1
|
Priego P, Juez LD, Cuadrado M, García Pérez JC, Sánchez-Picot S, Blázquez LA, Gil P, Galindo J, Fernández-Cebrián JM. Risk factors associated with radiological and clinical recurrences after laparoscopic repair of large hiatal hernia with TiO 2Mesh™ reinforcement. Hernia 2024; 28:1871-1877. [PMID: 39001940 DOI: 10.1007/s10029-024-03107-8] [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: 02/07/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Laparoscopic repair of large para-esophageal hiatal hernias (LPHH) remains controversial. Several meta-analyses suggest hiatus reinforcement with mesh has better outcomes over cruroplasty in terms of less recurrence. The aim of this study was to evaluate the medium-term results of treating LPHH with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). METHODS A retrospective observational study, using data extracted from a prospectively collected database was performed at XXX from December 2014 to June 2023. Included participants were all patients who underwent laparoscopic repair of large (> 5 cm) type III hiatal hernia in which a TiO2Mesh™ was used. The results of the study, including clinical and radiological recurrences as well as mesh-related morbidity, were analyzed. RESULTS Sixty-seven patients were finally analyzed. Laparoscopic approach was attempted in all but conversion was needed in one patient because of bleeding in the lesser curvature. With a median follow-up of 41 months (and 10 losses to follow-up), 22% of radiological recurrences and 19.3% of clinical recurrences were described. Regarding complications, one patient presented morbidity associated with the mesh (mesh erosion requiring endoscopic extraction). Recurrent hernia repair was an independent factor of clinical recurrence (OR 4.57 95% CI (1.28-16.31)). CONCLUSION LPHH with TiO2Mesh™ is safe and feasible with a satisfactory medium-term recurrence and a low complication rate. Prospective randomized studies are needed to establish the standard repair of LPHH.
Collapse
Affiliation(s)
- Pablo Priego
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luz Divina Juez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Marta Cuadrado
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Juan Carlos García Pérez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Silvia Sánchez-Picot
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Luis Alberto Blázquez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Pablo Gil
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Julio Galindo
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - José María Fernández-Cebrián
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| |
Collapse
|
2
|
Panici Tonucci T, Aiolfi A, Bona D, Bonavina L. Does crural repair with biosynthetic mesh improve outcomes of revisional surgery for recurrent hiatal hernia? Hernia 2024; 28:1687-1695. [PMID: 38551795 DOI: 10.1007/s10029-024-03023-x] [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: 12/03/2023] [Accepted: 03/08/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Laparoscopic revisional surgery for recurrent hiatal hernia (HH) is technically demanding. Re-recurrences are common and esophageal hiatus mesh reinforcement might improve durability of the repair, thus minimizing the risk of re-herniation. PURPOSE Assess safety and effectiveness of simple suture repair (no mesh group) vs. crural augmentation with a biosynthetic absorbable mesh (mesh group) in patients with recurrent HH. METHODS Observational retrospective study from September 2012 to December 2022. Only patients undergoing redo surgery for previous failures of hiatal hernia repair were enrolled. Surgical failure was defined as symptomatic recurrent HH with > 2 cm of gastric tissue above the diaphragmatic impression at upper gastrointestinal endoscopy and/or swallow study. Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and Short Form-36 (SF-36) questionnaires were used to assess and preoperative and postoperative symptoms and quality of life. RESULTS One hundred four patients were included. Overall, 60 patients (57.7%) underwent mesh-reinforced cruroplasty, whereas 44 (42.3%) underwent simple suture cruroplasty. Mesh and no mesh groups had similar baseline demographics, symptoms, prevalence of esophagitis and Barrett's esophagus, and HH size. A composite crural repair was most commonly performed in the mesh group (38.3% vs. 20.5%; p = 0.07). In addition to cruroplasty, most patients (91%) underwent a Toupet fundoplication. The 90-day postoperative complication rate was 8.6%, and there was no mortality. Recurrent HH was diagnosed in 21 patients (20.2%) with a clinical trend toward reduced incidence in the mesh group (16.7% vs. 25%; p = 0.06). Compared to baseline, there was a statistically significant improvement of median GERD-HRQL score (p < 0.01) and all SF-36 items (p < 0.01). CONCLUSIONS Laparoscopic revisional surgery for recurrent HH is safe and effective. Selective use of biosynthetic mesh may protect from early recurrence and has the potential to reduce re-herniation in the long-term.
Collapse
Affiliation(s)
- T Panici Tonucci
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Via Piercandido Decembrio 19/A, 20137, Milan, Italy
| | - A Aiolfi
- Division of General Surgery, Department of Biomedical Sciences for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, University of Milan, Milan, Italy
| | - D Bona
- Division of General Surgery, Department of Biomedical Sciences for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, University of Milan, Milan, Italy
| | - L Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Via Piercandido Decembrio 19/A, 20137, Milan, Italy.
- Division of General Surgery, Department of Biomedical Sciences for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, University of Milan, Milan, Italy.
| |
Collapse
|
3
|
Aiolfi A, Bonavina L. Hot topics in Hiatal Hernia. Hernia 2024; 28:1495-1496. [PMID: 39287828 DOI: 10.1007/s10029-024-03176-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Accepted: 09/11/2024] [Indexed: 09/19/2024]
Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| |
Collapse
|
4
|
Fuchs KH, Kafetzis I, Hann A, Meining A. Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications. Life (Basel) 2024; 14:1145. [PMID: 39337928 PMCID: PMC11433396 DOI: 10.3390/life14091145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment. METHODS Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context. RESULTS In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use. CONCLUSIONS The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.
Collapse
Affiliation(s)
- Karl Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Ioannis Kafetzis
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Alexander Hann
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
| | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
| |
Collapse
|
5
|
Anderson DJ, Kuchta K, Joseph S, Rwigema JC, Crafts T, Ishii S, Hedberg HM, Ujiki MB. Impact of Toupet fundoplication with bougie on post-operative dysphagia and quality of life. Surg Endosc 2024; 38:5350-5355. [PMID: 39028347 DOI: 10.1007/s00464-024-11038-9] [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: 04/20/2024] [Accepted: 06/30/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications. OBJECTIVE The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions. METHODS A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups. RESULTS Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19 months, versus 9 months in the non bougie group. There was no difference between early (3 weeks) and late dysphagia scores (6 months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year. CONCLUSION There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation.
Collapse
Affiliation(s)
- Derrius J Anderson
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Stephanie Joseph
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Jean-Christophe Rwigema
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Trevor Crafts
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| |
Collapse
|
6
|
Kumar SS, Rama M, Koeneman S, Tannouri S, Tatarian T, Palazzo F. Morbidity and mortality following hiatal hernia repair in geriatric patients: a multicenter research network study. Surg Endosc 2024; 38:3999-4005. [PMID: 38858249 PMCID: PMC11219371 DOI: 10.1007/s00464-024-10956-y] [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: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Hiatal hernia is a common surgical pathology. Such hernias can be found incidentally and patients may opt for an initial nonoperative approach though many will pursue surgery after symptom progression. Data on the effects of age on the outcomes of hiatal hernia repair may help inform this decision-making process. METHODS The TriNetX database was queried for all adult patients undergoing hiatal hernia repair from 2000 to 2023. Patients were divided into elective and emergent cohorts on the basis of diagnosis codes indicating obstruction or gangrene. Patients aged 80-89 were compared against those aged 65-79 in unadjusted analysis. Logistic regression models controlling for additional health history covariates were created to calculate odds ratios for primary outcomes. RESULTS There were 2310 octogenarians and 15,295 seniors who underwent elective hiatal hernia repair, and 406 octogenarians and 1462 seniors who underwent emergent repair during the study period. The vast majority of patients in both groups underwent minimally invasive operations. In the elective cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, respiratory failure, pneumonia, DVT, blood transfusion, and discharge to nursing facility. In the emergent cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, and respiratory failure. The odds ratios for mortality in the elective and emergent cohorts were 3.9 (95% CI 3.1-5.0) and 3.5 (95% CI 2.1-5.6), respectively. CONCLUSION Octogenarians are at a meaningfully increased risk for mortality and morbidity after both elective and emergent hiatal hernia repair compared to senior-aged patients. Greater consideration should be given to surgical repair prior to the 8th decade of life.
Collapse
Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Martina Rama
- Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th floor, Philadelphia, PA, 19107, USA
| | - Scott Koeneman
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Sami Tannouri
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Talar Tatarian
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
- Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th floor, Philadelphia, PA, 19107, USA.
| |
Collapse
|
7
|
Nickel F, Müller PC, Cizmic A, Häberle F, Muller MK, Billeter AT, Linke GR, Mann O, Hackert T, Gutschow CA, Müller-Stich BP. Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias. Langenbecks Arch Surg 2023; 409:15. [PMID: 38123861 PMCID: PMC10733223 DOI: 10.1007/s00423-023-03190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Symptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence. METHODS A systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine's scale. For each topic, only studies of the highest available level of evidence were considered. RESULTS Out of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a). CONCLUSION The current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.
Collapse
Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Philip C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Frida Häberle
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Muller
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Adrian T Billeter
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
| | - Georg R Linke
- Department of Surgery, Hospital STS Thun AG, Thun, Switzerland
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Beat P Müller-Stich
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
| |
Collapse
|
8
|
Aiolfi A, Bona D, Bonitta G, Manara M, Bonavina L. Comment on "Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh". ANNALS OF SURGERY OPEN 2023; 4:e304. [PMID: 37746622 PMCID: PMC10513235 DOI: 10.1097/as9.0000000000000304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/20/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Alberto Aiolfi
- From the I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Davide Bona
- From the I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- From the I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Michele Manara
- From the I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- From the I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| |
Collapse
|