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Bader NA, Sweeney M, Zeymo A, Villano AM, Houlihan B, Bayasi M, Al-Refaie WB, Chan KS. Defining a minimum hospital volume threshold for minimally invasive colon cancer resections. Surgery 2021; 171:293-298. [PMID: 34429201 DOI: 10.1016/j.surg.2021.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized. METHODS This evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes. RESULTS In hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers. CONCLUSION A high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital's practice as open procedures may yield better oncologic results in low volume settings.
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Affiliation(s)
- Nicholas A Bader
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Matthew Sweeney
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | - Anthony M Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Brenna Houlihan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Mohammed Bayasi
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; Department of Colorectal Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; Department of Surgical Oncology, MedStar-Georgetown University Hospital, Washington, DC.
| | - Kitty S Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
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Louridas M, de Montbrun S. Competency-Based Education in Minimally Invasive and Robotic Colorectal Surgery. Clin Colon Rectal Surg 2021; 34:155-162. [PMID: 33814997 DOI: 10.1055/s-0040-1718683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Minimally invasive and robotic techniques have become increasingly implemented into surgical practice and are now an essential part of the foundational skills of training colorectal surgeons. Over the past 5 years there has been a shift in the surgical educational paradigm toward competency-based education (CBE). CBE recognizes that trainees learn at different rates but regardless, are required to meet a competent threshold of performance prior to independent practice. Thus, CBE attempts to replace the traditional "time" endpoint of training with "performance." Although conceptually sensible, implementing CBE has proven challenging. This article will define competence, outline appropriate assessment tools to assess technical skill, and review the literature on the number of cases required to achieve competence in colorectal procedures while outlining the barriers to implementing CBE.
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Affiliation(s)
- Marisa Louridas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Shirakawa Y, Noma K, Kunitomo T, Hashimoto M, Maeda N, Tanabe S, Sakurama K, Fujiwara T. Initial introduction of robot-assisted, minimally invasive esophagectomy using the microanatomy-based concept in the upper mediastinum. Surg Endosc 2020; 35:6568-6576. [PMID: 33170337 PMCID: PMC7654354 DOI: 10.1007/s00464-020-08154-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
Background We have recently standardized upper mediastinal lymph node dissection (UMLND) using a microanatomy-based concept in thoracoscopic esophagectomy in the prone position (TEPP), and introduced robot-assisted minimally invasive esophagectomy (RAMIE) using the same concept as in TEPP while aiming at solo surgery. The purpose of this study was to investigate the outcomes of RAMIE using the microanatomy-based concept in the initial introduction phase. Methods We have performed more than 500 TEPP procedures as minimally invasive esophagectomy (MIE). After performing about 400 cases of MIE, we established a microanatomy-based standardization of UMLND. In October 2018, we introduced RAMIE, and have performed 75 procedures in 20 months. Two groups were analyzed: a group after microanatomy-based standardization in TEPP (100 cases after completing 400 cases of TEPP) and a RAMIE group (75 cases). Finally, 51 paired cases were matched using a propensity score. Furthermore, the change in postoperative short-term outcome for RAMIE in the initial introduction phase was analyzed. Results Although there were no significant differences between the two groups in the number of upper mediastinal lymph nodes dissected, there was a significant decrease (P = 0.036) in intraoperative blood loss volume with RAMIE, representing a definite benefit for patients. The thoracoscopic operative time for RAMIE decreased by almost 100 min following less than 50 cases of experience, reaching the same level as that for recent TEPP, but with only one-tenth the operator experience. There were no significant differences in the total postoperative morbidity rate including the recurrent laryngeal nerve palsy rate. Conclusion RAMIE has been introduced safely and smoothly using the microanatomy-based concept established in TEPP.
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Affiliation(s)
- Yasuhiro Shirakawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. .,Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan.
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoyoshi Kunitomo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masashi Hashimoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazufumi Sakurama
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Villano AM, Zeymo A, Houlihan BK, Bayasi M, Al-Refaie WB, Chan KS. Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes. J Surg Res 2020; 247:180-189. [DOI: 10.1016/j.jss.2019.07.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/24/2019] [Accepted: 07/07/2019] [Indexed: 02/07/2023]
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Kurek A, Pawlicki J, Lekstan A, Bula D, Cierpka L, Więcek A, Król R. Assessment of the Learning Process After Introducing a New Liver Transplantation Procedure in a Center With Extensive Experience in Kidney Transplantation. Transplant Proc 2018; 50:1985-1991. [PMID: 30177094 DOI: 10.1016/j.transproceed.2018.02.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Liver transplantation (LTx) is one of the most complex transplant procedures. The aim of the present study was to determine whether the learning process can be observed after the introduction of LTx in a center with extensive previous experience in renal transplantation. METHODS This retrospective analysis included 264 primary LTx procedures performed with the piggyback technique (2005-2016). The procedures were divided into 4 equal groups. The characteristics of the recipients, data related to the surgery, and the postoperative course and complications were analyzed. RESULTS We observed a significant reduction in surgical time and in the anhepatic phase duration between Group 1 and the other groups (median surgical time was 455 minutes vs 415 minutes, 410 minutes and 387 minutes, respectively, P < .05; median anhepatic phase duration was 75 min vs 60 min, 62 min, 60 min, respectively, P < .05). There was a decrease in the number of transfused blood units (median in Group 1 of 6 packs vs 3 packs in Group 4, P < .05) and a decrease in blood recovered from the operating field using the Cell Saver system (median in Group 1 of 1570 mL vs 1057 mL, 1123 mL, and 1045 mL, respectively, P < .05). A significant reduction in the number of hemorrhages was found (1.5% in Group 4 vs 13.6%, 10.6%, and 7.6% in the other groups P < .05). The remaining studied parameters were not statistically significant. CONCLUSIONS Extensive previous transplantation experience affected the lack of typical features of the learning process.
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Affiliation(s)
- A Kurek
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland.
| | - J Pawlicki
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland
| | - A Lekstan
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland
| | - D Bula
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland
| | - L Cierpka
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland
| | - A Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - R Król
- Department of General, Vascular and Transplantation Surgery, Medical University of Silesia, Katowice, Poland
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Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter? Int J Colorectal Dis 2017; 32:1447-1451. [PMID: 28710609 DOI: 10.1007/s00384-017-2865-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy. METHODS A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay. RESULTS There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%). CONCLUSION Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.
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Defining the association between operative time and outcomes in children's surgery. J Pediatr Surg 2017; 52:1561-1566. [PMID: 28343665 DOI: 10.1016/j.jpedsurg.2017.03.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/22/2017] [Accepted: 03/15/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery. METHODS 182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications. RESULTS Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28). CONCLUSIONS Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement. LEVEL OF EVIDENCE Level III.
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Rashidi L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017; 213:901-905. [DOI: 10.1016/j.amjsurg.2017.03.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/28/2017] [Indexed: 01/24/2023]
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Preoperative assessment of vascular anatomy by multidetector computed tomography before laparoscopic colectomy for transverse colon cancer: report of a case. Int Surg 2016; 100:208-12. [PMID: 25692419 DOI: 10.9738/intsurg-d-13-00232.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Although the safety of laparoscopic surgery for colon cancer has been reported in many randomized controlled trials, concerns about the difficulty of surgery for transverse colon cancer has not been fully resolved, mainly because of the variation in the vascular anatomy of mesenteric vessels, which leads to difficulty in determining the optimal operative procedure and the extent of lymph node dissection. We present the case of a patient with transverse colon cancer who underwent laparoscopic surgery after preoperative assessment using a combination of endoscopic clipping and three-dimensional computed tomography angiography (3DCTA). A 68-year-old man was diagnosed with transverse colon cancer, and laparoscopic surgery has been planned. 3DCTA showed right-middle and left-middle colic arteries arising independently from the superior mesenteric artery. The relationship between the clip and vessels showed that the right-middle colic artery was the feeding artery of the tumor. Operative findings were consistent with 3DCTA findings, and transverse colectomy with lymph node dissection was successfully performed.
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Laparoscopic adrenalectomy by transabdominal lateral approach: 20 years of experience. Surg Endosc 2016; 31:2743-2751. [DOI: 10.1007/s00464-016-4830-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/09/2016] [Indexed: 10/20/2022]
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Laparoscopic complete mesocolic excision via combined medial and cranial approaches for transverse colon cancer. Surg Today 2016; 47:643-649. [PMID: 27566603 DOI: 10.1007/s00595-016-1409-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the safety and feasibility of laparoscopic complete mesocolic excision via combined medial and cranial approaches with three-dimensional visualization around the gastrocolic trunk and middle colic vessels for transverse colon cancer. METHODS We evaluated prospectively collected data of 30 consecutive patients who underwent laparoscopic complete mesocolic excision between January 2010 and December 2015, 6 of whom we excluded, leaving 24 for the analysis. We assessed the completeness of excision, operative data, pathological findings, length of large bowel resected, complications, length of hospital stay, and oncological outcomes. RESULTS Complete mesocolic excision completeness was graded as the mesocolic and intramesocolic planes in 21 and 3 patients, respectively. Eleven, two, eight, and three patients had T1, T2, T3, and T4a tumors, respectively; none had lymph node metastases. A mean of 18.3 lymph nodes was retrieved, and a mean of 5.4 lymph nodes was retrieved around the origin of the MCV. The mean large bowel length was 21.9 cm, operative time 274 min, intraoperative blood loss 41 mL, and length of hospital stay 15 days. There were no intraoperative and two postoperative complications. CONCLUSION Our procedure for laparoscopic complete mesocolic excision via combined medial and cranial approaches is safe and feasible for transverse colon cancer.
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Minimally Invasive Component Separation Techniques in Complex Ventral Abdominal Hernia Repair. Surg Laparosc Endosc Percutan Tech 2015; 25:100-5. [DOI: 10.1097/sle.0000000000000114] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim DH, Kim IY, Kim BR, Kim YW. Factors affecting the selection of minimally invasive surgery for stage 0/I colorectal cancer. Int J Surg 2015; 16:44-48. [PMID: 25749437 DOI: 10.1016/j.ijsu.2015.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 02/19/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE To evaluate which factors affect selection of minimally invasive surgery (MIS) or open procedures for patients with stage 0/I colorectal cancer. The short-term and oncologic outcomes of MIS were also compared to those of open procedures. METHODS A total of 181 consecutive patients underwent either MIS (laparoscopy: n = 146, robot: n = 8) or open (n = 27) colorectal resection for stage 0/I disease. RESULTS Elderly patients (≥80) were more common in the open procedure group (22.2%) than the MIS (7.8%) group (p = .02). Surgeon A performed more MIS procedures than surgeon B (p = .003). There were no differences in the 30-day complication rate between open (37%) and MIS (21.4%) groups (p = .08). Time to tolerable diet (p = .002) and length of hospital stay (p = .02) were shorter in the MIS group. There were no differences in the cancer-specific survival (p = .71) and recurrence-free survival rates (p = .67) between open and MIS procedures. CONCLUSIONS Patient factors (old age) and surgeon factors (surgeon B) were barriers to the choice of MIS. Old age and operating surgeons were not associated with adverse 30-day complications. The short-term and oncologic outcomes of MIS were comparable to those of open procedures. It is safe to expand the indication for MIS to elderly patients.
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Affiliation(s)
- Dong Hyun Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Ik Yong Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Bo Ra Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Young Wan Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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