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Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
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Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
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Latorre-Rodríguez AR, Rajan A, Mittal SK. Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis. Surg Endosc 2024; 38:1685-1708. [PMID: 38351425 DOI: 10.1007/s00464-024-10683-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/30/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND Improved outcomes with the use of non-absorbable mesh (NAM) for inguinal hernia repairs led to its rapid adoption for hiatal hernia (HH) repairs; however, feared complications occurred, and the trend shifted toward using absorbable mesh (AM). We aimed to analyze the literature assessing objective HH recurrence rates after primary laparoscopic cruroplasty with or without the use of different mesh types. METHODS A systematic literature review with both pairwise and time-organized proportion meta-analyses of articles published between January 1993 and September 2022 was performed using the MEDLINE, EMBASE, and Taylor & Francis databases to identify relevant studies comparing groups undergoing cruroplasty with suture repair (SR) alone, AM, NAM, or partially absorbable mesh (PAM). Studies documenting an objective follow-up ≥ 6 months were included. The primary outcome was the HH recurrence rate confirmed by barium esophagram or upper GI endoscopy. RESULTS A total of 34 studies met the inclusion criteria, including 6 randomized clinical trials, 25 retrospectives studies, and 3 prospective cohort studies. A total of 2170 subjects underwent laparoscopic HH repair and completed an objective follow-up ≥ 6 months after surgery; the objective recurrence rate was 20.8% (99/477) at a mean follow-up of 25.8 ± 16.4 months for the SR group, 20.6% (244/1187) at 28.1 ± 13.8 months for the AM group, 13.7% (65/475) at 30.8 ± 15.3 months for the NAM group, and 0% (0/31) at 32.5 ± 13.5 months for the PAM group. However, the pairwise meta-analysis revealed that overall mesh use was not superior to SR in preventing long-term HH recurrence. CONCLUSION The use of AM does not appear to reduce HH recurrence compared to SR alone. Although the data favors NAM to decrease objective HH recurrence in the mid-term, the long-term (≥ 48 months) recurrence rate was similar with or without any type of mesh.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Suite 500, Phoenix, AZ, 85013, USA
- Universidad del Rosario. Escuela de Medicina y Ciencias de la Salud, Grupo de Investigación Clínica, Bogotá D.C., Colombia
| | - Ajay Rajan
- School of Medicine School, Creighton University, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Suite 500, Phoenix, AZ, 85013, USA.
- School of Medicine School, Creighton University, Phoenix, AZ, USA.
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Sillcox R, Jackson HT. Mesh Versus No Mesh for Cruroplasty. J Laparoendosc Adv Surg Tech A 2022; 32:1144-1147. [PMID: 35980377 DOI: 10.1089/lap.2022.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This review describes the evolution of hiatal hernia repair for the past several decades: From the use of a primary tissue repair only, the subsequent inclusion of synthetic mesh and its complications, to current day indications for mesh use. We will highlight the recent research in biologic and composite meshes as well as the ongoing limitations in studying their efficacy. Finally, we will describe our institutional indications and surgical technique practices in the utilization of biologic mesh.
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Affiliation(s)
- Rachel Sillcox
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Jelodari S, Sadroddiny E. Decellularization of Small Intestinal Submucosa. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1345:71-84. [PMID: 34582015 DOI: 10.1007/978-3-030-82735-9_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Small intestinal submucosa (SIS) is the most studied extracellular matrix (ECM) for repair and regeneration of different organs and tissues. Promising results of SIS-ECM as a vascular graft, led scientists to examine its applicability for repairing other tissues. Overall results indicated that SIS grafts induce tissue regeneration and remodeling to almost native condition. Investigating immunomodulatory effects of SIS is another interesting field of research. SIS can be utilized in different forms for multiple clinical and experimental studies. The aim of this chapter is to investigate the decellularization process of SIS and its common clinical application.
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Affiliation(s)
- Sahar Jelodari
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Sadroddiny
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Borman DA, Sunshein KE, Stigall KS, Madabhushi VV, Davenport DL, Plymale MA, Roth JS. Clinical and Quality of Life Assessment of Patients Undergoing Laparoscopic Hiatal Hernia Repair. Am Surg 2019. [DOI: 10.1177/000313481908501135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hiatal hernia repair (HHR) and fundoplication are similarly performed among all hiatal hernia types with similar techniques. This study evaluates the effect of HHR using a standardized technique for cruroplasty with a reinforcing polyglycolic acid and trimethylene carbonate mesh (PGA/TMC) on patient symptoms and outcomes. A retrospective review of patient perioperative characteristics and postoperative outcomes was conducted for cases of laparoscopic hiatal hernia repair (LHHR) using a PGA/TMC mesh performed over 21 months. Gastroesophageal reflux disease symptom questionnaire responses were compared between preoperative and three postoperative time points. Ninety-six patients underwent LHHR with a PGA/TMC mesh. Post-operatively, the number of overall symptoms reported by patients decreased across all postoperative periods ( P < 0.001). Patients reported a significant reduction in antacid use long term ( P < 0.001). Laryngeal and regurgitation symptoms decreased at all time points ( P < 0.05). There was no difference in dysphagia preoperatively and postoperatively at any time point. Individuals undergoing HHR with PGA/TMC mesh experienced improved regurgitation and laryngeal symptoms, and decreased use of antacid medication.
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Affiliation(s)
| | | | - Kyle S. Stigall
- University of Kentucky College of Medicine, Lexington, Kentucky
| | - Vashisht V. Madabhushi
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky; and
| | | | - Margaret A. Plymale
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky; and
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky; and
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Ilyashenko VV, Grubnyk VV, Grubnik VV. Laparoscopic management of large hiatal hernia: mesh method with the use of ProGrip mesh versus standard crural repair. Surg Endosc 2018; 32:3592-3598. [DOI: 10.1007/s00464-018-6087-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 02/01/2018] [Indexed: 12/23/2022]
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Abu Saleh WK, Morris LM, Tariq N, Kim MP, Chan EY, Meisenbach LM, Dunkin BJ, Sherman V, Rosenberg W, Bass BL, Graviss EA, Nguyen DT, Reardon P, Khaitan PG. Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae. Surg Endosc 2017; 32:879-888. [PMID: 28917000 DOI: 10.1007/s00464-017-5758-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair. METHODS Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone. RESULTS A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543). CONCLUSIONS Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.
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Affiliation(s)
- Walid K Abu Saleh
- Department of General Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Lee M Morris
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Nabil Tariq
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Leonora M Meisenbach
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Brian J Dunkin
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Vadim Sherman
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Wade Rosenberg
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Barbara L Bass
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Patrick Reardon
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Puja G Khaitan
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
- Department of Surgery, Division of Thoracic Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower, Suite 1601, Houston, 77030, TX, USA.
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Tam V, Luketich JD, Levy RM, Christie NA, Awais O, Shende M, Nason KS. Mesh cruroplasty in laparoscopic repair of paraesophageal hernias is not associated with better long-term outcomes compared to primary repair. Am J Surg 2017; 214:651-656. [PMID: 28826953 DOI: 10.1016/j.amjsurg.2017.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/06/2017] [Accepted: 06/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Equipoise still exists regarding routine mesh cruroplasty during laparoscopic paraesophageal hernia (PEH). We aimed to determine whether selective mesh cruroplasty is associated with differences in recurrence and patient-reported outcomes. METHODS We compared symptom outcomes (n = 688) and radiographic recurrences (n = 101; at least 10% [or 2 cm] of stomach above hiatus) for 795 non-emergent PEH repair with fundoplication (n = 106 with mesh). RESULTS Heartburn, regurgitation, epigastric pain, and anti-reflux medication use decreased significantly in both groups while postoperative dysphagia (mesh; p = 0.14), and bloating (non-mesh; p = 0.32), were unchanged. Radiographic recurrence rates were similar (15 mesh [22%] versus 86 non-mesh [17%]; p = 0.32; median 27 [IQR 14, 53] months), but was associated with surgical dissatisfaction (13% vs 4%; p = 0.007). CONCLUSIONS Selective mesh cruroplasty was not associated with differences in symptom outcomes or radiographic recurrence rates during laparoscopic PEH repair. Radiographic recurrence was associated with dissatisfaction, emphasizing the need for continued focus on reducing recurrences.
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Affiliation(s)
- Vernissia Tam
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ryan M Levy
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Neil A Christie
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Omar Awais
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manisha Shende
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katie S Nason
- Department of Cardiothoracic Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Antonakis F, Köckerling F, Kallinowski F. Functional Results after Repair of Large Hiatal Hernia by Use of a Biologic Mesh. Front Surg 2016; 3:16. [PMID: 27014698 PMCID: PMC4783575 DOI: 10.3389/fsurg.2016.00016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this observational study is to analyze the results of patients with large hiatal hernia and upside-down stomach after surgical closure with a biological mesh (Permacol(®), Covidien, Neustadt an der Donau, Germany). Biological mesh is used to prevent long-term detrimental effects of artificial meshes and to reduce recurrence rates. METHODS A total of 13 patients with a large hiatal hernia and endothoracic stomach, who underwent surgery between 2010 and 2014, were included. Interviews and upper endoscopy were conducted to determine recurrences, lifestyle restrictions, and current complaints. RESULTS After a mean follow-up of 26 ± 18 months (range: 3-58 months), 10 patients (3 men, mean age 73 ± 13, range: 26-81 years) were evaluated. A small recurrent axial hernia was found in one patient postoperatively. Dysphagia was the most common complaint (four cases); while in one case, the problem was solved after endoscopic dilatation. In three cases, bloat and postprandial pain were documented. In one case, an explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis, pyloroplasty was performed without success. The data are compared to the available literature. It was found that dysphagia and recurrence rates are unrelated both in biological and in synthetic meshes if the esophagus is encircled. In series preserving the esophagus at least partially uncoated, recurrences after the use of biological meshes relieve dysphagia. After the application of synthetic meshes, dysphagia is aggravated by recurrences. CONCLUSION Recurrence is rare after encircling hiatal hernia repair with the biological mesh Permacol(®). Dysphagia, gas bloat, and intra-abdominal pain are frequent complaints. Despite the small number of patients, it can be concluded that a biological mesh may be an alternative to synthetic meshes to reduce recurrences at least for up to 2 years. Our study demonstrates that local fibrosis and thickening of the mesh can affect the outcome being associated with abdominal discomfort despite a successful repair. The review of the literature indicates comparable results after 2 years with both biologic and synthetic meshes embracing the esophagus. At the same point in time, reconstruction with synthetic and biologic materials differs when the esophagus is not or only partially encircled in the repair. This is important since encircling artificial meshes can erode the esophagus after 5-10 years.
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Affiliation(s)
- Filimon Antonakis
- Department of General and Visceral Surgery, Asklepios Klinikum Harburg , Hamburg , Germany
| | - Ferdinand Köckerling
- Department of General, Visceral and Vascular Surgery, Vivantes Klinikum Spandau , Berlin , Germany
| | - Friedrich Kallinowski
- Department of General and Visceral Surgery, Asklepios Klinikum Harburg , Hamburg , Germany
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