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Alsourani A, Pastor C, Arredondo J, Colombari RC, Pellino G, Tejedor P, ADiFas Collaborative Study Group. Surveillance and follow-up in acute diverticulitis with pericolic free gas (ADiFas II): an age-specific analysis. Updates Surg 2025:10.1007/s13304-025-02251-9. [PMID: 40418426 DOI: 10.1007/s13304-025-02251-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2024] [Accepted: 05/07/2025] [Indexed: 05/27/2025]
Abstract
The objective of this study was to examine the differences in clinical presentation and complications during the first year of follow-up in patients who experienced an episode of acute diverticulitis (AD) with pericolic free gas, comparing outcomes across different age groups. A prospective subanalysis was conducted on a cohort from the ADiFAS study, which originally included 1099 patients. After excluding 289 patients who did not meet the inclusion criteria, 810 patients remained for analysis. From this cohort, 330 patients with AD and pericolic free gas were selected using propensity score matching and divided into two age groups: < 65 years and ≥ 65 years. The groups were matched based on sex, BMI, diabetes mellitus (DM), cardiovascular disease, previous episodes of AD, and the presence of free fluid on CT scan. Data were assessed for Hinchey classification, surgical procedures, complications, and the frequency of surveillance through colonoscopy and CT scans. The study found a significantly higher rate of surgery in the older group during the index episode (17% vs. 4.2%, p = 0.000). A higher proportion of patients in the older group were misclassified as Hinchey II (18.2% vs. 6.4%, p = 0.007) and Hinchey III (2.3% vs. 0.7%, p = 0.304). All patients classified as Hinchey III (1 in the younger group and 3 in the older group) underwent emergency surgery. In the younger group, 2 out of 8 emergency surgeries were for patients classified as Hinchey II, compared to 11 out of 28 in the older group. Only 58% of patients underwent any form of imaging or endoscopic surveillance during the first year of follow-up. Among those, complications such as abscess, fistula, or stenosis were observed in 17% of patients, occurring more frequently in the older group (16.9% vs. 5.7%, p = 0.089). Nearly 50% of these patients required surgery, with 6 cases in the younger group and 9 in the older group. Emergency surgeries were more common in the older group (2.4% vs. 0.6%, p = 0.186), as was elective surgery (10.3% vs. 7.9%, p = 0.283). A conservative approach, combined with meticulous monitoring through regular follow-ups and imaging, can be effectively employed in managing patients with acute diverticulitis and pericolic free gas. However, our findings highlight the critical need for rigorous surveillance, especially in older patients, due to the higher prevalence of long-term complications.
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Affiliation(s)
- Adnan Alsourani
- Colorectal Surgery Unit, Department of Colorectal Surgery, University Hospital Gregorio Marañon, Madrid, Spain
| | - Carlos Pastor
- Colorectal Surgery Unit, University Clinic of Navarre, Madrid-Pamplona, Spain
| | - Jorge Arredondo
- Colorectal Surgery Unit, University Clinic of Navarre, Madrid-Pamplona, Spain
| | - Renan Carlo Colombari
- Colorectal Surgery Unit, Department of Colorectal Surgery, University Hospital Gregorio Marañon, Madrid, Spain
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
- Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Patricia Tejedor
- Colorectal Surgery Unit, Department of Colorectal Surgery, University Hospital Gregorio Marañon, Madrid, Spain.
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Collaborators
Emmanuele Abate, Jorge Luis Aguilar Frasco, Giada Aizza, Natalia Alonso Hernández, Alfredo Alonso Poza, Alicia Alvarellos Pérez, Alfredo Annichiarico, Giaime Gonario Arru, Luis Asensio Gómez, Qurrat Al Ain Atif, Nicolas Avellaneda, Giuseppe Barletta, Matteo Bianchini, Alan Biloslavo, Jesús Bollo Rodríguez, Marina Bosch-Ramírez, Gioia Brachini, Morena Burati, James Byrne, Carmen Cagigas, Rubén Caiña Ruiz, Michela Campanelli, Esther María Cano Pecharromán, Augusto Carrie, Marta Castro Suárez, Fausto Catena, Sinue Cazarez-Huazano, Massimo Chiarugi, Enrico Cicuttin, Nicola Cillara, Federico Clerici, Federico Coccolini, Alba Correa Bonito, Vanesa Crespo García Del Castillo, Francesca D'Agostino, George Davis, Paola De Nardi, Gilda De Paola, Semra Demirli Atici, Antonello Deserra, Beatriz Diéguez Fernández, Beatriz Díaz San Andrés, German Espil, Eloy Espín-Basany, Mercedes Estaire Gómez, Giuseppe Esposito, Maria Luz Fernández, Laura Fernández Vega, María Luisa de Fuenmayor Valera, Alexander Forero, Alice Frontali, Àngels Gabarrell Oto, María Gallego, Gaetano Gallo, Sabrina Garbarino, Álvaro García-Granero, Felipe García Sánchez, Joseph Garvin, Zoe Garoufalia, Ludovica Gibelli, Mario Giuffrida, Zahira Gómez Carmona, Tatiana Gómez Sánchez, Jurij Aleš Košir, Michele Grande, Cristina Gras Gómez, Jan Grosek, Ugo Grossi, Hamid, Miguel Hernández García, Pablo Hernández Sanz, Arturan Ibrahimli, Andru Iruthayanathar Nitharsan, Carlos Jezieniecki Fernández, Luis Miguel Jiménez, Marta Jiménez-Toscano, Luz Divina Juez, Ariel Jullien Petrelli, Ata Khan, Mansoor Khan, María Labalde Martínez, Letizia Laface, Andrea Laghi, Pierfrancesco Lapolla, Martina Leonardis, Denis César Lévano-Linares, Tamara Llamero Sanz, Manuel Losada Ruiz, Caterina Maietta, Marco V Marino, Marco Massani, Rodrigo Mata, Pablo Menéndez Sánchez, Nuria Mestres Petit, Andrea Mingoli, Mauro Montuori, Javier Tomas Morales-Bernaldo de Quiros, Xavier Morales Sevillano, Vicente Muñoz López-Pérez, Hamid Mustafa, Antonio Navarro Sánchez, Giuseppe Nigri, Nikolaos Nikiteas, Juan Ocaña, Pilar Olivenza Palomar, Gian Marco Palini, Matteo Palmeri, Marta Paniagua García-Señoráns, Nicola Passuello, Sharjeel H Paul, María Pelloni, Gennaro Perrone, Carlos Petrola, Beatrice Pessia, Isabella Pezzoli, Enrico Pinotti, Mauro Podda, Fernando Prieto, Isabel Prieto, Aída Rahy-Martín, Ana Rodríguez, Laura Rodríguez Fernández, Giovanni Romano, Francesco Roscio, Alicia Ruiz de la Hermosa, Matteo Runfola, Elena Sagarra Cebolla, Noel Salgado-Nesme, Silvia Salvans, Elgun Samadov, Eduardo de San Pío Carvajal, Eva María Sancho Maraver, Carmen Sánchez de la Orden, Luis Sánchez-Guillén, Oscar Santes, Lodovico Sartarelli, Pietro Schettino, Vicente Simó, Leandro Siragusa, Iván Soto-Darias, Natalia Suárez, Nicolò Tamini, Dario Tartaglia, Marta Tasende Presedo, Valeria Tonini, Jeancarlos Trujillo-Díaz, Víctor Turrado, Roberta Tutino, Vicente Muñoz López-Pérez, Ainhoa Valle, Rosalía Velasco López, Vincenzo Vigorita, Mauro Zago, Giacomo Zanus, Marta Zerunian,
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Burgard M, Litchinko A, Meyer J, Toso C, Ris F, Delaune V. Outpatient Management Protocol for Uncomplicated Diverticulitis: A 3-Year Monocentric Experience in a Tertiary Hospital. J Clin Med 2024; 13:5920. [PMID: 39407980 PMCID: PMC11477958 DOI: 10.3390/jcm13195920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Revised: 09/22/2024] [Accepted: 10/02/2024] [Indexed: 10/20/2024] Open
Abstract
Background/Objectives: The management of acute uncomplicated diverticulitis (AUD) has shifted towards outpatient care in the last decade, challenging the traditional inpatient approach. We aimed to analyze the safety and feasibility of a structured outpatient treatment pathway for AUD in a tertiary hospital. Methods: We conducted a retrospective observational cohort analysis of patients who underwent outpatient management for AUD at the Geneva University Hospitals from 2019 to 2021. Patient demographics, selection criteria, treatment protocols, and outcomes were analyzed. Results: Two-hundred and twenty patients were included in the outpatient cohort. Four patients (1.8%) required hospitalization due to the failure of outpatient management, whereas the majority of patients (116 patients, 98.2%) experienced a successful resolution of their symptoms without hospitalization. In a univariate analysis, factors associated with treatment failure included elevated white blood cell counts at admission (14 G/l vs. 10.6 G/l, p = 0.049) and the first follow-up appointment, (10.7 G/l vs. 7.4 G/l, p = 0.011) and the presence of free air on their CT scan (25% vs. 2,3%, p = 0.033). In a multivariate analysis, the presence of free air was the only identified risk factor for unsuccessful outpatient management (p = 0.05). We observed high rates of follow-up compliance (99.1%). Conclusion: Under the condition of a warranted outpatient follow-up appointment and with adequate selection criteria, outpatient management appears to be an effective approach for most patients with AUD, emphasizing the importance of tailored therapeutic interventions and vigilant clinical assessments for optimal outcomes.
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Affiliation(s)
- Marie Burgard
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
| | - Alexis Litchinko
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
- Department of Surgery, Cantonal Hospital of Fribourg Chemin des Pensionnats 2/6, 1752 Villars-sur-Glâne, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
| | - Christian Toso
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
- Transplantation and Hepatology Laboratory, Geneva Medical University, Rue Michel Servet 1, 1206 Geneva, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
| | - Vaihere Delaune
- Division of Digestive Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; (A.L.); (J.M.); (C.T.); (F.R.); (V.D.)
- Transplantation and Hepatology Laboratory, Geneva Medical University, Rue Michel Servet 1, 1206 Geneva, Switzerland
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Tejedor P, Pastor C, Pellino G, Di Saverio S, Gorter-Stam M, Sylla P, Francis N. Management of acute diverticulitis with pericolic free gas (ADIFAS): an international multicenter observational study. Int J Surg 2023; 109:689-697. [PMID: 37010145 PMCID: PMC10389554 DOI: 10.1097/js9.0000000000000213] [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: 10/06/2022] [Accepted: 01/05/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid. METHODS A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure. RESULTS A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%. CONCLUSION Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation.
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Affiliation(s)
- Patricia Tejedor
- Department of Colorectal Surgery, University Hospital ‘Gregorio Marañón’, Madrid
| | - Carlos Pastor
- Department of Colorectal Surgery, University Clinic of Navarre, Madrid & Pamplona, Spain
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples
- Department of Colorectal Surgery,Vall d’Hebron University Hospital, Barcelona, Spain
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | | | - Patricia Sylla
- Department of Colorectal Surgery, Mount Sinai Hospital, New York, New York, USA
| | - Nader Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
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Huang SS, Sung CW, Wang HP, Lien WC. The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis. World J Emerg Surg 2022; 17:56. [PMID: 36320045 PMCID: PMC9628071 DOI: 10.1186/s13017-022-00463-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/31/2022] [Indexed: 11/07/2022] Open
Abstract
Background There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD. Methods A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure. Results Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8–13%, I2 = 86%, p < 0.01) in right-sided and 20% (95% CI 16–24%, I2 = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6–13%, I2 = 77%, p < 0.01) in right-sided and 15% (95% CI 8–27%, I2 = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2–10%, I2 = 84%, p < 0.01) in right-sided and 4% (95% CI 2–7%, I2 = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited. Conclusion Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hsin-Chu Hospital, Hsinchu City, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Ching Lien
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, Taipei, 100, Taiwan.
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Kang G, Son S, Shin YM, Pyo JS. Recurrence of Uncomplicated Diverticulitis: A Meta-Analysis. Medicina (B Aires) 2022; 58:medicina58060758. [PMID: 35744021 PMCID: PMC9228700 DOI: 10.3390/medicina58060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objective: This study aimed to investigate the estimated rate and risk of recurrence of uncomplicated diverticulitis (UCD) after the first episode through a meta-analysis. Methods: Eligible studies were searched and reviewed; 27 studies were included in this study. Subgroup analyses were performed, based on lesion location, medical treatment, follow-up period, and study location. Results: The estimated recurrence rate of UCD was 0.129 (95% confidence interval [CI] 0.102–0.162). The recurrence rates of the right-and left-sided colon were 0.092 (95% CI 27.063–0.133) and 0.153 (95% CI 0.104–0.218), respectively. The recurrence rate according to follow-up period was highest in the subgroup 1–2 years, compared with that of other subgroups. The recurrence rate of the Asian subgroup was significantly lower than that of the non-Asian subgroup (0.092, 95% CI 0.064–0.132 vs. 0.147, 95% CI 0.110–0.192; p = 0.043 in the meta-regression test). There were significant correlations between UCD recurrence and older age and higher body temperature. However, UCD recurrence was not significantly correlated with medications, such as antibiotics or anti-inflammatory drugs. Conclusions: In this study, detailed information on estimated recurrence rates of UCD was obtained. In addition, older age and higher body temperature may be risk factors for UCD recurrence after the first episode.
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Affiliation(s)
- Guhyun Kang
- Department of Pathology, Daehang Hospital, Seoul 06699, Korea;
| | - Soomin Son
- Division of Molecular Life and Chemical Sciences, College of Natural Sciences, Ewha Woman’s University, Seoul 03760, Korea;
| | - Young-Min Shin
- Eulji University School of Medicine, Daejeon 34824, Korea;
| | - Jung-Soo Pyo
- Department of Pathology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu 11759, Korea
- Correspondence:
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Karentzos A, Ntourakis D, Tsilidis K, Tsoulfas G, Papavramidis T. Hinchey Ia acute diverticulitis with isolated pericolic air on CT imaging; to operate or not? A systematic review. Int J Surg 2021; 85:1-9. [PMID: 33246153 DOI: 10.1016/j.ijsu.2020.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Colonic diverticulitis is one of the most common gastrointestinal pathologies and its prevalence increases with the aging of the population in Western countries. Approximately 15% of patients with Hinchey Ia acute diverticulitis present with concomitant isolated pericolic air bubbles that denote intestinal perforation and thus prompting a more "aggressive" treatment attitude, including emergency surgery, despite the absence of evidence-based indications. This study is trying to delineate whether this approach is justified or whether a conservative treatment would suffice for this group of patients. MATERIALS AND METHODS PubMed and Cochrane CENTRAL databases were systematically searched in order to identify all studies that reported the need for emergency surgery and for percutaneous drainage in patients presenting with Hinchey Ia colonic diverticulitis with extraluminal pericolic gas on CT imaging who were initially treated conservatively. The last database search was performed on November 29, 2019 and no language or study type restriction criteria were applied. The Newcastle-Ottawa scale was used to assess the risk of bias of selected studies. RESULTS Nine observational cohort studies with 411 patients reported the need for emergency surgery, with a pooled rate of 5.1%. Among these studies, four studies comprising 165 patients reported the need for percutaneous drainage separately with a pooled rate of 1.2%. CONCLUSION Non-operative management of Hinchey Ia acute diverticulitis with isolated pericolic air is feasible and safe with a success rate of 94.9%. Abscess formation requiring percutaneous drainage is present in only 1.2% of patients, thus rendering the conservative initial treatment of these patients justified. Nevertheless, low quality of included studies indicates further research to validate the outcomes of this review.
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Affiliation(s)
| | - Dimitrios Ntourakis
- European University Cyprus School of Medicine, 6 Diogenis Str 2404 Engomi, P.O. Box: 22006, 1516, Nicosia, Cyprus.
| | - Konstantinos Tsilidis
- University of Ioannina Faculty of Medicine, Department of Hygiene and Epidemiology, 45110, Ioannina, Greece.
| | - Georgios Tsoulfas
- Aristotle University of Thessaloniki, 1st Department of Surgery, AHEPA University Hospital, Kiriakidi 1, Thessaloniki, Greece.
| | - Theodossis Papavramidis
- Aristotle University of Thessaloniki, 3rd Department of Surgery, AHEPA University Hospital, Kiriakidi 1, Thessaloniki, Greece.
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