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Yang J, Wang G, Gao J, Zhong X, Gao K, Liu Q, Nan G, Yan C, Chen G, Lu P, Guo C. Liberal surgical laparoscopy reduction for acute intussusception: experience from a tertiary pediatric institute. Sci Rep 2024; 14:457. [PMID: 38172223 PMCID: PMC10764731 DOI: 10.1038/s41598-023-50493-7] [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: 04/16/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
The optimal treatment for acute intussusception has not yet been defined. In this study, we explored whether employing a liberal laparoscopic intervention for intussusception could lead to favorable outcomes. We performed a historical control analysis to evaluate the outcomes associated with this liberal surgical management protocol. This liberal surgical management protocol were revised to incorporate a new protocol centered around the laparoscopic approach. In some cases of acute intussusception, liberal laparoscopic exploration and intervention were undertaken without initial hydrostatic or pneumatic reduction. During the study interval, a retrospective review was conducted on a total of 3086 patients. These were categorized into two groups: 1338 cases before May 2019 (pre-protocol group) and 1748 cases after May 2019 (post-protocol group). Surgical intervention rates in the pre-protoco and post-protocol period were 10.2% and 27.4% respectively (odds ratio [OR] = 0.30 [95% CI 0.25-0.37]; p < 0.001). No significant differences were observed in baseline clinical characteristics or demographic features between the two groups. The duration from admission to operation was longer for the pre-protocol group (p = 0.008) than for the post-protocol group. The post-protocol group demonstrated decreases in both intestinal resection (OR = 1.50 [95% CI 0.96-2.35]; p = 0.048) and total recurrent events (OR = 1.27 [95% CI 1.04-1.55]; p = 0.012) compared to the pre-protocol group. Liberal laparoscopic intervention for intussusception may effectively reduce the risk of intestinal resection and total recurrent events, thereby exhibiting promising outcomes for patients with intussusception.
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Affiliation(s)
- Jian Yang
- Department of Pediatric General Surgery, Yongchuan Maternal and Child Health Hospital, Chongqing, People's Republic of China
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
| | - Guoyong Wang
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Jia Gao
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
- Department of Pediatrics, Hechuan Maternal and Child Health Hospital, Chongqing, People's Republic of China
| | - Xiaotong Zhong
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Kai Gao
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Qianyang Liu
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Guoxin Nan
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Chengwei Yan
- Department of Pediatrics, Three Gorges Hospital, Chongqing University, Chongqing, People's Republic of China
| | - Gongli Chen
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China
| | - Peng Lu
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China.
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China.
| | - Chunbao Guo
- Department of Pediatric General Surgery, Chongqing Health Center for Women and Children, Chongqing Medical University, Chongqing, People's Republic of China.
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, 120 Longshan Rd, Chongqing, 401147, People's Republic of China.
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Takamoto N, Konishi T, Fujiogi M, Kutsukake M, Morita K, Hashimoto Y, Matsui H, Fushimi K, Yasunaga H, Fujishiro J. Outcomes Following Laparoscopic Versus Open Surgery for Pediatric Intussusception: Analysis Using a National Inpatient Database in Japan. J Pediatr Surg 2023; 58:2255-2261. [PMID: 37507337 DOI: 10.1016/j.jpedsurg.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Laparoscopic surgery for pediatric intussusception has recently become more common as an alternative to open surgery. However, the differences in outcomes between laparoscopic and open surgery remain unclear. Thus, this study aimed to compare short-term surgical outcomes and recurrence rates between patients treated with laparoscopic and open surgery for pediatric intussusception. METHODS Patients aged <18 years who underwent laparoscopic (n = 192) and open (n = 416) surgery for intussusception between April 2016 and March 2021 were retrospectively identified using a Japanese nationwide inpatient database. Propensity-score overlap weighting analyses were conducted to compare the outcomes between the laparoscopic and open surgery groups. The outcomes included in-hospital morbidity, reoperation, readmission for intussusception, bowel resection, the diagnosis of Meckel's diverticulum, duration of anesthesia, postoperative length of hospital stay, and total hospitalization costs. RESULTS The laparoscopic surgery group was older, heavier, and had fewer congenital malformations and emergency admissions than the open surgery group did. Overlap weighting analyses showed no significant differences in in-hospital morbidity (odds ratio [95% confidence interval], 0.88 [0.35-2.23]), reoperation (1.88 [0.24-14.9]), readmission for intussusception within 30 days (0.80 [0.12-5.30]) and 1 year (0.90 [0.28-2.93]), bowel resection (0.69 [0.46-1.02]), the diagnosis of Meckel's diverticulum (0.97 [0.50-1.90]), duration of anesthesia (difference, 11 [-1-24] minutes), postoperative length of stay (difference, -1.9 [-4.2-0.4] days), or total hospitalization costs (difference, 612 [ -746-1970] US dollars) between the groups. CONCLUSIONS In this large nationwide cohort, no significant differences in outcomes were observed between laparoscopic and open surgery. Laparoscopic surgery is an acceptable treatment option for pediatric intussusception. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Naohiro Takamoto
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Michimasa Fujiogi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan; Division of Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Kutsukake
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kaori Morita
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Chang CY, Chen YY, Lin CH, Sheen JM, Shih WT, Chen KJ, Yang YH. Recurrence of pediatric intussusception: A nationwide population-based descriptive study in Taiwan. Medicine (Baltimore) 2023; 102:e34727. [PMID: 37657043 PMCID: PMC10476760 DOI: 10.1097/md.0000000000034727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/21/2023] [Indexed: 09/03/2023] Open
Abstract
Intussusception is frequently observed pediatric emergency that is often followed by recurrent intussusception after initial treatment. This study investigated the risk factors associated with recurrent intussusception in children aged ≤ 3 years. Between January 2007 and December 2015, a cohort study was conducted by linking the Taiwan Maternal and Child Health Database to the Birth Certificate Application database and the National Health Insurance Research Database in Taiwan. Patients aged ≤ 3 years with intussusception diagnosis and related treatment were included in our study. Multivariable logistic regression was used to analyze the risk factors associated with recurrent intussusception. In total, 5341 children with intussusception aged ≤ 3 years were enrolled in our cohort. The adjusted odds ratio (aOR) for recurrent intussusception in children aged 2 to 3 years was 0.62 (95% confidence interval [CI]: 0.47-0.82) compared with children aged < 1 year, and surgery decreased the risk of recurrent intussusception (aOR = 0.64, 95% CI: 0.46-0.88). Male patients had higher risk of recurrent intussusception than female patients had (aOR = 1.41, 95% CI: 1.13-1.75). Higher birth weight may increase the risk of recurrent intussusception, but this association was not statistically significant. Furthermore, gestational age did not seem to affect the risk of recurrent intussusception. Surgical treatment and delayed onset of intussusception are associated with a reduced risk of recurrent intussusception; males are associated with increased risk of recurrent intussusception. In addition, we suggest that in early infancy, patients who received non-surgical treatment as the initial treatment for intussusception should be closely followed up for potential recurrence of intussusception.
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Affiliation(s)
- Chao-Yang Chang
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Ying Chen
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chih-Hsuan Lin
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Wei-Tai Shih
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ko-Jung Chen
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Li Y, Li Y, Liu W, Wang B, Wang P, Qi Y. Th2/Th1 cytokine imbalance is associated with higher recurrent intussusception incidence in children: A 10-year retrospective study of 1657 patients. Medicine (Baltimore) 2023; 102:e33391. [PMID: 37000109 PMCID: PMC10063259 DOI: 10.1097/md.0000000000033391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023] Open
Abstract
Recurrent intussusception is one of the common acute abdominal diseases in infants, which seriously affects the physical and mental health of infants, but its risk factors have not been fully clarified. The objective of this study was to evaluate the relationship between Th2/Th1 cytokine imbalance and recurrent intussusception, so as to provide a theoretical basis for making a more comprehensive treatment strategy for patients with recurrent intussusception. A retrospective study was conducted between July 2012 and September 2022, enrolling patients with intussusception in Children's Hospital of Hebei Province. The patients were divided into recurrent group and non-recurrent group according to whether they suffered from recurrent intussusception. We summarized the clinical characteristics of recurrent intussusception and explored the role of T helper 2 (Th2)/T helper 1 (Th1) cytokine imbalance in it. A total of 2008 patients were initially enrolled and finally 1657 patients qualified for the study. The results showed that the incidence of recurrent intussusception was 18.41% and the Th2/Th1 cytokine imbalance was closely related to the incidence of recurrent intussusception. Th2/Th1 cytokine imbalance is a potential risk factor of recurrent intussusception and more likely to occur in children between the ages of 2 and 3. Future studies are needed to preemptively target the Th2/Th1 cytokine imbalance to formulate a reasonable treatment plan for children with intussusception to avoid recurrence.
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Affiliation(s)
- Yang Li
- The Second Department of General Surgery, Children’s Hospital of Hebei Province, Shijiazhuang City, China
| | - Yaxuan Li
- Chang’an Taoyuan Community Health Service Center, Shijiazhuang City, China
| | - Weidong Liu
- The Second Department of General Surgery, Children’s Hospital of Hebei Province, Shijiazhuang City, China
| | - Baorui Wang
- The Second Department of General Surgery, Children’s Hospital of Hebei Province, Shijiazhuang City, China
| | - Ping Wang
- The Second Department of General Surgery, Children’s Hospital of Hebei Province, Shijiazhuang City, China
| | - Yanwei Qi
- The Second Department of General Surgery, Children’s Hospital of Hebei Province, Shijiazhuang City, China
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Common Conditions II. Surg Clin North Am 2022; 102:797-808. [PMID: 36209746 DOI: 10.1016/j.suc.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chen X, Chen Q, Wang X, Gao Z. Clinical characteristics of recurrent intussusception: A single-center retrospective study. J Pediatr Surg 2021; 56:1831-1834. [PMID: 33896613 DOI: 10.1016/j.jpedsurg.2021.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 01/24/2023]
Abstract
PURPOSE we attempted to summarize the clinical characteristics of recurrent intussusception through a large sample size retrospective study. METHODS 5778 patients who were diagnosed with intussusception and treated in our hospital between January 2014 and December 2018 were reviewed. RESULTS the overall recurrence rate was 20.0%, with the recurrence frequency ranged from 1 to 17 episodes and the recurrence interval ranged from 0 to 5 years. 80.0% (926/1158) patients had only 1 to 2 episodes of recurrence. Most of the patients (88.3%) relapsed within 1 year after successful reduction, among which 616 patients (53.2%) relapsed within 3 days. The recurrence rate of intussusception was the lowest when the age was less than 1 year, increased and kept high level in patients aged from 1 to 5 years old, then decreased after 5 years. The pathologic lead point (PLP) proportion of recurrence group was higher than that of non-recurrence group (2.2% VS 1.2%, P = 0.005). CONCLUSIONS the overall recurrence rate was 20.0%. Most of the patients had only 1 to 2 episodes of recurrence and relapsed within 1 year after successful reduction. Age and PLP were risk factors for intussusception recurrence.
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Affiliation(s)
- Xiaoli Chen
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, 57 Zhugan Street, Xiacheng District, Hangzhou, Zhejiang, China.
| | - Qingjiang Chen
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiang Wang
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhigang Gao
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Fidancı İ, Derinöz Güleryüz O, Tokgöz A. Evaluation of spontaneous reduction among the invagination cases admitted to the paediatric emergency department; retrospective study. Int J Clin Pract 2021; 75:e14322. [PMID: 33960061 DOI: 10.1111/ijcp.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS We aimed to determine the factors that determine the conditions in cases of invagination with spontaneous reduction. METHODS Study was conducted retrospectively in the Paediatric Emergency Department (PED) of the tertiary University Hospital in Ankara, Turkey. Invagination cases admitted between January 1, 2019 and December 31, 2019 were included in the study. Patient information (demographic data such as age, gender, physical examination findings, laboratory and imaging methods, treatment and follow-up) were recorded on the data form prepared by the researchers before the study, using patient files and hospital patient information system. Data were analysed with IBM SPSS V23. RESULTS During the study period, the number of cases who applied to the PED was 33,849 and 74 of these cases were diagnosed with invagination. In the cases diagnosed with invagination, 69 (93%) of them spontaneously reduced during the follow-up. Among all cases, the male sex ratio was 56.5% (39/69). The average age was 44.6 months (minimum: 6; maximum: 154). The mean follow-up time in the emergency room was 12 hours and in the hospital service was 38 hours. Vomiting was observed in 89.9% (58/69) of all cases, abdominal pain in 68.1% (44/69) and rectal bleeding in 1.4% (1/69).The invagination of 21.7% (15/69) of the patients at the first USG was ileo-ileal. 63.8% (44/69) of the patients were discharged after followed up in emergency observation. The number of USGs was lower in the group that was discharged after the follow-up in the emergency room, than the follow-up groups in the service monitoring (P = .012). CONCLUSION Invagination is one of the surgical emergencies. With the widespread use of USG, most of these cases are followed up by clinical and USG follow-up in paediatric emergency services. Spontaneous reduction frequently develops in cases of intussusception with small bowel localisation and short bowel segment (less than 3 cm).
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Affiliation(s)
- İlknur Fidancı
- Department of Pediatrics, Department of Pediatric Emergency, Ankara Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Okşan Derinöz Güleryüz
- Division of Pediatric Emergency Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Aslıhan Tokgöz
- Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey
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A case of iatrogenic intussusception in adults: a rare case report. BMC Surg 2021; 21:271. [PMID: 34051773 PMCID: PMC8164803 DOI: 10.1186/s12893-021-01268-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Intussusception has a low incidence rate in adults. Many cases in adults are caused by tumors. Intussusception results from conditions other than tumors are uncommon. This is the first case report about intussusception that occurred after removing a long intestinal tube (LT). Case presentation A 69-year-old female complained of “recurrent abdominal pain with reduced flatus passage and frequency of bowel movement for 10 days” was admitted to the hospital. Plain abdominal radiography and abdominal CT upon admission showed intestinal obstruction. The patient’s abdominal pain was not relieved after symptomatic treatments, which involved fluid and electrolyte replacement, LT placement, spasmolytic agents, and analgesics. Hence, surgical exploration was carried out. The patient had a good recovery postoperatively. No abdominal pain or bloating developed after food intake. The patient passed flatus and had bowel movements later. On postoperative day 9, the LT was removed. On the 10th day, the patient suddenly developed abdominal distension and acute abdominal pain. Emergency abdominal CT showed small bowel intussusception. Surgical exploration was then performed. Severe small bowel dilatation located at 1.5 m from the ligament of Treitz was found during the procedure. Intussusception at the site was observed. No color change of the intestinal wall was detected, suggesting that no necrosis was present. So, a manual reduction was done. The patient was discharged on postoperative day 6. Conclusions This case serves as a warning that the simple action of pulling out the LT might also cause serious complications, which should be given more attention.
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Lazaro A, Simões J, da Costa AV, Ventura L. Anastomotic fistula after emergency enterectomy for retrograde intussusception after gastric bypass. BMJ Case Rep 2021; 14:14/5/e240756. [PMID: 33975836 PMCID: PMC8118074 DOI: 10.1136/bcr-2020-240756] [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: 11/03/2022] Open
Abstract
Retrograde intussusception is a rare complication of gastric bypass. It is commonly located in the common limb close to the jejunojejunostomy. The management of such condition dictates the outcome of the patient either in the immediate emergency setting or in the long-term bariatric surgery's expected results. We present a case of a retrograde intussusception 3 years after gastric bypass which warranted an emergency enterectomy, followed by an anastomotic fistula. The adequate management of these cases leads to recovery without compromising the effect of bariatric surgery in the future.
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Affiliation(s)
- Andre Lazaro
- Department of General Surgery, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - João Simões
- Department of General Surgery, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Valente da Costa
- Department of General Surgery, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Luis Ventura
- Department of General Surgery, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
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