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  1. Article: A novel use of the comprehensive complication index in perihilar cholangiocarcinoma surgery.

    Poletto, Edoardo / Conci, Simone / Campagnaro, Tommaso / De Bellis, Mario / Alaimo, Laura / Ruzzenente, Andrea

    Hepatobiliary surgery and nutrition

    2023  Volume 13, Issue 1, Page(s) 139–142

    Language English
    Publishing date 2023-12-28
    Publishing country China (Republic : 1949- )
    Document type Editorial
    ZDB-ID 2812398-0
    ISSN 2304-389X ; 2304-3881
    ISSN (online) 2304-389X
    ISSN 2304-3881
    DOI 10.21037/hbsn-23-585
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  2. Article ; Online: Perihilar cholangiocarcinoma: three-dimensional modelling algorithm to estimate tumour extension and bile duct resection margins.

    Ruzzenente, Andrea / Alaimo, Laura / D'Onofrio, Mirko / Marchese, Andrea / Roman, Diletta / Conci, Simone / De Bellis, Mario / Pedrazzani, Corrado / Campagnaro, Tommaso / Guglielmi, Alfredo

    The British journal of surgery

    2024  Volume 111, Issue 1

    MeSH term(s) Humans ; Klatskin Tumor/surgery ; Margins of Excision ; Bile Ducts ; Bile Duct Neoplasms/surgery
    Language English
    Publishing date 2024-01-02
    Publishing country England
    Document type Journal Article
    ZDB-ID 2985-3
    ISSN 1365-2168 ; 0263-1202 ; 0007-1323 ; 1355-7688
    ISSN (online) 1365-2168
    ISSN 0263-1202 ; 0007-1323 ; 1355-7688
    DOI 10.1093/bjs/znad428
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  3. Article ; Online: The Role of Three-Dimensional Modeling to Improve Comprehension of Liver Anatomy and Tumor Characteristics for Medical Students and Surgical Residents.

    Alaimo, Laura / Marchese, Andrea / Vignola, Damiano / Roman, Diletta / Conci, Simone / De Bellis, Mario / Pedrazzani, Corrado / Campagnaro, Tommaso / Manzini, Gessica / Guglielmi, Alfredo / Ruzzenente, Andrea

    Journal of surgical education

    2024  Volume 81, Issue 4, Page(s) 597–606

    Abstract: Objective: Studying liver anatomy can be challenging for medical students and surgical residents due to its complexity. Three-dimensional visualization technology (3DVT) allows for a clearer and more precise view of liver anatomy. We sought to assess ... ...

    Abstract Objective: Studying liver anatomy can be challenging for medical students and surgical residents due to its complexity. Three-dimensional visualization technology (3DVT) allows for a clearer and more precise view of liver anatomy. We sought to assess how 3DVT can assist students and surgical residents comprehend liver anatomy.
    Design: Data from 5 patients who underwent liver resection for malignancy at our institution between September 2020 and April 2022 were retrospectively reviewed and selected following consensus among the investigators. Participants were required to complete an online survey to investigate their understanding of tumor characteristics and vascular variations based on patients' computed tomography (CT) and 3DVT.
    Setting: The study was carried out at the General and Hepato-Biliary Surgery Department of the University of Verona.
    Participants: Among 32 participants, 13 (40.6%) were medical students, and 19 (59.4%) were surgical residents.
    Results: Among 5 patients with intrahepatic lesions, 4 patients (80.0%) had at least 1 vascular variation. Participants identified number and location of lesions more correctly when evaluating the 3DVT (84.6% and 80.9%, respectively) compared with CT scans (61.1% and 64.8%, respectively) (both p ≤ 0.001). The identification of any vascular variations was more challenging using the CT scans, with only 50.6% of correct answers compared with 3DVT (72.2%) (p < 0.001). Compared with CT scans, 3DVT led to a 23.5%, 16.1%, and 21.6% increase in the correct definition of number and location of lesions, and vascular variations, respectively. 3DVT allowed for a decrease of 50.8 seconds (95% CI 23.6-78.0) in the time needed to answer the questions. All participants agreed on the usefulness of 3DVT in hepatobiliary surgery.
    Conclusions: The 3DVT facilitated a more precise preoperative understanding of liver anatomy, tumor location and characteristics.
    MeSH term(s) Humans ; Retrospective Studies ; Internship and Residency ; Students, Medical ; Comprehension ; Liver Neoplasms/diagnostic imaging ; Liver Neoplasms/surgery ; Imaging, Three-Dimensional/methods
    Language English
    Publishing date 2024-02-22
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2277538-9
    ISSN 1878-7452 ; 1931-7204
    ISSN (online) 1878-7452
    ISSN 1931-7204
    DOI 10.1016/j.jsurg.2023.12.018
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  4. Article ; Online: Portal vein stenting in recurrent or locally advanced peri-hilar cholangiocarcinoma.

    De Bellis, Mario / Contro, Alberto / Bianco, Andrea / Gasparini, Clizia / Tripepi, Marzia / La Raja, Matilde / Alaimo, Laura / Conci, Simone / Campagnaro, Tommaso / Guglielmi, Alfredo / Mansueto, Giancarlo / Ruzzenente, Andrea

    European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology

    2024  Volume 50, Issue 3, Page(s) 107984

    Abstract: Background: Recurrent or locally advanced peri-hilar cholangiocarcinoma (PHCC) usually involves the portal vein (PV) leading to significant stenosis. With disease progression, clinical symptoms such as ascites, bleeding, and hepatic insufficiency are ... ...

    Abstract Background: Recurrent or locally advanced peri-hilar cholangiocarcinoma (PHCC) usually involves the portal vein (PV) leading to significant stenosis. With disease progression, clinical symptoms such as ascites, bleeding, and hepatic insufficiency are usually observed. Little is know about the benefit of PV stenting in relieving the symptoms associated to portal hypertension and allowing anticancer therapies. The aim of this study is to review our experience in PV stenting for PHCC patients.
    Methods: From 2014 to 2022, data from PHCC patients underwent PV stenting at Verona University Hospital, Italy, were reviewed. The indications were: gastrointestinal bleeding from esophagus-gastric varices, ascites not responsive to medical therapy, severe thrombocytopenia, liver insufficiency (hepatic jaundice, coagulopathy, and/or hyperammoniemia), or asymptomatic high-grade PV stenosis. Cavernous transformation and intrahepatic thrombosis in both sides of the liver were considered contraindication. Systematic anticoagulation therapy was not administered.
    Results: Technical success was achieved in all 16 (100 %) patients. The improvement of clinical symptoms were observed in 12 (75 %) patients. Anticancer therapy was administrated in 11 (69 %) patients. 2 (13 %) complications were observed: 1 biliary injury and 1 recurrent cholangitis that required a percutaneous trans-hepatic biliary drainage placement. Stent occlusion for tumor progression occurred in 1 patient and a re-stenting procedure was successfully performed. No case of thrombotic stent occlusion was observed during follow up. The 1-year stent patency was 86 % and the median patency period was 8 months (IQR, 4-12).
    Conclusion: PV stenting is a feasible and safe palliative treatment that improves clinical condition, allow anticancer therapies, and provide a better quality of life.
    MeSH term(s) Humans ; Klatskin Tumor/pathology ; Portal Vein/surgery ; Treatment Outcome ; Constriction, Pathologic/etiology ; Ascites/etiology ; Quality of Life ; Cholangiocarcinoma/surgery ; Cholangiocarcinoma/pathology ; Bile Ducts, Intrahepatic/surgery ; Bile Ducts, Intrahepatic/pathology ; Bile Duct Neoplasms/surgery ; Bile Duct Neoplasms/complications ; Stents/adverse effects ; Retrospective Studies
    Language English
    Publishing date 2024-01-30
    Publishing country England
    Document type Journal Article
    ZDB-ID 632519-1
    ISSN 1532-2157 ; 0748-7983
    ISSN (online) 1532-2157
    ISSN 0748-7983
    DOI 10.1016/j.ejso.2024.107984
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    Zs.A 1149: Show issues Location:
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  5. Article ; Online: The Relevance of Radial Margin Status in Perihilar Cholangiocarcinoma: A State-of-the-Art Narrative Review.

    De Bellis, Mario / Mastrosimini, Maria Gaia / Capelli, Paola / Alaimo, Laura / Conci, Simone / Campagnaro, Tommaso / Pecori, Sara / Scarpa, Aldo / Guglielmi, Alfredo / Ruzzenente, Andrea

    Digestive surgery

    2024  Volume 41, Issue 2, Page(s) 92–102

    Abstract: Background: Prognosis of perihilar cholangiocarcinoma (PHCC) is poor, and curative-intent resection is the most effective treatment associated with long-term survival. Surgery is technically demanding since it involves a major hepatectomy with en bloc ... ...

    Abstract Background: Prognosis of perihilar cholangiocarcinoma (PHCC) is poor, and curative-intent resection is the most effective treatment associated with long-term survival. Surgery is technically demanding since it involves a major hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Furthermore, to achieve negative margins, it may be necessary to perform concomitant vascular resection or pancreatoduodenectomy. Despite this aggressive approach, recurrence is often observed, considering 5-year recurrence-free survival below 15% and 5-year overall survival that barely exceeds 40%.
    Summary: The literature reports that survival rates are better in patients with negative margins, and surprisingly, R0 resections range between 19% and 95%. This variability is probably due to different surgical strategies and the pathologist's expertise with specimens. In fact, a proper pathological examination of residual disease should take into consideration both the ductal and the radial margin (RM) status. Currently, detailed pathological reports are lacking, and there is a likelihood of misinterpreting residual disease status due to the missing of RM description and the utilization of various definitions for surgical margins.
    Key messages: The aim of PHCC surgery is to achieve negative margins including RM. More clarity in reporting on RM is needed to define true radical resection and consistent design of oncological studies for adjuvant treatments.
    MeSH term(s) Humans ; Klatskin Tumor/surgery ; Klatskin Tumor/pathology ; Margins of Excision ; Survival Analysis ; Retrospective Studies ; Hepatectomy ; Bile Duct Neoplasms/pathology ; Cholangiocarcinoma
    Language English
    Publishing date 2024-03-06
    Publishing country Switzerland
    Document type Journal Article ; Review
    ZDB-ID 605888-7
    ISSN 1421-9883 ; 0253-4886
    ISSN (online) 1421-9883
    ISSN 0253-4886
    DOI 10.1159/000535995
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  6. Article ; Online: A machine learning analysis of difficulty scoring systems for laparoscopic liver surgery.

    Ruzzenente, Andrea / Bagante, Fabio / Poletto, Edoardo / Campagnaro, Tommaso / Conci, Simone / De Bellis, Mario / Pedrazzani, Corrado / Guglielmi, Alfredo

    Surgical endoscopy

    2022  Volume 36, Issue 12, Page(s) 8869–8880

    Abstract: Introduction: In the last decade, several difficulty scoring systems (DSS) have been proposed to predict technical difficulty in laparoscopic liver resections (LLR). The present study aimed to investigate the ability of four DSS for LLR to predict ... ...

    Abstract Introduction: In the last decade, several difficulty scoring systems (DSS) have been proposed to predict technical difficulty in laparoscopic liver resections (LLR). The present study aimed to investigate the ability of four DSS for LLR to predict operative, short-term, and textbook outcomes.
    Methods: Patients who underwent LLR at a single tertiary referral center from January 2014 to June 2020 were included in the present study. Four DSS for LLR (Halls, Hasegawa, Kawaguchi, and Iwate) were investigated to test their ability to predict operative and postoperative complications. Machine learning algorithms were used to identify the most important DSS associated with operative and short-term outcomes.
    Results: A total of 346 patients were included in the analysis, 28 (8.1%) patients were converted to open surgery. A total of 13 patients (3.7%) had severe (Clavien-Dindo ≥ 3) complications; the incidence of prolonged length of stay (> 5 days) was 39.3% (n = 136). No patients died within 90 days after the surgery. According to Halls, Hasegawa, Kawaguchi, and Iwate scores, 65 (18.8%), 59 (17.1%), 57 (16.5%), and 112 (32.4%) patients underwent high difficulty LLR, respectively. In accordance with a random forest algorithm, the Kawaguchi DSS predicted prolonged length of stay, high blood loss, and conversions and was the best performing DSS in predicting postoperative outcomes. Iwate DSS was the most important variable associated with operative time, while Halls score was the most important DSS predicting textbook outcomes. No one of the DSS investigated was associated with the occurrence of complication.
    Conclusions: According to our results DDS are significantly related to surgical complexity and short-term outcomes, Kawaguchi and Iwate DSS showed the best performance in predicting operative outcomes, while Halls score was the most important variable in predicting textbook outcome. Interestingly, none of the DSS showed any correlation with or importance in predicting overall and severe postoperative complications.
    MeSH term(s) Humans ; Liver Neoplasms/surgery ; Length of Stay ; Retrospective Studies ; Hepatectomy/methods ; Laparoscopy/methods ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Postoperative Complications/surgery ; Machine Learning
    Language English
    Publishing date 2022-05-23
    Publishing country Germany
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 639039-0
    ISSN 1432-2218 ; 0930-2794
    ISSN (online) 1432-2218
    ISSN 0930-2794
    DOI 10.1007/s00464-022-09322-7
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  7. Article ; Online: Factors Related to Textbook Outcome in Laparoscopic Liver Resections: a Single Western Centre Analysis.

    Ruzzenente, Andrea / Poletto, Edoardo / Conci, Simone / Campagnaro, Tommaso / Valle, Bernardo Dalla / De Bellis, Mario / Guglielmi, Alfredo

    Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract

    2022  Volume 26, Issue 11, Page(s) 2301–2310

    Abstract: Introduction: The selection of the most informative quality of care indicator for laparoscopic liver surgery (LLS) is still debated; among those proposed, textbook outcome (TO) seems to provide a compositive measure of the outcomes of surgery. The aim ... ...

    Abstract Introduction: The selection of the most informative quality of care indicator for laparoscopic liver surgery (LLS) is still debated; among those proposed, textbook outcome (TO) seems to provide a compositive measure of the outcomes of surgery. The aim of this study was to investigate the factors related with the TO in a cohort of patients who underwent LLS.
    Methods: Patients who underwent LLS from 2014 to 2021 were included. TO for LLS (TOLLS) was defined as: R0 resection, absence of intraoperative incidents, severe complications, reintervention, 30-day readmission and in-hospital mortality. When also considering no prolonged length of hospital stay (LOS), the outcome was called TOLLS+.
    Results: Four hundred twenty-one patients were included; TOLLS was achieved in 80.5%, TOLLS+ in 60.8% cases. R0 resection was obtained in 90.2% cases, intraoperative incidents occurred in 7.8%, severe complications in 5.0%, reintervention in 0.7%, readmission in 1.4% and in-hospital mortality in 0.2%. 32.5% of patients showed prolonged LOS. After univariate and multivariate analysis, factors influencing TOLLS were age (OR 0.967; p=0.003), concomitant surgery (OR 0.380; p=0.003), operative time (OR 0.996; p=0.008) and blood loss (OR 0.241; p<0.001); factors influencing TOLLS+ were ASA-score (OR 0.533; p=0.008), tumour histology (OR 0.421; p=0.021), concomitant surgery (OR 0.293; p<0.001), operative time (OR 0.997; p=0.016) and blood loss (OR 0.361; p=0.003).
    Conclusions: TOLLS can be achieved in most patients undergoing LLR, and it seems to be influenced mostly by surgery-related factors; conversely, TOLLS+ is achieved less frequently and seems to be influenced also by patient- and tumour-related factors.
    MeSH term(s) Humans ; Hepatectomy/adverse effects ; Hepatectomy/standards ; Laparoscopy/adverse effects ; Laparoscopy/standards ; Length of Stay ; Liver Neoplasms/surgery ; Postoperative Complications/etiology ; Retrospective Studies ; Treatment Outcome ; Quality Indicators, Health Care/standards
    Language English
    Publishing date 2022-08-12
    Publishing country United States
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2012365-6
    ISSN 1873-4626 ; 1934-3213 ; 1091-255X
    ISSN (online) 1873-4626 ; 1934-3213
    ISSN 1091-255X
    DOI 10.1007/s11605-022-05413-x
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    Zs.MO 354: Show issues

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  8. Article ; Online: Hyper accuracy three-dimensional (HA3D™) technology for planning complex liver resections: a preliminary single center experience.

    Ruzzenente, Andrea / Alaimo, Laura / Conci, Simone / De Bellis, Mario / Marchese, Andrea / Ciangherotti, Andrea / Campagnaro, Tommaso / Guglielmi, Alfredo

    Updates in surgery

    2022  

    Abstract: Three-dimensional visualization technology (3DVT) has been recently introduced to achieve a precise preoperative planning of liver surgery. The aim of this observational study was to assess the accuracy of 3DVT for complex liver resections. 3DVT with ... ...

    Abstract Three-dimensional visualization technology (3DVT) has been recently introduced to achieve a precise preoperative planning of liver surgery. The aim of this observational study was to assess the accuracy of 3DVT for complex liver resections. 3DVT with hyper accuracy three-dimensional (HA3D™) technology was introduced at our institution on February 2020. Anatomical characteristics were collected from two-dimensional imaging (2DI) and 3DVT, while intraoperative and postoperative outcomes were recorded prospectively. A total of 62 patients were enrolled into the study. 3DVT was able to study tumor extension and liver anatomy, identifying at least one vascular variation in 37 patients (59.7%). Future remnant liver volume (FRLV) was measured using 2DI and 3DVT. The paired samples t test assessed positive correlation between the two methods (p < 0.001). At least one vessel was suspected to be invaded by the tumor in 8 (15.7%) 2DI cases vs 16 (31.4%) 3DVT cases, respectively. During surgery, vascular invasion was detected in 17 patients (33.3%). A total of 73 surgical procedures were proposed basing on 2DI, including 2 alternatives for 16 patients. After 3DVT, the previously planned procedure was changed in 15 cases (29.4%), due to the clearer information provided. A total of 51 patients (82%) underwent surgery. The most frequent procedure was right hepatectomy (33.3%), followed by left hepatectomy (23.5%) and left trisectionectomy (13.7%). Vascular resection and reconstruction were performed in 10 patients (19.6%) and portal vein was resected in more than half of these cases (66.7%). 3DVT leads to a more detailed and tailored approach to complex liver surgery, improving surgeons' knowledge of liver anatomy and accuracy of liver resection.
    Language English
    Publishing date 2022-08-25
    Publishing country Italy
    Document type Journal Article
    ZDB-ID 2572692-4
    ISSN 2038-3312 ; 2038-131X
    ISSN (online) 2038-3312
    ISSN 2038-131X
    DOI 10.1007/s13304-022-01365-8
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  9. Article ; Online: Infectious complications after surgery for perihilar cholangiocarcinoma: A single Western center experience.

    Ruzzenente, Andrea / Alaimo, Laura / Caputo, Marco / Conci, Simone / Campagnaro, Tommaso / De Bellis, Mario / Bagante, Fabio / Pedrazzani, Corrado / Guglielmi, Alfredo

    Surgery

    2022  Volume 172, Issue 3, Page(s) 813–820

    Abstract: Background: The aim of this study was to analyze the risk factors for surgical infectious complications and the outcomes of patients undergoing surgery for perihilar cholangiocarcinoma according to the microbiological examinations.: Methods: Patients ...

    Abstract Background: The aim of this study was to analyze the risk factors for surgical infectious complications and the outcomes of patients undergoing surgery for perihilar cholangiocarcinoma according to the microbiological examinations.
    Methods: Patients who underwent surgery for perihilar cholangiocarcinoma in the last decade were enrolled, and all clinical and microbiological data were collected from a retrospective monocentric database. Univariate and multivariate analyses were performed distinguishing patients who developed at least 1 surgical infectious complication (surgical site infections, acute bacterial cholangitis, bacteremia).
    Results: A total of 98 patients were included. Among patients who developed surgical infectious complications (51%), many preoperative characteristics were significantly more frequent: American Society of Anesthesiologists score ≥3 (P = .026), neutrophil-to-lymphocyte ratio ≥3.4 (P = .001), endoscopic sphincterotomy (P = .032), ≥2 biliary drainage procedures (P = .013), acute cholangitis (P = .012), multidrug resistant (P = .009), and ≥3 microorganisms' detection (P = .042); whereas during the postoperative period, surgical infectious complications were associated to increased incidence of intensive care unit readmission (P = .031), major complications (P < .001), posthepatectomy liver failure (P = .005), ascites (P = .008), biliary leakage (P = .008), 90-day readmission (P = .003), and prolonged length of hospital stay (P < .001). At the multivariate analysis 3 independent preoperative risk factors for surgical infectious complications were identified: neutrophil-to-lymphocyte ratio ≥3.4 (P = .004), endoscopic sphincterotomy (P = .009), and acute cholangitis (P = .013). The presence of multidrug-resistance in the perioperative biliary cultures was related to postoperative multidrug-resistant species from all cultures (P < .001) and organ/space and incisional-surgical site infections (P ≤ .044).
    Conclusion: Infective complications after surgery for perihilar cholangiocarcinoma worsen the short-term outcomes. A careful microbiological surveillance should be carried out in all cases to prevent and promptly treat surgical infectious complications.
    MeSH term(s) Bile Duct Neoplasms/complications ; Bile Duct Neoplasms/surgery ; Cholangiocarcinoma/surgery ; Cholangitis/epidemiology ; Cholangitis/etiology ; Drainage/methods ; Humans ; Klatskin Tumor/complications ; Klatskin Tumor/surgery ; Postoperative Complications/etiology ; Postoperative Complications/microbiology ; Retrospective Studies ; Surgical Wound Infection/epidemiology ; Surgical Wound Infection/etiology
    Language English
    Publishing date 2022-05-24
    Publishing country United States
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 202467-6
    ISSN 1532-7361 ; 0039-6060
    ISSN (online) 1532-7361
    ISSN 0039-6060
    DOI 10.1016/j.surg.2022.04.028
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  10. Article ; Online: Tissue factor pathway-related biomarkers in liver cancer: activated factor VII-antithrombin complex and tissue factor mRNA levels are associated with mortality.

    Martinelli, Nicola / Moruzzi, Sara / Udali, Silvia / Castagna, Annalisa / Di Santo, Laura / Ambrosani, Francesca / Baroni, Marcello / Pattini, Patrizia / Pizzolo, Francesca / Ruzzenente, Andrea / Conci, Simone / Grusse, Matthieu / Campagnaro, Tommaso / Van Dreden, Patrick / Guglielmi, Alfredo / Bernardi, Francesco / Olivieri, Oliviero / Friso, Simonetta

    Research and practice in thrombosis and haemostasis

    2024  Volume 8, Issue 1, Page(s) 102310

    Abstract: Background: Tissue factor (TF), the main initiator of the coagulation cascade, plays a role in cancer progression and prognosis. Activated factor VII-antithrombin complex (FVIIa-AT) is considered an indirect marker of TF exposure by reflecting TF-FVIIa ... ...

    Abstract Background: Tissue factor (TF), the main initiator of the coagulation cascade, plays a role in cancer progression and prognosis. Activated factor VII-antithrombin complex (FVIIa-AT) is considered an indirect marker of TF exposure by reflecting TF-FVIIa interaction.
    Objectives: To assess the link between FVIIa-AT plasma levels,
    Methods: TF pathway-related coagulation biomarkers were assessed in 136 patients with cancer (52 with hepatocellular carcinoma, 41 with cholangiocarcinoma, and 43 with colon cancer) undergoing surgical intervention with curative intent.
    Results: FVIIa-AT levels were higher in patients with cancer than in 136 sex- and age-matched cancer-free controls. In patients with cancer, high levels of FVIIa-AT and total TF pathway inhibitor were associated with an increased mortality risk after adjustment for confounders, but only FVIIa-AT remained a predictor of mortality by including both FVIIa-AT and total TF pathway inhibitor in Cox regression (hazard ratio, 2.80; 95% CI, 1.23-6.39; the highest vs the lowest quartile). This association remained significant even after adjustment for extracellular vesicle-associated TF-dependent procoagulant activity. In the subgroup of patients with primary liver cancer, patients with high
    Conclusion: High FVIIa-AT levels may allow the identification of patients with cancer involving high TF expression and predict a higher mortality risk in liver cancer.
    Language English
    Publishing date 2024-01-02
    Publishing country United States
    Document type Journal Article
    ISSN 2475-0379
    ISSN (online) 2475-0379
    DOI 10.1016/j.rpth.2023.102310
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    Order via subito

    This service is chargeable due to the Delivery terms set by subito. Orders including an article and supplementary material will be classified as separate orders. In these cases, fees will be demanded for each order.

    Inter-library loan at ZB MED

    Your chosen title can be delivered directly to ZB MED Cologne location if you are registered as a user at ZB MED Cologne.

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