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Anyomih TT, Jennings T, Mehta A, O'Neill JR, Panagiotopoulou I, Gourgiotis S, Tweedle E, Bennett J, Davies RJ, Simillis C. Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon. Am J Surg 2023; 225:168-179. [PMID: 35927089 DOI: 10.1016/j.amjsurg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/23/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes. METHODS Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons. RESULTS Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05). CONCLUSIONS Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.
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Affiliation(s)
- Theophilus Tk Anyomih
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thomas Jennings
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alok Mehta
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Robert O'Neill
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ioanna Panagiotopoulou
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elizabeth Tweedle
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John Bennett
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Constantinos Simillis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Cheung KT, An V, Sorensen JC, Lin OM, Lie E, Mercier LL, Marguccio SA, Gumulia EN, Goonawardena J, Chan LH, Wong E. Elective Laparoscopic Cholecystectomy as an Entrustable Professional Activity (EPA) for General Surgical Trainees in Australia. JOURNAL OF SURGICAL EDUCATION 2022; 79:655-660. [PMID: 35123911 DOI: 10.1016/j.jsurg.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/17/2021] [Accepted: 01/11/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION To evaluate the operation time and surgical outcomes of elective laparoscopic cholecystectomy performed by surgical trainees at different levels of training at Eastern health and hence, to establish the efficacy and safety of elective laparoscopic cholecystectomy as an Entrustable Professional Activity for surgical trainees in general surgery. OBJECTIVE Elective laparoscopic cholecystectomies performed at our institution between January 2018 and January 2019 were included. Analyses were divided among three groups - consultants (C), fellows (F) and registrars (R). Standard technique with critical view of safety was used. RESULTS A total of 592 patients was included, with a mean age of 54 ± 63 years old. The average operation time was 84 ± 51 minutes. Surgical education and training (SET) 2 trainees took significantly longer when compared to their SET3 and above counterparts as a primary operator (SET2: 131 ± 32 min, Reference; SET3: 78 ± 21 min, p = 0.003; SET4: 80 ± 33 min, p = 0.004; SET5: 77 ± 28 min, p = 0.003; F: 93 ± 77 min, p = 0.036; C: 85 ± 59 min; p = 0.007). Consultant primary operators took an average of 15 minutes longer to complete the operation when assisted by a SET trainee compared to the non-SET registrars (p = 0.03). The overall complication rate was 3.2% and was not significantly different among all three groups (p = 0.17). No death was recorded during the study period. The readmission and return to theatre rates were 7.8% and 0.8% respectively and were not significantly different among the groups (p-values = 0.61 and 0.69). All conversion to open were performed by the consultant primary operator. CONCLUSIONS Elective laparoscopic cholecystectomy can be safely performed by surgical trainees at all SET levels when under appropriate supervision, although junior surgical trainees that is SET 2 took longer to complete the procedure. This operation seems to have a steep, but relatively short, learning curve and it may be broken down into various components. These components, with the addition of time, may be suitable as an Entrustable Professional Activity tool for assessing the competency of early SET trainees.
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Affiliation(s)
- King Tung Cheung
- Department of Upper Gastrointestinal Surgery, Box Hill Hospital, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia.
| | - Vinna An
- Department of Colorectal Surgery, Box Hill Hospital, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia
| | - James C Sorensen
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Olivia Miki Lin
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Elisa Lie
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Laura Le Mercier
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | | | | | - Janindu Goonawardena
- Department of Upper Gastrointestinal Surgery, Box Hill Hospital, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Lok Hang Chan
- Department of Agriculture and Food, The University of Melbourne, Victoria, Australia
| | - Enoch Wong
- Department of Upper Gastrointestinal Surgery, Box Hill Hospital, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia
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The Influence of Chronic Pain and Catastrophizing on Patient Outcomes in an Athletic Therapy Setting. J Sport Rehabil 2022; 31:60-68. [PMID: 34824164 DOI: 10.1123/jsr.2020-0450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT Chronic pain is a challenge for Athletic Trainers and Athletic Therapists working in a clinical or university setting. The fear avoidance model, including catastrophizing, is well established in other health professions but is not established in Athletic Training and Athletic Therapy and may affect rehabilitation outcomes. OBJECTIVE To measure the influence of catastrophizing on rehabilitation outcomes of patients being treated in an Athletic Therapy setting. DESIGN Prospective single group pre-post design. SETTING Student Athletic Therapy clinic. PATIENTS A total of 92 patients were evaluated at initial assessment, and 49 were evaluated at follow-up. INTERVENTION All participants completed self-reported function questionnaires to assess level of injury and then received individualized treatments for a variety of musculoskeletal injuries. All measures were completed at initial assessment and at follow-up approximately 6 weeks later. MAIN OUTCOME MEASURES The authors measured function using a variety of patient self-reported functional questionnaires: the Disability of the Arm, Shoulder, and Hand; Lower Extremity Functional Scale; the Neck Disability Index; and the Oswestry Disability Index depending on injury site. Catastrophizing was measured using the Pain Catastrophizing Scale. RESULTS Function significantly improved from the initial assessment to the follow-up (P > .001). Patients with acute pain experienced a significantly greater improvement in function between the initial assessment and follow-up compared with participants with chronic pain (P = .050). Those with high catastrophizing presented with lower levels of function at initial assessment (66.8%) and follow-up (72.1%) compared with those with low catastrophizing (80.8% and 87.0%, respectively). CONCLUSION Similar to other studies in other professions, the function of patients with chronic pain does not improve as much compared with patients recovering from acute pain in an Athletic Therapy setting. It is important to measure patient-reported outcomes to evaluate patient rehabilitation progress. Rehabilitating patients with chronic pain is a challenge, and pain catastrophizing should be evaluated at the initial assessment since catastrophizing is associated with worse function.
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Sousa JHBDE, Tustumi F, Steinman M, Santos OFPD. Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost? Rev Col Bras Cir 2021; 48:e20202907. [PMID: 34008798 PMCID: PMC10683462 DOI: 10.1590/0100-6991e-20202907] [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: 11/24/2020] [Accepted: 01/06/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons. METHODS this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS). RESULTS during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively. CONCLUSIONS laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.
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Affiliation(s)
| | - Francisco Tustumi
- - Hospital Israelita Albert Einstein, Serviço de Cirurgia Geral - São Paulo - SP - Brasil
| | - Milton Steinman
- - Hospital Israelita Albert Einstein, Serviço de Cirurgia Geral - São Paulo - SP - Brasil
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Boyd-Carson H, Doleman B, Lockwood S, Williams JP, Tierney GM, Lund JN. Trainee-led emergency laparotomy operating. Br J Surg 2020; 107:1289-1298. [DOI: 10.1002/bjs.11611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/21/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
Abstract
Background
To achieve completion of training in general surgery, trainees are required to demonstrate competency in common procedures performed at emergency laparotomy. The aim of this study was to describe the patterns of trainee-led emergency laparotomy operating and the association between postoperative outcomes.
Methods
Data on all patients who had an emergency laparotomy between December 2013 and November 2017 were extracted from the National Emergency Laparotomy Audit database. Patients were grouped by grade of operating surgeon: trainee (specialty registrar) or consultant (including post-Certificate of Completion of Training fellows). Trends in trainee operating by deanery, hospital size and time of day of surgery were investigated. Univariable and adjusted regression analyses were performed for the outcomes 90-day mortality and return to theatre, with analysis of patients in operative subgroups segmental colectomy, Hartmann's procedure, adhesiolysis and repair of perforated peptic ulcer disease.
Results
The study cohort included 87 367 patients. The 90-day mortality rate was 15·1 per cent in the consultant group compared with 11·0 per cent in the trainee group. There were no increased odds of death by 90 days or of return to theatre across any of the operative groups when the operation was performed with a trainee listed as the most senior surgeon in theatre. Trainees were more likely to operate independently in high-volume centres (highest- versus lowest-volume centres: odds ratio (OR) 2·11, 95 per cent c.i. 1·91 to 2·33) and at night (00.00 to 07.59 versus 08.00 to 11.59 hours; OR 3·20, 2·95 to 3·48).
Conclusion
There is significant variation in trainee-led operating in emergency laparotomy by geographical area, hospital size and by time of day. However, this does not appear to influence mortality or return to theatre.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - S Lockwood
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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Sibia US, Turcotte JJ, Klune JR, Feather CB. How Does a New General Surgery Residency Program's Junior Residents Impact Hospital Efficiency and Productivity? JOURNAL OF SURGICAL EDUCATION 2020; 77:309-315. [PMID: 31889692 DOI: 10.1016/j.jsurg.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The general surgery workforce deficit is projected to grow to 15% to 21% by 2050. An estimated 6.6% increase to existing general surgery residency (GSR) programs is needed to meet this shortfall. The purpose of this study was to examine the impact of a new GSR program on efficiency and productivity at a regional healthcare center. STUDY DESIGN An institutional database was retrospectively queried for all GSR related procedures between July 2015 and June 2018. Procedures done prior to GSR initiation (pre-GSR) were compared to those done after (post-GSR). Univariate and multivariate analyses were performed. RESULTS We reviewed 10,617 procedures (6365 pre-GSR vs. 4252 post-GSR). Patients had lower preoperative Hierarchical Condition Category scores in the post-GSR group (0.71 vs. 0.58, p < 0.01). Operative times increased post-GSR (101.7 vs. 109.1 minutes, p < 0.01), but length of stay decreased (6.4 vs. 5.5 days, p = 0.01). Thirty-day readmissions (4.0% vs. 3.4%, p = 0.11) were comparable, but reoperations significantly decreased post-GSR (10.1% vs. 8.6%, p = 0.01). Average hospital costs remained unchanged ($10,765 vs. $10,140, p = 0.12). Multivariate analysis revealed no statistical difference in operative times, length of stay, 30-day readmissions and reoperations, and hospital costs between the 2 groups. Subset analysis based on surgical service also showed no statistical difference. Productivity increased on the general surgery service post-GSR (7.1 vs. 7.8 cases per day, p = 0.02). Patient satisfaction increased post-GSR (76% vs. 81%, p = 0.31), but without statistical significance. CONCLUSION The initiation of a new GSR program did not negatively impact operative times, length of stay, 30-day readmissions and reoperations, hospital costs, case volume, or patient satisfaction.
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Affiliation(s)
- Udai S Sibia
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland.
| | - Justin J Turcotte
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland
| | - John R Klune
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland
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Yoshimura S, Migita M, Matsufuji H. The clinical outcomes of pediatric inguinal hernia repairs operated by surgical residents. Asian J Surg 2019; 43:730-734. [PMID: 31594686 DOI: 10.1016/j.asjsur.2019.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/19/2019] [Accepted: 08/27/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Inguinal hernia is one of the most common surgical diseases, and surgical residents perform inguinal hernia repairs during pediatric surgery rotation. The aims of this study were to examine the clinical outcomes of pediatric inguinal herniorrhaphy performed by surgical residents and to assess the suitability for surgical training. METHODS We extracted data on elective unilateral inguinal hernia repairs performed in children between 2014 and 2018. All eligible cases were divided into surgical resident and attending surgeon groups according to the operator. We reviewed medical records retrospectively and compared some clinical indicators between the 2 groups. RESULTS Of 294 eligible cases, 163 were performed by 37 surgical residents and 131 were performed by 4 attending surgeons. The median operative times in the resident and attending surgeon groups were 30 and 19 min, respectively. Operative time was statistically longer in the resident group (p < 0.001). The complication and recurrence rates in the resident and attending surgeon groups were 11.0% and 11.5%, and 0% and 0.8%, respectively (p = 1.000 and p = 0.466). CONCLUSION Inguinal hernia repairs could be properly performed by surgical trainees with the assistance of attending surgeons. Hernia operation might provide good opportunities for surgical residents to practice basic surgical skills.
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Affiliation(s)
- Shohei Yoshimura
- Department of Pediatric Surgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Misato Migita
- Department of Pediatric Surgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Hiroshi Matsufuji
- Department of Pediatric Surgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
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Nasri B, Saxe J. Impact of Residents on Safety Outcomes in Laparoscopic Cholecystectomy. World J Surg 2019; 43:3013-3018. [DOI: 10.1007/s00268-019-05141-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Löb S, Luetkens K, Krajinovic K, Wiegering A, Germer CT, Seyfried F. Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals. Int J Colorectal Dis 2018. [PMID: 29536237 DOI: 10.1007/s00384-018-3026-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity (3-40%) and mortality (0-4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome. METHODS Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (n = 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants). RESULTS Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (p < 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (p = 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%. CONCLUSION Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.
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Affiliation(s)
- S Löb
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.
| | - K Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - K Krajinovic
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - A Wiegering
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - C-T Germer
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - F Seyfried
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
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