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Torres-Jurado MJ, Gómez-Hernández MT, Valera-Montiel AE, Vicente-González L, Abdel-Lah-Fernández O, Parreño-Manchado FC, Jiménez-López MF. Non-hiatal diaphragmatic hernias: results of transabdominal and transthoracic surgical approaches at a fourth-level hospital. Hernia 2024:10.1007/s10029-024-03065-1. [PMID: 38767717 DOI: 10.1007/s10029-024-03065-1] [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: 02/15/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE The objective of this study is to elucidate the clinical and demographic profiles, as well as perioperative outcomes, of patients undergoing surgery for non-hiatal diaphragmatic hernias. Additionally, it aims to analyse these outcomes based on the surgical approach employed (transthoracic versus transabdominal). METHODS This retrospective, observational study was conducted at a single center and involved patients diagnosed with non-hiatal diaphragmatic hernia who underwent either emergency or elective surgery between July 2007 and March 2023. Clinical characteristics and perioperative outcomes of these patients were compared using appropriate statistical tests.The research protocol for this observational, retrospective, and comparative study followed the Declaration of Helsinki's ethical requirements. The need for Clinical Research Ethics Committee approval was waived according to our institutional law because the study was a retrospective cohort study based on anonymous data of patients. Informed consent was waived because this study involved the secondary analysis of patient medical records. Additionally, this study followed the STROBE guidelines for reporting observational studies. RESULTS The analysis included 22 patients being 59.1% men, with median age of 61 years. The predominant clinical presentation was restrictive lung disease (40.9%). The majority of cases (68%) had traumatic aetiology with a median defect size of 4 cm (range of 3-8 cm). Elective surgery was performed in 15 cases (68.1%) and transthoracic approach was employed in 13 patients (54.5%). Postoperative major morbidity reached 27.2% and mortality within 30 days was 9.1%. Emergency surgeries accounted for 44.4% of transabdominal interventions, compared to 23% in the transthoracic subgroup (p = 0.376). There were no statistically significant differences between the transabdominal and trasnthoracic approaches in terms of global postoperative complications (88.8% vs. 84.6%, p = 1), major complications (44.4% vs 15.4%, p = 0.734), mortality (11.1% v 7.6%, p = 1) and recurrence (11.1% vs 7.6%, p = 1). Postoperative stay was significantly shorter in the transthoracic subgroup (6 days vs. 14 days, p = 0.011). CONCLUSIONS Non-hiatal diaphragmatic hernias are characterized by significant postoperative major morbidity and mortality rates, standing at 27.2% and 9.1%, respectively, accompanied by a recurrence rate of 9.1%. Both transthoracic and transabdominal approaches demonstrate comparable short- and long-term outcomes.
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Affiliation(s)
| | | | - Andrés E Valera-Montiel
- General and Digestive Surgery Department, University Hospital of Salamanca, Salamanca, Spain
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Bridges CJ, Hasson RM. Congenital Hernias in Adults: Bochdalek Hernias. Thorac Surg Clin 2024; 34:155-162. [PMID: 38705663 DOI: 10.1016/j.thorsurg.2024.01.007] [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] [Indexed: 05/07/2024]
Abstract
Bochdalek hernias are a rare occurrence in adults and usually asymptomatic, resulting in incidental discovery. However, surgical intervention is recommended for both symptomatic and asymptomatic Bochdalek hernias due to the risk of acute morbidity and mortality. There are various possible surgical approaches that may be appropriate depending on the circumstance, with robotic repair becoming increasingly popular. To date, the rarity of the condition has limited the available data on postoperative outcomes.
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Affiliation(s)
- Connor J Bridges
- The Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
| | - Rian M Hasson
- The Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; The Dartmouth Institute of Health Policy and Clinical Practice, Williamson Translational Research Building, Level 51 Medical Center Drive, Lebanon, NH 03756, USA.
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Frey S, Chazal M, Sejor E, Baque P, Mouroux J. Case reports: a variety of clinical presentations and long-term evolution of Bochdalek hernias. Front Surg 2023; 10:1150241. [PMID: 37304187 PMCID: PMC10251140 DOI: 10.3389/fsurg.2023.1150241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023] Open
Abstract
Bochdalek hernias are the most common congenital diaphragmatic hernias, followed by Morgagni hernias. The failure of closure of the pleuroperitoneal membrane results in a posterolateral foramen, which can remain silent until adulthood. They remain a rare pathology with nearly a hundred cases published. Its clinical presentation is variable, making its diagnosis challenging for clinicians. Additionally, its symptoms are not necessarily representative of the content of the hernia. Its management is balanced between the abdominal and the thoracic approaches. However, no guidelines or algorithms are available to help surgeons in the decision-making process. We report here four consecutive cases of symptomatic Bochdalek hernias. Each case has a singular presentation, and we share how they were approached at our institution. In particular, this series shows no reoccurrence in 10+ years of follow-up in two cases and 20+ in one case, underlying the importance of surgical management when Bochdalek hernias are symptomatic.
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Affiliation(s)
- Sebastien Frey
- Department of General Surgical Emergency, Pasteur 2 Hospital, University Hospital of Nice, Nice, France
- Université Côte d’Azur, Nice, France
| | - Maurice Chazal
- Department of General Surgery, Princess Grace Hospital, Monaco, Monaco
| | - Eric Sejor
- Department of Digestive Surgery and Liver Transplantation, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Patrick Baque
- Department of General Surgical Emergency, Pasteur 2 Hospital, University Hospital of Nice, Nice, France
- Université Côte d’Azur, Nice, France
| | - Jerome Mouroux
- Université Côte d’Azur, Nice, France
- Department of Thoracic Surgery, Pasteur 1 Hospital, University Hospital of Nice, Nice, France
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Nistri C, Marinelli L, Di Giacomo A, Bonariol L, Massani M. Robotic repair of a giant Larrey-type congenital left-sided diaphragmatic hernia in a young woman. A case report and literature review. Int J Surg Case Rep 2022; 98:107507. [PMID: 36027832 PMCID: PMC9424357 DOI: 10.1016/j.ijscr.2022.107507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
Congenital diaphragmatic hernia is a rare condition caused by a malformation in the diaphragm that is usually diagnosed in newborns, infants and children. Sometimes it can be incidentally identified in adults. Once the diagnosis is made, surgery is indicated to avoid the risk of life-threatening complications of herniated viscera. Traditional approaches include laparotomy or thoracotomy or both; in the last decades minimally invasive techniques have proved to be a safe alternative to the open approach but only few cases of robotic hernia repair have been described so far, the most with a combined thoracic-abdomen approach. We report a case of an 18-year-old female presenting with abdominal pain due to a giant left-sided anterior diaphragmatic hernia (Larrey-type) that was repaired using a robotic-assisted laparoscopic approach with mesh placement. The hernia contents included gastric body and fundus, duodenum, jejunum, ileus, cecum, right colon and mesentery; spleen and pancreas were rotated and dislocated anteriorly. The outcome was unremarkable, with no major post-operative complications and no signs of long-term recurrence. The robotic approach seems to be a valid option for the treatment of diaphragmatic hernias, improving post-operative outcome and providing surgeon better visualization, greater precision and enhanced dexterity in a confined space. Congenital diaphragmatic hernias are a rare condition that may have a late onset. Once the diagnosis is made, surgery is mandatory due to the risk of life-threatening complications. Minimally invasive approaches are a safe option for congenital diaphragmatic hernia repair and can improve post-operative outcome. Robotic diaphragmatic hernia repair allows better visualization, greater precision and enhanced dexterity in a confined space. The use of a mesh is controversial, but in large defects it is recommended to reinforce the primary repair.
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Affiliation(s)
- C Nistri
- Chirurgia 1, Ospedale di Treviso Ca' Foncello, ULSS 2 Marca Trevigiana, Treviso, Italy.
| | - L Marinelli
- Chirurgia 1, Ospedale di Treviso Ca' Foncello, ULSS 2 Marca Trevigiana, Treviso, Italy
| | - A Di Giacomo
- Chirurgia 1, Ospedale di Treviso Ca' Foncello, ULSS 2 Marca Trevigiana, Treviso, Italy
| | - L Bonariol
- Chirurgia 1, Ospedale di Treviso Ca' Foncello, ULSS 2 Marca Trevigiana, Treviso, Italy
| | - M Massani
- Chirurgia 1, Ospedale di Treviso Ca' Foncello, ULSS 2 Marca Trevigiana, Treviso, Italy
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Surgical management of delayed-presentation diaphragm hernia: A single-institution experience. JTCVS Tech 2022; 13:263-269. [PMID: 35711179 PMCID: PMC9197083 DOI: 10.1016/j.xjtc.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/01/2022] [Accepted: 04/11/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives Delayed-presentation diaphragm hernias are uncommon, and surgical management varies widely across practices. We describe our surgical experience with delayed-presentation diaphragm hernias as a case series of 14 patients, 9 of whom underwent minimally invasive repair. Methods We performed a retrospective chart review of our prospective database of all patients treated surgically for delayed-presentation diaphragm hernia at our institution from January 1, 2005, to April 30, 2021. We excluded patients with poststernotomy, post–left ventricular assist device, and previously diagnosed congenital hernias. We recorded patient demographics, etiology, laterality, chronicity, operative details, postoperative complications, and long-term results. Results We performed surgical repair of delayed-presentation diaphragm hernia in 14 patients. Eleven patients (79%) were male, the median age was 61 (18-83) years, the median body mass index was 29.2 (14.5-33.7), and 8 (57%) hernias were left-sided. Etiology was trauma (n = 7, 50%), iatrogenic (n = 5, 36%), and unknown (n = 2, 14%). Median time to presentation in patients with traumatic and iatrogenic hernias was 7.5 years (6 weeks to 38 years). Nine patients (64%) underwent minimally invasive repair, and 5 patients (36%) underwent open repair. We used a synthetic patch in all but 2 patients (86%). Median length of stay was 5 (3-27) days. Two patients (14%) had major complications. There were no deaths. Twelve patients (86%) had follow-up imaging at a median follow-up of 17 months (1-192) with zero recurrences. Conclusions Our experience suggests that a minimally invasive or an open approach to patients with a delayed-presentation diaphragm hernia is safe and effective. We recommend tailoring the surgical approach based on patient characteristics, anatomic considerations, and surgeons’ experience.
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A systematic review on diagnostics and surgical treatment of adult right-sided Bochdalek hernias and presentation of the current management pathway. Hernia 2021; 26:47-59. [PMID: 34216313 PMCID: PMC8881253 DOI: 10.1007/s10029-021-02445-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/10/2021] [Indexed: 12/29/2022]
Abstract
Purpose Bochdalek hernia is a congenital diaphragmatic hernia. The incidence in adults is estimated around 0.17%. Right-sided hernias are much more seldom than left-sided ones because of faster closure of the right pleuroperitoneal canal and the protective effect of the liver. Due to its rarity, there have been no large prospective or retrospective studies following great need for evidence-based diagnostics and treatment strategies. In this systematic review, we evaluated the current evidence of diagnostics, treatment, and follow-up of adult right-sided Bochdalek hernias. Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines a systematic literature review was conducted in PubMed and Cochrane library from 2004 to January 2021. The literature search included all studies with non-traumatic right-sided Bochdalek hernias. Literature on left- or both-sided, pregnancy-associated, pediatric, and other types of hernias were explicitly excluded. Quality assessment of the included studies was performed. Results Database search identified 401 records. After eligibility screening 41 studies describing 44 cases of right-sided non-traumatic Bochdalek hernias in adulthood were included for final analysis. Based upon the systematic literature review, the current diagnostic, therapeutic, and follow-up management pathway for this rare surgical emergency is presented. Conclusion This systematic review underlined that most studies investigating management of adult non-traumatic right-sided Bochdalek hernias are of moderate to low methodological quality. Hernias tend to occur more frequently in middle-aged and older women presenting with abdominal pain and dyspnea. A rapid and accurate diagnosis following surgical repair and regular follow-up is mandatory. High-quality studies focusing on the management of this rare entity are urgently needed. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02445-1.
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Ouyang HG, Zhao ZD, Lu WJ, Wu HT. A report on the congenital hepatic diaphragmatic hernia. Chin Med J (Engl) 2020; 134:252. [PMID: 33086335 PMCID: PMC7817341 DOI: 10.1097/cm9.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hou-Gan Ouyang
- Department of Anatomy, Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi 330004, China
| | - Zhi-Dong Zhao
- Department of Anatomy, Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi 330004, China
| | - Wen-Jing Lu
- Department of Supervision Office, Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi 330004, China
| | - Hui-Ting Wu
- Department of Anatomy, Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi 330004, China
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Akita M, Yamasaki N, Miyake T, Mimura K, Maeda E, Nishimura T, Abe K, Kozuki A, Yokoyama K, Kominami H, Tanaka T, Takamatsu M, Kaneda K. Bochdalek hernia in an adult: two case reports and a review of perioperative cardiopulmonary complications. Surg Case Rep 2020; 6:72. [PMID: 32303918 PMCID: PMC7165220 DOI: 10.1186/s40792-020-00833-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Bochdalek hernia in an adult is very rare and often needs an immediate surgical repair for the herniation. Although its etiology and surgical techniques have frequently been reported, perioperative complications, especially cardiopulmonary problems, remain unknown. We reported two adults with Bochdalek hernia and reviewed the published literatures with a focus on these issues. Case presentation We experienced two adult cases of Bochdalek hernia with gastrointestinal strangulation. One case had massive herniation of the stomach, colon, spleen, and pancreas in the left chest, causing repeated vomiting. The other had a right-side hernia with strangulation of the colon. We successfully performed emergency repairs of these diaphragmatic hernias without any postoperative complications. Conclusions Our literature review revealed that life-threatening cardiopulmonary complications, such as empyema or cardiac arrest caused by the tamponade effect of the herniated viscera, sometimes occurred in patients with Bochdalek hernia. These complications were found in Bochdalek hernia with gastrointestinal strangulation.
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Affiliation(s)
- Masayuki Akita
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan.
| | - Nobuaki Yamasaki
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Taiichiro Miyake
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Kazuya Mimura
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Eri Maeda
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Tohru Nishimura
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Koichiro Abe
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Akihito Kozuki
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Kunio Yokoyama
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Hiroaki Kominami
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Tomohiro Tanaka
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Manabu Takamatsu
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Kunihiko Kaneda
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
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Lau NS, Crawford M, Sandroussi C. Surgical management of symptomatic right-sided Bochdalek hernias in adults: when is a minimally invasive approach appropriate? ANZ J Surg 2020; 90:1075-1079. [PMID: 32175658 DOI: 10.1111/ans.15830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Right-sided Bochdalek hernias are uncommon congenital diaphragmatic hernias that can be challenging to manage because they can contain bowel, omentum, kidney or liver. METHODS We describe our experience at a single centre and integrate this with all reported cases in the literature to evaluate how this rare problem has been managed and when a minimally invasive approach is appropriate. RESULTS A total of 31 patients were identified, four patients from our institution and 27 case reports from the literature. A minimally invasive approach was utilized in 15 of 31 patients (including two of four at our institution) and was more common if the operation was performed in the elective setting (10/12 versus 4/19). If a bowel resection was required, an open approach was more common (9/17 versus 1/14). The commonest method of repair was a primary suture repair (18/31), and the mesh was used in 13 cases, particularly in the elective setting (9/12 versus 4/19). CONCLUSION Right-sided Bochdalek hernias are an uncommon and challenging problem. These hernias can contain bowel, kidney and even liver but can still be successfully repaired using minimally invasive techniques, especially in the elective setting and when an emergency bowel resection is not required.
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Affiliation(s)
- Ngee-Soon Lau
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Crawford
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Bochdalek hernias associated with intrathoracic kidney: A case report and systematic review of outcomes including renal function. Clin Nephrol Case Stud 2020; 8:1-11. [PMID: 32002355 PMCID: PMC6990652 DOI: 10.5414/cncs109962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background: An intrathoracic kidney is a very rare form of ectopic kidney. Though increasingly recognized in the literature, impact on renal function is less well described. We report the case of a 67-year-old South Asian gentleman who presented with intrathoracic kidney and chronic kidney disease. We carried out a systematic review of the available literature on intrathoracic kidney, in order to characterize the typical clinical features, and describe likely clinical course and possible renal and extra-renal complications associated with this form of ectopia. Materials and methods: A structured search using PubMed identified all relevant published case reports from 1988 to 2018, with search restricted to papers in English, and to adult cases only (> 18 years of age). 124 records were identified, and after screening for eligibility, 34 case reports were analyzed. Results: Median age was 53.5 years, with no gender predominance. 68% (27/34) of cases were symptomatic. 29% (10/34) had a significant complication associated with their intrathoracic kidney, with 3 cases with either documented chronic or end-stage kidney disease. 26% (9/34) required surgical intervention. Conclusion: Though previously regarded as a benign entity, results from our systematic review, bearing in mind susceptibility to publication bias, suggests an appreciable risk of symptoms, complications, and in the minority a risk to kidney function. We recommend close biochemical and imaging surveillance of affected patients, with low threshold for intervention in those with renovascular stenosis, reflux, or hydronephrosis.
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Testini M, Girardi A, Isernia RM, De Palma A, Catalano G, Pezzolla A, Gurrado A. Emergency surgery due to diaphragmatic hernia: case series and review. World J Emerg Surg 2017; 12:23. [PMID: 28529538 PMCID: PMC5437542 DOI: 10.1186/s13017-017-0134-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/09/2017] [Indexed: 01/13/2023] Open
Abstract
Background Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations. Methods From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed. Results Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful. Conclusion Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.
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Affiliation(s)
- Mario Testini
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Antonia Girardi
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Roberta Maria Isernia
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Angela De Palma
- Department of Thoracic Surgery, University of Bari, Bari, Italy
| | - Giovanni Catalano
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Angela Pezzolla
- Unit of Laparoscopic Surgery, Department of Emergency and Organ Transplantation, University Medical School "A. Moro" of Bari, Bari, Italy
| | - Angela Gurrado
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
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