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Garg K, Mohan B, Luthra N, Grewal A, Bhardwaj D, Tandon R, Kapoor R, Luthra S. Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study. J Anaesthesiol Clin Pharmacol 2022; 38:440-444. [PMID: 36505213 PMCID: PMC9728451 DOI: 10.4103/joacp.joacp_510_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/30/2020] [Accepted: 03/07/2021] [Indexed: 11/07/2022] Open
Abstract
Background and Aims Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients. Material and Methods This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression. Results The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013). Conclusion HGS can be used as a preoperative test in predicting hospital LOS after major surgery.
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Affiliation(s)
- Kamakshi Garg
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Bishav Mohan
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Neeru Luthra
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India,Address for correspondence: Dr. Neeru Luthra, H. No. 1227/2b/1, Lane No. 2, Kitchlu Nagar Extn, Ethical Committee Approval Approved by Ethics Committee of Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail:
| | - Anju Grewal
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Dolly Bhardwaj
- Department of Anaesthesia, Fortis Hospital, Mohali, Punjab, India
| | - Rohit Tandon
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Richa Kapoor
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
| | - Shalini Luthra
- Central Queensland Mental Health Alcohol and Other Drug Services, Rockhampton, Central Queensland, Australia
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Aronson S, Murray S, Martin G, Blitz J, Crittenden T, Lipkin ME, Mantyh CR, Lagoo-Deenadayalan SA, Flanagan EM, Attarian DE, Mathew JP, Kirk AD, Caldwell DM, Williams DGA, Ulrich K, Flintom C. Roadmap for Transforming Preoperative Assessment to Preoperative Optimization. Anesth Analg 2020; 130:811-819. [DOI: 10.1213/ane.0000000000004571] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Lacey J, Khan N, Oliver CM. Perioperative risk. Br J Hosp Med (Lond) 2017; 78:616-621. [PMID: 29111800 DOI: 10.12968/hmed.2017.78.11.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.
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Affiliation(s)
- Jrn Lacey
- Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - N Khan
- Post-CCT Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - C M Oliver
- NIHR Clinical Lecturer in Anaesthesia, Division of Surgery and Interventional Science, University College London, London WC1E 6AU
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Implementation and Evaluation of a Clinical Pathway for Pancreaticoduodenectomy Procedures: a Prospective Cohort Study. J Gastrointest Surg 2017; 21:1428-1441. [PMID: 28589299 DOI: 10.1007/s11605-017-3459-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/16/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Medical and nursing protocols in perioperative care for pancreaticoduodenectomy are mainly mono-disciplinary, limiting their integration and transparency in a continuous health care system. The aims of this study were to evaluate adherence to a multidisciplinary clinical pathway for all pancreaticoduodenectomy patients during their entire hospital stay and to determine if the use of this clinical pathway is associated with beneficial effects on clinical end points. MATERIALS AND METHODS A prospective cohort study was conducted in 95 pancreaticoduodenectomy patients treated according to a clinical pathway, including a variance report, compared to a historical control group (n = 52) with a traditional treatment regime. RESULTS Process evaluation of the clinical pathway group revealed that protocol adherence throughout all units was above 80%. Major complications according to Clavien-Dindo classification grade ≥3 decreased from 27 to 13%; p = 0.02. Hospital length of stay was significantly shorter in the clinical pathway group, median 10 days [IQR 8-15], compared with the control group, median 13 days [IQR 10-18]; p = 0.02. CONCLUSION The use of a clinical pathway in pancreaticoduodenectomy patients was associated with high protocol adherence, improved outcome and shorter hospital length of stay. Variance report analysis and protocol adherence with a Prepare-Act-Reflect Cycle are essential in surveillance of outcome.
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Nimptsch U, Peschke D, Mansky T. [Impact of quality measurement, transparency and peer review on in-hospital mortality - retrospective before-after study with 63 hospitals]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2016; 115-116:10-23. [PMID: 27837956 DOI: 10.1016/j.zefq.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2008 the 'Initiative Qualitätsmedizin' (initiative for quality in medical care, IQM) was established as a voluntary non-profit association of hospital providers of all kinds of ownership. Currently, about 350 hospitals from Germany and Switzerland participate in IQM. Member hospitals are committed to a quality strategy based on measuring outcome indicators using administrative data, peer review procedures to improve medical quality, and transparency by public reporting. This study aims to investigate whether voluntary implementation of this approach is associated with improvements in medical outcome. METHODS Within a retrospective before-after study 63 hospitals, which started to participate in IQM between 2009 and 2011, were monitored. In-hospital mortality in these hospitals was studied for 14 selected inpatient services in comparison to the German national average. The analyses examine whether in-hospital mortality declined after participation of the studied hospitals in IQM, independently of secular trends or deviations in case mix when compared to the national average, and whether such findings were associated with initial hospital performance or peer review procedures. RESULTS Declining in-hospital mortality was observed in hospitals with initially subpar performance. These declines were statistically significant for treatment of myocardial infarction, heart failure, pneumonia, and septicemia. Similar, but statistically non-significant trends were observed for nine further treatments. Following peer-review procedures significant declines in in-hospital mortality were observed for treatments of myocardial infarction, heart failure, and pneumonia. Mortality declines after peer reviews regarding stroke, hip fracture and colorectal resection were not significant, and after peer reviews regarding mechanically ventilated patients no changes were observed. CONCLUSION The results point to a positive impact of the quality approach applied by IQM on clinical outcomes. A more targeted selection of hospitals to be peer-reviewed might further enhance the impact of this approach.
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Affiliation(s)
- Ulrike Nimptsch
- Technische Universität Berlin, Fachgebiet Strukturentwicklung und Qualitätsmanagement im Gesundheitswesen, Berlin, Deutschland.
| | - Dirk Peschke
- Universität Bremen, Institut für Public Health und Pflegeforschung (IPP), Bremen, Deutschland
| | - Thomas Mansky
- Technische Universität Berlin, Fachgebiet Strukturentwicklung und Qualitätsmanagement im Gesundheitswesen, Berlin, Deutschland
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Oliver CM, Walker E, Giannaris S, Grocott MPW, Moonesinghe SR. Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review. Br J Anaesth 2015; 115:849-60. [PMID: 26537629 DOI: 10.1093/bja/aev350] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.
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Affiliation(s)
- C M Oliver
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - E Walker
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - S Giannaris
- Centre for Anaesthesia, University College London, London, UK
| | - M P W Grocott
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, Southampton, UK University Hospital Southampton NHS Foundation Trust/University of Southampton, NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S R Moonesinghe
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
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Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial. THE LANCET RESPIRATORY MEDICINE 2015; 3:33-41. [DOI: 10.1016/s2213-2600(14)70205-x] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Pietri LD, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol 2014; 20:2304-20. [PMID: 24605028 PMCID: PMC3942834 DOI: 10.3748/wjg.v20.i9.2304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.
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Ludwig RB, Paludo J, Fernandes D, Scherer F. Menor tempo de jejum pré-operatório e alimentação precoce no pós-operatório são seguros? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:54-8. [DOI: 10.1590/s0102-67202013000100012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 10/02/2012] [Indexed: 11/22/2022]
Abstract
INTRODUÇÃO: O jejum noturno praticado antes de operações eletivas foi instituído para prevenir complicações pulmonares, vômitos, regurgitação e aspiração do conteúdo gástrico. No ano de 2005 foi desenvolvido o projeto de Aceleração da Recuperação Total Pós-operatória, denominado ACERTO. O projeto é composto por uma equipe multidisciplinar que visa à recuperação do paciente cirúrgico administrando de duas a seis horas antes da operação uma bebida rica em carboidratos (12,5% de dextrinomaltose). A equipe multidisciplinar é composta por anestesistas, cirurgiões, nutricionistas, enfermeiros e fisioterapeutas. OBJETIVO: Frente aos novos métodos de controle no pré-operatório verificar a qual a necessidade de jejum antes de procedimentos cirúrgicos. MÉTODOS: Revisão sobre jejum pré-operatório realizada nos meses de setembro e outubro de 2011, nos sites de busca Scielo e PubMed. Foram selecionados 24 artigos. CONCLUSÃO: Reduzir o tempo de jejum pré-operatório com solução rica em carboidratos até duas horas antes da operação, tal como alimentação precoce no pós-operatório, trazem inúmeros benefícios ao paciente. O projeto ACERTO tem demonstrado bons resultados e estas novas condutas devem ser encorajadas, diminuindo assim o tempo de recuperação do paciente cirúrgico.
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Abstract
PURPOSE OF REVIEW The development of preoperative clinics and the increasing importance of the anaesthetist in the management of surgical risk have expanded the concept of preoperative optimization. This review will focus on the rationale and process for cost-effective preoperative optimization. RECENT FINDINGS Postoperative morbidity, rather than mortality, is the most important surgical outcome in economic terms. Since preoperative comorbidity, in association with surgical complexity, is more predictive of hospital costs than the subsequent treatment of postoperative complications per se, preoperative optimization represents an appropriate economic target. Process management, including guidelines to reduce unnecessary investigations and specialist referrals and enhancing perioperative recovery, makes economical sense in the majority of patients who undergo noncardiac surgery with few complications. Preoperative optimization of a minority of high-risk surgical patients is also important given limited critical care resource. However, the evidence for specific optimization strategies in this latter group continues to evolve and requires further clarification in well designed trials. SUMMARY The requirement for appropriate methods of risk stratification of surgical patients targeted at the reduction of postoperative morbidity, underpins the development of cost-effective preoperative optimization. Specific process-based and clinical measures may then be applied to the development of individualized perioperative care packages.
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Sultan P, Hamilton MA, Ackland GL. Preoperative muscle weakness as defined by handgrip strength and postoperative outcomes: a systematic review. BMC Anesthesiol 2012; 12:1. [PMID: 22251661 PMCID: PMC3298484 DOI: 10.1186/1471-2253-12-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 01/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reduced muscle strength- commonly characterized by decreased handgrip strength compared to population norms- is associated with numerous untoward outcomes. Preoperative handgrip strength is a potentially attractive real-time, non-invasive, cheap and easy-to-perform "bedside" assessment tool. Using systematic review procedure, we investigated whether preoperative handgrip strength was associated with postoperative outcomes in adults undergoing surgery. METHODS PRISMA and MOOSE consensus guidelines for reporting systematic reviews were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (1980-2010) were systematically searched by two independent reviewers. The selection criteria were limited to include studies of preoperative handgrip strength in human adults undergoing non-emergency, cardiac and non-cardiac surgery. Study procedural quality was analysed using the Newcastle-Ottawa Quality Assessment score. The outcomes assessed were postoperative morbidity, mortality and hospital stay. RESULTS Nineteen clinical studies (17 prospective; 4 in urgent surgery) comprising 2194 patients were identified between1980-2010. Impaired handgrip strength and postoperative morbidity were defined inconsistently between studies. Only 2 studies explicitly ensured investigators collecting postoperative outcomes data were blinded to preoperative handgrip strength test results. The heterogeneity of study design used and the diversity of surgical procedures precluded formal meta-analysis. Despite the moderate quality of these observational studies, lower handgrip strength was associated with increased morbidity (n = 10 studies), mortality (n = 2/5 studies) and length of hospital stay (n = 3/7 studies). CONCLUSIONS Impaired preoperative handgrip strength may be associated with poorer postoperative outcomes, but further work exploring its predictive power is warranted using prospectively acquired, objectively defined measures of postoperative morbidity.
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Affiliation(s)
- Pervez Sultan
- Centre for Anaesthesia, Critical Care and Pain Management, University College London, London, UK.
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Grade M, Quintel M, Ghadimi BM. Standard perioperative management in gastrointestinal surgery. Langenbecks Arch Surg 2011; 396:591-606. [PMID: 21448724 PMCID: PMC3101361 DOI: 10.1007/s00423-011-0782-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/08/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex. OBJECTIVE The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.
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Affiliation(s)
- Marian Grade
- Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - B. Michael Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
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