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Ubels S, Verstegen MHP, Klarenbeek BR, Bouwense S, van Berge Henegouwen MI, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Nieuwenhuijzen G, Polat F, Schouten J, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Treatment of anastomotic leak after oesophagectomy for oesophageal cancer: large, collaborative, observational TENTACLE cohort study. Br J Surg 2023; 110:852-863. [PMID: 37196149 PMCID: PMC10364505 DOI: 10.1093/bjs/znad123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/16/2023] [Accepted: 04/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Anastomotic leak is a severe complication after oesophagectomy. Anastomotic leak has diverse clinical manifestations and the optimal treatment strategy is unknown. The aim of this study was to assess the efficacy of treatment strategies for different manifestations of anastomotic leak after oesophagectomy. METHODS A retrospective cohort study was performed in 71 centres worldwide and included patients with anastomotic leak after oesophagectomy (2011-2019). Different primary treatment strategies were compared for three different anastomotic leak manifestations: interventional versus supportive-only treatment for local manifestations (that is no intrathoracic collections; well perfused conduit); drainage and defect closure versus drainage only for intrathoracic manifestations; and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis. The primary outcome was 90-day mortality. Propensity score matching was performed to adjust for confounders. RESULTS Of 1508 patients with anastomotic leak, 28.2 per cent (425 patients) had local manifestations, 36.3 per cent (548 patients) had intrathoracic manifestations, 9.6 per cent (145 patients) had conduit ischaemia/necrosis, 17.5 per cent (264 patients) were allocated after multiple imputation, and 8.4 per cent (126 patients) were excluded. After propensity score matching, no statistically significant differences in 90-day mortality were found regarding interventional versus supportive-only treatment for local manifestations (risk difference 3.2 per cent, 95 per cent c.i. -1.8 to 8.2 per cent), drainage and defect closure versus drainage only for intrathoracic manifestations (risk difference 5.8 per cent, 95 per cent c.i. -1.2 to 12.8 per cent), and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis (risk difference 0.1 per cent, 95 per cent c.i. -21.4 to 1.6 per cent). In general, less morbidity was found after less extensive primary treatment strategies. CONCLUSION Less extensive primary treatment of anastomotic leak was associated with less morbidity. A less extensive primary treatment approach may potentially be considered for anastomotic leak. Future studies are needed to confirm current findings and guide optimal treatment of anastomotic leak after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ubels S, Lubbers M, Verstegen MHP, Bouwense SAW, van Daele E, Ferri L, Gisbertz SS, Griffiths EA, Grimminger P, Hanna G, Hubka M, Law S, Low D, Luyer M, Merritt RE, Morse C, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Reynolds JV, Ribeiro U, Rosati R, Shen Y, Wijnhoven BPL, Klarenbeek BR, van Workum F, Rosman C. Treatment of anastomotic leak after esophagectomy: insights of an international case vignette survey and expert discussions. Dis Esophagus 2022; 35:doac020. [PMID: 35411928 PMCID: PMC9753084 DOI: 10.1093/dote/doac020] [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: 11/18/2021] [Revised: 03/11/2022] [Accepted: 02/14/2022] [Indexed: 12/16/2022]
Abstract
Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merel Lubbers
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elke van Daele
- Department of Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter Grimminger
- Department of Surgery, University Medical Center Mainz, Mainz, Germany
| | - George Hanna
- Department of Surgery, Imperial College, London, UK
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Donald Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Robert E Merritt
- Department of Surgery, Ohio State University - Wexner Medical Center, Columbus, OH, USA
| | - Christopher Morse
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carmen L Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Surgery, Department of Upper Abdominal Diseases, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - John V Reynolds
- Department of Surgery, Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Ulysses Ribeiro
- Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital IRCCS, Milan, Italy
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Liesenfeld LF, Sauer P, Diener MK, Hinz U, Schmidt T, Müller-Stich BP, Hackert T, Büchler MW, Schaible A. Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection. BMC Surg 2020; 20:324. [PMID: 33298038 PMCID: PMC7726907 DOI: 10.1186/s12893-020-00995-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Early diagnosis of anastomotic leakage (AL) after esophageal resection is crucial for the successful management of this complication. Inflammatory serological markers are indicators of complications during the postoperative course. The aim of the present study was to evaluate the prognostic value of routine inflammatory markers to predict anastomotic leakage after transthoracic esophageal resection. METHODS Data from all consecutive patients undergoing transthoracic esophageal resection between January 2010 and December 2016 were analyzed from a prospective database. Besides clinicodemographic parameters, C-reactive protein, white blood cell count and albumin were analyzed and the Noble/Underwood (NUn) score was calculated to evaluate their predictive value for postoperative anastomotic leakage. Diagnostic accuracy was measured by sensitivity, specificity, and negative and positive predictive values using area under the receiver operator characteristics curve. RESULTS Overall, 233 patients with transthoracic esophageal resection were analyzed, 30-day mortality in this group was 3.4%. 57 patients (24.5%) suffered from AL, 176 patients were in the AL negative group. We found significant differences in WBCC, CRP and NUn scores between patients with and without AL, but the analyzed markers did not show an independent relevant prognostic value. For CRP levels below 155 mg/dl from POD3 to POD 7 the negative predictive value for absence of AI was > 80%. Highest diagnostic accuracy was detected for CRP levels on 4th POD with a cut-off value of 145 mg/l reaching negative predictive value of 87%. CONCLUSIONS In contrast to their prognostic value in other surgical procedures, CRP, WBCC and NUn score cannot be recommended as independent markers for the prediction of anastomotic leakage after transthoracic esophageal resection. CRP is an accurate negative predictive marker and discrimination of AL and no-AL may be helpful for postoperative clinical management. Trial registration The study was approved by the local ethical committee (S635-2013).
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Affiliation(s)
- Lukas F Liesenfeld
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ulf Hinz
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Anja Schaible
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
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Yadav K, Chaudhary S. Latissimus Dorsi Muscle Onlay Flap Post-esophagectomy Leakage with Mediastinitis and Failed Stenting. Indian J Surg Oncol 2020; 11:105-108. [DOI: https:/doi.org/10.1007/s13193-020-01045-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 01/27/2020] [Indexed: 10/30/2023] Open
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Latissimus Dorsi Muscle Onlay Flap Post-esophagectomy Leakage with Mediastinitis and Failed Stenting. Indian J Surg Oncol 2020; 11:105-108. [DOI: 10.1007/s13193-020-01045-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 01/27/2020] [Indexed: 11/26/2022] Open
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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Common postoperative anatomy that requires special endoscopic consideration. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Endoscopy after esophagectomy: Safety demonstrated in a porcine model. J Thorac Cardiovasc Surg 2017; 154:1152-1158. [DOI: 10.1016/j.jtcvs.2016.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/26/2016] [Accepted: 12/17/2016] [Indexed: 12/19/2022]
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Hao JF, Cui HM, Han JM, Bai JX, Song X, Cao N. Tele-ICU: the way forward in geriatric care? Aging Clin Exp Res 2014; 26:575-82. [PMID: 24803284 DOI: 10.1007/s40520-014-0217-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 03/25/2014] [Indexed: 11/24/2022]
Abstract
Aging population is set to increase in the near future, and will need specialized care when admitted to ICUs. The elderly are beset with chronic conditions, such as cardiovascular, COPD, diabetes, renal complications and depression. Specialist opinions can now be made available through telemedicine facilities. Tele-ICU is a specialized hub consisting of highly skilled staff trained in critical care able to deliver timely, quality care service to patients admitted to ICUs in remote areas using highly advanced information technology services. These specialists in the tele-ICU hub are able to analyze and gather data arriving at timely interventional management decisions and provide this vital feedback to the nursing staff and doctors manning remote ICU locations where specialized intensivist may not be available. Known clinical benefits of such a system include better patient outcomes, reduced medical errors, mortality and reduced hospital length of stay. The main disadvantage in implementation could be the upfront high cost involved, for which low-cost models are being explored. In the face of delivering such remote care, it is up to the local health policy to make legislative changes to include associated legal and ethical issues. Considering the burgeoning aging population, tele-ICU could become the way forward in delivering geriatric critical care.
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Affiliation(s)
- Jun-Feng Hao
- Department of Blood Purification, General Hospital of Shenyang Military Area Command, 83 Wenhua Road, Shenyang, 110000, China
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Agarwal BB, Jha SK, Agarwal S, Goyal K, Chintamani. Esophagectomy: anastomotic leak, stent the rent! Saudi J Gastroenterol 2014; 20:1-4. [PMID: 24496153 PMCID: PMC3952416 DOI: 10.4103/1319-3767.126304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Brij B. Agarwal
- Department of Surgical Disciplines, Ganga Ram Institute of Post-graduate Medical Education and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Sandeep K. Jha
- Department of Surgical Gastroenterology and Liver Transplant, Ganga Ram Institute of Post-graduate Medical Education and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Sneh Agarwal
- Department of Anatomy, Lady Hardinge Medical College, New Delhi, India
| | - Karan Goyal
- Department of General Surgery, Ganga Ram Institute of Post-graduate Medical Education and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Chintamani
- Department of Surgery, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India E-mail:
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