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Korenblik R, van Zon JFJA, Olij B, Heil J, Dewulf MJL, Neumann UP, Olde Damink SWM, Binkert CA, Schadde E, van der Leij C, van Dam RM, van Baardewijk LJ, Barbier L, Binkert CA, Billingsley K, Björnsson B, Andorrà EC, Arslan B, Baclija I, Bemelmans MHA, Bent C, de Boer MT, Bokkers RPH, de Boo DW, Breen D, Breitenstein S, Bruners P, Cappelli A, Carling U, Robert MCI, Chan B, De Cobelli F, Choi J, Crawford M, Croagh D, van Dam RM, Deprez F, Detry O, Dewulf MJL, Díaz-Nieto R, Dili A, Erdmann JI, Font JC, Davis R, Delle M, Fernando R, Fisher O, Fouraschen SMG, Fretland ÅA, Fundora Y, Gelabert A, Gerard L, Gobardhan P, Gómez F, Guiliante F, Grünberger T, Grochola LF, Grünhagen DJ, Guitart J, Hagendoorn J, Heil J, Heise D, Herrero E, Hess G, Hilal MA, Hoffmann M, Iezzi R, Imani F, Inmutto N, James S, Borobia FJG, Jovine E, Kalil J, Kingham P, Kollmar O, Kleeff J, van der Leij C, Lopez-Ben S, Macdonald A, Meijerink M, Korenblik R, Lapisatepun W, Leclercq WKG, Lindsay R, Lucidi V, Madoff DC, Martel G, Mehrzad H, Menon K, Metrakos P, Modi S, Moelker A, Montanari N, Moragues JS, Navinés-López J, Neumann UP, Nguyen J, Peddu P, Primrose JN, Olde Damink SWM, Qu X, Raptis DA, Ratti F, Ryan S, Ridouani F, Rinkes IHMB, Rogan C, Ronellenfitsch U, Serenari M, Salik A, Sallemi C, Sandström P, Martin ES, Sarría L, Schadde E, Serrablo A, Settmacher U, Smits J, Smits MLJ, Snitzbauer A, Soonawalla Z, Sparrelid E, Spuentrup E, Stavrou GA, Sutcliffe R, Tancredi I, Tasse JC, Teichgräber U, Udupa V, Valenti DA, Vass D, Vogl TJ, Wang X, White S, De Wispelaere JF, Wohlgemuth WA, Yu D, Zijlstra IJAJ. Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis. BJS Open 2022; 6:6844022. [PMID: 36437731 PMCID: PMC9702575 DOI: 10.1093/bjsopen/zrac141] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone. METHODS A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase. RESULTS Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients). CONCLUSION Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.
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Affiliation(s)
- Remon Korenblik
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
| | - Jasper F J A van Zon
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,GROW—Department of Surgery, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Heil
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Maxime J L Dewulf
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany,NUTRIM—Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Christoph A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Erik Schadde
- Department of General, Visceral and Transplant Surgery, Klinik Hirslanden, Zurich, Switzerland,Department of General, Visceral and Transplant Surgery, Hirslanden Klink St. Anna Luzern, Luzern, Switzerland
| | | | - Ronald M van Dam
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
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Korenblik R, Olij B, Aldrighetti LA, Hilal MA, Ahle M, Arslan B, van Baardewijk LJ, Baclija I, Bent C, Bertrand CL, Björnsson B, de Boer MT, de Boer SW, Bokkers RPH, Rinkes IHMB, Breitenstein S, Bruijnen RCG, Bruners P, Büchler MW, Camacho JC, Cappelli A, Carling U, Chan BKY, Chang DH, Choi J, Font JC, Crawford M, Croagh D, Cugat E, Davis R, De Boo DW, De Cobelli F, De Wispelaere JF, van Delden OM, Delle M, Detry O, Díaz-Nieto R, Dili A, Erdmann JI, Fisher O, Fondevila C, Fretland Å, Borobia FG, Gelabert A, Gérard L, Giuliante F, Gobardhan PD, Gómez F, Grünberger T, Grünhagen DJ, Guitart J, Hagendoorn J, Heil J, Heise D, Herrero E, Hess GF, Hoffmann MH, Iezzi R, Imani F, Nguyen J, Jovine E, Kalff JC, Kazemier G, Kingham TP, Kleeff J, Kollmar O, Leclercq WKG, Ben SL, Lucidi V, MacDonald A, Madoff DC, Manekeller S, Martel G, Mehrabi A, Mehrzad H, Meijerink MR, Menon K, Metrakos P, Meyer C, Moelker A, Modi S, Montanari N, Navines J, Neumann UP, Peddu P, Primrose JN, Qu X, Raptis D, Ratti F, Ridouani F, Rogan C, Ronellenfitsch U, Ryan S, Sallemi C, Moragues JS, Sandström P, Sarriá L, Schnitzbauer A, Serenari M, Serrablo A, Smits MLJ, Sparrelid E, Spüntrup E, Stavrou GA, Sutcliffe RP, Tancredi I, Tasse JC, Udupa V, Valenti D, Fundora Y, Vogl TJ, Wang X, White SA, Wohlgemuth WA, Yu D, Zijlstra IAJ, Binkert CA, Bemelmans MHA, van der Leij C, Schadde E, van Dam RM. Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy. Cardiovasc Intervent Radiol 2022; 45:1391-1398. [PMID: 35790566 PMCID: PMC9458562 DOI: 10.1007/s00270-022-03176-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/08/2022] [Indexed: 12/02/2022]
Abstract
STUDY PURPOSE The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. METHODS The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. RESULTS Not applicable. CONCLUSION DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. TRIAL REGISTRATION Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).
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Affiliation(s)
- R Korenblik
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands.
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - B Olij
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - M Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - M Ahle
- Deparment of Radiology, University Hospital, Linköping, Sweden
| | - B Arslan
- Department of Radiology, Rush University Medical Center, Chicago, USA
| | - L J van Baardewijk
- Department of Radiology, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - I Baclija
- Department of Radiology, Clinic Favoriten, Vienna, Austria
| | - C Bent
- Department of Radiology, Bournemouth and Christuchurch, The Royal Bournemouth and Christchurch Hospitals, Bournemouth and Christuchurch, UK
| | - C L Bertrand
- Department of Surgery, CHU UCLouvain Namur, Namur, Belgium
| | - B Björnsson
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University Hospital, Linköping, Sweden
| | - M T de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S W de Boer
- Deparment of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R P H Bokkers
- Department of Radiology, University Medical Center Groningen, Groningen, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Breitenstein
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - R C G Bruijnen
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Bruners
- Department of Radiology, University Hospital Aachen, Aachen, Germany
| | - M W Büchler
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - J C Camacho
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Cappelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - U Carling
- Department of Radiology, University Hospital Oslo, Oslo, Norway
| | - B K Y Chan
- Department of Surgery, Aintree University Hospitals NHS, Liverpool, UK
| | - D H Chang
- Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Choi
- Department of Surgery, Western Health Footscray, Footscray, Australia
| | - J Codina Font
- Department of Radiology, University Hospital Dr. Josep Trueta de Girona, Girona, Spain
| | - M Crawford
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
| | - D Croagh
- Department of Surgery, Monash Health, Clayton, Australia
| | - E Cugat
- Department of Surgery, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - R Davis
- Department of Radiology, Aintree University Hospitals NHS, Liverpool, UK
| | - D W De Boo
- Department of Radiology, Monash Health, Clayton, Australia
| | - F De Cobelli
- Department of Radiology, Ospedale San Raffaele, Milan, Italy
| | | | - O M van Delden
- Department of Radiology, Amsterdam University Medical Centers Location AMC, Amsterdam, The Netherlands
| | - M Delle
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - O Detry
- Department of Surgery, CHU de Liège, Liège, Belgium
| | - R Díaz-Nieto
- Department of Surgery, Aintree University Hospitals NHS, Liverpool, UK
| | - A Dili
- Department of Surgery, CHU UCLouvain Namur, Namur, Belgium
| | - J I Erdmann
- Department of Surgery, Amsterdam University Medical Centers Location AMC, Amsterdam, The Netherlands
| | - O Fisher
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
| | - C Fondevila
- Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Å Fretland
- Department of Surgery, University Hospital Oslo, Oslo, Norway
| | - F Garcia Borobia
- Department of Surgery, Hospital Parc Taulí de Sabadell, Sabadell, Spain
| | - A Gelabert
- Department of Radiology, Hospital Parc Taulí de Sabadell, Sabadell, Spain
- Department of Radiology, University Hospital Mútua Terassa, Terassa, Spain
| | - L Gérard
- Department of Radiology, CHU de Liège, Liège, Belgium
| | - F Giuliante
- Department of Surgery, Gemelli University Hospital Rome, Rome, Italy
| | - P D Gobardhan
- Department of Surgery, Amphia, Breda, The Netherlands
| | - F Gómez
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - T Grünberger
- Department of Surgery, HPB Center Vienna Health Network, Clinic Favoriten, Vienna, Austria
| | - D J Grünhagen
- Department of Surgery, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - J Guitart
- Department of Radiology, University Hospital Mútua Terassa, Terassa, Spain
| | - J Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Heil
- Department of Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - D Heise
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - E Herrero
- Department of Surgery, University Hospital Mútua Terassa, Terassa, Spain
| | - G F Hess
- Department of Surgery, Clarunis University Hospital, Basel, Switzerland
| | - M H Hoffmann
- Department of Radiology, St. Clara Spital, Basel, Switzerland
| | - R Iezzi
- Department of Radiology, Gemelli University Hospital, Rome, Italy
| | - F Imani
- Department of Radiology, Amphia, Breda, The Netherlands
| | - J Nguyen
- Department of Radiology, Western Health Footscray, Footscray, Australia
| | - E Jovine
- Department of Surgery, Ospedale Maggiore di Bologna, Bologna, Italy
| | - J C Kalff
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - G Kazemier
- Department of Surgery, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Kleeff
- Department of Surgery, University Hospital Halle (Saale), Halle, Germany
| | - O Kollmar
- Department of Surgery, Clarunis University Hospital, Basel, Switzerland
| | - W K G Leclercq
- Department of Surgery, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - S Lopez Ben
- Department of Surgery, University Hospital Dr. Josep Trueta de Girona, Girona, Spain
| | - V Lucidi
- Department of Surgery, Hôpital Erasme, Brussels, Belgium
| | - A MacDonald
- Department of Radiology, Oxford University Hospital NHS, Oxford, UK
| | - D C Madoff
- Department of Radiology, Yale School of Medicine, New Haven, USA
| | - S Manekeller
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - G Martel
- Department of Surgery, The Ottawa Hospital, Ottawa, Canada
| | - A Mehrabi
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - H Mehrzad
- Department of Radiology, Queen Elizabeth Hospital Birmingham NHS, Birmingham, UK
| | - M R Meijerink
- Department of Radiology, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - K Menon
- Department of Surgery, King's College Hospital NHS, London, UK
| | - P Metrakos
- Department of Surgery, McGill University Health Centre, Montréal, Canada
| | - C Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - A Moelker
- Department of Radiology and Nuclear Medicine, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - S Modi
- Department of Radiology, University Hospital Southampton NHS, Southampton, UK
| | - N Montanari
- Department of Radiology, Ospedale Maggiore Di Bologna, Bologna, Italy
| | - J Navines
- Department of Surgery, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - U P Neumann
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - P Peddu
- Department of Radiology, King's College Hospital NHS, London, UK
| | - J N Primrose
- Department of Surgery, University Hospital Southampton NHS, Southampton, UK
| | - X Qu
- Department of Radiology, Zhongshan Hospital, Fundan University, Shanghai, China
| | - D Raptis
- Department of Surgery, Royal Free Hospital NHS, London, UK
| | - F Ratti
- Department of Surgery, Ospedale San Raffaele, Milan, Italy
| | - F Ridouani
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C Rogan
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - U Ronellenfitsch
- Department of Surgery, University Hospital Halle (Saale), Halle, Germany
| | - S Ryan
- Department of Radiology, The Ottawa Hospital, Ottawa, Canada
| | - C Sallemi
- Department of Radiology, Fondazione Poliambulanza, Brescia, Italy
| | - J Sampere Moragues
- Department of Radiology, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - P Sandström
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University Hospital, Linköping, Sweden
| | - L Sarriá
- Department of Radiology, University Hospital Miguel Servet, Saragossa, Spain
| | - A Schnitzbauer
- Department of Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - M Serenari
- Department of Surgery, General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - A Serrablo
- Department of Surgery, University Hospital Miguel Servet, Saragossa, Spain
| | - M L J Smits
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E Sparrelid
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - E Spüntrup
- Department of Radiology, Klinikum Saarbrücken gGmbH, Saarbrücken, Germany
| | - G A Stavrou
- Department of Surgery, Klinikum Saarbrücken gGmbH, Saarbrücken, Germany
| | - R P Sutcliffe
- Department of Surgery, Queen Elizabeth Hospital Birmingham NHS, Birmingham, UK
| | - I Tancredi
- Department of Radiology, Hôpital Erasme, Brussels, Belgium
| | - J C Tasse
- Department of Radiology, Rush University Medical Center, Chicago, USA
| | - V Udupa
- Department of Surgery, Oxford University Hospital NHS, Oxford, UK
| | - D Valenti
- Department of Radiology, McGill University Health Centre, Montréal, Canada
| | - Y Fundora
- Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - T J Vogl
- Department of Radiology, University Hosptital Frankfurt, Frankfurt, Germany
| | - X Wang
- Department of Surgery, Zhongshan Hospital, Fundan University, Shanghai, China
| | - S A White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS, Newcastle upon Tyne, UK
| | - W A Wohlgemuth
- Department of Radiology, University Hospital Halle (Saale), Halle, Germany
| | - D Yu
- Department of Radiology, Royal Free Hospital NHS, London, UK
| | - I A J Zijlstra
- Department of Radiology, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - C A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - M H A Bemelmans
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - C van der Leij
- Deparment of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E Schadde
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Surgery, Rush University Medical Center Chicago, Chicago, USA
| | - R M van Dam
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands.
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany.
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