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Kanabolo D, Cain M, Brown M, Ahn J, Fernandez N, Halbach S, Shnorhavorian M, Merguerian P. Long term renal outcome and risk of elevated blood pressure in children undergoing complete primary repair of bladder exstrophy ( CPRE). J Pediatr Urol 2023:S1477-5131(23)00096-7. [PMID: 37002021 DOI: 10.1016/j.jpurol.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Since the initiation of staged reconstruction for bladder exstrophy (BE), hypertension has been a known complication of the procedure. Hypertension is a well-established risk factor for chronic kidney disease (CKD) progression and associated with cardiovascular/cerebrovascular morbidity and mortality. Few studies exist evaluating the risk of developing hypertension among patients with bladder exstrophy who underwent CPRE. We hypothesized that long-term blood pressure levels may be elevated in males vs females, and may be correlated with presence of hydronephrosis, bladder neck reconstruction, or continence status. OBJECTIVE We sought to revisit our long-term experience with CPRE and determine factors associated with incidence of elevated blood pressures. METHODS We reviewed all BE patients undergoing CPRE at our institution from 1999 to 2019. Patients were considered eligible for inclusion if last renal ultrasound was obtained at least 5 years after repair. Upper tract outcomes based on imaging, history of pyelonephritis and renal function tests measured by serum creatinine and estimated glomerular filtration rate (eGFR, Schwartz formula) were reviewed. Systolic/diastolic blood pressures (SBP/DBP) from all encounters were captured. All blood pressure values were age adjusted by percentile. RESULTS A total of 36 patients were considered eligible for review. Median follow-up of this cohort was 10.01 (5.16-21.47) years. The mean creatinine for the patients available was 0.58 mg/dL (SD = 0.20), at mean age of 8.90 years Neither SBP or DBP were significantly elevated in males vs females, but had lower odds of elevation >90th percentile for those with higher eGFR, lower renal length, and reimplantation. Pyelonephritis incidence was 38% (n = 14) with first episode at mean age of 8.8 years, and mean of 3.7 episodes per patient. DISCUSSION At long term follow up, blood pressures following CPRE were not significantly elevated, despite the relatively frequent occurrence of CKD, and hydronephrosis. Male gender does appear to suggest higher risk for long-term deterioration in this regard. Higher eGFR, higher renal length, and presence of ureteral reimplantation were associated with lower likelihood of systolic/diastolic blood pressure elevation. Continence status and bladder neck reconstruction were not associated with likelihood of blood pressure elevation. CONCLUSIONS Blood pressure and upper-tract outcomes for patients undergoing CPRE at birth are positive for the majority of patients. To avoid complications from hypertension, patients should be closely evaluated as the risks associated with elevated blood pressure are significant. Ultimately, larger-scale prospective and multi-institutional studies are further needed to characterize risks of hypertension in this complex patient population.
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Affiliation(s)
- Diboro Kanabolo
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.
| | - Mark Cain
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Marshall Brown
- Seattle Children's Hospital, Biostatistics, Epidemiology and Analytics in Research Core
| | - Jennifer Ahn
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Nicolas Fernandez
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Susan Halbach
- Seattle Children's Hospital, Section of Pediatric Nephrology, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Paul Merguerian
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
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Cruz-López JE, Guzmán-Aguilar R, Conde-Mora MA, Méndez-Ramírez LA. Management of post-ERCP duodenal perforations: experience at Hospital Juárez de México. CIR CIR 2023; 91:829-834. [PMID: 38096859 DOI: 10.24875/ciru.22000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 02/22/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic study in which the duodenum is observed laterally, and the bile duct is instrumented. There are several indications and complications in the procedure. OBJECTIVE To determine the incidence of duodenal perforations, using the Stapfer classification in the Hospital Juárez de Mexico over a period of 5 years, as well as the management implemented in such cases. METHOD The study was carried out at the Hospital Juárez de Mexico of the Ministry of Health. All patients who underwent ERCP between January 1, 2017, to May 30, 2022 were included. RESULTS 485 ERCP were performed in the study period. Incidence of 1.6% post-ERCP duodenal perforation. The average age of the subjects 56.37 years. In-hospital stay of post-ERCP perforations averaged 9.37 days. The time of the endoscopic study at the time of the surgical procedure is 10 h on average. CONCLUSIONS Post-ERCP duodenal perforation is a complication that occurs with a low incidence, it tends to increase the number of days of in-hospital stay and increases morbimortality of patients; therefore, it is important to be always alert.
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Affiliation(s)
- Jaime E Cruz-López
- Departamento de Cirugía General, Hospital Juárez de México, Secretaría de Salud, Ciudad de México, México
| | - Rafael Guzmán-Aguilar
- Departamento de Cirugía General, Hospital Juárez de México, Secretaría de Salud, Ciudad de México, México
| | - María A Conde-Mora
- Departamento de Cirugía General, Hospital Juárez de México, Secretaría de Salud, Ciudad de México, México
| | - Levi A Méndez-Ramírez
- Departamento de Cirugía General, Hospital Juárez de México, Secretaría de Salud, Ciudad de México, México
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Donatelli G, Cereatti F, Dhumane P, Antonelli G, Dumont JL, De Palma GD, Dagher I, Derhy S. Long-term Outcomes of Combined Endoscopic-Radiological Approach for the Management of Complete Transection of the Biliary Tract. J Gastrointest Surg 2022; 26:1873-1880. [PMID: 35668228 DOI: 10.1007/s11605-022-05365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center. METHODS All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification. RESULTS Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients. CONCLUSIONS CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.
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Affiliation(s)
- Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France. .,Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy.
| | - Fabrizio Cereatti
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France.,Department of Gastroenterology and Digestive Endoscopy, Castelli Hospital, Ariccia (Rm), Italy
| | - Parag Dhumane
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France.,Department of General and Laparoscopic Surgery, Lilavati Hospital and Research Center, Bandra(w), Mumbai, India
| | - Giulio Antonelli
- Department of Gastroenterology and Digestive Endoscopy, Castelli Hospital, Ariccia (Rm), Italy.,Department of Anatomical, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, HistologicalRome, Italy
| | - Jean-Loup Dumont
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France
| | | | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Serge Derhy
- Unité de Radiologie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, Paris, France
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Weiss DA, Shukla AR, Borer JG, Sack BS, Kryger JV, Roth EB, Groth TW, Frazier JR, Mitchell ME, Canning DA. Evaluation of outcomes following complete primary repair of bladder exstrophy at three individual sites prior to the establishment of a multi-institutional collaborative model. J Pediatr Urol 2020; 16:435.e1-435.e6. [PMID: 32616376 DOI: 10.1016/j.jpurol.2020.05.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/26/2020] [Accepted: 05/18/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE The Multi-Institutional Bladder Exstrophy Consortium (MIBEC) was established in 2013 to refine technical aspects of the complete primary repair of bladder exstrophy (CPRE), to decrease complications, and to improve outcomes. In order to place outcomes from the consortium into context of historic outcomes, we evaluated continence and dry intervals in children who were repaired prior to the beginning of the consortium at these institutions. We hypothesized that continence (voiding with dryness) is rarely achieved after primary CPRE and surgery following CPRE improves dryness but may hinder voiding per urethra. MATERIALS AND METHODS We reviewed prospectively maintained IRB approved databases of children who underwent CPRE for classic bladder exstrophy (BE) between 5/1993 and 1/2013 at 3 institutions. Exclusion criteria included: lack of continence documentation, and lack of follow up subsequent to January 2014. We recorded age at closure, method of bladder emptying, bladder capacity and surgical history. We used a 3 part dryness scale for both patients who void volitionally and those on CIC. Children were considered dry if they could hold urine for over 3 h. An intermediate group was defined as having a dry interval of 2-3 h, with minimal dampness in between voids. If dry intervals were <2 h with frequent leakage, children were considered wet. RESULTS A total of 54 of 73 (38 M) children met inclusion criteria. 35 of 54 (64.8%) children void per urethra, while 18 (33.3%) perform clean intermittent catheterization (CIC) and 1 underwent a vesicostomy due to incomplete emptying and UTI's. 25/35 (71.4%) of those voiding per urethra underwent CPRE only, while the remaining 10 underwent secondary continence procedures. In total, 26 of 54 (48.1%) are dry, that is either continent or not wet for > 3 h, while only 11/54 (20.4%) are truly continent, i.e., voiding per urethra. Only 9/54 (16.7%) are continent after a single surgery (CPRE). 14/54 children who are dry (25.9%) underwent a bladder neck procedure with or without augmentation and empty with CIC. DISCUSSION AND CONCLUSION Granular detail about the specifics of emptying, surgical history, and dry intervals is crucial to understand the true outcomes from the repair of BE. Children with BE undergoing CPRE prior to the institution of MIBEC experienced variable results, with only 17% achieving continence while spontaneously voiding per urethra without additional reconstruction. We are now engaged in MIBEC to identify factors that contribute to continence and to attempt to render such findings reproducible.
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Affiliation(s)
- Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Bryan S Sack
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - John V Kryger
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Elizabeth B Roth
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Travis W Groth
- Division of Urology, Children's Hospital Wisconsin, Milwaukee, WI, USA
| | - Jennifer R Frazier
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Douglas A Canning
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Del Olmo Martínez ML, Velayos Jiménez B, Almaraz-Gómez A. Hydration with Lactated Ringer's solution combined with rectal diclofenac in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterol Hepatol 2020; 44:20-26. [PMID: 32674877 DOI: 10.1016/j.gastrohep.2020.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/13/2020] [Accepted: 03/13/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Different measures are recommended to reduce pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We conducted a study in patients with ERCP treated with rectal diclofenac or lactated Ringer's solution, or both interventions, to assess whether there is a decrease in the number of cases of post-ERCP pancreatitis. MATERIAL AND METHODS A mixed cohort study involving 1,896 patients from 2009 to 2018. Up to June 2012 without treatment (Group I). Subsequently, 100mg of rectal diclofenac (Group II). Since 2016, lactated Ringer's solution 200ml/hour during the procedure and 4hours after it, in addition to 500ml over 30minutes when the pancreas was cannulated (Group III). Since 2017, lactated Ringer's solution plus Diclofenac (Group IV). There were 725 patients in group I, and 530, 227 and 414 patients in groups II, III and IV, respectively. Factors predisposing to post-ERCP pancreatitis and post-ERCP pancreatitis cases that were defined by consensus criteria have been collected. RESULTS There were 65 cases of post-ERCP pancreatitis (3.4%); 2.9%, 3.4%, 3.1% and 4.3% in groups I, II, III and IV, respectively (P=.640). In group I, there was 4.2% of post-ERCP pancreatitis in naïve papillae and 4%, 4.9% and 6.3% in groups II, III and IV, respectively (P=.585). The severity of post-ERCP pancreatitis and adverse effects were similar in all groups. 38.4% were high-risk patients. There were also no differences in post-ERCP pancreatitis in this group (P=.501). CONCLUSION In this work, no benefit was obtained with diclofenac plus hydration in reducing the number and severity of cases of post-ERCP pancreatitis nor with the other prophylactic measures.
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Affiliation(s)
| | - Benito Velayos Jiménez
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Ana Almaraz-Gómez
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
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Martínez-Segundo U, Pinto-Angulo VM, García-Álvarez J, Cruz-Reyes JM, Briceño-Sáenz G. Usefulness of serum amylase and lipase as predictors of the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis. CIR CIR 2020; 88:428-434. [PMID: 32567590 DOI: 10.24875/ciru.20001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Post-ERCP pancreatitis (PEP) is the most common complication of Post-endoscopic retrograde cholangiopancreatography. Objective to demonstrate whether serum amylase and lipase values correlate with the presence and severity of PEP. Method We conducted a retrospective, observational and analytical study of patients who underwent ERCP, those who developed pancreatitis were classified by severity according to the 2012 revised Atlanta criteria and their serum enzyme levels were analyzed. We used ROC (Receiver Operating Characteristics) curves to know the best enzyme cutoff points and analyzed their diagnostic yields. Chi-square, t-distribution and Mann-Whitney U test were used in the variable analysis and it was considered statistically significant when p < 0.05. Results A total 621 patients, 54 presented pancreatitis. For moderately severe and severe forms: lipase level of 1500 U/L had an area under the curve (AUC) = 0.827, 95% CI (0.67-0.98), sensitivity = 72.7%, specificity = 86%, negative predictive value = 92.5%, p < 0.05. Amylase level of 920 U/L presented AUC = 0.65, 95% CI (0.43-0.86), sensitivity = 63%, specificity = 67%, p > 0.05. Conclusions Serum lipase shows correlation with the presence and severity of PEP. Amylase shows no significant correlation with PEP.
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Jesús-Flores AD, Guerrero-Martínez GA. Impact of the protocol proposed by the American Society for Gastrointestinal Endoscopy in patients at high risk of choledocholithiasis, in Puebla Regional Hospital ISSSTE in Mexico. CIR CIR 2019; 87:423-427. [PMID: 31264993 DOI: 10.24875/ciru.19000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Choledocholithiasis is one of the main complications of cholelithiasis with a prevalence in the Mexican population of 14%. The management through the guide proposed by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 can support the surgeon for the timely resolution of the pathology. Objective To determine that the guide proposed by ASGE for the management of choledocholithiasis in patients with "high risk" reduces the complications of this pathology. Methods A comparative, retrospective case-control study was conducted from January 1, 2015 to December 31, 2017. We included patients who were stratified at high risk of choledocholithiasis according to the ASGE guidelines. They were divided into 2 groups: the case group (diagnosis by ASGE guidelines) was submitted directly to endoscopic retrograde cholangiopancreatography (ERCP), the second group (no ASGE) followed the protocol of performing computed tomography, magnetic cholangioresonance, and finally ERCP. Results Of 61 patients with choledocholithiasis, the following groups were compared: the appearance of cholangitis, the complications after ERCP, time of ERCP, days of hospital stay and mortality. Obtaining significant difference in: "complications post ERCP" group ASGE 3/35 (9%), group no ASGE 8/26 (30.7%) with OR of 0.2 (0.05 - 0.9 IC 95%) and a p = 0.03; "Cholangitis" group ASGE 2/35 (5.7%), group no ASGE 8/26 (30-7%) with ORP 0.13 (0.03-0.71 IC 95%) and p = 0.009. Conclusion In our setting, the use of the ASGE guideline reduces the presence of cholangitis and post-ERCP complications.
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Affiliation(s)
- Alberto De Jesús-Flores
- Servicio de Cirugía General, Hospital Regional de Alta Especialidad, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Puebla, Puebla, México
| | - Gustavo A Guerrero-Martínez
- Servicio de Cirugía General, Hospital Regional de Alta Especialidad, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Puebla, Puebla, México
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Molina Romero FX, Morón Canis JM, Llompart Rigo A, Rodríguez Pino JC, Morales Soriano R, González Argente FX. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography after biliopancreatic diversion. Cir Esp 2015; 93:594-8. [PMID: 26025065 DOI: 10.1016/j.ciresp.2015.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/26/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Abstract
Endoscopic retrograde cholangiopancreatography may be difficult in patients that have undergone Roux-en-Y gastric bypass. Due to the fact that prevalence of morbid obesity is increasing, and laparoscopic procedures for its treatment have increased, the incidence of biliary tract problems in patients of altered anatomy is also growing. We describe a laparoscopic technique to access the biliary tree by endoscope, through the excluded stomach.
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Affiliation(s)
- Francesc Xavier Molina Romero
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España.
| | - José Miguel Morón Canis
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Alfredo Llompart Rigo
- Servicio de Digestivo, Unidad de Endoscopia Digestiva, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - José Carlos Rodríguez Pino
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Rafael Morales Soriano
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Francesc Xavier González Argente
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
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