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Mari G, Santambrogio G, Crippa J, Cirocchi R, Origi M, Achilli P, Ferrari G, Megna S, Desio M, Cocozza E, Maggioni D, Montroni I, Spinelli A, Zuliani W, Costanzi A, Crestale S, Petri R, Bicelli N, Pedrazzani C, Boccolini A, Taffurelli G, Fingerhut A. 5 year oncological outcomes of the HIGHLOW randomized clinical trial. Eur J Surg Oncol 2023; 49:641-646. [PMID: 36335077 DOI: 10.1016/j.ejso.2022.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/18/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. RESULTS Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. CONCLUSION We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.
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Affiliation(s)
- Giulio Mari
- Colorectal Surgery Unit ASST Brianza, DesioHospital, Desio, Italy.
| | | | - Jacopo Crippa
- Division of Colon& Rectal Surgery, IRCCSHumanitasResearchHospital, Rozzano, Milan, Italy
| | - Roberto Cirocchi
- Department of General Surgery, University of Perugia, Terni, Italy
| | - Matteo Origi
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Pietro Achilli
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Giovanni Ferrari
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Stefano Megna
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Matteo Desio
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Eugenio Cocozza
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Dario Maggioni
- Colorectal Surgery Unit ASST Brianza, DesioHospital, Desio, Italy
| | - Isacco Montroni
- ColorectalSurgery and General Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Walter Zuliani
- Humanitas Mater Domini ClinicalInstitute, General Surgery, Castellanza, Varese, Italy
| | - Andrea Costanzi
- General Surgery Unit, San Leopoldo Mandic Hospital, Merate, ASST Lecco, Italy
| | - Sara Crestale
- General Surgery Unit, San Leopoldo Mandic Hospital, Merate, ASST Lecco, Italy
| | - Roberto Petri
- General Surgery Unit, University Hospital, Udine, Italy
| | | | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Andrea Boccolini
- Department of General and Emergency Surgery AOSP of Terni, Italy
| | | | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, MedicalUniversity of Graz, Austria and Department of General Surgery, RuijinHospital, ShanghaiJiaoTongUniversitySchool of Medicine, Shanghai Minimally Invasive SurgeryCenter, Shanghai, 200025, PR China
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Mari G, Crippa J, Montroni I, Maggioni D, Calini G, Totis M, Tamini N, Oldani M, Cocozza E, Berselli M, Borroni G, Magistro C, Ferrari G, Achilli P, Petri R, Ziccarelli A, Crestale S, Bagnardi V, Peveri G, Origi M. MRI-Pathology Agreement in Rectal Cancer: Real-World Data from a Prospective Rectal Cancer Registry. Chirurgia (Bucur) 2021; 116:583-590. [PMID: 34749854 DOI: 10.21614/chirurgia.116.5.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 11/23/2022]
Abstract
Introduction: Magnetic Resonance Imaging (MRI) is routinely used in preoperative rectal cancer staging. The concordance of MRI staging with final pathologic exam, albeit improved, has not yet reached perfection. The aim of this study is to analyze the agreement between MRI and pathologic exam in patients operated on for mid-low rectal cancer. Material and Method: Patients undergoing neoadjuvant chemoradiation therapy (nCRT) or upfront surgery were analyzed. Between January 2019 to December 2019, 140 patients enrolled in the AIMS Academy rectal cancer registry were analyzed. Sixty-two patients received nCRT and 78 underwent upfront surgery. Results: Overall, the agreement between MRI and pathologic exam on T stage and N stage were 64.7% and 69.2%, respectively. The agreement between MRI and pathologic exam on T stage was 62.7% for patients who did not receive nCRT and 67.4% for patients who received nCRT (p = 0.62). The agreement on N stage was 76.3% for patients who did not receive nCRT and 60.0% for patients who received nCRT (p = 0.075). Conclusions: Real-world data shows MRI is still far from being able to correlate with the pathology findings which raises questions about the accuracy of the real-life decision-making process during cancer boards.
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Bellio G, Germani P, Biloslavo A, Del Zotto G, Lirusso C, Crestale S, Silvestro R, Crespi S, Faion M, Ubiali P, DE Manzini N. Trend of emergency general surgery procedures during COVID-19 pandemic. Minerva Surg 2021; 76:397-406. [PMID: 34047527 DOI: 10.23736/s2724-5691.21.08517-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND In early 2020, the novel coronavirus infection (COVID-19) spread rapidly throughout the whole world, causing a massive response in terms of health resource disposal. Moreover, lockdowns were imposed in entire countries. This study aims to assess whether there was a downward trend in emergency general surgery (EGS) procedures accomplished throughout the COVID-19 pandemic and to determine patients' and diseases' characteristics. METHODS This is a multicentric retrospective observational cohort analysis conducted on patients who underwent EGS procedures during the lockdown and the same period of the previous year in the three Third Level Hospitals of Friuli Venezia Giulia, Italy. RESULTS During the study period, 138 patients underwent EGS procedures versus the 197 patients operated on in 2019, meaning a 30.0% decrease in the number of surgeries performed. The incidence rate for EGS procedures was 2.5 surgeries per day during the COVID-19 pandemic compared to 3.5 surgeries per day in 2019 (P<0.001). The characteristics of patients operated on in 2020 were comparable to those of patients who underwent EGS in 2019, except for the higher prevalence of male patients during the COVID-19 pandemic (76.8 vs. 55.8; P<0.001). No difference was recorded in disease severity between the two study periods. CONCLUSIONS During the COVID-19 pandemic, a significant reduction in EGS procedures carried out was recorded. However, no clear explanation can be given to elucidate this fact.
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Affiliation(s)
- Gabriele Bellio
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy -
| | - Paola Germani
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Alan Biloslavo
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Giulio Del Zotto
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Chiara Lirusso
- Division of General Surgery, Department of Surgery, ASUFC Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Sara Crestale
- Division of General Surgery, Department of Surgery, ASUFC Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Roberto Silvestro
- Division of General Surgery, Department of Surgery, ASUFC Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Stefania Crespi
- Department of General Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Matteo Faion
- Department of General Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Paolo Ubiali
- Department of General Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Nicolò DE Manzini
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
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Pravisani R, Isola M, Baccarani U, Crestale S, Tulissi P, Vallone C, Risaliti A, Cilloni D, Adani GL. Impact of kidney transplant morbidity on elderly recipients' outcomes. Aging Clin Exp Res 2021; 33:625-633. [PMID: 32323169 DOI: 10.1007/s40520-020-01558-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS Nowadays, advanced age does not represent an absolute contraindication to kidney transplantation (KT). However, aging is frequently associated with multiple comorbidities and lower performance status, making KT candidates less surgically fit. Limited data are available on the impact of KT morbidity on elderly recipients' outcomes. METHODS Retrospective study on a single center cohort of 130 KT recipients over 65 years old, representing 16.2% of KT clinical series, during the period 2000-2018. Number and severity of comorbidities were evaluated with the Charlson Comorbidity index (CCI). RESULTS The median age at transplantation was 67 [IQR66-71] years and median CCI was 5 [IQR4-6]. The prevalence of postoperative complications with a Clavien-Dindo (C-D) severity score > 2 was 29%. Increasing age did not predict KT morbidity in terms of C-D score > 2, infectious, respiratory, cardiologic, urologic or vascular complications, delayed graft function, symptomatic lymphocele, bleeding, acute or chronic rejection. Conversely, CCI score was a predictor of overall complications with C-D score > 2, cardiologic, respiratory and vascular complications, and bleeding. Among others, CCI score, post-KT cardiologic complications, C-D score > 2 were identified as significant predictors of both early mortality and graft loss in univariate analysis. Increasing recipient age did not correlate with graft loss risk and graft loss did not impact patient survival. C-D score > 2 was a predictor of poor survival even in multivariate analysis. CONCLUSIONS Elderly recipients showed a significant vulnerability to KT morbidity which correlates with CCI. While graft loss did not impact recipient survival, severe postoperative complications (C-D > 2) were independently associated increased mortality.
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Adani GL, Pravisani R, Crestale S, Baccarani U, Scott CA, D'Alì L, DeMaglio G, Tulissi P, Vallone C, Isola M, Righi E, Pizzolito S, Di Loreto C, Risaliti A. Effects of Delayed Hypothermic Machine Perfusion on Kidney Grafts with a Preliminary Period of Static Cold Storage and a Total Cold Ischemia Time of Over 24 Hours. Ann Transplant 2020; 25:e918997. [PMID: 32094320 PMCID: PMC7059438 DOI: 10.12659/aot.918997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Hypothermic machine perfusion (HMP) appears to exert a reconditioning effect on the ischemic damage of kidney grafts. However, some concerns still remain about its real effectiveness when it is delayed after a preliminary period of static cold storage (SCS) or with prolonged overall cold ischemia time (CIT). Material/Methods The effect of HMP on hemodynamic, metabolic, histological and ultrastructural features of grafts was investigated in 21 single-kidney grafts treated with a delayed HMP after SCS and with a total CIT of over 24 h. Results The mean CIT, SCS, and HMP times were 29 h, 12 h, and 18 h, respectively. Longer SCS was associated with higher vascular resistance and lower arterial flow. In the pre- vs. post-HMP comparison, a significant decrease in arterial resistances and increase of flow were recorded. The hemodynamic improvement was independent of HMP duration. The perfused grafts retained some metabolic activity, with a statistically significant decrease of pH, pO2, and glucose levels, and increase of lactates in the perfusion liquid, by the end of HMP. Longer SCS was associated with higher pH and greater pO2 decrease during HMP. Light microscopy and transmission electronic microscopy revealed no significant variations in nuclear, cytoplasmic, or ultrastructural damage. SCS, HMP, and CIT were not identified as risk factor for delayed graft function or rejection. Conclusions A delayed and extended HMP can recover the graft hemodynamic function, maintain some metabolic activity, and stabilize the accumulated ischemic damage due to a preliminary SCS.
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Affiliation(s)
- Gian Luigi Adani
- Department of Medicine, General Surgery and Transplantation, Academic Hospital (ASUIUD), University of Udine, Udine, Italy
| | - Riccardo Pravisani
- Department of Medicine, General Surgery and Transplantation, Academic Hospital (ASUIUD), University of Udine, Udine, Italy
| | - Sara Crestale
- Department of Medicine, General Surgery and Transplantation, Academic Hospital (ASUIUD), University of Udine, Udine, Italy
| | - Umberto Baccarani
- Department of Medicine, General Surgery and Transplantation, Academic Hospital (ASUIUD), University of Udine, Udine, Italy
| | - Cathryn A Scott
- Institute of Pathology - Department of Medicine, University of Udine, Udine, Italy
| | - Lorenzo D'Alì
- Institute of Pathology - Department of Medicine, University of Udine, Udine, Italy
| | - Giovanna DeMaglio
- Department of Pathology, Integrated University Healthcare of Udine (ASUIUD), Udine, Italy
| | - Patrizia Tulissi
- Department of Nephrology, Dialysis and Transplantation, Integrated University Healthcare of Udine (ASUIUD), Udine, Italy
| | - Clotilde Vallone
- Department of Nephrology, Dialysis and Transplantation, Integrated University Healthcare of Udine (ASUIUD), Udine, Italy
| | - Miriam Isola
- Division of Medical Statistic - Department of Medicine, University of Udine, Udine, Italy
| | - Elda Righi
- Department of Infectious Diseases, University of Verona, Verona, Italy
| | - Stefano Pizzolito
- Department of Pathology, Integrated University Healthcare of Udine (ASUIUD), Udine, Italy
| | - Carla Di Loreto
- Institute of Pathology - Department of Medicine, University of Udine, Udine, Italy
| | - Andrea Risaliti
- Department of Medicine, General Surgery and Transplantation, Academic Hospital (ASUIUD), University of Udine, Udine, Italy
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Pravisani R, Baccarani U, Toso F, Adani GL, Lorenzin D, Cherchi V, Calandra S, Scarpa E, Crestale S, Avellini C, Terrosu G, Sponza M, Risaliti A. Gastrointestinal Perforations in Adult Whole-Liver Transplant Patients: Clinical, Radiologic, and Histopathologic Analysis. Transplant Proc 2019; 51:2974-2976. [PMID: 31607622 DOI: 10.1016/j.transproceed.2019.02.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Gastrointestinal perforation (GIP) is a rare complication after adult liver transplant (LT) associated with high morbidity and mortality. Limited data are available about clinical risk factors and underlying pathogenic mechanisms. METHODS The retrospective study included all GIP cases from a consecutive cohort of 361 LT recipients during the period 2005-2017. Clinical variables were investigated as potential risk factors for GIP, and radiologic and histopathologic evaluations were undertaken to identify any causative mechanism. RESULTS A total of 22 patients developed at least 1 episode of GIP (prevalence 6.1%) at a median time of 18.5 [interquartile range, 12.5-28.5] days after LT. The perforations occurred in the small bowel (63.6%), transverse colon (27.3%), right colon (22.7%), left colon (9.1%), and stomach (9.1%). A total of 27.3% of patients developed multiple sites of GIP, and in 31% GIP recurred after curative surgery. The 30-day mortality rate after relaparotomy was 40%. A history of previous abdominal surgery (odds ratio, 2.5) and early post-LT relaparotomy due to other complications (odds ratio, 2.6) were significant risk factors for GIP. No thromboembolic or steno-occlusive complications of any splanchnic vessel were detected at computed tomography scan, while histopathology examination on perforated gastrointestinal segments excluded cytomegalovirus infection, graft-vs-host disease, and inflammatory bowel disease. In all the cases, ischemic necrosis with aspecific microangiopathy and microembolization were the pathologic features detected. CONCLUSIONS GIP is a severe complication after LT with frequent multiple gastrointestinal involvement and recurrence after curative surgery. The pathologic underlying mechanism is usually microvascular ischemia. Clinical risk factors are history of previous abdominal surgery and early post-LT relaparotomy.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy.
| | | | - Gian Luigi Adani
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Dario Lorenzin
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Vittorio Cherchi
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Sergio Calandra
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Edoardo Scarpa
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Sara Crestale
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | | | - Giovanni Terrosu
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | | | - Andrea Risaliti
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
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Londero F, Morelli A, Parise O, Grossi W, Crestale S, Tetta C, Johnson DM, Livi U, Maessen JG, Gelsomino S. Lymphadenectomy during pulmonary metastasectomy: Impact on survival and recurrence. J Surg Oncol 2019; 120:768-778. [PMID: 31297837 PMCID: PMC6771868 DOI: 10.1002/jso.25635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/28/2019] [Indexed: 12/26/2022]
Abstract
Background and Objectives: Lymphadenectomy during pulmonary metastasectomy (PM) is widely carried out. We assessed the potential benefit on patient survival and tumor recurrence of this practice. Methods: One hundred eighty‐one patients undergoing a first PM were studied. Eighty‐six patients (47.5%) underwent lymphadenectomy (L+ group) whereas 95 (52.5%) did not undergo nodal harvesting (L−group). Main outcomes were overall survival (OS) and disease‐free survival (DFS). Median follow‐up was 25 months (interquartile range [IQR], 13‐49). Results: At follow‐up 84 patients (46.4%) died, whereas 97 (53.6%) were still alive with recurrence in 78 patients (43%). There was no difference in 5‐year survival (L+ 30.0% vs L− 43.2%; P = .87) or in the 5‐year cumulative incidence of recurrence (L + 63.2% vs L−80%; P = .07) between the two groups. Multivariable analysis indicated that disease‐free interval (DFI) less than 29 months (P < .001) and lung comorbidities (P = .003) were significant predictors of death. Metastases from non‐small–cell lung cancer increased the risk of lung comorbidities by a factor of 19.8, whereas the risk of DFI less than 29 months was increased nearly 11‐fold. Competing risk regression identified multiple metastases (P = .004), head/neck primary tumor (P = .009), and age less than 67 years (P = .024) as independent risk factors for recurrence. Conclusion: Associated lymphadenectomy showed not to give any additional advantage in terms of survival and recurrence after PM.
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Affiliation(s)
- Francesco Londero
- Department of Cardiothoracic Surgery, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Angelo Morelli
- Department of Cardiothoracic Surgery, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Orlando Parise
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - William Grossi
- Department of Cardiothoracic Surgery, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Sara Crestale
- Department of Cardiothoracic Surgery, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Cecilia Tetta
- Radiology Department, Rizzoli Institute, Bologna, Italy
| | - Daniel M Johnson
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Ugolino Livi
- Department of Cardiothoracic Surgery, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Jos G Maessen
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
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