1
|
Ferreira MY, Mitre LP, Bishay AE, Batista S, Palavani LB, Oliveira LB, Semione G, Andreão FF, Porto Junior S, Sousa MP, Borges PGLB, Camerotte R, Bertani R, Lawton MT, Figueiredo EG. Enhancing the quality of evidence, comparability, and reproducibility in brain arteriovenous malformations treated with open surgery research: a systematic review and proposal of a reporting guideline for surgical and clinical outcomes. Neurosurg Rev 2024; 47:174. [PMID: 38643293 DOI: 10.1007/s10143-024-02422-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 04/22/2024]
Abstract
Brain Arteriovenous Malformations (bAVMs) are rare but high-risk developmental anomalies of the vascular system. Microsurgery through craniotomy is believed to be the mainstay standard treatment for many grades of bAVMs. However, a significant challenge emerges in the existing body of clinical studies on open surgery for bAVMs: the lack of reproducibility and comparability. This study aims to assess the quality of studies reporting clinical and surgical outcomes for bAVMs treated by open surgery and develop a reporting guideline checklist focusing on essential elements to ensure comparability and reproducibility. This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, for studies published between January 1, 2018, and December 1, 2023. Included studies were scrutinized focusing on seven domains: (1) Assessment of How Studies Reported on the Baseline Characteristics of the Patient Sample; (2) Assessment and reporting on bAVMs grading, anatomical characteristics, and radiological aspects; (3) Angioarchitecture Assessment and Reporting; (4) Reporting on Pivotal Concepts Definitions; (5) Reporting on Neurosurgeon(s) and Staff Characteristics; (6) Reporting on Surgical Details; (7) Assessing and Reporting Clinical and Surgical Outcomes and AEs. A total of 47 studies comprising 5,884 patients were included. The scrutiny of the studies identified that the current literature in bAVM open surgery is deficient in many aspects, ranging from fundamental pieces of information of methodology to baseline characteristics of included patients and data reporting. Included studies demonstrated a lack of reproducibility that hinders building cumulative evidence. A bAVM Open Surgery Reporting Guideline with 65 items distributed across eight domains was developed and is proposed in this study aiming to address these shortcomings. This systematic review identified that the available literature regarding microsurgery for bAVM treatment, particularly in studies reporting clinical and surgical outcomes, lacks rigorous scientific methodology and quality in reporting. The proposed bAVM Open Surgery Reporting Guideline covers all essential aspects and is a potential solution to address these shortcomings and increase transparency, comparability, and reproducibility in this scenario. This proposal aims to advance the level of evidence and enhance knowledge regarding the Open Surgery treatment for bAVMs.
Collapse
Affiliation(s)
| | - Lucas P Mitre
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Lucca B Palavani
- Faculty of Medicine, Max Planck University Center, Indaiatuba, SP, Brazil
| | - Leonardo B Oliveira
- School of Medicine, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | | | - Filipi F Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Marcelo P Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Pedro G L B Borges
- Technical-Educational Foundation Souza Marques, Rio de Janeiro, RJ, Brazil
| | - Raphael Camerotte
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, SP, Brazil
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurologic Institute, St. Joseph's Medical Center, Phoenix, AZ, USA
| | | |
Collapse
|
2
|
Lygre KB, Eide GE, Forsmo HM, Dicko A, Storli KE, Pfeffer F. Complications after open and laparoscopic right-sided colectomy with central lymphadenectomy for colon cancer: randomized controlled trial. BJS Open 2023; 7:zrad074. [PMID: 37643373 PMCID: PMC10465081 DOI: 10.1093/bjsopen/zrad074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND A central lymphadenectomy in right-sided colon cancer involves dissection along the superior mesenteric axis, but the extent is debated due to a lack of consensus and the fear of major complications. This randomized controlled trial compared the rate of postoperative morbidity in patients undergoing laparoscopic versus open right-sided colectomy with central lymphadenectomy. METHODS This open, prospective, randomized controlled trial compared patients operated on with open and laparoscopic right-sided colectomy (cStages I-III) with a central lymphadenectomy at two Norwegian institutions between October 2016 and December 2021. Dissections were conducted along the superior mesenteric vein in the laparoscopic group, and along the left anterior border of the superior mesenteric artery in the open group, both according to complete mesocolic excision principles. Surgery was standardized and performed by three experienced surgeons for each study group. The primary outcome of interest was to measure postoperative 30-day complications (Clavien-Dindo ≥ grade II). RESULTS Of 273 eligible patients, 135 were randomized and 128 analysed (63 operated on with open and 65 using laparoscopic procedures). Postoperative complications occurred in 42.8 per cent of the patients treated with open and 38.4 per cent of the patients treated using laparoscopic surgery, P = 0.372. The incidence of Clavien-Dindo grade IIIb complications was 7.9 per cent in the open versus 4.6 per cent in the laparoscopic group, P = 0.341. There were no grade IV or V complications, and no re-operations due to anastomotic leakages. There was no significant difference in the mean(s.e.m.) number of removed lymph nodes (open versus laparoscopic respectively: 31.9(1.8) versus 29.3(1.3); P = 0.235). CONCLUSION There was no significant difference in complications between the two groups. Standardized oncologic right-sided colectomy with central lymphadenectomy along the mesenterial root was performed safely, both open and laparoscopic, with incidence of major complications ranging between 4.6 and 7.9 per cent and no re-operations for anastomotic leakage. Radicality in terms of lymphadenectomy was comparable between the two groups.Registration number: NCT03776591 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- Kristin B Lygre
- Department of Gastrointestinal Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir E Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Havard M Forsmo
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Aly Dicko
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kristian E Storli
- Department of Gastrointestinal Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frank Pfeffer
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
3
|
Broggi M, Ferroli P, Schiavolin S, Zattra C, Schiariti M, Acerbi F, Caldiroli D, Raggi A, Vetrano I, Falco J, de Laurentis C, Broggi G. Surgical Complexity and Complications: The Need for a Common Language. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:1-12. [PMID: 37548717 DOI: 10.1007/978-3-030-12887-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Quality measurement and outcome assessment have recently caught an attention of the neurosurgical community, but lack of standardized definitions and methodology significantly complicates these tasks. OBJECTIVE To identify a uniform definition of neurosurgical complications, to classify them according to etiology, and to evaluate them comprehensively in cases of intracranial tumor removal in order to establish a new, easy, and practical grading system capable of predicting the risk of postoperative clinical worsening of the patient condition. METHODS A retrospective analysis was conducted on all elective surgeries directed at removal of intracranial tumor in the authors' institution during 2-year study period. All sociodemographic, clinical, and surgical factors were extracted from prospectively compiled comprehensive patient registry. Data on all complications, defined as any deviation from the ideal postoperative course occurring within 30 days of the procedure, were collected with consideration of the required treatment and etiology. A logistic regression model was created for identification of independent factors associated with worsening of the Karnofsky Performance Scale (KPS) score at discharge after surgery in comparison with preoperative period. For each identified statistically significant independent predictor of the postoperative worsening, corresponding score was defined, and grading system, subsequently named Milan Complexity Scale (MCS), was formed. RESULTS Overall, 746 cases of surgeries for removal of intracranial tumor were analyzed. Postoperative complications of any kind were observed in 311 patients (41.7%). In 223 cases (29.9%), worsening of the KPS score at the time of discharge in comparison with preoperative period was noted. It was independently associated with 5 predictive factors-major brain vessel manipulation, surgery in the posterior fossa, cranial nerve manipulation, surgery in the eloquent area, tumor size >4 cm-which comprised MCS with a range of the total score from 0 to 8 (higher score indicates more complex clinical situations). Patients who demonstrated KPS worsening after surgery had significantly higher total MCS scores in comparison with individuals whose clinical status at discharge was improved or unchanged (3.24 ± 1.55 versus 1.47 ± 1.58; P < 0.001). CONCLUSION It is reasonable to define neurosurgical complication as any deviation from the ideal postoperative course occurring within 30 days of the procedure. Suggested MCS allows for standardized assessment of surgical complexity before intervention and for estimating the risk of clinical worsening after removal of intracranial tumor. Collection of data on surgical complexity, occurrence of complications, and postoperative outcomes, using standardized prospectively maintained comprehensive patient registries seems very important for quality measurement and should be attained in all neurosurgical centers.
Collapse
Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvia Schiavolin
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Costanza Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Dario Caldiroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| |
Collapse
|
4
|
Azizkhanian I, Alcantara R, Ballinger Z, Cho E, Dore S, Gatzofilas S, Hossain RH, Honig J, Matluck N, Ogulnick JV, Rothbaum M, Rybkin I, Smith H, Tung B, Kazim SF, Miller I, Schmidt MH, Cole CD, Bowers CA. Spine surgery complexity score predicts outcomes in 671 consecutive spine surgery patients. Surg Neurol Int 2021; 12:206. [PMID: 34084633 PMCID: PMC8168653 DOI: 10.25259/sni_46_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The spine surgery complexity score (SSCS), previously reported by us, is a simple grading system to predict postoperative complications and hospital length of stay (LOS). This scale is based on the technical difficulty of the spinal procedures being performed. Methods: We performed a retrospective chart review to validate SSCS in 671 consecutive patients undergoing spine procedures at a quaternary academic hospital. Results: The SSCS was predictive of the hospital LOS and postoperative complications (defined by the ClavienDindo score), based on linear regression analysis (P < 0.001 for both). Conclusion: Categorizing procedures according to the SSCS may enable neurosurgeons to assess surgical risk and predict longer LOS courses after spine surgery. Thus, it may prove useful in preoperative patient evaluation/ education and determining a prognosis based on surgical complexity.
Collapse
Affiliation(s)
- Ida Azizkhanian
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Ryan Alcantara
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Zachary Ballinger
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Edward Cho
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Silvi Dore
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Stergios Gatzofilas
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | | | - Jesse Honig
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Nicole Matluck
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Jonathan V Ogulnick
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Michael Rothbaum
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Iliya Rybkin
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Harrison Smith
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Brian Tung
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Ivan Miller
- Department of Emergency Medicine, New York Medical College, Valhalla, New York, United States
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Chad D Cole
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| |
Collapse
|
5
|
Broggi M, Zattra C, Ferroli P. How to compare outcomes and complications in neurosurgery: We must make the mission possible! Surg Neurol Int 2018; 9:65. [PMID: 29629232 PMCID: PMC5875107 DOI: 10.4103/sni.sni_424_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/08/2018] [Indexed: 11/04/2022] Open
Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Costanza Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| |
Collapse
|
6
|
Green B, Janaway BM, Brennan PA. Quality improvement- where do we stand? Br J Oral Maxillofac Surg 2016; 54:594-5. [DOI: 10.1016/j.bjoms.2016.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 02/03/2016] [Indexed: 11/16/2022]
|
7
|
Wechter ME, Mohd J, Magrina JF, Cornella JL, Magtibay PM, Wilson JR, Kho RM. Complications in Robotic-Assisted Gynecologic Surgery According to Case Type: A 6-Year Retrospective Cohort Study Using Clavien-Dindo Classification. J Minim Invasive Gynecol 2014; 21:844-50. [DOI: 10.1016/j.jmig.2014.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/15/2014] [Accepted: 03/18/2014] [Indexed: 11/28/2022]
|
8
|
Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg 2014; 8:9. [PMID: 24559412 PMCID: PMC3936702 DOI: 10.1186/1754-9493-8-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 02/15/2014] [Indexed: 12/13/2022] Open
Affiliation(s)
- Philip F Stahel
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.
| | | | | |
Collapse
|
9
|
Quality Assessment in Surgery: Mission Impossible? Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
10
|
de la Rosette JJMCH, Opondo D, Daels FPJ, Giusti G, Serrano A, Kandasami SV, Wolf JS, Grabe M, Gravas S. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol 2012; 62:246-55. [PMID: 22487016 DOI: 10.1016/j.eururo.2012.03.055] [Citation(s) in RCA: 241] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 03/27/2012] [Indexed: 01/23/2023]
Abstract
BACKGROUND Although widely used, the validity and reliability of the Clavien classification of postoperative complications have not been tested in urologic procedures, such as percutaneous nephrolithotomy (PCNL). OBJECTIVE To validate the Clavien score and categorise complications of PCNL. DESIGN, SETTING, AND PARTICIPANTS Data for 528 patients with complications after PCNL were used to create a set of 70 unique complication-management combinations. Clinical case summaries for each complication-management combination were compiled in a survey distributed to 98 urologists, who rated each combination using the Clavien classification. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Interrater agreement for Clavien scores was estimated using Fleiss' kappa (κ). The relationship between Clavien score and the duration of postoperative hospital stay was analysed using multivariate nonlinear regression models that adjusted for operating time, preoperative urine microbial culture, presence of staghorn stone, and use of postoperative nephrostomy tube. RESULTS AND LIMITATIONS Overall interrater agreement in grading postoperative complications was moderate (κ=0.457; p<0.001). Agreement was highest for Clavien score 5 and decreased with lower Clavien scores. Higher agreement was found for Clavien scores 3 and 4 than in subcategories of these scores. Postoperative stay increased with higher Clavien scores and was unaffected by inherent differences between study centres. A standard list of post-PCNL complications and their corresponding Clavien scores was created. CONCLUSIONS Although the Clavien classification demonstrates high validity, interrater reliability is low for minor complications. To improve the reliability and consistency of reporting adverse outcomes of PCNL, we have assigned Clavien scores to complications of PCNL.
Collapse
|
11
|
Mehler PS, Colwell CB, Stahel PF. A structured approach to improving patient safety: Lessons from a public safety-net system. Patient Saf Surg 2011; 5:32. [PMID: 22133234 PMCID: PMC3247871 DOI: 10.1186/1754-9493-5-32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/01/2011] [Indexed: 11/10/2022] Open
Affiliation(s)
- Philip S Mehler
- Department of Patient Safety and Quality, Denver Health Medical Center, 777 Bannock Street, Denver, Denver, CO 80204.
| | | | | |
Collapse
|
12
|
Bosma E, Veen EJ, Roukema JA. Incidence, nature and impact of error in surgery. Br J Surg 2011; 98:1654-9. [DOI: 10.1002/bjs.7594] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2011] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Adverse events occur in 3·8–17 per cent of hospital admissions. The purpose of this study was to analyse the incidence of medical errors and assess the feasibility of an error registry for quality improvement programmes.
Methods
Errors were recorded prospectively in a complication registry between 1 June 2005 and 31 December 2007. Events were coded according to the Trauma Registry of the American College of Surgeons; the nature of events was recorded and the severity graded using the 1992 Clavien system. Recorded events were discussed by the medical staff on a daily basis and, if by consensus judged to be errors, were saved to the registry database.
Results
Of 12 121 patients admitted to the surgical ward during the study interval, 2033 (16·8 per cent) had a complication and 735 (6·1 per cent) had an error documented in the registry. Of 873 recorded errors, 607 (69·5 per cent) were of little or no consequence (Clavien grade I) and 220 (25·2 per cent) required therapeutic intervention (Clavien grade IIa and IIb). Errors leading to permanent injury (Clavien grade III) occurred in 41 instances (4·7 per cent) and five patients (0·6 per cent) died (Clavien grade IV).
Conclusion
This study shows that errors are common in surgery, and that near misses are more frequent than errors with serious consequences. It is hypothesized that registration of near misses might prevent errors with serious consequences and thus improve quality of care.
Collapse
Affiliation(s)
- E Bosma
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - E J Veen
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - J A Roukema
- Department of Surgery, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| |
Collapse
|