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Pancreas-related complications following gastrectomy: systematic review and meta-analysis of open versus minimally invasive surgery

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Abstract

Background

Postoperative pancreas-related complications are quite uncommon but potentially life-threatening occurrences that may occasionally complicate the postoperative course of gastrectomy. A number of reports have described such conditions after both standard open and minimally invasive surgery. Our study has the purpose to systematically determine the pooled incidence of pancreatic events following radical gastrectomy. We also aimed to elucidate whether any difference in incidence exists between patients operated via conventional open or minimally invasive surgery.

Methods

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized or well-matched studies comparing conventional with minimally invasive oncological gastrectomy and reporting pancreas-related postoperative complications. We evaluated possible differences in outcomes between open and minimally invasive surgery. A meta-analysis of relevant comparisons was performed using RevMan 5.3.

Results

A total of 20 studies, whereby 6 randomized and 14 non-randomized comparative studies including a total of 7336 patients, were considered eligible for data extraction. Globally, more than 1% of patients experienced some pancreatic occurrences during the postoperative course. The use of minimally invasive surgery showed a trend toward increased overall pancreatic morbidity (OR 1.39), pancreatitis (OR 2.69), and pancreatic fistula (OR 1.13).

Conclusions

Although minimally invasive radical gastrectomy is currently established as a valid alternative to open surgery for the treatment of gastric cancer, a higher risk of pancreas-related morbidity should be taken into account.

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References

  1. Ponka JL, Landrum SE, Chaikof L (1961) Acute pancreatitis in the postoperative patient. Arch Surg 83:475–490

    Article  CAS  PubMed  Google Scholar 

  2. Huang J, Qian L (2014) The study on the efficacy of fibrin glue in preventing post-traumatic focal pancreatitis (PTFP) after radical gastrectomy. J Gastrointest Surg 18:476–480

    Article  PubMed  Google Scholar 

  3. Herbella FA, Tineli AC, Wilson JL Jr, Del Grande JC (2008) Gastrectomy and lymphadenectomy for gastric cancer: is the pancreas safe? J Gastrointest Surg 12:1912–1914

    Article  PubMed  Google Scholar 

  4. Maruyama K, Sasako M, Kinoshita T, Sano T, Katai H, Okajima K (1995) Pancreas-preserving total gastrectomy for proximal gastric cancer. World J Surg 19:532–536

    Article  CAS  PubMed  Google Scholar 

  5. Obama K, Okabe H, Hosogi H, Tanaka E, Itami A, Sakai Y (2011) Feasibility of laparoscopic gastrectomy with radical lymph node dissection for gastric cancer: from a viewpoint of pancreas-related complications. Surgery 149:15

    Article  PubMed  Google Scholar 

  6. Nobuoka D, Gotohda N, Konishi M, Nakagohri T, Takahashi S, Kinoshita T (2008) Prevention of postoperative pancreatic fistula after total gastrectomy. World J Surg 32:2261

    Article  PubMed  Google Scholar 

  7. Sano T, Sasako M, Katai H, Maruyama K (1997) Amylase concentration of drainage fluid after total gastrectomy. Br J Surg 84:1310

    Article  CAS  PubMed  Google Scholar 

  8. Jiang X, Hiki N, Nunobe S et al (2012) Postoperative pancreatic fistula and the risk factors of laparoscopy-assisted distal gastrectomy for early gastric cancer. Ann Surg Oncol 19:115

    Article  PubMed  Google Scholar 

  9. Miyai H, Hara M, Hayakawa T, Takeyama H (2013) Establishment of a simple predictive scoring system for pancreatic fistula after laparoscopy-assisted gastrectomy. Dig Endosc 25:585–592

    Article  PubMed  Google Scholar 

  10. Kobayashi D, Iwata N, Tanaka C, Kanda M, Yamada S, Nakayama G, Fujii T, Koike M, Fujiwara M, Kodera Y (2015) Factors related to occurrence and aggravation of pancreatic fistula after radical gastrectomy for gastric cancer. J Surg Oncol 112:381–386

    Article  CAS  PubMed  Google Scholar 

  11. Iwata N, Kodera Y, Eguchi T, Ohashi N, Nakayama G, Koike M, Fujiwara M, Nakao A (2010) Amylase concentration of the drainage fluid as a risk factor for intra-abdominal abscess following gastrectomy for gastric cancer. World J Surg 34:1534–1539

    Article  PubMed  Google Scholar 

  12. Bo T, Zhihong P, Peiwu Y, Feng Q, Ziqiang W, Yan S, Yongliang Z, Huaxin L (2009) General complications following laparoscopic-assisted gastrectomy and analysis of techniques to manage them. Surg Endosc 23:1860–1865

    Article  CAS  PubMed  Google Scholar 

  13. Yu HW, Jung do H, Son SY, Lee CM, Lee JH, Ahn SH, Park do J, Kim HH (2013) Risk factors of postoperative pancreatic fistula in curative gastric cancer surgery. J Gastric Cancer 13:179–184

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kung CH, Lindblad M, Nilsson M, Rouvelas I, Kumagai K, Lundell L, Tsai JA (2014) Postoperative pancreatic fistula formation according to ISGPF criteria after D2 gastrectomy in Western patients. Gastric Cancer 17:571–577

    Article  PubMed  Google Scholar 

  15. Li HZ, Chen JX, Zheng Y, Zhu XN (2016) Laparoscopic-assisted versus open radical gastrectomy for resectable gastric cancer: systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials. J Surg Oncol 113:756–767

    Article  PubMed  Google Scholar 

  16. Zou ZH, Zhao LY, Mou TY, Hu YF, Yu J, Liu H, Chen H, Wu JM, An SL, Li GX (2014) Laparoscopic vs open D2 gastrectomy for locally advanced gastric cancer: a meta-analysis. World J Gastroenterol 20:16750–16764

    Article  PubMed  PubMed Central  Google Scholar 

  17. Lee JH, Nam BH, Ryu KW, Ryu SY, Park YK, Kim S, Kim YW (2015) Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer. Br J Surg 102:1500–1505

    Article  CAS  PubMed  Google Scholar 

  18. Chang KK, Park do J, Yoon SS (2016) Laparoscopic versus open surgery for gastric adenocarcinoma: innovation continues to challenge tradition. Ann Surg 264:223–225

    Article  PubMed  Google Scholar 

  19. Tokunaga M, Kondo J, Tanizawa Y, Bando E, Kawamura T, Terashima M (2012) Postoperative intra-abdominal complications assessed by the Clavien-Dindo classification following open and laparoscopy-assisted distal gastrectomy for early gastric cancer. J Gastrointest Surg 16:1854–1859

    Article  PubMed  Google Scholar 

  20. Viñuela EF, Gonen M, Brennan MF, Coit DG, Strong VE (2012) Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg 255:446–456

    Article  PubMed  Google Scholar 

  21. Kim HI, Han SU, Yang HK, Kim YW, Lee HJ, Ryu KW, Park JM, An JY, Kim MC, Park S, Song KY, Oh SJ, Kong SH, Suh BJ, Yang DH, Ha TK, Kim YN, Hyung WJ (2016) Multicenter prospective comparative study of robotic versus laparoscopic gastrectomy for gastric adenocarcinoma. Ann Surg 263:103–109

    Article  PubMed  Google Scholar 

  22. Okholm C, Goetze JP, Svendsen LB, Achiam MP (2014) Inflammatory response in laparoscopic vs. open surgery for gastric cancer. Scand J Gastroenterol 49(9):1027–1034

    Article  CAS  PubMed  Google Scholar 

  23. Lu C, Zhou S, Peng Z, Chen L (2015) Quality of D2 lymphadenectomy for advanced gastric cancer: is laparoscopic-assisted distal gastrectomy as effective as open distal gastrectomy? Surg Endosc 29:1537–1544

    Article  PubMed  Google Scholar 

  24. Herrera-Almario G, Strong VE (2016) Minimally invasive gastric surgery. Ann Surg Oncol 23:3792–3797

    Article  PubMed  PubMed Central  Google Scholar 

  25. Inaki N, Etoh T, Ohyama T, Uchiyama K, Katada N, Koeda K, Yoshida K, Takagane A, Kojima K, Sakuramoto S, Shiraishi N, Kitano S (2015) A multi-institutional,prospective, phase II feasibility study of laparoscopy-assisted distal gastrectomy with D2 Lymph node dissection for locally advanced gastric cancer (JLSSG0901). World J Surg 39:2734–2741

    Article  PubMed  Google Scholar 

  26. Ojima T, Iwahashi M, Nakamori M, Nakamura M, Naka T, Ishida K, Ueda K, Katsuda M, Iida T, Tsuji T, Yamaue H (2009) Influence of overweight on patients with gastric cancer after undergoing curative gastrectomy: an analysis of 689 consecutive cases managed by a single center. Arch Surg 144:351–358

    Article  PubMed  Google Scholar 

  27. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Ann Intern Med 18(151):W65–W94

    Google Scholar 

  28. Stroup DF, Berlin JA, Morton SC, et al (2000) Meta-analysis of observational studies in epidemiology. JAMA 283:2008–2012

  29. Katai H, Yoshimura K, Fukagawa T, Sano T, Sasako M (2005) Risk factors for pancreas-related abscess after total gastrectomy. Gastric Cancer 8:137–141

    Article  PubMed  Google Scholar 

  30. Miki Y, Tokunaga M, Bando E, Tanizawa Y, Kawamura T, Terashima M (2011) Evaluation of postoperative pancreatic fistula after total gastrectomy with D2 lymphadenectomy by ISGPF classification. J Gastrointest Surg 15:1969–1976

    Article  PubMed  Google Scholar 

  31. Tanaka K, Miyashiro I, Yano M, Kishi K, Motoori M, Seki Y, Noura S, Ohue M, Yamada T, Ohigashi H, Ishikawa O (2009) Accumulation of excess visceral fat is a risk factor for pancreatic fistula formation after total gastrectomy. Ann Surg Oncol 16:1520–1525

    Article  PubMed  Google Scholar 

  32. Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. The cochrane collaboration. http://www.cochrane-handbook.org

  33. Aoyama T, Yoshikawa T, Hayashi T, Hasegawa S, Tsuchida K, Yamada T, Cho H, Ogata T, Fujikawa H, Yukawa N, Oshima T, Rino Y, Masuda M (2014) Randomized comparison of surgical stress and the nutritional status between laparoscopy-assisted and open distal gastrectomy for gastric cancer. Ann Surg Oncol 21:1983–1990

    Article  PubMed  Google Scholar 

  34. Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, Xue Y, Suo J, Tao K, He X, Wei H, Ying M, Hu W, Du X, Chen P, Liu H, Zheng C, Liu F, Yu J, Li Z, Zhao G, Chen X, Wang K, Li P, Xing J, Li G (2016) Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial. J Clin Oncol 34:1350–1357

    Article  PubMed  Google Scholar 

  35. Huscher CG, Mingoli A, Sgarzini G et al (2005) Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 241:232–237

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, Cho GS, Kim CY, Yang HK, Park do J, Song KY, Lee SI, Ryu SY, Lee JH, Lee HJ; Korean Laparo-endoscopic Gastrointestinal Surgery Study (KLASS) Group (2016) Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg 263:28–35.

    Article  PubMed  Google Scholar 

  37. Kitano S, Shiraishi N, Fujii K et al (2002) A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery 131:S306–S311

    Article  PubMed  Google Scholar 

  38. Takiguchi S, Fujiwara Y, Yamasaki M, Miyata H, Nakajima K, Sekimoto M, Mori M, Doki Y (2013) Laparoscopy-assisted distal gastrectomy versus open distal gastrectomy. A prospective randomized single-blind study. World J Surg 37:2379–2386

    Article  PubMed  Google Scholar 

  39. Caruso S, Patriti A, Marrelli D, Ceccarelli G, Ceribelli C, Roviello F, Casciola L (2011) Open vs robot-assisted laparoscopic gastric resection with D2 lymph node dissection for adenocarcinoma: a case-control study. Int J Med Robot 7:452–458

    Article  PubMed  Google Scholar 

  40. Chen QY, Huang CM, Lin JX, Zheng CH, Li P, Xie JW, Wang JB, Lu J (2012) Laparoscopy-assisted versus open D2 radical gastrectomy for advanced gastric cancer without serosal invasion: a case control study. World J Surg Oncol 16(10):248

    Article  Google Scholar 

  41. Cianchi F, Quirici E, Trallori G, Macrì G, Indennitate G, Ortolani M, Paoli B, Biagini MR, Galli A, Messerini L, Mallardi B, Badii B, Staderini F, Perigli G (2013) Totally laparoscopic versus open gastrectomy for gastric cancer: a matched cohort study. J Laparoendosc Adv Surg Tech 23:117–122

    Article  Google Scholar 

  42. Hao Y, Yu P, Qian F, Zhao Y, Shi Y, Tang B, Zeng D, Zhang C (2016) Comparison of laparoscopy-assisted and open radical gastrectomy for advanced gastric cancer: A retrospective study in a single minimally invasive surgery center. Medicine 95:e3936

    Article  PubMed  PubMed Central  Google Scholar 

  43. Honda M, Hiki N, Kinoshita T, Yabusaki H, Abe T, Nunobe S, Terada M, Matsuki A, Sunagawa H, Aizawa M, Healy MA, Iwasaki M, Furukawa TA (2016) Long-term outcomes of laparoscopic versus open surgery for clinical stage I gastric cancer: the LOC-1 study. Ann Surg 264:214–222

    Article  PubMed  PubMed Central  Google Scholar 

  44. Inokuchi M, Otsuki S, Murase H, Kawano T, Kojima K (2016) Feasibility of laparoscopy-assisted gastrectomy for patients with poor physical status: a propensity-score matching study. Int J Surg 31:47–51

    Article  PubMed  Google Scholar 

  45. Kelly KJ, Selby L, Chou JF, Dukleska K, Capanu M, Coit DG, Brennan MF, Strong VE (2015) Laparoscopic versus open gastrectomy for gastric adenocarcinoma in the west: a case-control study. Ann Surg Oncol 22:3590–3596

    Article  PubMed  PubMed Central  Google Scholar 

  46. Kunisaki C, Makino H, Kosaka T, Oshima T, Fujii S, Takagawa R, Kimura J, Ono HA, Akiyama H, Taguri M, Morita S, Endo I (2012) Surgical outcomes of laparoscopy-assisted gastrectomy versus open gastrectomy for gastric cancer: a case-control study. Surg Endosc 26:804–810

    Article  PubMed  Google Scholar 

  47. Lin J, Huang C, Zheng C, Li P, Xie J, Wang J, Lu J (2014) A matched cohort study of laparoscopy-assisted and open total gastrectomy for advanced proximal gastric cancer without serosa invasion. Chin Med J (Engl) 127:403–407

    Google Scholar 

  48. Procopiuc L, Tudor S, Manuc M, Diculescu M, Vasilescu C (2016) Open vs robotic radical gastrectomy for locally advanced gastric cancer. Int J Med Robot 12:502–508

    Article  PubMed  Google Scholar 

  49. Shinohara T, Satoh S, Kanaya S, Ishida Y, Taniguchi K, Isogaki J, Inaba K, Yanaga K, Uyama I (2013) Laparoscopic versus open D2 gastrectomy for advanced gastric cancer: a retrospective cohort study. Surg Endosc 27:286–294

    Article  PubMed  Google Scholar 

  50. Shuang J, Qi S, Zheng J, Zhao Q, Li J, Kang Z, Hua J, Du J (2011) A case-control study of laparoscopy-assisted and open distal gastrectomy for advanced gastric cancer. J Gastrointest Surg 15:57–62

    Article  PubMed  Google Scholar 

  51. Topal B, Leys E, Ectors N, Aerts R, Penninckx F (2008) Determinants of complications and adequacy of surgical resection in laparoscopic versus open total gastrectomy for adenocarcinoma. Surg Endosc 22:980–984

    Article  CAS  PubMed  Google Scholar 

  52. Zhang Y, Qi F, Jiang Y, Zhai H, Ji Y (2015) Long-term follow-up after laparoscopic versus open distal gastrectomy for advanced gastric cancer. Int J Clin Exp Med 8:13564–13570

    PubMed  PubMed Central  Google Scholar 

  53. Popper HL, Necheles H, Russell KC (1948) Transition of pancreatic edema into pancreatic necrosis. Surg Gynecol Obstet 87:79–82

    CAS  PubMed  Google Scholar 

  54. Klar E, Messmer K, Warshaw AL, Herfarth C (1990) Pancreatic ischaemia in experimental acute pancreatitis: mechanism, significance and therapy. Br J Surg 77:1205–1210

    Article  CAS  PubMed  Google Scholar 

  55. Thompson JS, Bragg LE, Hodgson PE, Rikkers LF (1988) Postoperative pancreatitis. Surg Gynecol Obstet 167:377–380

    CAS  PubMed  Google Scholar 

  56. Seo HS, Shim JH, Jeon HM, Park CH, Song KY (2015) Postoperative pancreatic fistula after robot distal gastrectomy. J Surg Res 194:361–366

    Article  PubMed  Google Scholar 

  57. Fujita T, Ohta M, Ozaki Y, Takahashi Y, Miyazaki S, Harada T, Iino I, Kikuchi H, Hiramatsu Y, Kamiya K, Konno H (2015) Collateral thermal damage to the pancreas by ultrasonic instruments during lymph node dissection in laparoscopic gastrectomy. Asian J Endosc Surg 8:281–8

    Article  PubMed  Google Scholar 

  58. Ryska M, Rudis J (2014) Pancreatic fistula and postoperative pancreatitis after pancreatoduodenectomy for pancreatic cancer. Hepatobiliary Surg Nutr 3:268–275

    PubMed  PubMed Central  Google Scholar 

  59. Kuo IM, Wang F, Liu KH, Jan YY (2009) Post-gastrectomy acute pancreatitis in a patient with gastric carcinoma and pancreas divisum. World J Gastroenterol 15:4596–4600

    Article  PubMed  PubMed Central  Google Scholar 

  60. Park JM, Jin SH, Lee SR, Kim H, Jung IH, Cho YK, Han SU (2008) Complications with laparoscopically assisted gastrectomy: multivariate analysis of 300 consecutive cases. Surg Endosc 22:2133–2139

    Article  PubMed  Google Scholar 

  61. Tomimaru Y, Miyashiro I, Kishi K, Motoori M, Yano M, Shingai T, Noura S, Ohue M, Ohigashi H, Ishikawa O (2011) Is routine measurement of amylase concentration in drainage fluid necessary after total gastrectomy for gastric cancer? J Surg Oncol 104:274–277

    Article  CAS  PubMed  Google Scholar 

  62. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M; International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13.

    Article  PubMed  Google Scholar 

  63. Suda K, Man-I M, Ishida Y, Kawamura Y, Satoh S, Uyama I (2015) Potential advantages of robotic radical gastrectomy for gastric adenocarcinoma in comparison with conventional laparoscopic approach: a single institutional retrospective comparative cohort study. Surg Endosc 29:673–685

    Article  PubMed  Google Scholar 

  64. Kobayashi N, Shinohara H, Haruta S, Ohkura Y, Mizuno A, Ueno M, Udagawa H, Sakai Y (2016) Process of pancreas head as a risk factor for postoperative pancreatic fistula in laparoscopic gastric cancer surgery. World J Surg 40:2194–2201

    Article  PubMed  Google Scholar 

  65. Migita K, Matsumoto S, Wakatsuki K, Ito M, Kunishige T, Nakade H, Nakatani M, Kitano M, Nakajima Y (2016) The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy. Surg Endosc 30:5481–5489

    Article  PubMed  Google Scholar 

  66. Matsunaga T, Saito H, Murakami Y, Kuroda H, Fukumoto Y, Osaki T (2016) Usefulness of T-shaped gauze for precise dissection of supra-pancreatic lymph nodes and for reduced postoperative pancreatic fistula in patients undergoing laparoscopic gastrectomy for gastric cancer. Yonago Acta Med 59:232–236.

    PubMed  PubMed Central  Google Scholar 

  67. Noshiro H, Shimizu S, Nagai E, Ohuchida K, Tanaka M (2003) Laparoscopy-assisted distal gastrectomy for early gastric cancer: is it beneficial for patients of heavier weight? Ann Surg 238:680–685

    Article  PubMed  PubMed Central  Google Scholar 

  68. Yamamoto M, Rashid OM, Wong J (2015) Surgical management of gastric cancer: the East vs. West perspective. J Gastrointest Oncol 6:79–88

    PubMed  PubMed Central  Google Scholar 

  69. Kitano S, Iso Y, Moriyama M, Sugimachi K (1994) Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 4:146–148

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy

    Francesco Guerra & Andrea Coratti

  2. Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy

    Giuseppe Giuliani & Paolo Pietro Bianchi

  3. Division of General Surgery, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy

    Martina Iacobone

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  1. Francesco Guerra
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  2. Giuseppe Giuliani
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  3. Martina Iacobone
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  4. Paolo Pietro Bianchi
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  5. Andrea Coratti
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Correspondence to Francesco Guerra.

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Drs Francesco Guerra, Giuliani Giuseppe, Martina Iacobone, Paolo Pietro Bianchi, and Andrea Coratti have no conflicts of interest or financial ties to disclose.

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Guerra, F., Giuliani, G., Iacobone, M. et al. Pancreas-related complications following gastrectomy: systematic review and meta-analysis of open versus minimally invasive surgery. Surg Endosc 31, 4346–4356 (2017). https://doi.org/10.1007/s00464-017-5507-z

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