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Zhang X, Liu S, Liu L, Zhu Z. Low Hartmann's procedure versus abdominoperineal resection for rectal cancer, a propensity score matching cohort study. BMC Gastroenterol 2024; 24:194. [PMID: 38840108 PMCID: PMC11155091 DOI: 10.1186/s12876-024-03244-5] [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: 12/31/2023] [Accepted: 04/26/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND This study aimed to compare low Hartmann's procedure (LHP) with abdominoperineal resection (APR) for rectal cancer (RC) regarding postoperative complications. METHOD RC patients receiving radical LHP or APR from 2015 to 2019 in our center were retrospectively enrolled. Patients' demographic and surgical information was collected and analyzed. Propensity score matching (PSM) was used to balance the baseline information. The primary outcome was the incidence of major complications. All the statistical analysis was performed by SPSS 22.0 and R. RESULTS 342 individuals were primarily included and 134 remained after PSM with a 1:2 ratio (50 in LHP and 84 in APR). Patients in the LHP group were associated with higher tumor height (P < 0.001). No significant difference was observed between the two groups for the incidence of major complications (6.0% vs. 1.2%, P = 0.290), and severe pelvic abscess (2% vs. 0%, P = 0.373). However, the occurrence rate of minor complications was significantly higher in the LHP group (52% vs. 21.4%, P < 0.001), and the difference mainly lay in abdominal wound infection (10% vs. 0%, P = 0.006) and bowel obstruction (16% vs. 4.8%, P = 0.028). LHP was not the independent risk factor of pelvic abscess in the multivariate analysis. CONCLUSION Our data demonstrated a comparable incidence of major complications between LHP and APR. LHP was still a reliable alternative in selected RC patients when primary anastomosis was not recommended.
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Affiliation(s)
- Xubing Zhang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of USTC Division of Life Sciences and Medicine, University of Science and Technology of China, Lujiang Road No. 17, Hefei, 230001, China
| | - Shaojun Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of USTC Division of Life Sciences and Medicine, University of Science and Technology of China, Lujiang Road No. 17, Hefei, 230001, China
| | - Liu Liu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of USTC Division of Life Sciences and Medicine, University of Science and Technology of China, Lujiang Road No. 17, Hefei, 230001, China
| | - Zhiqiang Zhu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of USTC Division of Life Sciences and Medicine, University of Science and Technology of China, Lujiang Road No. 17, Hefei, 230001, China.
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Åkerlund V, Nikberg M, Wagner P, Chabok A. Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR). ANNALS OF SURGERY OPEN 2024; 5:e428. [PMID: 38911665 PMCID: PMC11191996 DOI: 10.1097/as9.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 04/09/2024] [Indexed: 06/25/2024] Open
Abstract
Objective The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III). Background There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable. Methods Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed. Results Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45). Conclusions HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.
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Affiliation(s)
- Viktor Åkerlund
- From the Department of Surgery, Västmanland’s Hospital Västerås
- Centre for Clinical Research Region, Västmanland Uppsala University, Sweden
| | - Maziar Nikberg
- From the Department of Surgery, Västmanland’s Hospital Västerås
- Centre for Clinical Research Region, Västmanland Uppsala University, Sweden
| | - Philippe Wagner
- Centre for Clinical Research Region, Västmanland Uppsala University, Sweden
| | - Abbas Chabok
- From the Department of Surgery, Västmanland’s Hospital Västerås
- Centre for Clinical Research Region, Västmanland Uppsala University, Sweden
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Mariusdottir E, Jörgren F, Lydrup ML, Buchwald P. Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study. Colorectal Dis 2024; 26:1250-1257. [PMID: 38802985 DOI: 10.1111/codi.17033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 02/01/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
AIM There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. METHODS All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. RESULTS A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. CONCLUSIONS For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.
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Affiliation(s)
- Elin Mariusdottir
- Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
- Lund University, Lund, Sweden
| | - Fredrik Jörgren
- Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
- Lund University, Lund, Sweden
| | - Marie-Louise Lydrup
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Pamela Buchwald
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Mariusdottir E, Jörgren F, Saeed M, Wikström J, Lydrup ML, Buchwald P. Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study. Langenbecks Arch Surg 2024; 409:55. [PMID: 38321307 PMCID: PMC10847187 DOI: 10.1007/s00423-024-03237-8] [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: 11/07/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure. METHODS Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis. RESULTS Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure. CONCLUSIONS The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.
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Affiliation(s)
- Elin Mariusdottir
- Department of Surgery, Helsingborg Hospital, Charlotte Yhlens gata 10, 25223, Helsingborg, Sweden.
- Lund University, Lund, Sweden.
| | - Fredrik Jörgren
- Department of Surgery, Helsingborg Hospital, Charlotte Yhlens gata 10, 25223, Helsingborg, Sweden
- Lund University, Lund, Sweden
| | - Maria Saeed
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jens Wikström
- Lund University, Lund, Sweden
- Department of Surgery, Kristianstad Hospital, Kristianstad, Sweden
| | - Marie-Louise Lydrup
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Pamela Buchwald
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Smart N. New year, new beginning? The death of the single institution case series. Colorectal Dis 2024; 26:5-6. [PMID: 38279533 DOI: 10.1111/codi.16858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
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Secher J, Balachandran R, Iversen LH. Incidence and risk factors of blowout within 90 days after a primary Hartmann's procedure: a retrospective cohort study. Langenbecks Arch Surg 2023; 408:275. [PMID: 37442862 PMCID: PMC10345077 DOI: 10.1007/s00423-023-02967-5] [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: 11/14/2022] [Accepted: 06/01/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE The literature reports a varying occurrence (3-33%) of blowout of the rectal remnant after Hartmann's procedure, and there is a lack of multivariate analyses on potential risk factors for blowout following Hartmann's procedure. We aimed to estimate the incidence of blowout within 90 days after a primary Hartmann's procedure and to identify potential risk factors for blowout through multivariate analysis. METHODS A retrospective cohort study was conducted at the Department of Surgery, Aarhus University Hospital, a Danish primary and tertiary hospital. Patients who underwent primary surgery with Hartmann's procedure irrespective of surgical setting and indications between September 2016 and August 2021 were included. Blowout was defined as a defective closure line of the rectal stump or a pelvic abscess. RESULTS A total of 178 patients were included, and blowout occurred in 30 patients (16.9%) within 90 days after a primary Hartmann's procedure. Multivariate analysis showed increased risk of blowout among patients with Hinchey IV diverticulitis (relative risk 6.32 (95% CI 4.09-9.75)), previous radiotherapy (relative risk 3.35 (95% CI 1.67-6.74)), and alcohol overconsumption (relative risk 1.69 (95% CI 1.05-2.72)). Intraoperative insertion of a Foley catheter in the rectal remnant significantly reduced the risk of blowout within 90 days after a primary Hartmann's procedure (relative risk 0.18 (95% CI 0.05-0.65)). CONCLUSION Blowout remains a severe and common complication within 90 days after a primary Hartmann's procedure. Hinchey IV diverticulitis, pelvic radiotherapy, and alcohol overconsumption are risk factors. An intraoperatively inserted rectal Foley catheter is a protective factor and can be considered used in all patients undergoing Hartmann's procedure.
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Affiliation(s)
- Josefine Secher
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark.
| | - Rogini Balachandran
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Mariusdottir E, Jörgren F, Mondlane A, Wikström J, Lydrup ML, Buchwald P. Low incidence of pelvic sepsis following Hartmann's procedure for rectal cancer: a retrospective multicentre study. BMC Surg 2022; 22:421. [PMID: 36494661 PMCID: PMC9733326 DOI: 10.1186/s12893-022-01858-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Results of previous studies regarding pelvic sepsis after Hartmann's procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated. METHODS Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007-2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model. RESULTS A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20-92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54-35.36) and BMI over 25 kg/m2 (OR 5.26, 95% CI 1.80-19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery. CONCLUSION Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.
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Affiliation(s)
- Elin Mariusdottir
- grid.413823.f0000 0004 0624 046XDepartment of Surgery, Helsingborg Hospital, Charlotte Yhlens Gata 10, 25223 Helsingborg, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
| | - Fredrik Jörgren
- grid.413823.f0000 0004 0624 046XDepartment of Surgery, Helsingborg Hospital, Charlotte Yhlens Gata 10, 25223 Helsingborg, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
| | - Amelia Mondlane
- grid.411843.b0000 0004 0623 9987Department of Surgery, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
| | - Jens Wikström
- Department of Surgery, Kristianstad Hospital, Kristianstad, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
| | - Marie-Louise Lydrup
- grid.411843.b0000 0004 0623 9987Department of Surgery, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
| | - Pamela Buchwald
- grid.411843.b0000 0004 0623 9987Department of Surgery, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Lund University, Lund, Sweden
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Choy KT, Lee DJ, Prabhakaran S, Warrier S, Heriot A, Kong JC. The complication profile of low Hartmann's in rectal cancer: a systematic review and meta-analysis. ANZ J Surg 2022; 92:2829-2839. [PMID: 35727062 DOI: 10.1111/ans.17827] [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: 11/30/2021] [Revised: 04/12/2022] [Accepted: 05/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Non-restorative options for low rectal cancer not invading the sphincter includes low Hartmann's procedure (LH) and inter-sphincteric abdominoperineal resection (ISAPR). There is currently little comparative data to differentiate these options. OBJECTIVES The aim of this review was to assess the peri-operative morbidity of LH, and then to compare it to that of ISAPR. DATA SOURCES An up-to-date systematic review was performed on the available literature between 2000-2020 on PubMed, EMBASE, Medline, and Cochrane Library databases. STUDY SELECTION All studies reporting on non-restorative surgeries for rectal cancer were analysed. Outcomes were firstly analysed between LH and non-LH groups, with further sub-analysis comparing the LH and ISAPR groups. MAIN OUTCOME MEASURE The main outcome measures were the rates of pelvic sepsis, rates of overall post-operative complication rates, oncological outcomes, and survival. RESULTS A total of 12 observational studies were included. There were 3526 patients (61.1%) in the LH group, and 2238 patients (38.9%) in the non-LH group, which included 461 patients who underwent ISAPR. The LH group had a higher rate of pelvic sepsis as compared to the non-LH group (OR: 1.79, 95% CI: 1.39-2.29, P < 0.001). The difference is more marked in the sub-analysis comparing LH and ISAPR alone (OR: 3.94, 95% CI: 1.88-7.84, P < 0.01) corresponding to a higher rate of unplanned re-intervention. LH was associated with a higher rate of short-term post-operative mortality as compared to the non-LH group. CONCLUSION ISAPR is the preferred option for non-restorative rectal surgery, with a more favourable peri-operative morbidity and short-term mortality profile as compared to LH.
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Affiliation(s)
- Kay Tai Choy
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Dewei Jordan Lee
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Swetha Prabhakaran
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Satish Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer. Int J Colorectal Dis 2021; 36:2585-2598. [PMID: 34272997 DOI: 10.1007/s00384-021-03993-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Non-restorative surgery for rectal cancer is indicated in patients with comorbidities, advanced disease and poor continence. The aim of this meta-analysis was to compare the postoperative morbidity of Hartmann's procedure (HP) with that of extrasphincteric and intersphincteric abdominoperineal resection (APR) in the treatment of rectal cancer. METHODS The Medline, Embase and Cochrane databases were searched for publications comparing postoperative morbidity of HP and APR. The incidence of overall surgical complications, pelvic-perineal complications and pelvic abscess was analysed as primary endpoints. Readmissions requiring reintervention and postoperative mortality were also compared. RESULTS A cumulative analysis showed a significantly higher rate of overall complications (odds ratio (OR) 0.553, 95% confidence interval (CI) 0.320 to 0.953 and P value 0.033) and pelvic-perineal complications (OR 0.464, 95% CI 0.250 to 0.861 and P value 0.015) after APR. The incidence of isolated pelvic abscess formation was significantly higher after HP (OR 2.523, 95% CI 1.383 to 4.602 and P value 0.003). A subgroup analysis of intersphincteric APR compared with HP did not show any significant difference in the incidence of overall complications, pelvic-perineal complications or pelvic abscess formation (P values of 0.452, 0.258 and 0.100, respectively). There was no significant difference in readmissions, reinterventions and mortality after HP and APR (P 0.992, 0.198 and 0.151). CONCLUSION An extrasphincteric APR is associated with higher overall and pelvic-perineal complications and may be reserved for tumours invading the anal sphincter complex. In the absence of sphincter involvement, both HP and intersphincteric APR are better alternatives with comparable morbidity.
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Mathew R. Hartmann's procedure versus intersphincteric abdominoperineal excision for mid to low rectal cancers - are they comparable? Colorectal Dis 2021; 23:751-752. [PMID: 33368939 DOI: 10.1111/codi.15505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Ronnie Mathew
- Department of Colorectal Surgery, Singhealth, Singapore City, Singapore
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