery (CRS) yields promising results, but the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. Here we aimed to compare outcomes between CRS-HIPEC versus CRS alone (CRSa) among patients with PMs from GC. PATIENTS AND METHODS From prospective databases, we identified 277 patients with PMs from GC who were treated with complete CRS with curative intent (no residual nodules > 2.5 mm) at 19 French centers from 1989 to 2014. Of these patients, 180 underwent CRS-HIPEC and 97 CRSa. Tumor burden was assessed using the peritoneal cancer index. A Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used to assess the effect of HIPEC and account for confounding factors. RESULTS After IPTW adjustment, the groups were similar, except that median peritoneal cancer index remained higher in the CRS-HIPEC group (6 v 2; P = .003). CRS-HIPEC improved overall survival (OS) in both crude and IPTW models. Upon IPTW analysis, in CRS-HIPEC and CRSa groups, median OS was 18.8 versus 12.1 months, 3- and 5-year OS rates were 26.21% and 19.87% versus 10.82% and 6.43% (adjusted hazard ratio, 0.60; 95% CI, 0.42 to 0.86; P = .005), and 3- and 5-year recurrence-free survival rates were 20.40% and 17.05% versus 5.87% and 3.76% ( P = .001), respectively; the groups did not differ regarding 90-day mortality (7.4% v 10.1%, respectively; P = .820) or major complication rate (53.7% v 55.3%, respectively; P = .496). CONCLUSION Compared with CRSa, CRS-HIPEC improved OS and recurrence-free survival, without additional morbidity or mortality. When complete CRS is possible, CRS-HIPEC may be considered a valuable therapy for strictly selected patients with limited PMs from GC.
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Affiliation(s)
- Pierre-Emmanuel Bonnot
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | - Vahan Kepenekian
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Delphine Vaudoyer
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | | | | | - Guillaume Passot
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
| | - Olivier Glehen
- Centre Hospitalier Universitaire (CHU) Lyon Sud, Lyon, France
- University of Lyon 1, Lyon, France
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Fichmann D, Roth L, Raptis DA, Kajdi ME, Gertsch P, Vonlanthen R, de Rougemont O, Moral J, Beck-Schimmer B, Lehmann K. Standard Operating Procedures for Anesthesia Management in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Improve Patient Outcomes: A Patient Cohort Analysis. Ann Surg Oncol 2019; 26:3652-3662. [DOI: 10.1245/s10434-019-07644-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Indexed: 12/12/2022]
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10
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Dumitra S, Lee B. ASO Author Reflections: A Novel Tool to Assess and Describe HIPEC Complications. Ann Surg Oncol 2019; 26:557-558. [PMID: 30600405 DOI: 10.1245/s10434-018-7053-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Sinziana Dumitra
- Department of Surgery, Division of General Surgery, McGill University, Montreal, Canada.
| | - Byrne Lee
- Department of Surgery, City of Hope, Duarte, CA, USA
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Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 2018; 20:992-1003. [PMID: 29807807 DOI: 10.1016/j.hpb.2018.04.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/09/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive. METHODS A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition. RESULTS 122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT. CONCLUSION The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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Brandl A, Pratschke J, Rau B. Chirurgisch-onkologische Therapie primärer und sekundärer peritonealer Neoplasien. Eur Surg 2018. [DOI: 10.1007/s10353-018-0553-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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13
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Batista TP, Sarmento BJQ, Loureiro JF, Petruzziello A, Lopes A, Santos CC, Quadros CDA, Akaishi EH, Cordeiro EZ, Coimbra FJF, Laporte GA, Castro LS, Batista RMSS, Aguiar S, Costa WL, Ferreira FO. A proposal of Brazilian Society of Surgical Oncology (BSSO/SBCO) for standardizing cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma. ACTA ACUST UNITED AC 2018; 44:530-544. [PMID: 29019584 DOI: 10.1590/0100-69912017005016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/08/2017] [Indexed: 12/13/2022]
Abstract
Cytoreductive surgery plus hypertermic intraperitoneal chemotherapy has emerged as a major comprehensive treatment of peritoneal malignancies and is currently the standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome as well as malignant peritoneal mesothelioma. Unfortunately, there are some worldwide variations of the cytoreductive surgery and hypertermic intraperitoneal chemotherapy techniques since no single technique has so far demonstrated its superiority over the others. Therefore, standardization of practices might enhance better comparisons between outcomes. In these settings, the Brazilian Society of Surgical Oncology considered it important to present a proposal for standardizing cytoreductive surgery plus hypertermic intraperitoneal chemotherapy procedures in Brazil, with a special focus on producing homogeneous data for the developing Brazilian register for peritoneal surface malignancies.
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Affiliation(s)
- Thales Paulo Batista
- - Medicina Integral Professor Fernando Figueira Institute, Department of Surgery / Oncology, Recife, PE, Brazil.,- University of Pernambuco, Department of Surgery, Recife, PE, Brazil
| | | | | | - Andrea Petruzziello
- - Marcelino Champagnat Hospital, Department of Surgical Oncology, Curitiba, PR, Brazil.,- AC Camargo Cancer Center, Department of Abdominal Surgery, São Paulo, SP, Brazil
| | - Ademar Lopes
- - AC Camargo Cancer Center, Department of Pelvic Surgery, São Paulo, SP, Brazil
| | | | | | - Eduardo Hiroshi Akaishi
- - Hospital das Clínicas, University of São Paulo, Department of Surgical Oncology, São Paulo, SP, Brazil
| | | | | | - Gustavo Andreazza Laporte
- - Santa Casa de Misericórdia de Porto Alegre, Department of Surgical Oncology, Porto Alegre, RS, Brazil
| | - Leonaldson Santos Castro
- - Complexo Hospitalar de Niterói, Service of Surgical Oncology, Niterói, RJ, Brazil.,- Nacional Cancer Institute, Service of Abdomino-Pelvic Surgery, Rio de Janeiro, RJ, Brazil
| | | | - Samuel Aguiar
- - AC Camargo Cancer Center, Department of Pelvic Surgery, São Paulo, SP, Brazil
| | - Wilson Luiz Costa
- - AC Camargo Cancer Center, Department of Abdominal Surgery, São Paulo, SP, Brazil
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Eshmuminov D, Leoni F, Schneider MA, Becker D, Muller X, Onder C, Hefti M, Schuler MJ, Dutkowski P, Graf R, Rudolf von Rohr P, Clavien PA, Bautista Borrego L. Perfusion settings and additives in liver normothermic machine perfusion with red blood cells as oxygen carrier. A systematic review of human and porcine perfusion protocols. Transpl Int 2018; 31:956-969. [PMID: 29928775 DOI: 10.1111/tri.13306] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/10/2018] [Accepted: 06/18/2018] [Indexed: 12/30/2022]
Abstract
Liver machine perfusion (MP) at normothermic temperature (NMP) is a promising way to preserve and evaluate extended criteria donor livers. Currently, no consensus exists in methodology and perfusion protocols. Here, the authors performed a systematic literature search to identify human and porcine studies reporting on liver NMP with red blood cells. A qualitative synthesis was performed concerning technical aspects of MP, fluid composition, gas supply, and liver positioning. Thirty-seven publications including 11 human and 26 porcine studies were considered for qualitative synthesis. Control mode, pressure, flow, perfusate additives, and targeted blood gas parameters varied across human as well as porcine studies. For future analyses, it is advisable to report flow adjusted to liver weight and exact pressure parameters including mean, systolic, and diastolic pressure. Parenteral nutrition and insulin addition was common. Parenteral nutrition included amino acids and/or glucose without lipids. Taurocholic acid derivatives were used as bile flow promoters. However, short-term human NMP without taurocholic acid derivatives seems to be possible. This finding is relevant due to the lack of clinical grade bile salts. Near physiological oxygen tension in the perfusate is doable by adjusting gas flows, while blood gas parameters regulation needs more detailed description.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Filippo Leoni
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel André Schneider
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christopher Onder
- Institute for Dynamic Systems and Control, ETH Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Martin J Schuler
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Graf
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
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15
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Dumitra S, O'Leary M, Raoof M, Wakabayashi M, Dellinger TH, Han ES, Lee SJ, Lee B. The Comprehensive Complication Index: a New Measure of the Burden of Complications After Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2017; 25:688-693. [PMID: 29260417 DOI: 10.1245/s10434-017-6157-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) are complex surgeries with multiple comorbidities. The Clavien-Dindo classification (CDC) is the most commonly used method to report surgical morbidity, but limits it to the highest-grade complication. The Comprehensive Complication Index (CCI) is a score ranging from 0 to 100, calculated using all 30-day complications and their treatment after abdominal surgery. The aim of this study is to assess the CCI's validity in the HIPEC patient population. METHODS A review of our institutional cytoreduction database from 2009 to 2015 was undertaken. Patient demographics, pathology, Peritoneal Carcinomatosis Index (PCI), complications and their treatments, and length of stay (LOS) were reviewed. The CCI was calculated for each patient. Linear regression was used to assess whether the CCI and CDC were predictors of LOS. RESULTS Of 157 patients reviewed, 110 (70.1%) underwent HIPEC. The majority were female (77, 66.9%), and the mean age was 53.7 years. Mean PCI was 13.2 [interquartile range (IQR) 7-18]. Median CDC was grade 2 (IQR 0-2), and only 9.8% had CDC of grade 4 or higher. Mean CCI was 21.4, while the median was 20.9 (IQR 0-30.8). Mean LOS was 16.2 days, while the median was 11 days (IQR 8-15 days). The CCI strongly correlated with LOS with coefficient of 0.46 [95% confidence interval (CI) 0.38-0.54, p = 0.000]. CONCLUSIONS The CCI is an adequate tool to capture all complications and their overall burden in patients having undergone HIPEC. This study shows that the CCI can predict LOS and could be used to quantify and compare the burden of multiple complications.
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Affiliation(s)
| | | | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, CA, USA
| | | | | | - Ernest S Han
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Stephen J Lee
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Byrne Lee
- Department of Surgery, City of Hope, Duarte, CA, USA
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16
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Alyami M, Kim BJ, Villeneuve L, Vaudoyer D, Képénékian V, Bakrin N, Gilly FN, Cotte E, Glehen O, Passot G. Ninety-day post-operative morbidity and mortality using the National Cancer Institute’s common terminology criteria for adverse events better describe post-operative outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Hyperthermia 2017; 34:532-537. [DOI: 10.1080/02656736.2017.1367846] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Mohammad Alyami
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- King Salman Scholarship Program, Saudi Arabian Cultural Bureau, Paris, France
| | - Bradford J. Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laurent Villeneuve
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- Pole IMER, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Delphine Vaudoyer
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Vahan Képénékian
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Naoual Bakrin
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Francois-Noel Gilly
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Eddy Cotte
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Olivier Glehen
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Guillaume Passot
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
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17
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Schneider MA, Eshmuminov D, Lehmann K. Major Postoperative Complications Are a Risk Factor for Impaired Survival after CRS/HIPEC. Ann Surg Oncol 2017; 24:2224-2232. [DOI: 10.1245/s10434-017-5821-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Indexed: 12/19/2022]
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18
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Eveno C, Pocard M. Randomized controlled trials evaluating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in prevention and therapy of peritoneal metastasis: a systematic review. Pleura Peritoneum 2016; 1:169-182. [PMID: 30911621 PMCID: PMC6386515 DOI: 10.1515/pp-2016-0027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 12/12/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to prevent or treat peritoneal metastases (PM) in selected indications. The objective of this article was to review published, recruiting or planned randomized controlled trials (RCTs) evaluating CRS and HIPEC versus standard of care. Comparator was systemic chemotherapy and/or CRS alone. CONTENT Systematic review according to PRISMA guidelines. Electronic searches for published RCT using PubMed (from 1980 to November 2016) and for ongoing RCT in the United States and European clinical databases (until November 2016). Current update on ongoing trials from the 10th PSOGI meeting in November 2016 in Washington DC. Fourteen RCTs on CRS and HIPEC were excluded for various reasons. SUMMARY Thirty-eight trials designed for randomizing 7,303 patients were identified: 11 in colorectal cancer (6 for prevention of PM, n=1,107 patients; 5 for therapy, n=781), 10 in ovarian cancer (5 in frontline therapy, n=438 patients; 5 for treating recurrence, n=1,062) and 17 in gastric cancer (14 for prevention of PM, n=3,659 patients; 3 for therapy, n=256). Results of 9 RCTs have been published: 1 in colorectal cancer (105 patients), 1 in ovarian cancer (130 patients) and 7 in gastric cancer (together 669 patients). Five RCTs have completed recruitment and follow-up is ongoing. There is a clear trend in recent trial design from therapeutic to preventive indications. OUTLOOK The number of published RCT evaluating CRS and HIPEC in prevention or therapy of PM is relatively small. There is some evidence that CRS and HIPEC improve survival in recurrent colorectal origin, evidence in ovarian and gastric cancer remains debated. A large number of studies is ongoing that might deliver additional evidence. Trial design and interpretation of results remain difficult because of multiple methodological challenges.
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Affiliation(s)
- Clarisse Eveno
- Paris Diderot University, Sorbonne Paris Cité, CART, INSERM U965, Paris, France
- Surgical Oncologic & Digestive Unit, Lariboisière Hospital, AP-HP, Paris Cedex, France
| | - Marc Pocard
- Paris Diderot University, Sorbonne Paris Cité, CART, INSERM U965, Paris, France
- Surgical Oncologic & Digestive Unit, Lariboisière Hospital, AP-HP, Paris Cedex, France
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19
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Eshmuminov D, Raptis DA, Linecker M, Wirsching A, Lesurtel M, Clavien PA. Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy. Br J Surg 2016; 103:1768-1782. [PMID: 27633328 DOI: 10.1002/bjs.10290] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. METHODS A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. RESULTS Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. CONCLUSION ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.
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Affiliation(s)
- D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Linecker
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - A Wirsching
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Lesurtel
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland.,Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - P-A Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
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