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Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study. Sci Rep 2020; 10:8449. [PMID: 32439944 PMCID: PMC7242459 DOI: 10.1038/s41598-020-65532-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/30/2020] [Indexed: 01/15/2023] Open
Abstract
Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4–5 ml.kg−1.h−1 according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg−1.h−1), Cutoff (4–5 ml.kg−1.h−1) and High (≥6 ml.kg−1.h−1) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35–0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4–5 ml.kg−1.h−1 was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.
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Jeong H, Choi JW, Ahn HJ, Choi YS, Kim JA, Yang M, Kim JK, Kim DK, Shin BS, Lee SH, Kim YR, Park M, Chung YJ. The effect of preventive use of corticosteroids on postoperative complications after esophagectomy: A retrospective cohort study. Sci Rep 2019; 9:11984. [PMID: 31427671 PMCID: PMC6700144 DOI: 10.1038/s41598-019-48349-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022] Open
Abstract
Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively (n = 980). Patients were divided into Steroid (n = 120) and Control (n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.
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Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Yong Soo Choi
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Byung Seop Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mihye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Yoon Joo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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Phillips S, Dedic-Hagan J, Baxter DF, Van der Wall H, Falk GL. A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy. World J Surg 2018; 42:1787-1791. [PMID: 29164294 DOI: 10.1007/s00268-017-4369-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema. METHODS We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n = 21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n = 21). RESULTS Inotrope use was reduced by 29% in the WC group (p = 0.03) and the mean intensive care stay reduced by 2.4 days (p = 0.03), as was reintubation rate (p = 0.01) and early mobilisation (p = 0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined. CONCLUSION The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.
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Affiliation(s)
- Stephanie Phillips
- Sydney Adventist Hospital, Wahroonga, Sydney, Australia.,University of Sydney, Sydney, Australia
| | | | | | | | - G L Falk
- University of Sydney, Sydney, Australia. .,Macquarie University, Sydney, Australia. .,, Suite 29, 12 Tryon Road, Lindfield, NSW, 2070, Australia.
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Bootsma BT, Huisman DE, Plat VD, Schoonmade LJ, Stens J, Hubens G, van der Peet DL, Daams F. Towards optimal intraoperative conditions in esophageal surgery: A review of literature for the prevention of esophageal anastomotic leakage. Int J Surg 2018; 54:113-123. [PMID: 29723676 DOI: 10.1016/j.ijsu.2018.04.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/02/2018] [Accepted: 04/25/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Esophageal anastomotic leakage (EAL) is a severe complication following gastric and esophageal surgery for cancer. Several non-modifiable, patient or surgery related risk factors for EAL have been identified, however, the contribution of modifiable intraoperative parameters remains undetermined. This review provides an overview of current literature on potentially modifiable intraoperative risk factors for EAL. MATERIALS AND METHODS The PubMed, EMBASE and Cochrane databases were searched by two researchers independently. Clinical studies published in English between 1970 and January 2017 that evaluated the effect of intraoperative parameters on the development of EAL were included. Levels of evidence as defined by the Centre of Evidence Based Medicine (CEBM) were assigned to the studies. RESULTS A total of 25 articles were included in the final analysis. These articles show evidence that anemia, increased amount of blood loss, low pH and high pCO2 values, prolonged duration of procedure and lack of surgical experience independently increase the risk of EAL. Supplemental oxygen therapy, epidural analgesia and selective digestive decontamination seem to have a beneficial effect. Potential risk factors include blood pressure, requirement of blood products, vasopressor use and glucocorticoid administration, however the results are ambiguous. CONCLUSION Apart from fixed surgical and patient related factors, several intraoperative factors that can be modified in clinical practice can influence the risk of developing EAL. More prospective, observational studies are necessary focusing on modifiable intraoperative parameters to assess more evidence and to elucidate optimal values of these factors.
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Affiliation(s)
| | | | - Victor Dirk Plat
- Department of Surgery, VU Medical Center Amsterdam, The Netherlands
| | | | - Jurre Stens
- Department of Anesthesiology, VU Medical Center Amsterdam, The Netherlands
| | - Guy Hubens
- Department of Surgery, UZA Antwerpen, Belgium
| | | | - Freek Daams
- Department of Surgery, VU Medical Center Amsterdam, The Netherlands
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Veelo DP, van Berge Henegouwen MI, Ouwehand KS, Geerts BF, Anderegg MCJ, van Dieren S, Preckel B, Binnekade JM, Gisbertz SS, Hollmann MW. Effect of goal-directed therapy on outcome after esophageal surgery: A quality improvement study. PLoS One 2017; 12:e0172806. [PMID: 28253353 PMCID: PMC5333843 DOI: 10.1371/journal.pone.0172806] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/09/2017] [Indexed: 12/21/2022] Open
Abstract
Background Goal-directed therapy (GDT) can reduce postoperative complications in high-risk surgery patients. It is uncertain whether GDT has the same benefits in patients undergoing esophageal surgery. Goal of this Quality Improvement study was to evaluate the effects of a stroke volume guided GDT on post-operative outcome. Methods and findings We compared the postoperative outcome of patients undergoing esophagectomy before (99 patients) and after (100 patients) implementation of GDT. There was no difference in the proportion of patients with a complication (56% vs. 54%, p = 0.82), hospital stay and mortality. The incidence of prolonged ICU stay (>48 hours) was reduced (28% vs. 12, p = .005) in patients treated with GDT. Secondary analysis of complication rate showed a decrease in pneumonia (29 vs. 15%, p = .02), mediastinal abscesses (12 vs. 3%, p = .02), and gastric tube necrosis (5% vs. 0%, p = .03) in patients treated with GDT. Patients in the GDT group received significantly less fluids but received more colloids. Conclusions The implementation of GDT during esophagectomy was not associated with reductions in overall morbidity, mortality and hospital length of stay. However, we observed a decrease in pneumonia, mediastinal abscesses, gastric tube necrosis, and ICU length of stay.
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Affiliation(s)
- Denise P. Veelo
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Kirsten S. Ouwehand
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bart F. Geerts
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | | | - Susan van Dieren
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan M. Binnekade
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Markus W. Hollmann
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
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Cai L, Li Y, Sun L, Yang XW, Wang WB, Feng F, Xu GH, Guo M, Lian X, Zhang HW. Better perioperative outcomes in thoracoscopic-esophagectomy with two-lung ventilation in semi-prone position. J Thorac Dis 2017; 9:117-122. [PMID: 28203413 DOI: 10.21037/jtd.2017.01.27] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND One-lung ventilation (OLV) anesthesia intubation route is often used in patients undergoing thoracoscopic-esophagectomy in semi-prone position. Recently, the two-lung ventilation (TLV) approach becomes popular. However, limited studies have compared the two ventilation approaches in parallel. Here, we report a single-center, retrospective study of comparing TLV and OLV approach in patients undergoing thoracoscopic-esophagectomy in semi-prone position. METHODS From January 2013 to November 2014, 147 patients were enrolled into the current study and were given thoracoscopic-esophagectomy in semi-prone position either by OLV or TLV. Intraoperative respiratory functional data and perioperative surgical parameters of the two approaches were collected and analyzed. RESULTS Of the 147 patients, 64 patients received OLV and 83 patients received TLV, and all of them were successfully under gone thoracoscopic procedures without conversion to open thoracotomy. There was no incidence of major intraoperative complications or perioperative death. There were no statistically different in postoperative respiratory complications, either. However, TLV approach resulted in better intraoperative respiratory function (PaCO2, PaO2, SaO2), shorter preparation time for anesthesia induction, less blood loss, shorter thoracoscopic operating time and less postoperative hospital stay (P<0.05). The incidence of postoperative respiratory complications and quantity of the resected thoracic lymph node showed no difference between the two ventilation approach (P>0.05). CONCLUSION This study demonstrated that TLV intubation approach is superior to OLV approach during the thoracoscopic-esophagectomy in semi-prone position. According to this, TLV approach is a technically feasible, convenient and safe anesthesia induction approach for esophageal cancer surgery.
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Affiliation(s)
- Lei Cai
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yan Li
- Department of Anesthesiology, Northwest Women's and Children's Hospital, Xi'an 710061, China
| | - Li Sun
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Xue-Wen Yang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wen-Bin Wang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Fan Feng
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guang-Hui Xu
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Man Guo
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao Lian
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Hong-Wei Zhang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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van der Kaaij RT, van Sandick JW, van der Peet DL, Buma SA, Hartemink KJ. First Experience with Three-Dimensional Thoracolaparoscopy in Esophageal Cancer Surgery. J Laparoendosc Adv Surg Tech A 2016; 26:773-777. [DOI: 10.1089/lap.2016.0078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Rosa T. van der Kaaij
- Department of Surgical Oncology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Johanna W. van Sandick
- Department of Surgical Oncology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Sannine A. Buma
- Department of Anesthesiology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Koen J. Hartemink
- Department of Surgical Oncology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Abstract
Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.
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Affiliation(s)
- Adam Carney
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, City Campus, Hucknall Road, Nottingham NG5 1PB, UK.
| | - Matt Dickinson
- Department of Anaesthesia, Perioperative Medicine and Pain, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX, UK
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9
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Bartels K, Fiegel M, Stevens Q, Ahlgren B, Weitzel N. Approaches to perioperative care for esophagectomy. J Cardiothorac Vasc Anesth 2014; 29:472-80. [PMID: 25649698 DOI: 10.1053/j.jvca.2014.10.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Fiegel
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Quinn Stevens
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Bryan Ahlgren
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Nathaen Weitzel
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
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Lee L, Li C, Robert N, Latimer E, Carli F, Mulder DS, Fried GM, Ferri LE, Feldman LS. Economic impact of an enhanced recovery pathway for oesophagectomy. Br J Surg 2013; 100:1326-34. [PMID: 23939844 DOI: 10.1002/bjs.9224] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy. METHODS This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups. RESULTS A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs. CONCLUSION A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.
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Affiliation(s)
- L Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, Quebec, Canada
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