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Cancers Mar 2023To date, gross total resection (GTR) of the contrast-enhancing area of glioblastoma (GB) is the benchmark treatment regarding surgical therapy. However, GB infiltrates... (Review)
Review
A Systematic Review and Meta-Analysis of Supramarginal Resection versus Gross Total Resection in Glioblastoma: Can We Enhance Progression-Free Survival Time and Preserve Postoperative Safety?
To date, gross total resection (GTR) of the contrast-enhancing area of glioblastoma (GB) is the benchmark treatment regarding surgical therapy. However, GB infiltrates beyond those margins, and most tumors recur in close proximity to the initial resection margin. It is unclear whether a supramarginal resection (SMR) enhances progression-free survival (PFS) time without increasing the incidence of postoperative surgical complications. The aim of the present meta-analysis was to investigate SMR with regard to PFS and postoperative surgical complications. We searched for eligible studies comparing SMR techniques with conventional GTR in PubMed, Cochrane Library, Web of Science, and Medline databases. From 3158 initially identified records, 11 articles met the criteria and were included in our meta-analysis. Our results illustrate significantly prolonged PFS time in SMR compared with GTR (HR: 11.16; 95% CI: 3.07-40.52, = 0.0002). The median PFS of the SMR arm was 8.44 months (95% CI: 5.18-11.70, < 0.00001) longer than the GTR arm. The rate of postoperative surgical complications (meningitis, intracranial hemorrhage, and CSF leaks) did not differ between the SMR group and the GTR group. SMR resulted in longer median progression-free survival without a negative postoperative surgical risk profile. Multicentric prospective randomized trials with a standardized definition of SMR and analysis of neurologic functioning and health-related quality of life are justified and needed to improve the level of evidence.
PubMed: 36980659
DOI: 10.3390/cancers15061772 -
Journal of Vascular Surgery May 2022The long-term outcomes after endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) have been inferior to those after open surgical repair... (Review)
Review
OBJECTIVE
The long-term outcomes after endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) have been inferior to those after open surgical repair with regard to reinterventions and late mortality. AAA sac remodeling after EVAR has been associated with endoleaks, reinterventions, and mortality. Therefore, knowledge of the predictors of AAA sac remodeling could indirectly give insight into the long-term EVAR outcomes. In the present review, we aimed to provide an overview of the evidence for anatomic predictors of positive and negative AAA sac remodeling after EVAR.
METHODS
A systematic literature review and analysis were conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) and Cochrane guidelines. The PubMed and Scopus databases were searched using terms of AAA sac growth, shrinkage, and remodeling. Eligible studies were identified, and only those studies that had included currently used endografts were included.
RESULTS
A total of 19 studies that had reported on a total of 27 anatomic parameters of the aortoiliac anatomy were included. Only 4 parameters had been investigated by more than five studies, 7 parameters were investigated by three to five studies, 7 parameters were investigated by two studies, and 9 parameters were investigated by one study. For the presence of neck thrombus, three of four studies had reported similar results, indicating that the presence of neck thrombus might predict for less AAA sac shrinkage. AAA thrombus, the total AAA volume, the flow-lumen volume, aortic calcification, and the number of hostile neck parameters were only investigated by two to three studies. However, these parameters seemed promising for the prediction of sac remodeling. For hostile neck anatomy, neck length, infrarenal neck angulation, and patency of the inferior mesenteric artery, no significant association with any category of AAA sac remodeling was found.
CONCLUSIONS
The present review demonstrates neck thrombus, AAA thrombus, number of hostile neck parameters, total AAA volume, AAA flow-lumen volume, and aortic calcification as important anatomic features that are likely to play a role in AAA remodeling after endovascular repair and should be further explored using advanced imaging techniques. We also found that strong, consistent evidence regarding the anatomic predictors of AAA sac remodeling after EVAR is lacking. Therefore, further research with large patient groups for a broad range of predictors of AAA sac change after EVAR is needed to complement the current gap in the evidence.
Topics: Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Stents; Treatment Outcome
PubMed: 34952192
DOI: 10.1016/j.jvs.2021.11.071 -
Langenbeck's Archives of Surgery Aug 2023Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity... (Meta-Analysis)
Meta-Analysis Review
The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis.
BACKGROUND
Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC).
METHODS
A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS).
RESULTS
Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group.
CONCLUSIONS
This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately.
PROTOCOL REGISTRATION
PROSPERO (CRD42021277495) on the 25th of October 2021.
Topics: Humans; Pancreaticoduodenectomy; Duodenal Neoplasms; Prospective Studies; Pancreas; Postoperative Complications; Laparoscopy; Pancreatic Neoplasms; Retrospective Studies
PubMed: 37581763
DOI: 10.1007/s00423-023-03047-4 -
The Cochrane Database of Systematic... Jul 2018The choice of the appropriate perioperative thromboprophylaxis for people with cancer depends on the relative benefits and harms of different anticoagulants. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The choice of the appropriate perioperative thromboprophylaxis for people with cancer depends on the relative benefits and harms of different anticoagulants.
OBJECTIVES
To systematically review the evidence for the relative efficacy and safety of anticoagulants for perioperative thromboprophylaxis in people with cancer.
SEARCH METHODS
This update of the systematic review was based on the findings of a comprehensive literature search conducted on 14 June 2018 that included a major electronic search of Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 6), MEDLINE (Ovid), and Embase (Ovid); handsearching of conference proceedings; checking of references of included studies; searching for ongoing studies; and using the 'related citation' feature in PubMed.
SELECTION CRITERIA
Randomized controlled trials (RCTs) that enrolled people with cancer undergoing a surgical intervention and assessed the effects of low-molecular weight heparin (LMWH) to unfractionated heparin (UFH) or to fondaparinux on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, and thrombocytopenia.
DATA COLLECTION AND ANALYSIS
Using a standardized form, we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, PE, symptomatic venous thromboembolism (VTE), asymptomatic DVT, major bleeding, minor bleeding, postphlebitic syndrome, health related quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE Handbook).
MAIN RESULTS
Of 7670 identified unique citations, we included 20 RCTs with 9771 randomized people with cancer receiving preoperative prophylactic anticoagulation. We identified seven reports for seven new RCTs for this update.The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.63 to 1.07; risk difference (RD) 9 fewer per 1000, 95% CI 19 fewer to 4 more; moderate-certainty evidence), PE (RR 0.49, 95% CI 0.17 to 1.47; RD 3 fewer per 1000, 95% CI 5 fewer to 3 more; moderate-certainty evidence), symptomatic DVT (RR 0.67, 95% CI 0.27 to 1.69; RD 3 fewer per 1000, 95% CI 7 fewer to 7 more; moderate-certainty evidence), asymptomatic DVT (RR 0.86, 95% CI 0.71 to 1.05; RD 11 fewer per 1000, 95% CI 23 fewer to 4 more; low-certainty evidence), major bleeding (RR 1.01, 95% CI 0.69 to 1.48; RD 0 fewer per 1000, 95% CI 10 fewer to 15 more; moderate-certainty evidence), minor bleeding (RR 1.01, 95% CI 0.76 to 1.33; RD 1 more per 1000, 95% CI 34 fewer to 47 more; moderate-certainty evidence), reoperation for bleeding (RR 0.93, 95% CI 0.57 to 1.50; RD 4 fewer per 1000, 95% CI 22 fewer to 26 more; moderate-certainty evidence), intraoperative transfusion (mean difference (MD) -35.36 mL, 95% CI -253.19 to 182.47; low-certainty evidence), postoperative transfusion (MD 190.03 mL, 95% CI -23.65 to 403.72; low-certainty evidence), and thrombocytopenia (RR 3.07, 95% CI 0.32 to 29.33; RD 6 more per 1000, 95% CI 2 fewer to 82 more; moderate-certainty evidence). LMWH was associated with lower incidence of wound hematoma (RR 0.70, 95% CI 0.54 to 0.92; RD 26 fewer per 1000, 95% CI 39 fewer to 7 fewer; moderate-certainty evidence). The meta-analyses found the following additional results: outcomes intraoperative blood loss (MD -6.75 mL, 95% CI -85.49 to 71.99; moderate-certainty evidence); and postoperative drain volume (MD 30.18 mL, 95% CI -36.26 to 96.62; moderate-certainty evidence).In addition, the meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with Fondaparinux for the following outcomes: any VTE (DVT or PE, or both; RR 2.51, 95% CI 0.89 to 7.03; RD 57 more per 1000, 95% CI 4 fewer to 228 more; low-certainty evidence), major bleeding (RR 0.74, 95% CI 0.45 to 1.23; RD 8 fewer per 1000, 95% CI 16 fewer to 7 more; low-certainty evidence), minor bleeding (RR 0.83, 95% CI 0.34 to 2.05; RD 8fewer per 1000, 95% CI 33 fewer to 52 more; low-certainty evidence), thrombocytopenia (RR 0.35, 95% CI 0.04 to 3.30; RD 14 fewer per 1000, 95% CI 20 fewer to 48 more; low-certainty evidence), any PE (RR 3.13, 95% CI 0.13 to 74.64; RD 2 more per 1000, 95% CI 1 fewer to 78 more; low-certainty evidence) and postoperative drain volume (MD -20.00 mL, 95% CI -114.34 to 74.34; low-certainty evidence) AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH and LMWH compared with fondaparinux in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in people with cancer. There was a lower incidence of wound hematoma with LMWH compared to UFH.
Topics: Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Neoplasms; Postoperative Complications; Pulmonary Embolism; Randomized Controlled Trials as Topic; Thrombocytopenia; Thrombosis; Venous Thrombosis
PubMed: 29993117
DOI: 10.1002/14651858.CD009447.pub3 -
Neuroradiology Feb 2016Delayed aneurysm rupture and delayed intraparenchymal hemorrhages (DIPH) are poorly understood and often fatal complications of flow diversion (FD) for intracranial... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Delayed aneurysm rupture and delayed intraparenchymal hemorrhages (DIPH) are poorly understood and often fatal complications of flow diversion (FD) for intracranial aneurysms. The purpose of this study was to identify risk factors for these complications.
METHODS
We performed a systematic review on post-FD delayed aneurysm rupture and DIPH. For each reported case, we collected the following information: aneurysm location, size and rupture status, type of flow diverter used, timing of the hemorrhage, and neurological outcome. We reported descriptive statistics of patients suffering DIPH and delayed aneurysm rupture to determine if there were any characteristics consistently present among patients with these complications.
RESULTS
We identified 81 delayed aneurysm ruptures and 101 DIPH. Of the delayed ruptures, 76.6% (45/58) occurred within 1 month. The prognosis of delayed ruptures was poor, with 81.3% (61/75) experiencing death or poor neurological outcome. Giant aneurysms accounted for 46.3% of ruptures (31/67). Of these aneurysms, 80.9% (55/68) were initially unruptured. Of the delayed ruptured aneurysms, 17.8% (13/73) had prior or concomitant coiling. DIPHs were ipsilateral to the treated aneurysm in 82.2% (60/73) of cases. Of the DIPH, 86.0% (43/50) occurred within 1 month after FDS. Combined morbidity/mortality rate was 68.5% (50/73) following DIPH. Of DIPHs, 23.0% (14/61) occurred in patients with giant aneurysms.
CONCLUSIONS
Our study demonstrates that giant aneurysms represent almost 50% of delayed aneurysm ruptures in the flow diverter literature. About 2% of delayed ruptures occurred despite associated coiling. A substantial proportion of DIPHs occur early following FDS treatment of giant aneurysms.
Topics: Aneurysm, Ruptured; Cerebral Hemorrhage; Endovascular Procedures; Female; Humans; Intracranial Aneurysm; Male; Postoperative Complications; Prevalence; Risk Factors; Stents; Survival Rate
PubMed: 26553302
DOI: 10.1007/s00234-015-1615-4 -
Medicine Jan 2017To assess the efficacy and safety of tranexamic acid (TA) in reducing blood loss and lowering transfusion needs for patients undergoing caesarean section (CS) or vaginal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
To assess the efficacy and safety of tranexamic acid (TA) in reducing blood loss and lowering transfusion needs for patients undergoing caesarean section (CS) or vaginal delivery (VD).
METHODS
An electronic literature search of PubMed, EMBASE, OVID, Cochrane library, Scopus, Central, and Clinical trials.gov was performed to identify studies that evaluating the usage of TA in CS or VD. The methodological quality of included trials was assessed and data extraction was performed.
RESULTS
Finally, 25 articles with 4747 participants were included. Our findings indicated TA resulted in a reduced intra-, postoperative, and total blood loss by a mean volume of 141.25 mL (95% confidence interval [CI] -186.72 to -95.79, P < 0.00001), 36.42 mL (95% CI -46.50 to -26.34, P < 0.00001), and 154.25 mL (95% CI -182.04 to -126.47, P < 0.00001) in CS. TA administration in VD was associated with a reduced intra-, postoperative, and total blood loss by a mean volume of 22.88 mL (95% CI -50.54 to 4.77, P = 0.10), 41.24 mL (95% CI -55.50 to -26.98, P < 0.00001), and 84.79 mL (95% CI -109.93 to -59.65, P < 0.00001). In addition, TA could lower the occurrence rate of postpartum hemorrhage (PPH) and severe PPH, and reduce the risk of blood transfusions. No increased risk of deep vein thrombosis (DVT) after CS or VD was associated with TA usage, while the minor side effects were more common.
CONCLUSIONS
Our findings indicated that intravenous TA for patients undergoing CS was effective and safe. Although prophylactic TA administration is associated with reduced PPH, current existing data are insufficient to draw definitive recommendations about its clinical significance due to the poor to moderate quality of the included literatures. Thus, high-quality randomized controlled trials with larger samples are needed to validate our findings.
Topics: Antifibrinolytic Agents; Cesarean Section; Chemoprevention; Female; Humans; Natural Childbirth; Postpartum Hemorrhage; Pregnancy; Tranexamic Acid; Treatment Outcome
PubMed: 28072700
DOI: 10.1097/MD.0000000000005653 -
Surgical Neurology International 2022The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural... (Review)
Review
BACKGROUND
The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural hematoma (SDH) of the infratentorial space without associated subarachnoid hemorrhage (SAH).
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature review was conducted in PubMed and Scopus electronic databases for relevant published cases of aneurysmal SDH (AnSDH) of the infratentorial compartment without associated SAH. The presentation, treatment, clinical course, and outcome of identified cases are compiled. In addition, a patient suffering from an infratentorial SDH following aneurysm rupture is presented with an illustrative case.
RESULTS
Three articles were identified and met inclusion criteria. All cases occurred from ruptured posterior communicating artery aneurysms. All patients arrived with a Hunt and Hess classification of 2 or less. Only one case was managed with operative aneurysm clipping and hematoma evacuation while the other three cases were managed endovascularly. There were no reported postoperative complications, vasospasm, or seizures reported. All patients had a final Modified Rankin score of 3 or less at last reported follow-up.
CONCLUSION
Infratentorial AnSDH without associated SAH is an etiology rarely reported in the literature. Here, we present a case report and systematic review demonstrating a relatively benign clinical course and outcome compared to report aneurysm rupture associated with SAH or mixed SAH and SDH. Moreover, there appear to be lower rates of vasospasm and improved outcomes in patients with isolated AnSDH compared to the literature aneurysmal SAH rates.
PubMed: 36447858
DOI: 10.25259/SNI_758_2022 -
PloS One 2017This systematic review and meta-analysis aims to determine the current evidence on risk factors for type II endoleaks after endovascular aneurysm repair (EVAR). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
This systematic review and meta-analysis aims to determine the current evidence on risk factors for type II endoleaks after endovascular aneurysm repair (EVAR).
MATERIALS AND METHODS
A systematic literature search was carried out for studies that evaluated the association of demographic, co-morbidity, and other patient-determined factors with the onset of type II endoleaks. Pooled prevalence of type II endoleaks after EVAR was updated.
RESULTS
Among the 504 studies screened, 45 studies with a total of 36,588 participants were included in this review. The pooled prevalence of type II endoleaks after EVAR was 22% [95% confidence interval (CI), 19%-25%]. The main factors consistently associated with type II endoleaks included age [pooled odds ratio (OR), 0.37; 95% CI, 0.31-0.43; P<0.001], smoking (pooled OR, 0.71; 95% CI, 0.55-0.92; P<0.001), patent inferior mesenteric artery (pooled OR, 1.98; 95% CI, 1.06-3.71; P = 0.012), maximum aneurysm diameter (pooled OR, 0.23; 95% CI, 0.17-0.30; P<0.001), and number of patent lumbar arteries (pooled OR, 3.07; 95% CI, 2.81-3.33; P<0.001). Sex, diabetes, hypertension, anticoagulants, antiplatelet, hyperlipidemia, chronic renal insufficiency, types of graft material, and chronic obstructive pulmonary diseases (COPD) did not show any association with the onset of type II endoleaks.
CONCLUSIONS
Clinicians can use the identified risk factors to detect and manage patients at risk of developing type II endoleaks after EVAR. However, further studies are needed to analyze a number of potential risk factors.
Topics: Endoleak; Humans; Prevalence; Risk Factors; Vascular Surgical Procedures
PubMed: 28182753
DOI: 10.1371/journal.pone.0170600 -
Journal of Cardiothoracic and Vascular... Feb 2018The aim was to evaluate the predictive value of thromboelastometry for postoperative blood loss in adult cardiac surgery with cardiopulmonary bypass. (Review)
Review
OBJECTIVE
The aim was to evaluate the predictive value of thromboelastometry for postoperative blood loss in adult cardiac surgery with cardiopulmonary bypass.
DESIGN
Retrospective cohort study and systematic review of the literature.
SETTING
A tertiary university hospital.
PARTICIPANTS
202 patients undergoing elective cardiac surgery.
INTERVENTIONS
Thromboelastometry was performed before cardiopulmonary bypass and 3 minutes after protamine administration.
MEASUREMENTS AND MAIN RESULTS
The cohort study showed that the preoperative and postoperative thromboelastometric positive predicting value was poor (0%-22%); however, the negative predicting value was high (89%-94%). The systematic review of the literature to evaluate the predictive value of thromboelastometry for major postoperative bleeding in cardiac surgery resulted in 1,311 articles, 11 of which were eligible (n = 1,765; PubMed and Embase, until June 2016). Two studies found a good predictive value, whereas the other 9 studies showed a poor predictability for major postoperative bleeding after cardiac surgery. The overall negative predicting value was high.
CONCLUSIONS
Thromboelastometry does not predict which patients are at risk for major postoperative bleeding.
Topics: Adult; Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cohort Studies; Humans; Middle Aged; Postoperative Hemorrhage; Predictive Value of Tests; Retrospective Studies; Thrombelastography
PubMed: 29126688
DOI: 10.1053/j.jvca.2017.08.025 -
World Journal of Surgery Mar 2016Studies on postoperative complications and survival in patients with pancreatic neuroendocrine tumors (pNET) are sparse and randomized controlled trials are not... (Review)
Review
Studies on postoperative complications and survival in patients with pancreatic neuroendocrine tumors (pNET) are sparse and randomized controlled trials are not available. We reviewed all studies on postoperative complications and survival after resection of pNET. A systematic search was performed in the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE from 2000-2013. Inclusion criteria were studies of resected pNET, which described postoperative complications separately for each surgical procedure and/or 5-year survival after resection. Prospective and retrospective studies were pooled separately and overall pooled if heterogeneity was below 75%. The random-effect model was used. Overall, 2643 studies were identified and after full-text analysis 62 studies were included. Pancreatic fistula (PF) rate of the prospective studies after tumor enucleation was 45%; PF-rates after distal pancreatectomy, pancreatoduodenectomy, or central pancreatectomy were, respectively, 14-14-58%. Delayed gastric emptying rates were, respectively, 5-5-18-16%. Postoperative hemorrhage rates were, respectively, 6-1-7-4%. In-hospital mortality rates were, respectively, 3-4-6-4%. The 5-year overall survival (OS) and disease-specific survival (DSS) of resected pNET without synchronous resected liver metastases were, respectively, 85-93%. Heterogeneity between included studies on 5-year OS in patients with synchronous resected liver metastases was too high to pool all studies. The 5-year DSS in patients with liver metastases was 80%. Morbidity after pancreatic resection for pNET was mainly caused by PF. Liver resection in patients with liver metastases seems to have a positive effect on DSS. To reduce heterogeneity, ISGPS criteria and uniform patient groups should be used in the analysis of postoperative outcome and survival.
Topics: Adenoma, Islet Cell; Global Health; Hospital Mortality; Humans; Morbidity; Neuroendocrine Tumors; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications
PubMed: 26661846
DOI: 10.1007/s00268-015-3328-6