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Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up

  • Landino Fei1Email author,
  • Gianluca Rossetti1,
  • Francesco Moccia1,
  • Teresa Marra1,
  • Paolo Guadagno1,
  • Ludovico Docimo1,
  • Marco Cimmino1,
  • Vincenzo Napolitano1,
  • Giovanni Docimo1,
  • Domenico Napoletano1,
  • Ludovica Guerriero1 and
  • Beniamino Pascotto1
BMC Surgery201313(Suppl 2):S13

https://doi.org/10.1186/1471-2482-13-S2-S13

Published: 8 October 2013

Abstract

Background

In this prospective non randomized observational cohort study we haveevaluated the influence of age on outcome of laparoscopic totalfundoplication for GERD.

Methods

Six hundred and twenty consecutive patients underwent total laparoscopicfundoplication for GERD. Five hundred and twenty-four patients were youngerthan 65 years (YG), and 96 patients were 65 years or older (EG). Thefollowing parameters were considered in the preoperative and postoperativeevaluation: presence, duration, and severity of GERD symptoms, presence of ahiatal hernia, manometric and 24 hour pH-monitoring data, duration ofoperation, incidence of complications and length of hospital stay.

Results

Elderly patients more often had atypical symptoms of GERD and at manometricevaluation had a higher rate of impaired esophageal peristalsis incomparison with younger patients. The duration of the operation was similarbetween the two groups. The incidence of intraoperative and postoperativecomplications was low and the difference was not statistically significantbetween the two groups. An excellent outcome was observed in 93.0% of youngpatients and in 88.9% of elderly patients (p = NS).

Conclusions

Laparoscopic antireflux surgery is a safe and effective treatment for GERDeven in elderly patients, warranting low morbidity and mortality rates and asignificant improvement of symptoms comparable to younger patients.

Keywords

EsophagitisHiatal HerniaLower Esophageal SphincterElderly GroupErosive Esophagitis

Background

Digestive diseases represent very common causes of morbidity and mortality in theelderly patients [1]. Among them gastroesophageal reflux disease (GERD) is usually more severethan in younger patients, and is frequently under-diagnosed and less treated [1]. The advent of laparoscopic surgery and its diffusion [2], has also greatly reduced the morbidity of fundoplication antirefluxsurgery and now it is considered the surgical treatment of choice for GERD [3, 4]. The aim of our study is to compare the outcome of young and elderlypatients undergoing laparoscopic antireflux surgery for the treatment of GERD.

Materials and methods

From September 1992 to December 2011, 620 consecutive patients, 269 male and 351female, mean age 43.7 years (range 12-81) with GERD underwent laparoscopicNissen-Rossetti fundoplication. The preoperative and postoperative data wereprospectively collected. Demographic data were obtained at the time of first visit.Ninety-six patients older than 65 years of age (40 M, 56 F) (mean age 73.1 ±3.4) were defined as the elderly group (EG) whereas the remaining 524 younger than65 years of age (229 M, 295 F) (mean age 47.8 ± 2.9) were defined as the younggroup (YG). Ethics board approval for collecting and using these data wasobtained.

Preoperative study

Preoperatively all patients underwent clinical and instrumental examinations. Themedical evaluation included a structured questionnaire based on modified DeMeestersymptom scoring system (Table 1). Instrumentalexaminations comprised upper gastrointestinal endoscopy, esophageal manometry and24-h pH monitoring; for pHmetric and manometric examinations, patients had tosuspend at least for a week the assumption of antisecretive and antiacid drugs, andstop the assumption of prokinetic drugs and other pharmaceutical products that couldinterfere with the basal tone of the lower esophageal sphincter (LES) (nitrates,calcium-antagonists, aminophylline, beta2-agonists, etc) at least 24 hours beforethe investigations [57]. Esophagitis severity was assessed by means of Savary-Miller gradingsystem. Patients with esophageal strictures and/or paraesophageal hernias wereexcluded from the study.
Table 1

Modified DeMeester scoring system

Symptoms

Score

Description

Dysphagia

0

1

2

3

None

Occasional transient episodes

Require liquids to clear

Impactionrequiring medical attention

Heartburn

0

1

2

3

None

Occasional brief episodes

Frequent episodes requiring medical treatment

Interference with daily activities

Regurgitation

0

1

2

3

None

Occasional episodes

Predictable by posture

Interference with daily activities

Esophageal manometry: Different parameters were evaluated: (1) LESpressure; (2) LES relaxation in response to swallowing; (3) amplitude andpropagation of peristalsis (esophageal peristalsis was considered impaired when<30 mmHg). The LES was studied by both the stationary and the rapid pull-throughmethods.

24 hours pH-monitoring: The electrodes were placed, respectively, 5 cmabove the proximal margin and 5 cm below the distal margin of the LES, identified bymeans of stationary manometry [8, 9].

Postoperative study

On an outpatient basis, the patients came to our department each six months for thefirst postoperative year and, after, each year and were invited to fulfill astandardized questionnaire dealing with presence of typical or atypical symptoms andbased on the modified DeMeester score (Table 1).Satisfaction of the procedure and the will of undergoing the same operation afterknowing its effects were defined as excellent outcome.

Instrumental follow-up included: esophageal manometry (performed at 6 months, 1 year,and 2 years after surgery) and 24h pH monitoring (performed at 1 year aftersurgery).

Statistical analysis

It was carried out using SPSS for Windows (version 12.0, SPSS Inc. Chicago, IL).Results were expressed as mean ± SD unless otherwise indicated. Student'st-test, the Chi-square test, the Fischer's exact test and the Wilcoxonsigned rank test were used as appropriate. Correlations among the various parameterswere analysed using Fischer's exact test. The Wilcoxon signed rank test was used tocompare the preoperative and postoperative modified DeMeester symptom score. P value < 0.05 was considered statistically significant.

Results

In the YG, the mean duration of preoperative symptoms was 4.2 ± 2.1 years (range1-12) whereas in the EG it was 8.5 ± 2.7 years (range 4-21). Incidence andseverity of preoperative symptoms in the two groups are summarized in Table 2 and Table 3. At manometric evaluation,no statistically significant differences in the mean LES pressure were found whenthe two groups were compared (p = NS) but the EG had a higher rate of impairedesophageal peristalsis (defined as peristaltic waves with a pressure value lowerthan 30 mmHg) in comparison with their younger counterparts (P < 0.05)(Table 4). Incidence of Hiatal Hernia (HH)was 88.5% (85/96) in elderly patients and 71.7% (376/524) in young patients (P <0.05). Table 5 shows the prevalence of HH and esophagitis andpH metric values either in elderly and younger patients. In the EG, 69.8% of thepatients(67/96) presented esophagitis: 16 of 67 (23.9%) had a grade I esophagitiswhile 51 out of 67 (76.1%) had a grade II-III esophagitis. In the YG, 34.9% of thepatients (183/524) presented esophagitis: 111 out of 183 (60.6 %) had a grade Iesophagitis while 72 of 183 (39.3%) had a grade II-III esophagitis. Therefore, inthe EG, a significant higher grade of esophagitis has been found along with a higherincidence of Barrett esophagus (Table 5). Apathologic DeMeester score was found at pH-monitoring in all patients of bothsubgroups: in the YG, it was 12.6 ± 1.3 whereas in the EG it was 13.2 ±1.3 (p = NS). The mean percentage of total time at pH< 4 observed at 24-h pHmonitoring in both groups is shown in Table 5: there was asignificant major incidence of acid reflux in EG, either total either in supine andupright position.
Table 2

Incidence of preoperative symptoms in EG and YG

Symptoms

EG (%)

YG (%)

P

Heartburn

67/96(69.8%)

475/524(90.6%)

<0.05

Acid regurgitation

58/96(60.4%)

461/524(88.0%)

<0.05

Solid food dysphagia

37/96(38.5%)

41/524(7.8%)

<0.05

Chest pain

25/96(26.0%)

70/524(13.4%)

<0.05

Respiratory complication

(chronic cough,sleep apnea,asthma,laryngitis)

40/96(41.7%)

24/524(4.6%)

<0.05

Table 3

Severity of preoperative symptoms in EG and YG

Symptoms

EG

YG

P

Heartburn

1.6 ± 0.89

2.8 ± 0.76

<0.05

Acid regurgitation

1.6 ± 0.98

2.4 ± 0.91

<0.05

Solid food dysphagia

1.7 ± 0.78

0.6 ± 0.22

<0.05

Chest pain

1.7 ± 0.84

1.5 ± 0.89

>0.05

Respiratory complication

1.9 ± 1.06

1.1 ± 0.47

<0.05

Table 4

Preoperative manometric evaluation in EG and YG

Manometry

EG

YG

P

LES pressure (mmHg)

10.8 ± 1.6

11.1 ± 1.4

>0.05

Impaired esophageal peristaltis (<30 mmHg)

64/96 (66.6%)

179/524 (34.2%)

<0.05

Table 5

Preoperative evaluation: incidence of hiatal hernia, esophagitis, Barrett andpHmetric data in EG and YG

 

EG

YG

P

Hiatal Hernia

85/96 (88.5%)

376/524 (71.7%)

<0.05

Esophagitis

67/96 (69.8%)

183/524 (34.9%)

<0.05

Barrett

7/96 (7.3%)

14/524 (2.7%)

<0.05

De Meester score

13.2 ± 1.3

12.6 ± 1.3

>0.05

(%)time pH<4 (total)

12 ± 2

7 ± 2

<0.05

(%)time pH<4 (supine)

13 ± 3

8 ± 2

<0.05

(%)time pH<4 (upright)

10 ± 4

5 ± 3

<0.05

All the interventions were completed via laparoscopic approach. Mean operative timewas 48 ± 13 min in YG and 51 ± 15 min in EG (p = NS). Intraoperative bloodloss was similar (30 ± 10 ml vs 35 ± 15 ml, respectively in YG and EG) (p= NS). No mortality was observed in both groups. A major complication occurred in4/524 patients (0.7%), all among the YG (p = NS). Mean postoperative hospital staywas 2.5 ± 0.8 days in YG patients (range 1-5) and 2.7 ± 1.1 days in EGpatients (range 1-6) (p:NS). Normal activity resumed in 8.4 ± 3.5 days in YGand 11.6 ± 8.7 days in EG (p < 0.05).

We followed up clinically 589 (95.0%) of 620 patients, 90 (93.8%) patients in the EGand 499 (95.2%) patients in YG. Two patients in the EG died four years after surgeryfor no surgery correlated event. In the YG, the mean follow-up was 89.7 ± 8months (range 6-180) whereas in EG it was 71.2 ± 9 months (range 6-107). Anexcellent outcome was observed in 464/499 (93.0%) younger patients and in 80/90(88.9%) elderly patients (p = NS). Both groups showed significant improvement inclinical symptom score (Table 6). At 6 months,persisting postoperative dysphagia (DeMeester score 2-3) leading to >15% ofweight loss was observed in 16 of 499 patients (3.2%) in YG (Table 7). In EG, persisting postoperative dysphagia wasobserved in 3 of 90 patients (3.3%) (p = NS) (Table 7). No statistically significant difference was observed betweenpatients with normal and impaired peristalsis. Seven patients in YG and the threepatients in EG were treated with endoscopic dilatation, whereas the remaining ninepatients in YG underwent a laparoscopic redo-funduplication with partial resolutionof dysphagia. Recurrent heartburn was observed and confirmed by means of esophageal24 h pH monitoring in 20/589 patients (3.4%), which was due to a disrupted wrap, anherniated wrap, and a slipped Nissen detected at X-ray barium in nine, six, and fivecases, respectively. Fifteen patients resumed their antisecretory drugs; theremaining five patients, all in YG, underwent redo-fundoplication with partialresolution of symptoms. Respiratory symptoms showed a significant improvement inboth groups. Other data regarding hyper-flatulence, early satiety and bloating areshowed in Table 7. Esophageal manometric follow-up (performedat 6, 12, and 24 months after surgery) was made in 483 of 589 patients (82.0%) at 6months (69/90, (76.7%) in EG and 414/499, (83.0%) in YG), 403/589 (68.4%) at 12months (55/90, (61.1%) in EG and 348/499, (69.7%) in YG), and 391/589 (66.4%) at 24months (52/90, (57.8%) in EG and 339/499, (67.9%) in YG). Stationary esophagealmanometry showed a significant improvement in the mean new high pressure zone(N-HPZ) value in comparison with preoperative values in the two groups (p <0.05) (Table 8and Figure 1). Manometric evaluation at 24 months after surgery showed anincrease of mean peristalsis waves in 39/52 patients of the EG (75.0%) and in149/339 patients of the YG(44.0%) (Table 8).Twenty-four hour pH monitoring at 1 year after surgery was performed in 278/589(47.2%) patients. There was a significant postoperative decrease in esophagealDeMeester score and percentage of time at pH<4 during 24 h in both groups(Table 9).
Table 6

Pre/postoperative symptoms score in EG and YG (mean symptomscore±SD)

Symptoms

________EG_______

P

_______YG_______

P

 

Preop.

Postop.

 

Preop.

Postop.

 

Heartburn

1.6 ± 0.89

0.3 ± 0.14

<0.05

2.8 ± 0.76

2.8 ± 0.76

0.4 ± 0.11

<0.05

Acid regurgitation

1.6 ± 0.98

0.4 ± 0.15

<0.05

2.4 ± 0.91

0.3 ± 0.14

<0.05

Solid food dysphagia

1.7 ± 0.78

0.5 ± 0.14

<0.05

0.6 ± 0.22

0.3 ± 0.17

<0.05

Chest pain

1.7 ± 0.84

0.4 ± 0.24

<0.05

1.5 ± 0.89

0.3 ± 0.15

<0.05

Respiratory complication

1.9 ± 1.06

0.4 ± 0.13

<0.05

1.1 ± 0.47

0.3 ± 0.14

<0.05

Table 7

Postoperative side effects in EG and YG

 

EG

YG

P

Side effects:

number patients (%)

   

Dysphagia

3/90 (3.3%)

16/499 (3.2%)

>0.05

Heartburn

3/90 (3.3%)

17/499 (3.4%)

>0.05

Hyperflautolence

2/90 (2.2%)

8/499 (1.6%)

>0.05

Early satiety

2/90 (2.2%)

11/499 (2.2%)

>0.05

Bloating

3/90 (3.3%)

6/499 (3.2%)

>0.05

Chest pain

1/90 (0.1%)

2/499 (0.4%)

>0.05

Table 8

Postoperative manometric evaluation at 24 months after surgery in EG andYG

Manometry

________EG_______

P

_______YG_______

P

 

Preop.

Postop.

 

Preop.

Postop.

 

N-HPZ pressure (mmHg)

10.8 ± 1.6

28.3 ± 1.6

<0.05

11.1 ± 1.4

2.8 ± 0.76

28.2 ± 1.3

<0.05

Increase of mean peristalsis

39/52(75.0%)

  

149/339(44.0%)

  

waves patients n(%)

      
Table 9

Preoperative and postoperative DeMeester score and percentage of esophagealreflux time during 24 h in EG and YG

 

Preoperative

1 yr after surgery

DeMeester score

EG

YG

13.2 ± 1.3

12.6 ± 1.3

1.3 ± 0.7

1.2 ± 0.2

(%) time pH<4

EG

YG

12 ± 2.0

7.0 ± 2.0

1.5 ± 0.3

0.9 ± 0.8

Discussion

Gastroesophageal reflux disease (GERD) is one of the most common disorders of theupper gastrointestinal tract. Symptoms occur in approximately 20% of adults amongwestern population [10] with great impact on life quality and elevated social costs [1]. GERD ethiopatogenesis is certainly multifactorial with alterations thatinclude a less effective antireflux barrier, defective esophageal-clearance, alteredesophageal mucosal resistance, and delayed gastric emptying [11]. Hiatal hernia as a structural defect of the antireflux barrier is adetermining factor of GERD, by impairing both the diaphragmatic component and theclearance of acid refluxate from the distal esophagus [1217]. GERD has nearly the same prevalence among elderly and young people, butolder patients have more severe esophageal mucosal injuries like grade 3 or 4esophagitis and Barrett disease [1823]. Furthermore, also hiatal hernia incidence seems greater in elderlypatients (about 60% in patients >60 years old) [24].

Also in our study, the elderly group (EG) had a higher rate of erosive esophagitis(69.8% vs 34.9.%) and a lower rate of Grade I esophagitis (23.9% vs 60.6%).Moreover, incidence of Barrett esophagus as well as mean percentage of total time< 4 at pH-monitoring were significantly higher in the EG. Furthermore, we noteda significant higher rate of hiatal hernia in the EG (88.5% vs 71.7%) (Table5).

Previous studies observed esophagitis and Barrett Esophagus in 81% of patients aged60 years vs 47% of young people (p < 0.002) [20]. Zhu [19] and Pizza [25] found that the percentage of time with pH<4 was greater in olderpatients with GERD than in younger ones (p < 0.05). Furthermore, among elderlypatients with esophagitis, nearly 21% had grade III-IV disease compared with only3.4% of younger patients (p < 0.002) [19]. Cameron [18] demonstrated that the prevalence of Barrett esophagus increased with ageto reach a plateau by the seventh decade. Fass [22] reported that the mean incidence rate of erosive esophagitis was 74% inthe elderly and 64% in the younger patients and the frequency of symptoms was lowerin the elderly group.

Many factors associated with ageing could be implicated in the different severity ofmucosal injuries, such as increased gastric acid secretion, reduced salivarybicarbonate secretion, delayed esophageal and gastric emptying, disorderedesophageal peristalsis, increased incidence of hiatal hernia and frequent use ofinjurious medications for esophageal mucosa (like non steroidal anti-inflamatorydrugs) [26]. We found elderly often present with less severe heartburn and acidregurgitation (Tables 2, 2). It is notclear which factors reduce frequency and severity of these symptoms: alteredesophageal pain perception to acid in the elderly may be the result of an ageingprocess [22]. On the other hand, we observed higher frequency and severity of atypicalsymptoms on elderly GERD-affected patients, such as chest pain, respiratorycomplications (chronic cough, sleep apnea, asthma, laryngitis) and dysphagia forsolid foods (Tables 2, 3). Thesecharacteristics surely make prevalence of GERD underestimated in elderlypopulation.

Despite this, in Western Countries life expectancy increased and keep on increasing [23], so always more GERD-affected patients are 65 years old or more. Thisrapidly enlarges demands for effective therapy with greater costs for health caresystems all over the world. According to this, it is necessary to evaluate botheffectiveness and safety of laparoscopic fundoplication in patients more than 65years old in comparison with this surgical approach in younger patients.

Surgical correction of GERD has been shown to be a cost-effective treatment byreducing long-term

complications such as Barrett esophagus and stricture and by eliminating the need ofa life-long medical therapy especially for young patients [2736]. However, a high morbidity and mortality rate of open surgery performedin the elderly, limited the number of these patients referred to surgery [37]. Instead, in elderly population with GERD, laparoscopic surgery hasproven to be effective with low morbidity and mortality rates: Richter [1] and Pizza [25], observed that laparoscopic Nissen fundoplication did not increase themortality, morbility and hospital stay in the elderly patients compared to youngersurgical patients. Kamolz [38] showed that age should not be considered a contraindication tolaparoscopic surgical treatment of GERD as 97% of elderly patients would choosesurgical treatment again if necessary. Also in our study we confirmed theseexcellent results: except for preoperative disease severity, we did not find anysignificant difference in perioperative and postoperative results as well as insubjective and objective outcome between the two groups.

After surgical treatment we found significant improvement in heartburn, acidregurgitation, chest pain and respiratory complications of GERD in both EG and YG(Table 6). An excellent outcome was observedin 464/499 (93.0%) younger patients and in 80/90 (88.9%) elderly patients.Persisting dysphagia occurred in 16/499 (3.2%) in YG and 3/90 (3.3%) in EG while17/499 (3.4%) in YG and 3/90 (3.3%) in EG had recurrence of heartburn (p = NS).Differences between the two groups were not statistically significant also regardingthe incidence of other side effects (flatulence, early satiety, etc) (Table7).

There have been debates in literature regarding the realization of partialfundoplication in patients with defective esophageal peristalsis, and it seemedreasonable therefore, to choose this kind of wrap in elderly patients. Many Authorssupported the realization of a partial fundoplication in patients with impairedesophageal peristalsis to lower the incidence of persistent postoperative dysphagia [3941] because partial wrap was considered as effective as total wrap to controlgastroesophageal reflux, and short-term follow-up seemed to validate the choice ofpartial fundoplication [42, 43]. Later on, partial antireflux procedure showed its inadequacy to assure agood protection from reflux at a long-term follow-up [4446]. Livingston [47] reported a 1.4% recurrence rate of reflux in patients with totalfundoplication versus 6.7% in those with partial fundoplication. At a long-termfollow-up, Fernando [48] observed that 38% of Toupet patients used PPI versus 20% with Nissen.Jobe [49], in a ten years follow-up, noted a recurrence rate for reflux until 51%in patients treated with partial fundoplication (Toupet and Dor). Moreover, totalfundoplication seems not to determine a higher incidence of postoperative dysphagiacompared with the partial wraps, even in patients with impaired peristalsis [5053]. In a prospective randomized trial, Bessell [54] concluded that calibrating the antireflux wrap according to esophagealmotility was not necessary, because the postoperative persistent dysphagia rate wassimilar between patients with total or partial wrap. Velanovich [55] did not find any statistically significant difference in postoperativedysphagia rate related to esophageal motility disorders (MD) (15.8% MD+ versus 16.4%MD-) in a group of patients undergoing total fundoplication.

Besides, total wrap seems to bring about an improvement of esophageal peristalsis.Heider [56] observed an increase of 47% of mean peristaltic waves in distal esophaguscompared with preoperative time (p < 0.01), with the normalization of theesophageal motility in 74% of patients. Oleynikov [57] in a trial comparing total and partial fundoplication noticed that inpatients undergoing partial wrap, the mean amplitude of peristaltic waves increasedfrom 27.8 mmHg before surgery to 35.6 mmHg postoperatively (p < 0.05), while inpatients treated with total fundoplication, these values were respectively 28.2 mmHgversus 49.0 mmHg (p < 0.05). These evidences strongly support the choice ofperforming a total fundoplication even in elderly patients. Also our choice, since1972, has always been favorable to the total Nissen-Rossetti fundoplication [29, 30, 50]. Routinely, we perform intraoperative endoscopy and manometry in order tocalibrate antireflux wrap [29, 30, 50]. Usually, we calibrate the N-HPZ at values ranging from 20 to 45 mmHg('hypercalibrated Nissen'), building the wrap around the gastroscope (with adiameter of 9 mm). This hypercalibration, in contrast with the 'floppy Nissen' ofDonahue and DeMeester [58], resulted from the retrospective evaluation of a former series in whichwe used to calibrate the fundoplication to pressure values similar to those of anormal sphincter ('normocalibrated Nissen': 10-20 mmHg). This experience wasfollowed by a high rate of gastroesophageal reflux recurrence (28.5%) in the first12 months after surgery [59], demonstrating that high pressure zone (HPZ) values of theNissen-Rossetti wrap decrease after surgery with time. Our preference for totalcalibrated wrap led us to consider it also in the treatment of patients affectedwith severe motility disorders such as achalasia and epiphrenic diverticula withexcellent outcome [50, 6062]. Also evidences from this study confirm our choice, as excellent resultshave been observed either in elderly either in young group, with no differences infunction of esophageal peristalsis impairement.

Conclusions

In conclusion, even in elderly patients, laparoscopic antireflux surgery is a safeand effective treatment for GERD, with low morbidity rates and improvement ofsymptoms comparable to younger patients. Total Nissen-Rossetti fundoplicationrepresents the best therapeutic choice even in this group of patients.

Authors' information

L.F.: Full Professor of Surgery at Second University of Naples, Chief Division ofGastrointestinal Surgery at Second University of Naples.

G.R.: Resident in Surgery at Second University of Naples

F.M.: Resident in Surgery at Second University of Naples

T.M.: Resident in Surgery at Second University of Naples

P.G.: Associate Professor of Surgery at Second University of Naples

L.D.: Full Professor of Surgery at Second University of Naples

M.C.: Resident in Surgery at Second University of Naples

V.N.: Assistant Professor of Surgery at Second University of Naples

G.D.: Associate Professor of Surgery at Second University of Naples

D.N.: Resident in Surgery at Second University of Naples

L.G.: Resident in Surgery at Second University of Naples

B.P.: Resident in Surgery at Second University of Naples

Declarations

Declarations

Funding for this article came from personal funds.

This article has been published as part of BMC Surgery Volume 13Supplement 2, 2013: Proceedings from the 26th National Congress of the ItalianSociety of Geriatric Surgery. The full contents of the supplement are availableonline at http://www.biomedcentral.com/bmcsurg/supplements/13/S2

Authors’ Affiliations

(1)
Division of Gastrointestinal Surgery Department of Anaesthesiological, Surgical and Emergency Sciences Second University of Naples-School of Medicine, Naples, Italy

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