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ORIGINAL ARTICLE
Year :   |  Volume :   |  Issue :   |  Page :
 

Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution


 Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China

Date of Submission31-Oct-2021
Date of Decision25-Jan-2022
Date of Acceptance06-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Yahui Liu,
Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, Jilin 130021
China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_336_21

PMID: 35915533

  Abstract 


Background: Pancreatic fistula (PF) and biliary fistula (BF) are two major leakage complications after pancreatoduodenectomy (PD). The aim of this study is to investigate the risk factors of PF and BF after laparoscopic PD (LPD).
Materials and Methods: We conducted a retrospective analysis of 500 patients who underwent LPD from 1 April 2015 to 31 March 2020. Clinical data from patients were analysed using multivariate logistic regression analysis.
Results: PF occurred in 86 (17.2%) patients. Univariate and multivariate analysis indicated that the soft texture of the pancreas (P = 0.001) was the independent risk factor for PF. BF occurred in 32 (6.4%) patients. Univariate and multivariate analysis indicated that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent risk factors for BF.
Conclusion: The texture of the pancreas was an independent risk factor for PF after LPD, which was consistent with the literatures. In addition, history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin were new independent risk factors for BF after LPD. Therefore, patients with high-risk factors of BF should be informed that they are at a high risk for this complication.


Keywords: Biliary fistula, laparoscopic pancreatoduodenectomy, pancreatic fistula, pancreatoduodenectomy



How to cite this URL:
Wang R, Jiang P, Chen Q, Liu S, Jia F, Liu Y. Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=351250





  Introduction Top


Pancreatic cancer is one of the leading malignancies globally, with a low 5-year survival rate.[1] This kind of disease is usually characterised by insidious onset, high degree of malignancy and rapid progression. In the past decades, therapies for patients with pancreatic cancer have been greatly improved; however, pancreatic resection remains the only available curative treatment for malignant pancreatic tumours.

Pancreatoduodenectomy (PD) is one of the most complicated abdominal surgeries, which is a standard treatment for various diseases of the pancreatic head and periampullary region.[2] Since the advent of laparoscopic cholecystectomy, laparoscopic surgery has been widely accepted in the field of abdominal surgery.[3] The laparoscopic PD (LPD) was first reported in 1994 by Gagner and Pomp.[4] As one of the most technically challenging procedures, it was controversial at the beginning and underwent a difficult development process. Due to the advantages of low incidence of post-operative complications, less intra-operative blood loss, comparable overall survival and shorter hospital stay time compared to open PD (OPD), LPD has been widely used in the resection of pancreatic tumours.[5]

The post-operative mortality rate of PD has significantly decreased during the last decades, while the occurrence rate of potentially lethal post-operative complications remains high.[6] Pancreatic fistula (PF) is the most serious complication of PD. Although a series of strategies have been applied to reduce its occurrence, post-operative PF (POPF) remains one of the intractable complications.[7],[8] Some literatures suggested that approximately 50% of post-operative complications after PD are related to POPF.[9],[10] If the occurrence of POPF could be predicted in advance and preventive measures could be taken, it would be beneficial to the patients who have undergone PD. Therefore, it is significant to analyse the risk factors of PF to evaluate the patients with a high risk of POPF. In addition to POPF, post-operative haemorrhage and delayed gastric emptying are two other major complications for PD. Compared with numerous published studies focusing on these three complications, there have been few reports of biliary fistula (BF) in the pancreatic literature.[11],[12] Consequently, it is also necessary to explore the potential risk factors for BF after PD.

In this study, we intended to investigate the risk factors of PF and BF after LPD procedures at a single institution, which may help to better understand the occurrence of post-operative complications of LPD. In addition, our research is one of the largest single-institution studies of LPD so far, and the results could provide guidance for surgeons on the post-operative management of LPD.


  Materials and Methods Top


Study design and data collection

We conducted a retrospective study of 500 patients who underwent LPD procedure between 1 April 2015 and 31 March 2020 at the First Hospital of Jilin University and the study was approved by the Ethics Committee of the Hospital. We collected the data from a prospectively maintained database by full-time staff in our department. All the operations were performed by two senior surgeons, who performed 492 and 8 cases, respectively. All patients in this study underwent total LPD. Of the 500 patients, 277 patients were male and 223 were female. Their ages ranged from 9 to 79, and the average age is 60 years. The data of these patients included demographics (age, gender, body mass index [BMI], comorbidity and ASA score), previous abdominal surgery, pre-operative biliary drainage, operational details (surgical time, intra-operative blood loss, intra-operative blood transfusion, pancreatic texture and pancreatic duct size), pre-operative laboratory data (total bilirubin, direct bilirubin, CA199, CA125), post-operative complications (POPF, BF, post-operative haemorrhage, abdominal infection, pulmonary infection), time to first flatus and pathological diagnosis.

Surgical technique

Patients were placed in a supine position under general anaesthesia. After the establishment of pneumoperitoneum by a trocar placed slightly lower than the umbilicus, two trocars were placed both lateral to the umbilicus on the left and right in the midclavicular lines. Two other trocars were placed at the left and right infracostal arch (1 cm subcostal) on both sides of the anterior axillary line. The operation was started at the beginning of the horizontal part of the duodenum at the right side of the root of the transverse mesocolon. After lifting up the transverse colon, the transverse mesocolon was cut open to expose the inferior vena cava. There was loose connective tissue without blood vessels between the posterior part of the descending duodenum and the inferior vena cava. The posterior and right wall of descending duodenum could be completely dissociated here. The left renal vein into the inferior vena cava was observed on the left side, and the root of the superior mesenteric artery (SMA) could be easily exposed. The superior mesentery vein (SMV) was found above the horizontal part of the duodenum. The Henle's trunk and small branches of the portal vein were transected along the SMV. SMV was continuously dissociated upwards to the inferior border of the pancreas. The pancreatic uncinate process was dissociated along SMV, and all lymph nodes and nerve tissues on the right side of SMA were resected. The pancreas uncinate process was completely dissociated for ligation and dissection. The jejunum was transected approximately 15 cm distal to the Treitz ligament. After the Treitz ligament was cut, the proximal jejunum was pulled to the right from the rear of the mesenteric vessels. This approach is suitable for early-stage duodenal papillary carcinoma, terminal cholangiocarcinoma and pancreatic head carcinoma without invasion of mesenteric vessels. From the rear of the uncinate process, the pancreatic uncinate process was mobilised from bottom to top along SMV. The inferior pancreaticoduodenal artery (IPDA) was then ligated and dissected, and the branches of the SMV should be carefully handled until the uncinate process was completely dissected. To avoid hepatic ischaemia, the injury to the aberrant right hepatic artery arising from the SMA should be prevented. After complete dissociation of the uncinate process, the stomach was transected, and the common hepatic artery was dissociated at the superior border of the pancreas. Then, the proper hepatic artery was dissociated, and the right gastric artery and gastroduodenal artery were divided and dissected. The pancreatic neck was transected with ultrasonic shears at the ventral side of SMV, and the pancreatic duct was found. Finally, the gallbladder was removed, and the common hepatic duct was transected. The specimen was removed through an enlarged periumbilical incision. The pancreaticojejunostomy was performed as a double-layer duct-to-mucosa approach. The outer layer was sutured with 3-0 Prolene running sutures, and the inner layer was sutured with 5-0 Prolene interrupted sutures. A pancreatic stent was inserted into the pancreatic duct. The hepaticojejunostomy was performed using a 4-0 polydioxanone in a running suture. Gastrojejunostomy was performed using 3-0 Stratafix.

Diagnostic criteria of post-operative pancreatic fistula and biliary fistula

In this study, we adopted the diagnostic criteria of POPF defined by the International Study Group of Pancreatic Surgery.[13] The diagnostic criteria of BF after LPD were defined by the International Study Group of Liver Surgery.[14]

Statistical analysis

All statistical analysis was performed with SPSS (Version 24.0, IBM, USA). P < 0.05 were considered to be statistically significant. Related factors of PF and BF after LPD were estimated using univariate analysis of the Chi-square test and Student's t-test. Then, the factors statistically significant were analysed using binary logistic regression analysis.


  Results Top


The clinical data of patients

A total of 500 patients were included in this study, and all the patients underwent LPD. The clinical data are summarised in [Table 1].
Table 1: Demographic and clinical characteristics of patients

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Risk factors for pancreatic fistula analysis

Five hundred patients were divided into POPF group (n = 86) and without POPF group (n = 414). The demographics and perioperative data are shown in [Table 2]. Results of Pearson's Chi-squared test showed that POPF was significantly associated with surgical time (P = 0.048), pancreatic texture (P < 0.001), pancreatic duct size (P = 0.012), several post-operative complications (BF, post-operative haemorrhage, pulmonary infection and abdominal infection) and time to first flatus (P = 0.003); however, there is no correlation between the incidence of POPF and age, gender, BMI, diabetes history, chronic pancreatitis history, ASA score, history of abdominal surgery, pre-operative biliary drainage, intra-operative blood loss, intra-operative blood transfusion and pre-operative laboratory data (total bilirubin, direct bilirubin, CA199, CA125) (P > 0.05) [Table 2]. Results of multivariate logistic regression analysis indicated that pancreas texture (P = 0.001) is the prognostic factor of POPF [Table 2].
Table 2: Results of univariate analysis and multivariate logistic regression analysis of pancreatic fistula after laparoscopic pancreatoduodenectomy

Click here to view


Risk factors for biliary fistula analysis

Five hundred patients were divided into BF group (n = 32) and without BF group (n = 468). The demographics and perioperative data are shown in [Table 3]. Univariate analysis showed that BF had a correlation with cardiovascular disease history (P = 0.003), surgical time (P = 0.018), pre-operative total bilirubin (P = 0.004), pre-operative direct bilirubin (P = 0.002), pre-operative CA125 (P = 0.045), intra-operative blood loss (P = 0.046) and several post-operative complications (POPF, post-operative haemorrhage, pulmonary infection and abdominal infection); however, there is no correlation between the incidence of BF and age, gender, BMI, history of diabetes, history of chronic pancreatitis, ASA score, history of abdominal surgery, pre-operative biliary drainage, intra-operative blood transfusion, pancreatic texture, pancreatic duct size, pre-operative CA199 and time to first flatus (P > 0.05) [Table 3]. Multivariate analysis identified that that history of cardiovascular (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) are prognostic factors of BF after LPD [Table 3].
Table 3: Results of univariate analysis and multivariate logistic regression analysis of biliary fistula after laparoscopic pancreatoduodenectomy

Click here to view



  Discussion Top


The incidence of pancreatic cancer has increased worldwide. Moreover, the only available curative treatment for this aggressive disease is surgical resection. In the past few decades, the safety of PD procedure has been significantly improved, and the operative mortality rate of high-volume centres has been reduced to below 3%.[15],[16] Minimally invasive surgeries have recently become more popular in pancreatic resection. Therefore, some studies have compared the LPD with the open approach. These researches revealed that LPD provided benefits in terms of hospital stay time but no significant difference in the overall complication rates.[17],[18]

PF is considered to be the most relevant and severe complication of pancreatic surgery, which is also the main cause of death and other complications.[19],[20] POPF has resulted in an increase of health-care-related costs and hospital stay time. The risk assessment of POPF can not only provide guidance for the selection of perioperative protocols but also demonstrates its value by improving the management of high-risk patients. It has been reported that pre-operative risk assessment for pancreatic cancer patients can predict the occurrence of POPF.[21],[22] However, there are still few studies on the factors influencing the PF after LPD alone.

It has been reported that both small pancreatic duct diameter and soft pancreas texture were significantly associated with the occurrence of POPF.[23],[24],[25] In this study, we found that surgical time, pancreatic texture, pancreatic duct size, several post-operative complications and time to first flatus were significantly associated with PF after LPD. All these factors associated with POPF were further analysed by multivariate logistic regression. Results from our research indicated that the soft texture of the pancreas (P = 0.001) was an independent factor of PF after LPD.

BF is the second-most common leakage complication after PD, with an incidence of 3%–8%.[26] Compared with other complications of PD, there is a scarcity of literature on post-operative BF, especially for its independent risk factors. In univariate analyses, BF was reported to be associated with longer operation time, older age, higher ASA score, history of coronary disease, blood transfusion, POPF, post-operative haemorrhage, delayed gastric emptying, sepsis, low serum albumin level and higher BUN level of post-operative day 1.[11],[12],[27] An earlier study involving 1033 hepaticojejunostomies (486 were PDs) indicated that previous endoscopic biliary drainage, the anastomosis on segmental biliary ducts, and BMI >35 kg/m2 were independent risk factors of BF.[28] There were still results showed that substantial atherosclerotic celiac axis stenosis, smaller pre-operative common bile duct (CBD) diameter and older age were independent risk factors for post-operative BF.[12] However, a study of 1618 patients after PD suggested that a smaller CBD diameter was the only independent risk factor.[11]

Our results showed that a history of cardiovascular disease, surgical time, pre-operative total bilirubin, pre-operative direct bilirubin, pre-operative CA125, intra-operative blood loss and several post-operative complications were significantly associated with BF after LPD. Results of multivariate logistic regression analysis from our research showed that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent prognostic factors of BF after LPD. Moreover, these independent prognostic factors of BF were first identified. Unfortunately, due to the lack of CBD data in our database, we cannot analyse whether it could be an independent prognostic factor for BF.

Among the above independent prognostic factors of BF, history of cardiovascular disease, pre-operative CA125 and pre-operative total bilirubin are available before the operation. Therefore, the patients who have high-risk factors of BF should be informed that they are at a high risk for this complication. Previous studies showed that clinical and economic resources could be reasonably allocated using the classification system as BF happened.[29],[30] It would be beneficial for the patients who underwent LPD if these independent risk factors could contribute to the classification of BF in the future.

The limitation of this study was the lack of some data in our database, such as the CBD diameter and pancreatic computed tomography (CT) value. Previous studies found that CBD diameter and pancreatic CT value are independent factors of BF and PF, respectively. Thus, we cannot analyse these factors in our study. Another limitation was that this study was based on patients at a single institution, which meant the surgical procedures and perioperative management in other hospitals may different. Therefore, multicentre prospective studies are necessary to confirm the results of our study. In future studies, we will attempt to explore the difference in risk factors between laparoscopic and OPD.


  Conclusion Top


Our research suggested that surgical time, pancreatic texture, pancreatic duct size, several post-operative complications and time to first flatus were associated with the occurrence of PF after LPD. Among these factors, texture of the pancreas was an independent prognostic factor of PF after LPD. In addition, the BF after LPD was associated with a history of cardiovascular disease, surgical time, pre-operative total bilirubin, pre-operative direct bilirubin, pre-operative CA125, intra-operative blood loss and several post-operative complications. The independent prognostic factors of BF were history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin.

Acknowledgement

This study was supported by the Jilin Province Health Technology Innovation Project (2017J047), the Jilin Province Medical Scientist Fund Project (3D5197909428), and the Natural Science Foundation of Jilin Province (20200201417JC).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: The unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 2014;74:2913-21.  Back to cited text no. 1
    
2.
Conzo G, Gambardella C, Tartaglia E, Sciascia V, Mauriello C, Napolitano S, et al. Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review. Int J Surg 2015;21 Suppl 1:S4-9.  Back to cited text no. 2
    
3.
Nakamura M, Nakashima H. Laparoscopic distal pancreatectomy and pancreatoduodenectomy: Is it worthwhile? A meta-analysis of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci 2013;20:421-8.  Back to cited text no. 3
    
4.
Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 1994;8:408-10.  Back to cited text no. 4
    
5.
Chen K, Liu XL, Pan Y, Maher H, Wang XF. Expanding laparoscopic pancreaticoduodenectomy to pancreatic-head and periampullary malignancy: Major findings based on systematic review and meta-analysis. BMC Gastroenterol 2018;18:102.  Back to cited text no. 5
    
6.
Farges O, Bendersky N, Truant S, Delpero JR, Pruvot FR, Sauvanet A. The theory and practice of pancreatic surgery in France. Ann Surg 2017;266:797-804.  Back to cited text no. 6
    
7.
Corcione F, Pirozzi F, Cuccurullo D, Piccolboni D, Caracino V, Galante F, et al. Laparoscopic pancreaticoduodenectomy: Experience of 22 cases. Surg Endosc 2013;27:2131-6.  Back to cited text no. 7
    
8.
Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbecks Arch Surg 2008;393:459-71.  Back to cited text no. 8
    
9.
Machado NO. Pancreatic fistula after pancreatectomy: Definitions, risk factors, preventive measures, and management-review. Int J Surg Oncol 2012;2012:602478.  Back to cited text no. 9
    
10.
El Nakeeb A, Salah T, Sultan A, El Hemaly M, Askr W, Ezzat H, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg 2013;37:1405-18.  Back to cited text no. 10
    
11.
Andrianello S, Marchegiani G, Malleo G, Pollini T, Bonamini D, Salvia R, et al. Biliary fistula after pancreaticoduodenectomy: Data from 1618 consecutive pancreaticoduodenectomies. HPB (Oxford) 2017;19:264-9.  Back to cited text no. 11
    
12.
Zhou Y, Wang W, Shi Y, Lu X, Zhan Q, Chen H, et al. Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy. Int J Surg 2018;49:62-7.  Back to cited text no. 12
    
13.
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;161:584-91.  Back to cited text no. 13
    
14.
Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011;149:680-8.  Back to cited text no. 14
    
15.
Kimura W, Miyata H, Gotoh M, Hirai I, Kenjo A, Kitagawa Y, et al. A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: The 30-day and in-hospital mortality rates for pancreaticoduodenectomy. Ann Surg 2014;259:773-80.  Back to cited text no. 15
    
16.
Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg 2015;220:530-6.  Back to cited text no. 16
    
17.
Nakamura M, Wakabayashi G, Miyasaka Y, Tanaka M, Morikawa T, Unno M, et al. Multicenter comparative study of laparoscopic and open distal pancreatectomy using propensity score-matching. J Hepatobiliary Pancreat Sci 2015;22:731-6.  Back to cited text no. 17
    
18.
Mehrabi A, Hafezi M, Arvin J, Esmaeilzadeh M, Garoussi C, Emami G, et al. A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: It's time to randomize. Surgery 2015;157:45-55.  Back to cited text no. 18
    
19.
Hackert T, Büchler MW. Management of postoperative pancreatic fistula. Chirurg 2015;86:519-24.  Back to cited text no. 19
    
20.
Addeo P, Delpero JR, Paye F, Oussoultzoglou E, Fuchshuber PR, Sauvanet A, et al. Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: A multicentre study of the French Surgical Association. HPB (Oxford) 2014;16:46-55.  Back to cited text no. 20
    
21.
Shubert CR, Wagie AE, Farnell MB, Nagorney DM, Que FG, Reid Lombardo KM, et al. Clinical risk score to predict pancreatic fistula after pancreatoduodenectomy: Independent external validation for open and laparoscopic approaches. J Am Coll Surg 2015;221:689-98.  Back to cited text no. 21
    
22.
Lao M, Zhang X, Guo C, Chen W, Zhang Q, Ma T, et al. External validation of alternative fistula risk score (a-FRS) for predicting pancreatic fistula after pancreatoduodenectomy. HPB (Oxford) 2020;22:58-66.  Back to cited text no. 22
    
23.
Lee SE, Jang JY, Lim CS, Kang MJ, Kim SH, Kim MA, et al. Measurement of pancreatic fat by magnetic resonance imaging: Predicting the occurrence of pancreatic fistula after pancreatoduodenectomy. Ann Surg 2010;251:932-6.  Back to cited text no. 23
    
24.
Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8:951-9.  Back to cited text no. 24
    
25.
Deng Y, Zhao B, Yang M, Li C, Zhang L. Association between the incidence of pancreatic fistula after pancreaticoduodenectomy and the degree of pancreatic fibrosis. J Gastrointest Surg 2018;22:438-43.  Back to cited text no. 25
    
26.
Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 2007;11:1704-11.  Back to cited text no. 26
    
27.
Burkhart RA, Relles D, Pineda DM, Gabale S, Sauter PK, Rosato EL, et al. Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy. J Gastrointest Surg 2013;17:451-60.  Back to cited text no. 27
    
28.
de Castro SM, Kuhlmann KF, Busch OR, van Delden OM, Laméris JS, van Gulik TM, et al. Incidence and management of biliary leakage after hepaticojejunostomy. J Gastrointest Surg 2005;9:1163-71.  Back to cited text no. 28
    
29.
Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg 2009;250:1029-34.  Back to cited text no. 29
    
30.
Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076-81.  Back to cited text no. 30
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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2004 Journal of Minimal Access Surgery
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