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Elnaggar AA, Diab KR, El-Hangour BA, Kamel IS, Farhat AM, Abdelsattar AT, Zarad MS. Direct trocar insertion vs. Veress needle technique in laparoscopic surgeries. A systematic review and meta-analysis. J Visc Surg 2023; 160:337-345. [PMID: 36842955 DOI: 10.1016/j.jviscsurg.2023.02.001] [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: 02/28/2023]
Abstract
AIM To compare the safety and efficacy between Veress needle insertion and direct trocar insertion in laparoscopic surgeries. METHODS Relevant clinical trials were retrieved from major databases; Web of Science, Cochrane CENTRAL, PubMed, and SCOPUS. The following outcomes were pooled for analysis: failed entry, extraperitoneal insufflation, vascular lesion, omental lesion and visceral lesion, site bleeding, reintervention, subcutaneous emphysema, solid organ lesion, and infection of the trocar site. A fixed-effects model was used to analyze homogeneous outcomes, whereas random-effects models were used to analyze heterogeneous outcomes. RESULTS We included a total of twelve clinical trials. The pooled analysis showed that the Veress needle was accompanied by a significant increase in the incidences of extraperitoneal insufflation (RR = 0.204; 95% Cl [0.136, 0.307], P=0.001), omental lesion (RR=0.444 95% Cl [0.239, 0.825], P=0.01), and failed entry (RR=0.169 95% Cl [0.101, 0.284], P=0.001). There is no significant difference between both cohort regarding the vascular lesion (RR=0.847 95% Cl [0.259, 2.777), P=0.7), infection of the trocar site (RR=0.583 95%Cl [0.106, 3.216], P=0.5, and visceral lesion (RR=1.308 95% Cl [0.314, 5.438], P=0.7. CONCLUSION The DTI was accompanied by a significantly lower incidence of complications such as extraperitoneal insufflation, failed entry, omental lesion, and subcutaneous emphysema. On the other hand, both cohorts showed similar results regarding; vascular lesions, visceral lesions, reintervention, site bleeding, and solid organ lesion.
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Affiliation(s)
- A A Elnaggar
- Department of General Sugery, Faculty of medicine, Fayoum University, Fayuom, Egypt
| | - K R Diab
- Department of General Sugery, Faculty of medicine, Fayoum University, Fayuom, Egypt
| | - B A El-Hangour
- Department of General Sugery, Faculty of medicine, Al-Azhar University, Cairo, Egypt
| | | | - A M Farhat
- Faculty of Medicine, Fayoum University, Fayoum, Egypt.
| | | | - M S Zarad
- Department of General Sugery, Faculty of medicine, Al-Azhar University, Cairo, Egypt
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2
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Miti C, Busuulwa P, Scott R, Bloomfield-Gadelha H. Primary entry trocar design and entry-related complications at laparoscopy in obese patients: meta-analysis. BJS Open 2023; 7:zrad047. [PMID: 37352873 PMCID: PMC10289830 DOI: 10.1093/bjsopen/zrad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/07/2023] [Accepted: 03/19/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe primary entry at laparoscopy could present challenges in obese patients. Various techniques have been proposed in previous studies, however, the characteristics of the actual device utilized may be more influential than the technique in achieving successful abdominal entry in patients with increased BMI. METHODS This systematic review and meta-analysis included both randomized and non-randomized studies gathered with no date filters from MEDLINE, Embase, Scopus, Web of Science and Clinicaltrials.gov. PRISMA guidelines underpinned the conduct and reporting of the review. The meta-analysis of proportions was conducted using a generalized linear mixed model and analyses included random-effects models. The primary outcome was the proportion of first access vascular and visceral injuries incurred in the process of laparoscopic abdominal surgery in patients with a BMI >30 kg/m2. Subgroup analysis was performed for optical versus non-optically enabled devices. RESULTS In total, 5403 patients were analysed across 13 observational studies with a mean BMI of 45.93 kg/m2. In 216 patients from two randomized studies, the mean BMI was 39.92 kg/m2. The overall incidence using a random-effects model was 8.1 per 1000 events of visceral and vascular injuries (95 per cent c.i. 0.003 to 0.024). Heterogeneity was statistically significant at I2 = 80.5 per cent (69.6 per cent; 87.5 per cent, P< 0.0001). In a subgroup analysis, a tendency towards reduced injuries when optical devices were employed was observed with one per 100 injuries in these trocars (95 per cent c.i. 0.001 to 0.018) versus four per 100 (95 per cent c.i. -0.019 to -0.102) in non-optically enabled devices. CONCLUSION Injuries during primary laparoscopic entry undertaken in obese patient groups are uncommon. Due to considerable heterogeneity in the small number of examined studies, evidence was insufficient and largely of low quality to ascribe differences in the incidence of injuries to the characteristics of the primary entry trocar utilized.
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Affiliation(s)
- Chimwemwe Miti
- Department of Electrical and Electronic Engineering, EPSRC Centre for Doctoral Training in Digital Health and Care, University of Bristol, Bristol, UK
| | - Paula Busuulwa
- Department of Academic Obstetrics & Gynaecology, Liverpool Women’s Hospital, Liverpool, UK
| | - Richard Scott
- Department of Engineering Mathematics and Bristol Robotics Laboratory, University of Bristol, Bristol, UK
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Taliento C, Pontrelli G, Rondoni A, Desgro M, Steinkasserer M, Scutiero G, Vizzielli G, Greco P. Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:152. [PMID: 37069276 DOI: 10.1007/s00423-023-02891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/09/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques. DATA SOURCE A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO. METHODS The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020. RESULTS Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD = - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78). CONCLUSION There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.
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Affiliation(s)
- C Taliento
- Department of Medical Sciences, Institute of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy.
| | - G Pontrelli
- Policlinico Abano Terme, Abano Terme, Padua, Italy
| | - A Rondoni
- Department of Medical Sciences, Institute of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy
| | - M Desgro
- Policlinico Abano Terme, Abano Terme, Padua, Italy
| | - M Steinkasserer
- Department of Obstetrics and Gynecology, Bolzano Hospital, Bolzano, Italy
| | - G Scutiero
- Department of Medical Sciences, Institute of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy
| | - G Vizzielli
- Department of Medical Area (DAME), Clinic of Obstetrics and Gynecology, University of Udine, Santa Maria Della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - P Greco
- Department of Medical Sciences, Institute of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy
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Barrea L, Verde L, Schiavo L, Sarno G, Camajani E, Iannelli A, Caprio M, Pilone V, Colao A, Muscogiuri G. Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery. Nutrients 2023; 15:nu15081907. [PMID: 37111126 PMCID: PMC10142118 DOI: 10.3390/nu15081907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/24/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.
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Affiliation(s)
- Luigi Barrea
- Dipartimento di Scienze Umanistiche, Università Telematica Pegaso, Centro Direzionale, Via Porzio, Isola F2, 80143 Naples, Italy
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Ludovica Verde
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Complex Operative Unit of General and Emergency Surgery and Bariatric Centre of Excellence SICOB, University of Salerno, 84081 Salerno, Italy
| | - Gerardo Sarno
- San Giovanni di Dio e Ruggi D'Aragona University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Elisabetta Camajani
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, 00166 Rome, Italy
| | - Antonio Iannelli
- Centre Hospitalier Universitaire de Nice-Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, CEDEX 3, 06200 Nice, France
- Faculté de Medicine, Université Côte d'Azur, 06000 Nice, France
- Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", 06204 Nice, France
| | - Massimiliano Caprio
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, 00166 Rome, Italy
- Laboratory of Cardiovascular Endocrinology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele, 00166 Rome, Italy
| | - Vincenzo Pilone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Complex Operative Unit of General and Emergency Surgery and Bariatric Centre of Excellence SICOB, University of Salerno, 84081 Salerno, Italy
| | - Annamaria Colao
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
- Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
- Cattedra Unesco "Educazione Alla Salute e Allo Sviluppo Sostenibile", Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Giovanna Muscogiuri
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
- Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
- Cattedra Unesco "Educazione Alla Salute e Allo Sviluppo Sostenibile", Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy
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5
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Raimondo D, Raffone A, Travaglino A, Ferla S, Maletta M, Rovero G, Renzulli F, de Laurentiis U, Borghese G, Ambrosio M, Salucci P, Casadio P, Mollo A, Seracchioli R. Laparoscopic entry techniques: Which should you prefer? Int J Gynaecol Obstet 2023; 160:742-750. [PMID: 35980870 PMCID: PMC10087714 DOI: 10.1002/ijgo.14412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite a debate spanning two decades, no consensus has been achieved about the safest laparoscopic entry technique. OBJECTIVES To update the evidence about the safety of the main different laparoscopic entry techniques. SEARCH STRATEGY Six electronic databases were searched from inception to February 2021. SELECTION CRITERIA All randomized controlled trials (RCTs) comparing different laparoscopic entry techniques were included. DATA COLLECTION AND ANALYSIS Entry-related complications and total time for entry were compared among the different methods of entry calculating pooled odds ratios (ORs) and mean differences, with 95% confidence intervals (CIs); P < 0.05 was considered significant. MAIN RESULTS In total, 25 RCTs (6950 patients) were included. Complications considered were vascular, visceral and omental injury, failed entry, extraperitoneal insufflation, bleeding and infection at the trocar site bleeding, and incisional hernia. Compared to direct trocar, the OR for Veress needle was significantly higher for omental injury (OR 3.65, P < 0.001), for failed entry (OR 4.19, P < 0.001), and for extraperitoneal insufflation (OR 5.29, P < 0.001). Compared to the open method, the OR for Veress needle was significantly higher for omental injury (OR 4.93, P = 0.001), for failed entry (OR 2.99, P < 0.001), for extraperitoneal insufflation (OR 4.77; P = 0.04), and for incisional hernia. Compared to the open method, the OR for direct trocar was significantly lower for visceral injury (OR 0.17, P = 0.002) and for trocar site infection (OR 0.27, P = 0.001). CONCLUSIONS The direct trocar method may be preferred over Veress needle and open methods as a laparoscopic entry technique since it appears associated to a lower risk of complications.
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Affiliation(s)
- Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Raffone
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Travaglino
- Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Stefano Ferla
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Manuela Maletta
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giulia Rovero
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federica Renzulli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Umberto de Laurentiis
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana,", University of Salerno, Baronissi, Italy
| | - Giulia Borghese
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Ambrosio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Salucci
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana,", University of Salerno, Baronissi, Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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6
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Marchand GJ, Masoud A, King A, Brazil G, Ulibarri H, Parise J, Arroyo A, Coriell C, Goetz S, Moir C, Christensen A, Alexander T, Govindan M. Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 4:e000121. [PMID: 35865828 PMCID: PMC9240888 DOI: 10.1136/bmjsit-2021-000121] [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: 10/27/2021] [Accepted: 05/31/2022] [Indexed: 11/07/2022] Open
Abstract
Objective Although many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery. Design Systematic review with meta-analysis. Setting We searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis. Participants Inclusion criteria included women undergoing gynecological laparoscopic surgery. Intervention The intervention of direct trocar insertion technique compared with Veress needle entry technique. Main outcome measures We compared five different outcomes associated with the efficacy and complications of laparoscopic entry. Results The pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), p<0.001), omental injury (RR=0.418, 95% Cl (0.195 to 0.896), p<0.001), failed entry (RR=0.173, 95% Cl (0.102 to 0.292), p<0.001), and trocar site infection (RR=0.404, 95% Cl (0.180 to 0.909), p<0.029). There was no significant difference between the two groups regarding the visceral injury (RR=0.562, 95% Cl (0.047 to 6.676), p<0.648). Conclusions When excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels. Trial registration number CRD42021273726
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Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ahmed Masoud
- Fayoum University Faculty of Medicine, Fayoum, Egypt
| | - Alexa King
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Sydnee Goetz
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Carmen Moir
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ashley Christensen
- Midwestern University College of Osteopathic Medicine, Glendale, California, USA
| | - Tia Alexander
- Midwestern University College of Osteopathic Medicine, Glendale, California, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
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Şahan A, Ozkaptan O, Cubuk A, Şimşek B, Tanidir Y, Akça O. Fast, Easy, and Safe Establishment of Pneumoperitoneum in Laparoscopic Surgery: The Fingertip Technique. JSLS 2021; 25:JSLS.2020.00069. [PMID: 33628003 PMCID: PMC7881279 DOI: 10.4293/jsls.2020.00069] [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] [Indexed: 01/18/2023] Open
Abstract
Background and Objectives: There is no consensus on an ideal abdominal entry in laparoscopic surgery; as such, we aimed to assess the feasibility of the fingertip technique for safe entry and the establishment of pneumoperitoneum in transperitoneal laparoscopic surgery. Methods: We prospectively assessed 96 consecutive patients who underwent laparoscopic transperitoneal surgery between December 2018 and September 2019. For all patients, pneumoperitoneum was performed using the fingertip technique, which we recently defined. The duration of time for initial entry, the occurrence of gas leakage, and the complications were evaluated. Results: The median duration of initial entry was 90 (75 – 145) seconds. Pneumoperitoneum was established on the first attempt in all patients. Some events were encountered at the time of implementation of the fingertip technique, such as subcutaneous minor bleeding (5.2%) and gas leakage (4.1%). These events were controlled with cauterization and suturing. There was no visceral or major vascular injury in any patient case. Conclusions: The fingertip technique is a fast, safe, and feasible method for establishing pneumoperitoneum in transperitoneal laparoscopic surgery.
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Affiliation(s)
- Ahmet Şahan
- Department of Urology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Orkunt Ozkaptan
- Department of Urology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Alkan Cubuk
- Department of Urology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Berkan Şimşek
- Department of Urology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | | | - Oktay Akça
- Department of Urology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
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8
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Randomized control trial on effectiveness and safety of direct trocar versus Veress needle entry techniques in obese women during diagnostic laparoscopy. Arch Gynecol Obstet 2021; 304:815-822. [PMID: 33417065 DOI: 10.1007/s00404-020-05957-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine the benefits and safety of direct trocar insertion versus Veress needle technique in obese women undertaking diagnostic laparoscopy procedures. METHODS Randomized-controlled trial on 135 obese women undergoing diagnostic laparoscopy and dye test for infertility was conducted. Women were randomly assigned to either direct trocar access (n = 68) or Veress needle access (n = 67) before achieving pneumoperitoneum. The same surgeon executed the laparoscopic techniques with a single-puncture technique. The primary outcome measures included total length of the procedure and incidence of any complications, while the mean laparoscopic entry time, volume of CO2 required, and total of tries needed to attain successful entry were secondary outcomes. Intention-to-treat principle was applied to analysis. RESULTS Women in both groups had similar socio-demographic and clinical characteristics and none were lost to follow-up. The overall length of the procedure was significantly lesser in the direct trocar group compared to the Veress needle group (9.9 ± 6.0 vs 16.7 ± 4.7 min; p < 0.001). No significant differences occurred in other outcomes including mean entry time, volume of CO2 used, number of attempts for successful entry, and major/minor complications (p > 0.05). CONCLUSIONS Direct trocar technique may be an effective alternative to Veress needle for pneumoperitoneum in obese women for diagnostic laparoscopy. It has a comparable rapid laparoscopic entry time but a significantly lower duration of the procedure and shorter exposure to anesthesia. Both methods are equally effective as there was no significant difference in the complications recorded. A greater sample trial may be essential for more corroborative substantiation. CLINICAL TRIAL REGISTRATION PACTR201510000999192.
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9
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Pantoja Garrido M, Frías Sánchez Z, Zapardiel Gutiérrez I, Torrejón R, Jiménez Sánchez C, Polo Velasco A, Márquez Maraver F, Rodríguez Jiménez I, Jiménez Gallardo J, Fernández Alba JJ. Direct trocar insertion without previous pneumoperitoneum versus insertion after insufflation with Veress needle in laparoscopic gynecological surgery: a prospective cohort study. J OBSTET GYNAECOL 2019; 39:1000-1005. [PMID: 31210067 DOI: 10.1080/01443615.2019.1590804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to determine whether direct trocar entry without prior pneumoperitoneum at umbilical level (DTI) can be a safe alternative to access the abdominal cavity in gynaecological laparoscopic surgery. We present a prospective observational analytical study of cohorts, comparing DTI with umbilical entry with trocar after previous insufflation with a Veress needle at umbilical level (V). The study period was performed from June 2013 to April 2016; data was collected on 600 patients who underwent gynaecological laparoscopic surgery. There were no significant differences in the risk of suffering a complication during the access manoeuvres between DTI (6.49%) and V (7.39%), OR 0.89 (95% CI: 0.42-1.81). The duration of the access manoeuvres was 69 s in DTI and 193 s in V (p < .001). The percentage of patients in whom two or more access attempts were performed was lower in DTI (7.8%) than in V (12.3%) (p > .05). We concluded that DTI is at least as safe as V, regarding the risk of suffering complications arising from access into the abdominal cavity. DTI has advantages with regard to V, such as: the shorter duration of access manoeuvres or the lesser number of unsuccessful entry or insufflation attempts. Impact statement What is already known on this subject? There are few international publications comparing DTI and V. When we conducted a search in PubMed for the terms 'Veress needle and direct trocar insertion', 51 publications were obtained. When we increased the restriction and added the terms 'laparoscopic entry and laparoscopy complications', 27 publications were obtained; thus, the uniqueness of our study. What do the results of this study add? We present a 3-year observational prospective study of cohorts that included 600 patients. The aim of this study was to determine that in laparoscopic gynaecological surgery, DTI is an access method to the abdominal cavity at least as safe as V, with respect to the risk of complications. On the other hand, DTI has some advantages such as the shorter duration of access manoeuvres or the lower number of failed entry attempts. What are the implications of these findings for clinical practice and/or further research? Given the limited number of publications that compared both techniques, our study indicates that DTI can be a safe alternative for access to abdominal cavity in gynaecological surgery, compared to the traditional V.
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Affiliation(s)
- Manuel Pantoja Garrido
- Department of Gynecology and Obstetrics, University Hospital Virgen Macarena , Seville , Spain
| | - Zoraida Frías Sánchez
- Department of Gynecology and Obstetrics, University Hospital Virgen del Rocío , Seville , Spain
| | | | - Rafael Torrejón
- Department of Gynecology and Obstetrics, University Hospital Puerta del Mar , Cádiz , Spain
| | | | - Alfredo Polo Velasco
- Department of Gynecology and Obstetrics, University Hospital Virgen Macarena , Seville , Spain
| | | | | | - Julián Jiménez Gallardo
- Department of Gynecology and Obstetrics, University Hospital Virgen Macarena , Seville , Spain
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Abstract
BACKGROUND Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity. OBJECTIVES To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, and trials registers in January 2018. We also checked the references of articles retrieved. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared one laparoscopic entry technique versus another. Primary outcomes were major complications including mortality, vascular injury of major vessels and abdominal wall vessels, visceral injury of bladder or bowel, gas embolism, solid organ injury, and failed entry (inability to access the peritoneal cavity). Secondary outcomes were extraperitoneal insufflation, trocar site bleeding, trocar site infection, incisional hernia, omentum injury, and uterine bleeding. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods. MAIN RESULTS The review included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques. Most studies selected low-risk patients, and many studies excluded patients with high body mass index (BMI) and previous abdominal surgery. Researchers did not find evidence of differences in major vascular or visceral complications, as would be anticipated given that event rates were very low and sample sizes were far too small to identify plausible differences in rare but serious adverse events.Open-entry versus closed-entryTen RCTs investigating Veress needle entry reported vascular injury as an outcome. There was a total of 1086 participants and 10 events of vascular injury were reported. Four RCTs looking at open entry technique reported vascular injury as an outcome. There was a total of 376 participants and 0 events of vascular injury were reported. This was not a direct comparison. In the direct comparison of Veress needle and Open-entry technique, there was insufficient evidence to determine whether there was a difference in rates of vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n = 915; I² = N/A, very low-quality evidence). Evidence was insufficient to show whether there were differences between groups for visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n = 915: I² = 0%; very low-quality evidence), or failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n = 865; I² = 63%; very low-quality evidence). Two studies reported mortality with no events in either group. No studies reported gas embolism or solid organ injury.Direct trocar versus Veress needle entryTrial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; N = 3185; I² = 45%; moderate-quality evidence). Evidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.59, 95% CI 0.18 to 1.96; 6 RCTs; n = 1603; I² = 75%; very low-quality evidence), visceral injury (Peto OR 2.02, 95% CI 0.21 to 19.42; 5 RCTs; n = 1519; I² = 25%; very low-quality evidence), or solid organ injury (Peto OR 0.58, 95% Cl 0.06 to 5.65; 3 RCTs; n = 1079; I² = 61%; very low-quality evidence). Four studies reported mortality with no events in either group. Two studies reported gas embolism, with no events in either group.Direct vision entry versus Veress needle entryEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n = 186; very low-quality evidence) or visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n = 380; I² = N/A; very low-quality evidence). Trials did not report our other primary outcomes.Direct vision entry versus open entryEvidence was insufficient to show whether there were differences between groups in rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n = 392; I² = N/A; very low-quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n = 60; very low-quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n = 60; very low-quality evidence). Two studies reported vascular injury with no events in either arm. Trials did not report our other primary outcomes.Radially expanding (STEP) trocars versus non-expanding trocarsEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n = 331; I² = 0%; very low-quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n = 331; very low-quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n = 244; very low-quality evidence). Trials did not report our other primary outcomes.Other studies compared a wide variety of other laparoscopic entry techniques, but all evidence was of very low quality and evidence was insufficient to support the use of one technique over another. AUTHORS' CONCLUSIONS Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Jade Baker
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | | | - Kevin Phillips
- Castle Hill HospitalObstetrics and GynaecologyCastle RoadCottinghamNorth HumbersideUKHU16 5JQ
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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Jung JJ, Adams-McGavin RC, Grantcharov TP. Underreporting of Veress Needle Injuries: Comparing Direct Observation and Chart Review Methods. J Surg Res 2018; 236:266-270. [PMID: 30694765 DOI: 10.1016/j.jss.2018.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/11/2018] [Accepted: 11/20/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.
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Affiliation(s)
- James J Jung
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Robert Chris Adams-McGavin
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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12
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Abstract
Background and Objectives Rates of morbid obesity are skyrocketing worldwide. Not only bariatric surgeons, but also general surgeons are often operating on morbidly obese patients. Many general surgeons still use the same anatomic landmarks for patients with body mass index (BMI) over 35 mg/kg2 as they do for patients of normal weight and can therefore find accessing the morbidly obese abdominal organs difficult. This paper will describe a technique that is easily reproducible and applicable in a wide range of laparoscopic cases. Method The xiphoid process is the only landmark referenced. From the xiphoid process, the surgeon puts 2 fists together and places the first trocar inferiorly 2 cm lateral to the midline in either direction. The umbilicus is not used as a landmark. This placement is 15-18 cm inferior to the xiphoid process, but allows adequate visualization for any foregut case. An optical trocar is used. Results In over 1400 bariatric cases, the initial trocar was safely placed with this technique. Most of these cases were performed with the method, but some had one modification: the first trocar was placed in the midclavicular line in the subcostal area if there were previous midline scars. In no cases was an extra-long, or bariatric, trocar used. Conclusions Laparoscopic access in morbidly obese patients does not have to be difficult. Using an optical trocar off the midline 15-18 cm below the xiphoid process will provide reliable, safe access in the morbidly obese patient, with excellent visualization of the target anatomy.
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Habibi M, Seyit H, Kones O, Kartal B, Alis H. Direct Trocar Insertion with Elevation of the Rectus Sheath in Bariatric Surgery: A Novel Technique. POLISH JOURNAL OF SURGERY 2018; 89:23-25. [PMID: 29335390 DOI: 10.5604/01.3001.0010.6740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Initial trocar entry, the first step in laparoscopic surgery, is associated with several complications. In morbidly obese patients, initial trocar placement is associated with a greater number of complications compared to non-obese patients. Materials and Surgical Technique. In this study, we describe our use of an initial trocar entry technique which is direct trocar insertion with elevation of the rectus sheath by a single Backhaus towel clamp and we would like to evaluate the sa fety and efficacy of its administration in bariatric surgery. DISCUSSION Our results indicate that gaining initial trocar entry using our technique leads to successful laparoscopic bariatric surgery. Our technique is a safe, effective, and reliable first step in successful laparoscopic surgery for almost all patients, and is only contraindicated in patients with severe hepatomegaly.
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Affiliation(s)
- Mani Habibi
- Alaaddin Keykubat University, Alanya Training and Research Hsopital, Antalya, Turkey
| | - Hakan Seyit
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, General Surgery Department, Istanbul, Turkey
| | - Osman Kones
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, General Surgery Department, Istanbul, Turkey
| | - Bahadir Kartal
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, General Surgery Department, Istanbul, Turkey
| | - Halil Alis
- Istanbul Aydın University, Florda VM Medikal Park Hospital, General Surgery Department, Istanbul, Turkey
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Loureiro M, Ramadan M, Skalli EM, Blanc P, Fabre JM, Nocca D. A multicentric prospective study evaluating the safety and efficacy of Kii ® Fios ® First Entry Trocar in laparoscopic bariatric surgery. Surg Endosc 2017; 31:4680-4687. [PMID: 28389805 DOI: 10.1007/s00464-017-5536-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 03/20/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Laparoscopic surgery has evolved as an important field of surgery due to its clear benefits when compared to open laparotomy surgery. However, specific complications of laparoscopic surgery have been reported, of which the majority are complications associated with first entry to the abdominal cavity. The emergence of bariatric surgery, combined with the special considerations of the abdominal wall and cavity of obese patients, leads to seeking new modalities of access to the abdominal cavity in this specific population.Kii Fios First Entry Bladeless Trocar (Applied) is a new device that may allow surgeons to facilitate the creation of pneumoperitoneum. This prospective multicenter nonrandomized trial aims to evaluate the safety and efficacy of Kii Fios First Entry Bladeless Trocar in laparoscopic bariatric surgery. METHODS In the period between December 2013 and June 2014, 588 patients were included by 18 surgeons from several French hospitals to undergo laparoscopic surgery using Kii Fios First Entry Trocar as a first-entry trocar. The surgeons filled out a questionnaire assessing the safety and efficacy of the trocar for every patient. RESULTS There were no mortality and no major complications. However, 11 cases (1.87%) of minor complications (liver and greater omentum injuries) were reported. The surgeons reported successful entry in less than 1 min for 70.58% of the cases. CONCLUSIONS Kii Fios First Entry Trocar (Applied) is a safe and efficient method to establish first entry in laparoscopic bariatric surgery when all the recommendations are followed and respected.
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Affiliation(s)
- Marcelo Loureiro
- CHU de Montpellier, Montpellier, France.
- University Montpellier 1, Montpellier, France.
- Universidade Positivo, Rua Angelo Bom 315 casa 1, Curitiba, 81210340, Brazil.
| | | | | | | | - Jean Michel Fabre
- CHU de Montpellier, Montpellier, France
- University Montpellier 1, Montpellier, France
| | - David Nocca
- CHU de Montpellier, Montpellier, France
- University Montpellier 1, Montpellier, France
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