1
|
Park Y, Hwang DW, Lee JH, Song KB, Jun E, Lee W, Kwak BJ, Kim SC. Evaluation of postoperative outcomes of minimally invasive distal pancreatectomy for left-sided pancreatic tumors based on the modified frailty index: a retrospective cohort study. Int J Surg 2023; 109:3497-3505. [PMID: 37598358 PMCID: PMC10651302 DOI: 10.1097/js9.0000000000000670] [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: 05/03/2023] [Accepted: 07/30/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND This study compared the postoperative outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors based on the modified frailty index (mFI). MATERIALS AND METHODS This retrospective study included 2212 patients who underwent MIDP for left-sided pancreatic tumors between 2005 and 2019. Postoperative outcomes, including complications (morbidity and mortality), were analyzed using mFI, and the participants were divided into two groups: frail ( n =79) and nonfrail ( n =2133). A subanalysis of 495 MIDPs for pancreatic ductal adenocarcinoma was conducted to compare oncological outcomes. RESULTS Clinically relevant postoperative pancreatic fistula was significantly higher in the frail group than in the nonfrail group. A significant between-group difference was observed in overall complications with Clavien-Dindo classification grade ≥III. Furthermore, the proportion of all complications before readmission was higher in the frail group than in the nonfrail group. Among all readmitted patients, the frail group had a higher number of grade ≥IV patients requiring ICU treatment. The frail group's 90-day mortality was 1.3%; the difference was statistically significant (nonfrail: 0.3%, P =0.021). In the univariate and multivariate logistic regression analyses, mFI ≥0.27 (odds ratio 3.231, 95% CI: 1.889-5.523, P <0.001), extended pancreatectomy, BMI ≥30 kg/m 2 , male sex, and malignancy were risk factors for Clavien-Dindo classification grade ≥III. CONCLUSION mFI is a potential preoperative tool for predicting severe postoperative complications, including mortality, in patients who have undergone MIDP for left-sided tumors.
Collapse
Affiliation(s)
- Yejong Park
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Dae Wook Hwang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Jae Hoon Lee
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Ki Byung Song
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Eunsung Jun
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
- Department of Convergence Medicine, Asan Institute for Life Sciences, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Woohyung Lee
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Bong Jun Kwak
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| | - Song Cheol Kim
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery
| |
Collapse
|
2
|
Zhang K, Liu C, Sha X, Yao S, Li Z, Yu Y, Lou J, Fu Q, Liu Y, Cao J, Zhang J, Yang Y, Mi W, Li H. Development and validation of a prediction model to predict major adverse cardiovascular events in elderly patients undergoing noncardiac surgery: A retrospective cohort study. Atherosclerosis 2023; 376:71-79. [PMID: 37315395 DOI: 10.1016/j.atherosclerosis.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS Current existing predictive tools have limitations in predicting major adverse cardiovascular events (MACEs) in elderly patients. We will build a new prediction model to predict MACEs in elderly patients undergoing noncardiac surgery by using traditional statistical methods and machine learning algorithms. METHODS MACEs were defined as acute myocardial infarction (AMI), ischemic stroke, heart failure and death within 30 days after surgery. Clinical data from 45,102 elderly patients (≥65 years old), who underwent noncardiac surgery from two independent cohorts, were used to develop and validate the prediction models. A traditional logistic regression and five machine learning models (decision tree, random forest, LGBM, AdaBoost, and XGBoost) were compared by the area under the receiver operating characteristic curve (AUC). In the traditional prediction model, the calibration was assessed using the calibration curve and the patients' net benefit was measured by decision curve analysis (DCA). RESULTS Among 45,102 elderly patients, 346 (0.76%) developed MACEs. The AUC of this traditional model was 0.800 (95% CI, 0.708-0.831) in the internal validation set, and 0.768 (95% CI, 0.702-0.835) in the external validation set. In the best machine learning prediction model-AdaBoost model, the AUC in the internal and external validation set was 0.778 and 0.732, respectively. Besides, for the traditional prediction model, the calibration curve of model performance accurately predicted the risk of MACEs (Hosmer and Lemeshow, p = 0.573), the DCA results showed that the nomogram had a high net benefit for predicting postoperative MACEs. CONCLUSIONS This prediction model based on the traditional method could accurately predict the risk of MACEs after noncardiac surgery in elderly patients.
Collapse
Affiliation(s)
- Kai Zhang
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chang Liu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaoling Sha
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Siyi Yao
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhao Li
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yao Yu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jingsheng Lou
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qiang Fu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yanhong Liu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiangbei Cao
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Weidong Mi
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| | - Hao Li
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
3
|
Mederos MA, Starr S, Park JY, King JC, Tomlinson JS, Hines OJ, Donahue TR, Girgis MD. Robotic versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis. HPB (Oxford) 2023; 25:301-310. [PMID: 36529625 DOI: 10.1016/j.hpb.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/24/2022] [Accepted: 11/29/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is complex procedure with high morbidity in the elderly. This retrospective study aimed to compare post-operative outcomes in patients ≥75 years of age who underwent robot-assisted (RA)PD and open PD. METHODS We analyzed 2502 patients ≥75 years of age who underwent PD from 2015 to 2018 in the National Surgical Quality Improvement Program (NSQIP) database. RAPD and open PD patients were propensity score matched 1:5 to assess the 30-day outcomes of interest: postoperative complications, length of stay, discharge destination, and readmissions. RESULTS Of 725 matched patients, 110 underwent RAPD, 615 OPD, and 12 were converted to an open operation. Post-operative outcomes were largely similar between cohorts. RAPD was associated a shorter length of stay (median 8 days, interquartile range [IQR] 6 to 11) than OPD (median 8 days, IQR 7 to 13) (p = 0.003). However, RAPD was associated with more readmissions (28.1% vs. 17.7%; p = 0.02). CONCLUSIONS RAPD in patients ≥75 years of age appears to be safe and has a similar complication profile to open PD. Randomized or well-designed prospective matched studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Michael A Mederos
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA.
| | - Savannah Starr
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Joon Y Park
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Jonathan C King
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - James S Tomlinson
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
| | - O J Hines
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Timothy R Donahue
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA
| | - Mark D Girgis
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Division of Surgical Oncology, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Surgical Oncology, Los Angeles, CA, USA
| |
Collapse
|
4
|
Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
5
|
Amini N, D'Adamo CR, Khashchuk D, Dodson R, Katlic M, Wolf J, Mavanur A. Accuracy of National Surgical Quality Improvement Program Risk Calculator Among Elderly Patients Undergoing Pancreas Resection. J Surg Res 2022; 279:567-574. [DOI: 10.1016/j.jss.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/12/2022] [Accepted: 06/28/2022] [Indexed: 10/31/2022]
|
6
|
Bereza-Carlson P, Nilsson J, Andersson B. Preoperative Risk Score for Early Mortality After Up-Front Pancreatic Cancer Surgery: A Nationwide Cohort Study. World J Surg 2022; 46:2769-2777. [PMID: 35939088 PMCID: PMC9529690 DOI: 10.1007/s00268-022-06678-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 12/02/2022]
Abstract
Background Pancreatic ductal adenocarcinoma is a highly fatal malignancy. The aim was to identify preoperative factors for early mortality in up-front resectable patients following pancreatoduodenectomy (PD) and develop an early mortality risk score. Methods Patients registered in the Swedish National Registry for Pancreatic and Periampullary Cancer were included. Relevant preoperative factors (n = 21) were investigated. Early mortality was defined as death within 12 months after surgery. Based on the identified risk factor odds ratios (ORs), the Score Predicting Early Mortality (SPEM) was developed.
Results In total, 2183 PDs were performed, and 926 patients met the study criteria. The mean age was 68 (SD ± 8.8) years, and 48% were female. A total of 233 (24%) patients died within 12 months. In the multivariable analyses, age > 75 years (OR 1.7; 95% CI 1.1–2.4; p = 0.008), CRP ≥ 15 mg/L (OR 2.0; 95% CI 1.3–3.1; p = 0.001), CA 19-9 > 500 U/mL (OR 1.8; 95% CI 1.0–3.2; p = 0.040), diabetes mellitus (OR 1.40; 95% CI 1.00–2.1; p = 0.042), and active smoking (OR 1.47; 95%CI 1.00–2.00; p = 0.050) were found to be independent risk factors for early mortality. Conclusion Five independent preoperative risk factors for early mortality following PD were identified and together formed SPEM. The score might be a useful tool in establishing individualized treatment plans.
Collapse
Affiliation(s)
- Paulina Bereza-Carlson
- Department of Clinical Sciences Lund, Surgery, Lund University, Lund, Sweden
- Central Hospital of Kristianstad, Kristianstad, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Lund, Sweden.
- Skåne University Hospital, Lund, Sweden.
| |
Collapse
|
7
|
Burgdorf SK, Storkholm JH, Chen IM, Hansen CP. Postoperative and long-term survival in relation to life-expectancy after pancreatic surgery in elderly patients (cohort study). Ann Med Surg (Lond) 2021; 69:102724. [PMID: 34457257 PMCID: PMC8379474 DOI: 10.1016/j.amsu.2021.102724] [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: 06/10/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022] Open
Abstract
Background An evaluation of the outcome after pancreatic surgery with focus on post-operative and late survival in elderly patients was performed. Methods The study included 1.556 patients from a single HBP unit operated from 1. January 2010 to 31. December 2019. Patients were divided into two cohorts, < 75 years (n = 1.296) and ≥75 years (n = 260). Post-operative outcome was evaluated in all patients and late outcome in patients with adenocarcinoma in the pancreas (n = 765) and the duodenum (n = 117). The follow-up of patients with benign disease and adenocarcinoma was 57.95 (12.1–132.7) and 39.85 (12.0–131.7) months, respectively. Results Length of hospital-stay and surgical complications were not significantly different in the two cohorts, but in-hospital death was 1.1% (<75 years) and 3.5% (≥75 years) (p = 0.008). The median overall survival of adenocarcinoma was 29.7 (<75 years) and 24.3 months (≥75 years) (p = 0.3228) with a one, two, and five-years survival of 74.5%, 56.6% and 28.6% vs. 73.6%, 51.1%, and 25.5%. Median time to relapse (46.2% of patients <75 years and 40.5% of patients ≥75 years) was 9 (1 - 51) and 8 (1 - 78) months (p = 0.534), respectively. Adjuvant chemotherapy did not have impact on the survival of the old cohort. Patients who died during the observation period had lost 94% (<75 years) and 87% (≥75 years) of expected remnant life. Estimated years lost in the old cohort was 4.2 in males and 4.9 in females (p = 0.025) Conclusion Elderly patients may undergo pancreatic surgery with a low mortality and for adenocarcinoma with an acceptable long-term survival. Surgery is the only potentially curable treatment to pancreatic cancer. Elderly patients may tolerate pancreatic surgery with low mortality. Radical pancreatic surgery improves long-term survival, also in elderly patients. Operability should be evaluated from morbidity and biological age. Pancreatic surgery in elderly should only be performed in high volume centers.
Collapse
Affiliation(s)
- S K Burgdorf
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
| | - J H Storkholm
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
| | - I M Chen
- Department of Oncology, Herlev Hospital, University of Copenhagen, Denmark
| | - C P Hansen
- Department of Surgery Rigshospitalet, University of Copenhagen, Denmark
| |
Collapse
|
8
|
Tsukagoshi M, Harimoto N, Araki K, Kubo N, Watanabe A, Igarashi T, Ishii N, Yamanaka T, Hagiwara K, Hoshino K, Muranushi R, Yajima T, Shirabe K. Skeletal Muscle Loss and Octogenarian Status Are Associated with S-1 Adjuvant Therapy Discontinuation and Poor Prognosis after Pancreatectomy. Cancers (Basel) 2021; 13:cancers13164105. [PMID: 34439259 PMCID: PMC8391507 DOI: 10.3390/cancers13164105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/13/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary Significant advances in surgical techniques and perioperative care, together with adjuvant chemotherapy, have contributed to the increasing number of patients with pancreatic cancer undergoing surgery. However, the results of some studies suggest that the postoperative complications and mortality might be higher in elderly patients undergoing pancreatectomy. We aimed to identify the utility of S-1 adjuvant chemotherapy in elderly patients with resected pancreatic cancer. In our cohort of 80 patients, including 16 octogenarians, univariate and multivariate analyses revealed that S-1 adjuvant chemotherapy was associated with improved prognosis in patients with pancreatic cancer. However, we also observed that skeletal muscle loss and age of 80 years or older predicted the failure to complete adjuvant chemotherapy with S-1. We propose that evaluation of skeletal muscle mass should be considered as a useful preoperative assessment approach for determining feasibility of adjuvant chemotherapy in elderly patients. Abstract The efficacy and prognosis of adjuvant chemotherapy for resected pancreatic cancer remain unclear. We investigated the utility and risk factors of S-1 adjuvant chemotherapy in patients with pancreatic cancer undergoing pancreatectomy. This study comprised 80 patients, including 58 patients who received S-1 adjuvant chemotherapy. Skeletal muscle loss was defined using cutoff values of skeletal muscle mass index. In total, 16 (20%) octogenarian patients underwent pancreatectomy. Skeletal muscle loss was present in 56 (70%) patients. The entire course of S-1 adjuvant chemotherapy for 6 months was completed in 33 patients (41%). S-1 adjuvant chemotherapy <6 months was an independent prognostic indicator of poor overall survival. Patients who completed S-1 adjuvant chemotherapy exhibited significantly longer overall and relapse-free survival rates than those did not complete the chemotherapy (p < 0.0001 and p = 0.0003, respectively). Being an octogenarian and skeletal muscle loss were independent variables associated with the discontinuation of S-1 adjuvant chemotherapy. Finally, the S-1 adjuvant chemotherapy rates were 6.3% (1/16) and 28.6% (16/56) in octogenarian patients and those with skeletal muscle loss, respectively. S-1 adjuvant chemotherapy completion was associated with improved prognosis in patients with pancreatic cancer. Skeletal muscle loss and octogenarian status predicted the failure of S-1 adjuvant chemotherapy completion.
Collapse
Affiliation(s)
- Mariko Tsukagoshi
- Department of Innovative Cancer Immunotherapy, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (M.T.); (T.Y.)
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
- Correspondence: ; Tel.: +81-27-220-8224
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norio Kubo
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Takahiro Yamanaka
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| | - Toshiki Yajima
- Department of Innovative Cancer Immunotherapy, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (M.T.); (T.Y.)
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi 371-8511, Japan; (K.A.); (N.K.); (A.W.); (T.I.); (N.I.); (T.Y.); (K.H.); (K.H.); (R.M.); (K.S.)
| |
Collapse
|
9
|
Tessman D, Chou J, Shebrain S, Munene G. Surgical Outcomes of Distal Pancreatectomy in Elderly Patients. Am Surg 2020; 88:115-119. [PMID: 33342301 DOI: 10.1177/0003134820982574] [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: 11/17/2022]
Abstract
BACKGROUND The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (≤75 years) and B (>75 years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days). RESULTS Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [±6.7] vs. 27.4 [±5.6], P = .001).Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [±6.36] vs. 7.30 [±4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859). CONCLUSION(S) Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75 years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.
Collapse
Affiliation(s)
- Derek Tessman
- Department of Surgery, 51374Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Surgery, 51374Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Saad Shebrain
- Department of Surgery, 51374Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Gitonga Munene
- Department of Surgery, 51374Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA.,Western Michigan Cancer Center, Kalamazoo, MI, USA
| |
Collapse
|
10
|
Hendi M, Mou Y, Lu C, Pan Y, Zhang B, Chen K, Xu X, Zhang R, Zhou Y, Jin W. Laparoscopic pancreaticodoudenectomy: An excellent approach in elderly patients, a multicenter, comparative study. Medicine (Baltimore) 2020; 99:e22175. [PMID: 32957341 PMCID: PMC7505399 DOI: 10.1097/md.0000000000022175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Management of malignant diseases in elderly patients has become a global clinical issue because of increased life expectancy worldwide. Advancements in surgical techniques and perioperative management have reduced age-related contraindications for LPD. Past articles have reported that elderly patients undergoing laproscopic pancreatoduodenectomy (LPD) are at an increased risk compared to younger patients. The aim of this article is to compare a multicenter center risk of LPD in elderly and nonelderly patients. METHODS Retrospective review (n = 237) of perisurgical outcomes in patients undergoing LPD during the months of September 2012 to December 2017. Outcomes in elderly patients (aged ≥75 years) were compared with those in nonelderly patients. RESULTS Transfer to ICU was more frequent in elderly patients (odds ratio [OR] 6.49, P = .001) and the mean hospital stay was longer (21.4 days compared with 16.6 days), (P = .0033) than for nonelderly patients. There was no statistically significant difference in operation time (P = .494), estimated blood loss (P = .0519), blood transfusion (P = .863), decreased gastric emptying (P = .397), abdominal pain (P = .454), food intake (P = .241), time to self-ambulation (P = 1), reoperation (P = .543), postoperative pancreatic fistula (POPF) grade A (P = .454), POPF grade B (P = .736), POPF grade C (P = .164), hemorrhage (P = .319), bile leakage (P = .428), infection (P = .259), GI bleeding (P = .286), morbidity (P = .272) or mortality (P = .449) between the 2 groups. CONCLUSIONS Elderly patients who underwent LPD in this study had good overall outcomes after LPD that were similar to young patients. The perioperative and long-term outcomes of LPD are not worse. Rates of ICU admission and hospital stays increased in elderly patients undergoing LPD when compared with nonelderly ones. LPD can be performed on elderly patients with similar outcomes as younger patients; therefore, age itself should not be a contraindication for LPD for pancreatic cancer, but it suggests that elderly patients with comorbidities should be more stringently selected for surgery.
Collapse
Affiliation(s)
- Maher Hendi
- Zhejiang University, School of Medicine
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yiping Mou
- Zhejiang University, School of Medicine
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Chao Lu
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yu Pan
- Zhejiang University, School of Medicine
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bin Zhang
- Zhejiang University, School of Medicine
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ke Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaowu Xu
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Renchao Zhang
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | - Yucheng Zhou
- Department of Gastrointestinal and Pancreas Surgery, Zhejiang Provincial People's Hospital
| | | |
Collapse
|
11
|
Altoukhi KH, Morris DL. A commentary on "Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis" [Int. J. Surg. 2019, 72:59-68]. Int J Surg 2019; 73:87-88. [PMID: 31759117 DOI: 10.1016/j.ijsu.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - David L Morris
- Department of Surgery, St George Hospital, Sydney, NSW, Australia.
| |
Collapse
|
12
|
Abstract
Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.
Collapse
|
13
|
Guyton RL, Mosquera C, Spaniolas K, Fitzgerald TL. Association of Increasing Frailty with Detrimental Outcomes after Pancreatic Resection. Am Surg 2018. [DOI: 10.1177/000313481808400423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
An association between detrimental outcomes and frailty has been documented; however, the impact specific to pancreatic surgery is unknown. Using NSQIP data, patients were classified as non-, mildly, moderately, or severely frail. A total of16,028 patients were included inthe study; most of the patients were white (78.5%) and underwent pancreaticoduodenectomy (PD) (67%). Complications occurred in 17.6 per cent cases, and the median length of stay (LOS) was 11.89 days. Prolonged LOS and mortality occurred in 9.1 and 2.3 per cent of the cases. In the PD group, most of the patients were mildly frail (40.6%), followed by nonfrail (39.83%), whereas in the distal pancreatectomy (DP) group, the majority were nonfrail (43.82%), followed by mildly frail (39.37%) ( P < 0.0001). The 30-day complications, mortality, and LOS were significantly higher in patients undergoing PD compared with DP (19.5 vs 14.3%, 2.8 vs 1.2%, and 13.4 vs 8.7 days, respectively; P < 0.0001). PD conferred a significantly higher risk of death in all frailty groups compared with DP [nonfrail: odds ratio (OR) 1.76, mildly frail: OR 1.03, moderately frail: OR 2.03, P < 0.05], with the exception of severely frail patients. Compared with DP, PD conferred a significant risk of complication in all the frailty groups. Increases in frailty are associated with poorer outcomes after pancreatectomy.
Collapse
Affiliation(s)
- Rodney Lane Guyton
- Divisions of Surgical Oncology and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Catalina Mosquera
- Divisions of Surgical Oncology and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Konstantinos Spaniolas
- Divisions of Bariatric and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Timothy L. Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine
| |
Collapse
|
14
|
Chen YT, Ma FH, Wang CF, Zhao DB, Zhang YW, Tian YT. Elderly patients had more severe postoperative complications after pancreatic resection: A retrospective analysis of 727 patients. World J Gastroenterol 2018; 24:844-851. [PMID: 29467554 PMCID: PMC5807942 DOI: 10.3748/wjg.v24.i7.844] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/03/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the impact of aging on the short-term outcomes following pancreatic resection (PR) in elderly patients.
METHODS A retrospective cohort study using prospectively collected data was conducted at the China National Cancer Center. Consecutive patients who underwent PR from January 2004 to December 2015 were identified and included. ‘Elderly patient’ was defined as ones age 65 and above. Comorbidities, clinicopathology, perioperative variables, and postoperative morbidity and mortality were compared between the elderly and young patients. Univariate and multivariate analyses were performed using the Cox proportional hazard model for severe postoperative complications (grades IIIb-V).
RESULTS A total of 454 (63.4%) patients were < 65-years-old and 273 (36.6%) patients were ≥ 65-years-old, respectively. Compared to patients < 65-years-old, elderly patients had worse American Society of Anesthesiologists scores (P = 0.007) and more comorbidities (62.6% vs 32.4%, P < 0.001). Elderly patients had more severe postoperative complications (16.8% vs 9.0%, P = 0.002) and higher postoperative mortality rates (5.5% vs 0.9%, P < 0.001). In the multivariate Cox proportional hazards model for severe postoperative complications, age ≥ 65 years [hazard ratio (HR) = 1.63; 95% confidence interval (CI): 1.18-6.30], body mass index ≥ 24 kg/m2 (HR = 1.20, 95%CI: 1.07-5.89), pancreaticoduodenectomy (HR = 4.86, 95%CI: 1.20-8.31) and length of operation ≥ 241 min (HR = 2.97; 95%CI: 1.04-6.14) were significant (P = 0.010, P = 0.041, P = 0.017 and P = 0.012, respectively).
CONCLUSION We found that aging is an independent risk factor for severe postoperative complications after PR. Our results might contribute to more informed decision-making for elderly patients.
Collapse
Affiliation(s)
- Ying-Tai Chen
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fu-Hai Ma
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Cheng-Feng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dong-Bing Zhao
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ya-Wei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT 06520, United States
| | - Yan-Tao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
15
|
Eubanks A, Pepe J, Veldhuis P, de la Fuente SG. Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer. J Geriatr Oncol 2018; 9:362-366. [PMID: 29330039 DOI: 10.1016/j.jgo.2017.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/31/2017] [Accepted: 12/28/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy. METHODS/MATERIALS National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n=17,924) and no adjuvant chemotherapy (n=12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence. RESULTS There was a statistical difference in age (adjuvant therapy 64.86±9.89 vs. no therapy 67.78±11.22, p<0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59days following surgery, and at academic cancer programs (52%). CONCLUSIONS Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.
Collapse
Affiliation(s)
- Alicia Eubanks
- University of Central Florida College of Medicine, United States
| | - Julie Pepe
- Department of Surgery, Florida Hospital Orlando, Orlando, FL, United States
| | - Paula Veldhuis
- Department of Surgery, Florida Hospital Orlando, Orlando, FL, United States
| | - Sebastian G de la Fuente
- University of Central Florida College of Medicine, United States; Department of Surgery, Florida Hospital Orlando, Orlando, FL, United States.
| |
Collapse
|
16
|
Ansari D, Tingstedt B, Andersson B, Holmquist F, Sturesson C, Williamsson C, Sasor A, Borg D, Bauden M, Andersson R. Pancreatic cancer: yesterday, today and tomorrow. Future Oncol 2016; 12:1929-46. [PMID: 27246628 DOI: 10.2217/fon-2016-0010] [Citation(s) in RCA: 252] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is one of our most lethal malignancies. Despite substantial improvements in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since the 1960s. Pancreatic cancer is usually detected at an advanced stage and most treatment regimens are ineffective, contributing to the poor overall prognosis. Herein, we review the current understanding of pancreatic cancer, focusing on central aspects of disease management from radiology, surgery and pathology to oncology.
Collapse
Affiliation(s)
- Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Fredrik Holmquist
- Department of Radiology, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Christian Sturesson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Agata Sasor
- Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - David Borg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Monika Bauden
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| |
Collapse
|
17
|
Agalianos C, Dervenis C. Pancreatic surgery in the elderly: overcoming the prejudices. Ann Gastroenterol 2016; 29:101-2. [PMID: 27065723 PMCID: PMC4805729 DOI: 10.20524/aog.2016.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Christos Dervenis
- Department of Surgery, Konstantopouleion General Hospital of Athens (Christos Dervenis), Greece
| |
Collapse
|