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Hu H, Zhou T, Qiu Y, Li Y, Liu W, Meng R, Zhang X, Ma A, Li H. Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:439-455. [PMID: 38222754 PMCID: PMC10783382 DOI: 10.1097/ms9.0000000000001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 01/16/2024] Open
Abstract
Background Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown. Objectives To investigate the prevalence of and risk factors for SSIs after PD. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs. Results A total of 98 704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust. Conclusion and relevance The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.
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Affiliation(s)
- Hongfei Hu
- School of International Pharmaceutical Business
| | - Ting Zhou
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Yijin Qiu
- School of International Pharmaceutical Business
| | - Yuxin Li
- School of International Pharmaceutical Business
| | - Wei Liu
- School of International Pharmaceutical Business
| | - Rui Meng
- School of International Pharmaceutical Business
| | - Xueke Zhang
- School of International Pharmaceutical Business
| | - Aixia Ma
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Hongchao Li
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
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Iida H, Kaibori M, Maehira H, Mori H, Nitta N, Maekawa T, Takebayashi K, Kaida S, Miyake T, Tani M. Colonization of the gastric juice by Candida spp. promotes surgical site infection after hepatectomy. Langenbecks Arch Surg 2023; 408:240. [PMID: 37338609 DOI: 10.1007/s00423-023-02978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/10/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Candida spp. cause opportunistic infections in conditions of immunodeficiency. Here, we investigated the relationship between colonization of the gastric juice by Candida spp. and surgical site infection (SSI) in hepatectomy. METHODS Consecutive hepatectomy cases between November 2019 and April 2021 were enrolled. Gastric juice samples (collected intraoperatively through a nasogastric tube) were cultured. We compared factors related to patient background, blood test findings, surgical findings, and postoperative complications between the Candida + group (positive for colonization of the gastric juice by Candida spp.) and the Candida - group (negative). In addition, we identified the factors that contribute to SSI. RESULTS There were 29 and 71 patients in the Candida + and Candida - groups, respectively. The Candida + group was significantly older (average age: Candida + 74 years vs. Candida - 69 years; p = 0.02) and contained more patients negative for the hepatitis B and C virus (Candida + 93% vs. Candida - 69%; p = 0.02). SSI was significantly more common in the Candida + group (Candida + 31% vs. Candida - 9%; p = 0.01). Postoperative bile leakage and colonization of the gastric juice by Candida spp. were independent predictors of SSI. CONCLUSION Colonization of the gastric juice by Candida spp. is a risk factor for SSI after hepatectomy.
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Affiliation(s)
- Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
| | - Masaki Kaibori
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Nobuhito Nitta
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
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S. U, Sumana MN. Retrospective analysis on distribution and antifungal susceptibility profile of Candida in clinical samples: a study from Southern India. Front Public Health 2023; 11:1160841. [PMID: 37261242 PMCID: PMC10228385 DOI: 10.3389/fpubh.2023.1160841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/13/2023] [Indexed: 06/02/2023] Open
Abstract
Introduction Candida is one of the rising primary causes of infections connected with health care. However, their distribution and susceptibility patterns vary widely amongst different regions. Method The study was carried out to retrospectively analyze the distribution of Candida in various clinical samples, their species types and susceptibility, in a tertiary care hospital, in India for 4 years using the Vitek-2 database. Results Candida infection was identified in 751 clinical samples, and the major source of infection was found to be urine samples accounting for about 58.32%. A total of 18 different Candida species were recorded. Non-albicans Candida (NAC) 73.64% (n = 553) predominated Candida albicans 26.36% (n = 198). Candida tropicalis was found to be identified at a higher frequency followed by C. albicans, Candida glabrata and Candida parapsilosis. Candida tropicalis was the only species which were recovered from bile; Candida pelliculosa was recorded merely from blood and Candida lipolytica from urine and blood and not in any other samples. In vaginal swabs, C. albicans accounted for 63.64% (n = 14) compared to NAC 36.36% (n = 8). The susceptibility test revealed that 75.44% (n = 559) isolates were susceptible and 24.56% (n = 182) were resistant to one or more drugs tested. Major resistance was exhibited to flucytosine by C. tropicalis 77.46% (n = 55) compared to C. albicans 11.27% (n = 8). Apart from C. albicans, NAC-C. tropicalis, C. glabrata and Candida krusei showed resistance to echinocandins, and Candida haemulonii to amphotericin-B. Conclusion The knowledge of the incidence, resistance and emergence of different species might guide clinicians to select an appropriate antifungal therapy and plan effective strategies to control invasive and systemic Candida infections.
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Affiliation(s)
- Umamaheshwari S.
- Department of Microbiology, School of Life Sciences, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - M. N. Sumana
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
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Intraoperative Bile Culture in Pancreaticoduodenectomy: Teaching Old Dogma New Tricks. J Gastrointest Surg 2022; 26:30-38. [PMID: 34704185 DOI: 10.1007/s11605-021-05182-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/15/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Biliary stents increase surgical site infections (SSIs) following pancreaticoduodenectomy due to bactibilia and contaminated intraoperative bile spillage. Intraoperative bile culture (IOBC) is performed to guide empiric therapy for SSIs; however, its utility is poorly studied. We sought to evaluate IOBC and the interplay between stenting, bactibilia, and SSI following pancreaticoduodenectomy. METHODS Patients undergoing pancreaticoduodenectomy from January 2008 to April 2020 were identified through our institutional National Surgical Quality Improvement Project (NSQIP) database; patients without IOBC were excluded. Odds of SSI were analyzed with multivariable logistic regression. RESULTS Four-hundred-eighty-three patients were identified. One-hundred-eighty-nine (39%) patients had plastic stents and 154 (32%) had metal stents. Three-hundred-twenty-nine (96%) patients with stents had bactibilia versus 18 (13%) without stents (P < 0.001). The biliary microbiome and antibiotic resistance patterns in patients with metal and plastic stents were nearly identical. Of 159 NSQIP-defined SSIs, most were incisional (n = 92, 58%). Bactibilia and stent presence were associated with incisional (OR 3.69 and 3.39, both P < 0.001) but not organ space SSI (P > 0.1); however, stent type was not (P > 0.5). Of the 73 speciated SSI cultures, an IOBC-identified organism was present in 42 (58%), while at least one organism not found in the IOBC was present in 49 (67%). CONCLUSION Bactibilia is associated with incisional but not organ space SSI following pancreaticoduodenectomy and is strongly associated with stent presence. Stent type does not independently influence the biliary microbiome or SSI risk. IOBC has a poor ability to predict causative organisms in SSIs following pancreaticoduodenectomy and is not recommended for routine use.
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Lin YJ, Ho TW, Wu CH, Kuo TC, Yang CY, Wu JM, Tien YW. Specific Bile Microorganisms Caused by Intra-Abdominal Abscess on Pancreaticoduodenectomy Patients: A Retrospective Cohort Study. Curr Oncol 2021; 29:111-121. [PMID: 35049683 PMCID: PMC8774444 DOI: 10.3390/curroncol29010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
We retrospectively collected PD patients with a performance of bile culture between 2007 and 2019 in our institute. As to bile culture, we used a swab to do intraoperative bile cultures after transection of the CBD. IAA was defined as the documental bacteriological culture from either a turbid discharge from the intraoperatively placed drain in patients with a clinical picture consistent with infection or a postoperative fluid collection managed by CT-guided placement of drains. A total of 1244 PD patients were identified, and 539 (43.3%) subjects with bile sampling were included for analysis. Among these study patients, 433 (80.3%) developed bile contamination (positive bile culture). Bile contamination showed a significantly higher rate of IAA compared to non-bile contamination (17.1% vs. 0.9%, p < 0.001). The rate of co-shared microorganisms in both bile and abscess was 64.1%. On the multivariate analysis, age and specific bile microorganisms (Enterococcus species, Escherichia Coli, Streptococcus species, Citrobacter species, and Candida) are significantly associated with development of IAA. Specific bile microorganisms are the highly significant factors associated with development of IAA. The strategy to prevent bile spillage during PD should be considered to minimize afterward contamination of the abdominal cavity and prevent IAA.
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Affiliation(s)
- Young-Jen Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Te-Wei Ho
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Chien-Hui Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County 302, Taiwan
- Correspondence: (J.-M.W.); (Y.-W.T.)
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County 302, Taiwan
- Correspondence: (J.-M.W.); (Y.-W.T.)
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Gyoten K, Kato H, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kuriyama N, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. Association between gastric Candida colonization and surgical site infections after high-level hepatobiliary pancreatic surgeries: the results of prospective observational study. Langenbecks Arch Surg 2020; 406:109-119. [PMID: 33057821 PMCID: PMC7870610 DOI: 10.1007/s00423-020-02006-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 10/01/2020] [Indexed: 01/05/2023]
Abstract
AIM High-level hepatobiliary pancreatic (HBP) surgeries are highly associated with surgical site infections (SSIs), in which microorganisms have a significant role. In the present study, we investigated whether gastric Candida colonization had a significant role in SSIs after high-level HBP surgeries. METHODS Between May 2016 and February 2017, the 66 patients who underwent high-level HBP surgeries were enrolled in the present study. The gastric juice was prospectively collected through nasogastric tube after general anesthesia induction and was incubated onto the CHROMagar Candida plate for the cultivation of various Candida species. First of all, we compared the incidence of SSIs according to the presence or absence of Candida species in gastric juice. Secondly, we evaluated the variables contributing to the development of SSIs by multivariate analysis. The protocol was approved by the medical ethics committee of Mie University Hospital (No.2987). RESULTS Gastric Candida colonization was identified in 21 patients (group GC) and was not identified in the other 45 patients (group NGC). There were no differences in preoperative variables including compromised status, such as age, nutritional markers, complications of diabetes mellitus, and types of primary disease between the two groups. SSIs occurred in 57.1% (12/21) of group GC and in 17.8% (8/45) of group NGC, showing a significant difference (p = 0.001). Multivariate analysis revealed gastric Candida colonization as a significant risk factor of SSIs (OR 6.17, p = 0.002). CONCLUSION Gastric Candida colonization, which is not a result of immunocompromised status, is highly associated with SSIs after high-level HBP surgeries. TRIAL REGISTRATION Japan Primary Registries Network; UMIN-CTR ID: UMIN000040486 (retrospectively registered on 22nd May, 2020).
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Affiliation(s)
- Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan.
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
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Abe K, Kitago M, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Yokose T, Endo Y, Kitagawa Y. High risk pathogens and risk factors for postoperative pancreatic fistula after pancreatectomy; a retrospective case-controlled study. Int J Surg 2020; 82:136-142. [DOI: 10.1016/j.ijsu.2020.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022]
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Tortajada P, Sauvanet A, Truant S, Regenet N, Souche R, Benoist S, Muscari F, Regimbeau JM, Gaujoux S, Cunha AS, Schwarz L. Does Fungal Biliary Contamination after Preoperative Biliary Drainage Increase Postoperative Complications after Pancreaticoduodenectomy? Cancers (Basel) 2020; 12:E2814. [PMID: 33007843 PMCID: PMC7599947 DOI: 10.3390/cancers12102814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
(1) Background: preoperative biliary drainage before pancreaticoduodenectomy (PD) is associated with bacterial biliary contamination (>85%) and a significant increase in global and infectious complications. In view of the lack of published data, the aim of our study was to investigate the impact of fungal biliary contamination after biliary drainage on the complication rate after PD. (2) Methods: a multicentric retrospective study that included 224 patients who underwent PD after biliary drainage with intraoperative biliary culture. (3) Results: the global rate of positive intraoperative biliary sample was 92%. Respectively, the global rate of biliary bacterial contamination and the rate of fungal contamination were 75% and 25%, making it possible to identify two subgroups: bacterial contamination only (B+, n = 154), and bacterial and fungal contamination (BF+, n = 52). An extended duration of preoperative drainage (62 vs. 49 days; p = 0.08) increased the risk of fungal contamination. The overall and infectious complication rates were not different between the two groups. In the event of postoperative infectious or surgical complications, the infectious samples taken did not reveal more fungal infections in the BF+ group. (4) Conclusions: fungal biliary contamination, although frequent, does not seem to increase the rate of global and infectious complications after PD, preceded by preoperative biliary drainage.
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Affiliation(s)
- Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, CEDEX, France;
| | - Alain Sauvanet
- Department of Hepatobiliary and Liver Transplantation, Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118 Clichy, France;
| | - Stephanie Truant
- Department of Digestive Surgery and Transplantation, Hôpital Huriez, Rue Michel Polonowski, 59037 Lille, France;
| | - Nicolas Regenet
- Department of Digestive Surgery, CHU Nantes, 1 Place Alexis Ricordeau, 44000 Nantes, France;
| | - Régis Souche
- Department of Hepatobiliary and Transplantation, CHU Montpelliers, 191 Avenue du Doyen Gaston Giraud, 34295 Montpellier, CEDEX 5, France;
| | - Stéphane Benoist
- Department of Digestive Surgery, CHU du Kremlin Bicêtre, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France;
| | - Fabrice Muscari
- Department of Digestive Surgery and Transplantation, CHU Toulouse Rangueil, 1, Avenue du Pr Jean Poulhès, 31059 Toulouse, CEDEX, France;
| | - Jean Marc Regimbeau
- Department of Digestive Surgery, CHU Amiens-Picardie Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054 Amiens, CEDEX 1, France;
| | - Sebastien Gaujoux
- Department of Digestive Surgery, Hepatobiliary and Metabolic Surgery, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France;
| | - Antonio Sa Cunha
- Department of Hepatobiliary and Liver Transplantation, Centre Hépato-Biliaire de Paul Brousse, 38 rue de la Chapelle, 94800 Villejuif, France;
| | - Lillian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, CEDEX, France;
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