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Patel SV, Wiseman V, Zhang L, Merchant SJ, Caycedo-Marulanda A, MacDonald PH. The impact of robotic rectal cancer surgery at a Canadian regional cancer centre: a retrospective cohort study. Can J Surg 2024; 67:E206-E213. [PMID: 38692680 PMCID: PMC11068423 DOI: 10.1503/cjs.002523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Although robotic surgery has several advantages over other minimally invasive surgery (MIS) techniques for rectal cancer surgery, the uptake in Canada has been limited owing to a perceived increase in cost and lack of training. The objective of this study was to determine the impact of access to robotic surgery in a Canadian setting. METHODS We conducted a retrospective cohort study involving consecutive adults undergoing surgical resection for rectal cancer between 2017 and 2020. The primary exposure was access to robotic surgery. Outcomes included MIS utilization, short-term outcomes, total cost of care, and quality of surgical resection. We completed univariate and multivariate analyses. RESULTS We included 171 individuals in this cohort study (85 in the prerobotic period and 86 in the robotic period). The 2 groups had similar baseline characteristics. A higher proportion of individuals underwent successful MIS in the robotic phase (86% v. 46%, p < 0.001). Other benefits included a shorter mean length of hospital stay (5.1 d v. 9.2 d, p < 0.001). The quality of surgical resection was similar between groups. The total cost of care was $16 746 in the robotic period and $18 808 in the prerobotic period (mean difference -$1262, 95% confidence interval -$4308 to $1783; p = 0.4). CONCLUSION Access to robotic rectal cancer surgery increased successful completion of MIS and shortened hospital stay, with a similar total cost of care. Robotic rectal cancer surgery can enhance patient outcomes in the Canadian setting.
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Affiliation(s)
- Sunil V Patel
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda).
| | - Vanessa Wiseman
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda)
| | - Lisa Zhang
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda)
| | - Shaila J Merchant
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda)
| | - Antonio Caycedo-Marulanda
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda)
| | - P Hugh MacDonald
- From the Department of Surgery, Queen's University, Kingston, Ont. (Patel, Wiseman, Merchant, MacDonald); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Zhang); Orlando Health, Orlando, United States (Caycedo-Marulanda)
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Guo J, Yang D, Zhang B, Xu X, Yang Z, Zhao Y, Zheng Z, Meng X, Zhang T. The safety of Pfannenstiel incision for specimen extraction in laparoscopic colorectal surgery for colorectal cancer: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne 2024; 19:1-10. [PMID: 38974765 PMCID: PMC11223536 DOI: 10.5114/wiitm.2023.134194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/18/2023] [Indexed: 07/09/2024] Open
Abstract
Introduction The Pfannenstiel incision is often used in gynecological Cesarean section; however, there is limited research on the use of the Pfannenstiel incision for specimen extraction in laparoscopic surgery for the treatment of colorectal cancer. Aim To evaluate the safety of using the Pfannenstiel incision for specimen extraction in laparoscopic surgery for colorectal cancer patients. Material and methods PubMed, Embase, Web of Science, Cochrane Library, CNKI, VIP and WanFangData were searched for studies published up to March 10, 2023; a random-effects model (RCT) and a fixed-effect model were used to evaluate the safety. Operative time, length of extraction skin incision, overall complications, superficial wound infection, organ/space surgical site infection and incisional hernia were evaluated. Results A total of 5 studies were included in this research. There were no significant advantages in operation time, length of the incision, overall complications, superficial wound infection and organ/space surgical site in the Pfannenstiel group compared to the no Pfannenstiel group. However, the Pfannenstiel incision has a tendency to increase the length of the incision (SMD = 0.05; 95% CI = -0.22 to 0.33; p = 0.71) and the results of the remaining five (operative time,overall complications,incisional hernia, incisional infection and organ/space surgical site infection) are slightly skewed toward the Pfannenstiel incision. It is worth mentioning that incisional hernia (IH) may have an advantage in the Pfannenstiel group compared to the no Pfannenstiel group. Four studies were not at clear risk of bias and two studies were at risk of bias. Conclusions Our study concludes that the Pfannenstiel incision has a good safety record and it is a good option for extracting specimens during laparoscopic surgery for colon cancer. The Pfannenstiel incision used for laparoscopic surgical specimen extraction has a significantly lower incidence of incisional hernia over no Pfannenstiel.
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Affiliation(s)
- Jingjing Guo
- Liaoning University of Traditional Chinese Medicine, China
| | - Dong Yang
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Bao Zhang
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Xing Xu
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Zhuo Yang
- Department of Gynecology, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Yan Zhao
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Zhichao Zheng
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Xiangyu Meng
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
| | - Tao Zhang
- Department of Gastric Cancer, Cancer Hospital of Dalian University of Technology (Liaoning Cancer Hospital and Institute), Shenyang, Liaoning, China
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Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes. J Clin Med 2022; 11:jcm11071827. [PMID: 35407434 PMCID: PMC8999956 DOI: 10.3390/jcm11071827] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 12/24/2022] Open
Abstract
In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.
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Patel SV, Wiseman V, Zhang L, MacDonald PH, Merchant SM, Barnett KW, Caycedo-Marulanda A. The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short term outcomes: A Canadian perspective. Surg Endosc 2022; 36:6084-6094. [PMID: 35212820 DOI: 10.1007/s00464-022-09059-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Robotic surgery for colorectal pathology has gained interest as it can overcome technical challenges and limitations of traditional laparoscopic surgery. A lack of training and costs have been cited as reasons for limiting its use in Canada. The objective of this paper was to assess the impact of robotic surgery on outcomes and costs in a Canadian setting. METHODS This is a retrospective study of consecutive patients undergoing left sided colorectal surgery ("Pre-Robotic Phase" n = 145 vs. "Post Robotic Phase" n = 150) and a single tertiary care centre in Ontario, Canada. Utilization and success of minimally invasive surgery (MIS), length of stay, complications and hospital costs were compared. Univariate and Multivariate analysis was used for these comparisons. RESULTS Characteristics, diagnosis and type of resection were similar between groups. Robotic Implementation resulted in higher rates of successful MIS (i.e. attempt at MIS without conversion) (85% vs. 47%, P < 0.001), shorter mean length of stay (4.7 days vs. 8.4 days, P < 0.001), and similar mean operative times (3.9 h vs. 3.9 h, P = 0.93). Emergency Department visits were fewer in the Robotic Phase (24% vs. 34%, P = 0.04), with no difference in readmission, anastomotic leak or unplanned reoperation. After robotic implementation, the mean total hospital costs decreased, but this was not statistically significant (-$1453, 95% CI -$3974 to +$1068, P = 0.25). Regression analysis, adjusting for age, gender, obesity, ASA and procedure showed similar findings (Robotic Phase -$657, 95% CI -$3038 to +$1724, vs Pre Robotic Phase [Reference], P = 0.59). INTERPRETATION Implementation of a robotic colorectal surgery program in a Canadian tertiary care centre showed improved clinical outcomes, without a significant increase in the cost of care. Although this study is from a single institution, we have demonstrated that robotic colorectal surgery is feasible and can be cost effective in the right setting.
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Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queens University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Vanessa Wiseman
- Department of Surgery, Queens University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Lisa Zhang
- Department of Surgery, Queens University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - P Hugh MacDonald
- Department of Surgery, Queens University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Shaila M Merchant
- Department of Surgery, Queens University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | | | - Antonio Caycedo-Marulanda
- Department of Surgery, Queens University, Kingston, ON, Canada. .,Kingston Health Sciences Centre, Kingston, ON, Canada.
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Link KH, Kornmann M, Staib L, Kreuser ED, Gaus W, Röttinger E, Suhr P, Maulbecker-Armstrong C, Danenberg P, Danenberg K, Schatz M, Sander S, Ji ZL, Li JT, Peng SY, Bittner R, Beger HG, Traub B. Patient-centered developments in colon- and rectal cancer with a multidisciplinary international team: From translational research to national guidelines. World J Gastrointest Surg 2021; 13:1597-1614. [PMID: 35070066 PMCID: PMC8727190 DOI: 10.4240/wjgs.v13.i12.1597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/07/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023] Open
Abstract
Rarely, scientific developments centered around the patient as a whole are published. Our multidisciplinary group, headed by gastrointestinal surgeons, applied this research philosophy considering the most important aspects of the diseases "colon- and rectal cancer" in the long-term developments. Good expert cooperation/knowledge at the Comprehensive Cancer Center Ulm (CCCU) were applied in several phase III trials for multimodal treatments of primary tumors (MMT) and metastatic diseases (involving nearly 2000 patients and 64 centers), for treatment individualization of MMT and of metastatic disease, for psycho-oncology/quality of life involving the patients' wishes, and for disease prevention. Most of the targets initially were heavily rejected/discussed in the scientific communities, but now have become standards in treatments and national guidelines or are topics in modern translational research protocols involving molecular biology for e.g., "patient centered individualized treatment". In this context we also describe the paths we had to tread in order to realize our new goals, which at the end were highly beneficial for the patients from many points of view. This description is also important for students and young researchers who, with an actual view on our recent developments, might want to know how medical progress was achieved.
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Affiliation(s)
- Karl-Heinrich Link
- Asklepios Tumor Center (ATC) and Surgical Center, Asklepios Paulinen Klinik, Wiesbaden 65197, Germany
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Marko Kornmann
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Ludger Staib
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Ernst-Dietrich Kreuser
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
| | - Wilhelm Gaus
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Biometry and Medical Documentation, University of Ulm, Ulm 89081, Germany
| | - Erwin Röttinger
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Radiotherapy, University of Ulm, Ulm 89081, Germany
| | - Peter Suhr
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Radiotherapy, University of Ulm, Ulm 89081, Germany
| | - Catharina Maulbecker-Armstrong
- Fachbereich Gesundheit, Medizinisches Management, Sozialversicherungssysteme, Internationales Versorgungsmanagement, e-Health, Technische Hochschule Mittelhessen, Giessen 35390, Germany
| | - Peter Danenberg
- Department of Biochemistry and Molecular Medicine, Keck-USC School of Medicine, Los Angeles, CA 90033, United States
| | - Kathleen Danenberg
- Norris Comprehensive Cancer Center, Keck-USC School of Medicine, Los Angeles, CA 90033, United States
| | - Miriam Schatz
- Private Practice for Psychology, Adelsdorf 91325, Germany
| | - Silvia Sander
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Biometry and Medical Documentation, University of Ulm, Ulm 89081, Germany
| | - Zhen-Ling Ji
- Department of General Surgery, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Jiang-Tao Li
- Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Shu-You Peng
- Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Reinhard Bittner
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Surgical Clinic, Marienhospital, Stuttgart 70177, Germany
| | - Hans Günther Beger
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Benno Traub
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
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Cuk P, Kjær MD, Mogensen CB, Nielsen MF, Pedersen AK, Ellebæk MB. Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis. Surg Endosc 2021; 36:32-46. [PMID: 34724576 PMCID: PMC8741661 DOI: 10.1007/s00464-021-08782-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/17/2021] [Indexed: 12/12/2022]
Abstract
Background Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS). Methods Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I2, and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE. Results Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD = − 0.29, 95% CI [− 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE. Conclusion RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08782-7.
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Affiliation(s)
- Pedja Cuk
- Surgical Department, University Hospital of Southern Jutland, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Mie Dilling Kjær
- Research Unit for Surgery, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | | | - Michael Festersen Nielsen
- Surgical Department, University Hospital of Southern Jutland, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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Cuk P, Simonsen RM, Komljen M, Nielsen MF, Helligsø P, Pedersen AK, Mogensen CB, Ellebæk MB. Improved perioperative outcomes and reduced inflammatory stress response in malignant robot-assisted colorectal resections: a retrospective cohort study of 298 patients. World J Surg Oncol 2021; 19:155. [PMID: 34022914 PMCID: PMC8141231 DOI: 10.1186/s12957-021-02263-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
Background Robot-assisted surgery is increasingly implemented for the resection of colorectal cancer, although the scientific evidence for adopting this technique is still limited. This study’s main objective was to compare short-term complication rates, oncological outcomes, and the inflammatory stress response after colorectal resection for cancer performed laparoscopic or robot-assisted. Methods We conducted a retrospective cohort study comparing the robot-assisted approach to laparoscopic surgery for elective malignant colorectal neoplasm. Certified colorectal and da Vinci ® robotic surgeons performed resections at a Danish tertiary colorectal high volume center from May 2017 to March 2019. We analyzed the two surgical groups using uni- and multivariate regression analyses to detect differences in intra- and postoperative clinical outcomes and the inflammatory stress response. Results Two hundred and ninety-eight patients were enrolled in the study. Significant differences favoring robot-assisted surgery was demonstrated for; length of hospital stay (4 days, interquartile range (4, 5) versus 5 days, interquartile range (4–7), p < 0.001), and intraoperative blood loss (50 mL, interquartile range (20–100) versus 100 mL, interquartile range (50–150), p < 0.001) compared to laparoscopic surgery. The inflammatory stress response was significantly higher after laparoscopic compared to robot-assisted surgery reflected by an increase in C-reactive protein concentration (exponentiated coefficient = 1.23, 95% confidence interval (1.06–1.46), p = 0.008). No differences between the two groups were found concerning mortality, microradical resection rate, conversion to open surgery, and surgical or medical short-term complication rates. Conclusion Robot-assisted surgery is feasible and can be safely implemented for colorectal resections. The robot-assisted approach, when compared to laparoscopic surgery, was associated with improved intra- and postoperative outcomes. Extensive prospective studies are needed to determine the short- and long-term outcomes of robotic surgery for colorectal cancer.
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Affiliation(s)
- Pedja Cuk
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark. .,Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark. .,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
| | | | - Mirjana Komljen
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Michael Festersen Nielsen
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark.,Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark
| | - Per Helligsø
- Department of Surgery, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Surgical Department, Odense University Hospital, Odense, Denmark
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