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Madadi-Sanjani O, Brendel J, Kuebler JF, Ure BM. Definition, Documentation, and Classification of Complications in Pediatric Surgical Literature-A Plea for Standardization. Eur J Pediatr Surg 2023; 33:105-113. [PMID: 36720251 DOI: 10.1055/s-0043-1760835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Severity grading systems for complications in surgical patients have been used since 1992. An increasing assessment of these instruments in pediatric surgery is also noticed, without their validation in children. To analyze the current practice, we performed a literature review with focus on the assessment and grading of complications. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting on postoperative complications as a primary or secondary endpoint using a severity grading system were included. Definition for simple adverse events, classification systems used, and the time horizon of postoperative documentation were analyzed. A total of 566 articles were screened, of which 36 met the inclusion criteria. About 86.1% of the papers were retrospective and 13.9% prospective analyses. None of the studies were prospective-randomized trials. Twenty (55.6%) studies did not include a definition of adverse events, whereas the remaining 16 (44.4%) showed variations in their definitions. All studies applied the Clavien-Dindo classification, whereas five (13.9%) additionally used the Comprehensive Complication Index. One study compared alternative grading instruments with the Clavien-Dindo classification, without demonstrating the superiority of any classification in pediatric surgery. Twenty-two studies (61.1%) did not report the time horizon of perioperative complication documentation, while 8 studies (22.2%) used 30 days and 6 studies (16.7%) used 3 months of postoperative documentation. Definition and classification of postoperative complications are inconsistent in the pediatric surgical literature. Establishment of a standardized protocol is mandatory to accurately compare outcome data.
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Affiliation(s)
| | - Julia Brendel
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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D’Silva M, Cho JY, Han HS, Yoon YS, Lee HW, Lee JS, Lee B, Jo Y, Lee E, Kang M, Park Y. The value of analyzing textbook outcomes after laparoscopic hepatectomy-a narrative review. Transl Cancer Res 2023; 12:631-637. [PMID: 37033349 PMCID: PMC10080324 DOI: 10.21037/tcr-22-2122] [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: 08/26/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
Background and Objective Guidelines are required because of the wide variability in care provided to patients with similar characteristics and similar medical conditions. Quality indicators were developed many years ago to assess the quality of care provided by hospitals. Since then, it has become evident that a composite set of factors can better characterize the patient's quality of care. The objectives of this review were to analyze the textbook outcomes (TO) applied in surgery, focusing on laparoscopic hepatectomy. Methods Data pertaining to quality indicators used in hospitals and their surgical applications were retrieved from medical literature by searching PubMed and Google Scholar for articles published between 1912 and 2022. Search terms included quality indicators, outcome indicators, TOs, TOs after surgery, TOs after hepatectomy, and clinical indicators. Key Content and Findings Since their inception, TO have been applied to various procedures and their impacts on patients have been assessed. TO and their implications have been studied for a variety of surgical procedures and were recently extended to laparoscopic hepatectomy. TO of laparoscopic left lateral sectionectomy and right hemihepatectomy were recently assessed, and benchmark values have been defined. TO are useful tools for assessing hospital performance and for optimizing the outcomes of patients undergoing laparoscopic hepatectomy. Conclusions At present, TO only consider surgeon-related factors. However, it is important to include the patient's perspective when defining TO. Although TO were recently applied to laparoscopic hepatectomy, there is still a need to further evaluate their application in this setting. Achieving TO was shown to have a positive impact on long-term outcomes and this needs to be studied for different liver resection procedures.
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Affiliation(s)
- Mizelle D’Silva
- Department of Surgery, Holy Family Hospital and Research Centre, Bandra, Mumbai, India
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yeongsoo Jo
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eunhye Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - MeeYoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yeshong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
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Fuchs J, Ruping F, Murtha-Lemekhova A, Kessler M, Günther P, Mehrabi A, Hoffmann K. Comparison of transection techniques in pediatric major hepatectomy: a matched pair analysis. HPB (Oxford) 2023; 25:593-601. [PMID: 36882355 DOI: 10.1016/j.hpb.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Evidence on safety and efficacy of different liver transection techniques in pediatric major hepatectomy is completely lacking, as no study has been conducted so far. The use of stapler hepatectomy has never before been reported in children. METHODS Three liver transection techniques were compared: (1) ultrasonic dissector (CUSA), (2) tissue sealing device (LigaSure™), and (3) stapler hepatectomy. All pediatric hepatectomies performed at a referral center in a 12-year study period were analyzed, patients were pair-matched in a 1:1:1-fashion. Intraoperative weight-adjusted blood loss, operation time, use of inflow occlusion, liver injury (peak-transaminase levels), postoperative complications (CCI), and long-term outcome were compared. RESULTS Of 57 pediatric liver resections, 15 patients were matched as triples based on age, weight, tumor stage, and extent of resection. Intraoperative blood loss was not significantly different between the groups (p = 0.765). Stapler hepatectomy was associated with significantly shorter operation time (p = 0.028). Neither postoperative death nor bile leakage occurred, and no reoperation due to hemorrhage was needed in any patient. CONCLUSION This is the first comparison of transection techniques in pediatric liver resection and the first report on stapler hepatectomy in children. All three techniques can be safely applied and may harbor individual advantages in pediatric hepatectomy each.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany.
| | - Fabian Ruping
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | | | - Markus Kessler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | - Patrick Günther
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Division of Pediatric Surgery, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Germany
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Madadi-Sanjani O, Brendel J, Uecker M, Pfister ED, Baumann U, Ohlendorf J, Kuebler JF. Accumulation of Postoperative Unexpected Events Assessed by the Comprehensive Complication Index ® as Prognostic Outcome Parameters for Kasai Procedure. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101590. [PMID: 36291526 PMCID: PMC9600743 DOI: 10.3390/children9101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022]
Abstract
Introduction The Kasai procedure in children with biliary atresia (BA) is associated with several complications in the short-term. The Comprehensive Complication Index (CCI®) is a validated metric in adult surgery for the analysis of complications and morbidity in surgical patients. We aimed to analyze the CCI® for the first time in BA infants and to correlate its association with outcomes. Material and Methods We conducted a retrospective review of medical records of infants with type III BA undergoing the Kasai procedure between January 2011 and December 2021 at our institution. All unexpected events were ranked according to the Clavien−Dindo classification, and the CCI® per patient was subsequently calculated. Clavien−Dindo grades, individual events, CCI®, and total event numbers per patient were correlated with one- and two-year outcomes post-surgery. Results A total of 131 events were identified in 101 patients (ranging 0−11 per patient). Forty-four Grade I (33.6%), 67 Grade II (51.1%), 18 Grade III (13.7%), and two sentinel events [>Grade IV] (1.5%) were documented according to Clavien−Dindo, including one death in a cardiac-associated BA patient. None of the complications significantly correlated with a poor outcome. Sixty-three (62.4%) CCI® scores were calculated (range 0−100). The mean CCI® score during the in-patient treatment post-surgery was significantly higher in patients with a poorer outcome than patients with native liver survival at one- and two-year follow-up (22.7 ± 21.7 vs. 13.2 ± 18.1; p = 0.02). Conclusion Not the severity of complications, but the accumulation of numerous events related to Kasai procedure were associated with a poorer outcome. Therefore, the CCI® is an excellent instrument for the postoperative morbidity assessment of BA patients.
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Affiliation(s)
- Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
- Correspondence: ; Tel.: +49-511-5329043; Fax: +49-511-5328095
| | - Julia Brendel
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Marie Uecker
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Johanna Ohlendorf
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
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Leoni J, Rougemont AL, Calinescu AM, Ansari M, Compagnon P, Wilde JCH, Wildhaber BE. Effect of Centralization on Surgical Outcome of Children Operated for Liver Tumors in Switzerland: A Retrospective Comparative Study. CHILDREN 2022; 9:children9020217. [PMID: 35204937 PMCID: PMC8870146 DOI: 10.3390/children9020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/18/2022] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Abstract
Background: Pediatric liver surgery is complex, and complications are not uncommon. Centralization of highly specialized surgery has been shown to improve quality of care. In 2012, pediatric liver surgery was centralized in Switzerland in one national center. This study analyses results before and after centralization. Methods: Retrospective monocentric comparative study. Analysis of medical records of children (0–16 years) operated for any liver tumor between 1 January 2001 and 31 December 2020. Forty-one patients were included: 14 before centralization (before 1 January 2012) and 27 after centralization (after 1 January 2012). Epidemiological, pre-, intra-, and post-operative data were collected. Fischer’s exact and t-test were used to compare groups. Results: The two cohorts were homogeneous. Operating time was reduced, although not significantly, from 366 to 277 min. Length of postoperative stay and mortality were not statistically different between groups. Yet, after centralization, overall postoperative complication rate decreased significantly from 57% to 15% (p = 0.01), Clavien > III complications decreased from 50% to 7% (p < 0.01), and hepatic recurrences were also significantly reduced (40% to 5%, p = 0.03). Conclusion: Centralization of the surgical management of liver tumors in Switzerland has improved quality of care in our center by significantly reducing postoperative complications and hepatic recurrence.
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Affiliation(s)
- Jasmine Leoni
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Anne-Laure Rougemont
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Diagnostic Department, Division of Clinical Pathology, Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Ana M. Calinescu
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Marc Ansari
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
- Unit of Oncology and Haematology, Department of Women, Child and Adolescent, Geneva University Hospitals and CANSEARCH Research Platform in Pediatric Oncology and Hematology, 1205 Geneva, Switzerland
| | - Philippe Compagnon
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Department of Surgery, Division of Transplantation, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Jim C. H. Wilde
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Barbara E. Wildhaber
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
- Correspondence:
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Fuchs J, Murtha-Lemekhova A, Kessler M, Günther P, Hoffmann K. The role of liver resection in metastatic nephroblastoma: a systematic review and Meta-regression analysis. BMC Cancer 2022; 22:76. [PMID: 35038991 PMCID: PMC8764777 DOI: 10.1186/s12885-022-09182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of hepatic resection for liver metastases (LM) on the survival of pediatric patients with Wilms' tumor (WT) is unclear. So far, there is a lack of studies investigating the best suited treatment for patients with WTLM, and the role of liver resection has rarely been investigated. Thus, the development of evidence-based guidelines concerning indications of liver resection for WTLM remains difficult. AIM To investigate the role of surgery in the therapy of WTLM. All available data on liver resections and subgroup outcomes of patients with WTLM are analyzed. Main research question is whether liver resection improves survival rates of patients with WTLM compared to non-surgical treatment. METHODS A systematic literature search of MEDLINE, Web of Science, and Central provided the basis for this PRISMA-compliant systematic review. For the main analysis (I), all studies reporting on surgical treatment of pediatric WTLM were included. To provide a representative overview of the general outcome of WTLM patients, in analysis II all studies with cohorts of at least five WTLM patients, regardless of the kind of treatment, were reviewed and analyzed. A Multiple meta-regression model was applied to investigate the impact liver resection on overall survival. RESULTS 14 studies with reports of liver resection for WTLM were found (Analysis I). They included a total of 212 patients with WTLM, of which 93 underwent a liver resection. Most studies had a high risk of bias, and the quality was heterogenous. For the analysis II, eight studies with subgroups of at least five WTLM patients were found. The weighted mean overall survival (OS) of WTLM patients across the studies was 55% (SD 29). A higher rate of liver resection was a significant predictor of better OS in a multiple meta-regression model with 4 covariates (I2 29.43, coefficient 0.819, p = 0.038). CONCLUSIONS This is the first systematic review on WTLM. Given a lack of suited studies that specifically investigated WTLM, ecological bias was high in our analyses. Generating evidence is complicated in rare pediatric conditions and this study must be viewed in this context. Meta-regression analyses suggest that liver resection may improve survival of patients with WTLM compared to non-surgical treatment. Especially patients with persisting disease after neoadjuvant chemotherapy but also patients with metachronous LM seem to benefit from resection. Complete resection of LM is vital to achieve higher OS. Studies that prospectively investigate the impact of surgery on survival compared to non-surgical treatment for WTLM are highly needed to further close the current evidence gap. STUDY REGISTRATION PROSPERO 2021 CRD42021249763 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249763 .
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Department of General, Visceral and Transplantation Surgery, Division of Pediatric Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
- Division of Liver surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Fuchs J, Murtha-Lemekhova A, Rabaux-Eygasier L, Kessler M, Ruping F, Günther P, Hoffmann K. Evidence on Indications and Techniques to Increase the Future Liver Remnant in Children Undergoing Extended Hepatectomy: A Systematic Review and Meta-Analysis of Individual Patient Data. Front Pediatr 2022; 10:915642. [PMID: 35712634 PMCID: PMC9197416 DOI: 10.3389/fped.2022.915642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Techniques to increase the future liver remnant (FLR) have fundamentally changed the indications and criteria of resectability in adult liver surgery. In pediatric patients however, these procedures have rarely been applied and the potential benefit or harm as well as suited indications are unclear. METHODS A systematic literature search of MEDLINE, Web of Science, and CENTRAL was conducted. Based on a PRISMA-compliant, predefined methodology, all studies reporting pediatric patients (< 18y) undergoing liver resection with either associating liver partition and portal vein ligation for stages hepatectomy (ALPPS) or preoperative portal vein embolization or ligation (PVE/PVL) were included. Baseline data, periinterventional morbidity, increase of FLR and outcomes were analyzed. RESULTS 15 studies reporting on 21 pediatric patients with a mean age of 4 years and 7 months (range 1.8 months - 17 years) were included. 12 ALPPS procedures, 8 PVE and 1 PVL were performed. The applied criteria for performing ALPPS or PVE were heterogenous and thresholds for minimally acceptable FLR varied. Mean FLR [% of total liver volume] before the intervention was 23.6% (range 15.0 - 39.3%) in the ALPPS group and 31.4% (range 21.5 - 56.0%) in the PVE group. Mean increase of FLR before stage 2 resection was 69.4% (range 19.0 - 103.8%) for ALPPS and 62.8% (range 25.0 - 108.0%) after PVE. No postoperative death occurred, one early intrahepatic recurrence after an ALPPS procedure was reported. Overall postoperative morbidity was 23.8%. CONCLUSION Validated criteria for minimal FLR in pediatric liver resection are lacking and so are clear indications for ALPPS or PVE. In special cases, ALPPS and PVE can be valuable techniques to achieve complete resection of pediatric liver tumors. However, more data are needed, and future studies should focus on a definition and validation of posthepatectomy liver failure as well as the minimally needed FLR in pediatric patients undergoing extended hepatectomy. SYSTEMATIC REVIEW REGISTRATION [www.clinicaltrials.gov], identifier [PROSPERO 2021 CRD42021274848].
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany
| | - Lucas Rabaux-Eygasier
- Department of Pediatric Surgery, Hôpital Kremlin Bicêtre, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Markus Kessler
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany.,Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Fabian Ruping
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany.,Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany.,Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Generating Evidence for Diagnosis and Therapy of RarE LIVEr Disease: The RELIVE Initiative for Systematic Reviews and Meta-Analyses, University of Heidelberg, Heidelberg, Germany
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