Received: 12 December 2021 | Accepted: 10 January 2022

DOI: 10.1111/jocs.16271

ORIGINAL ARTICLE

Mid‐term outcomes of stentless Bio‐Bentall vs. David

Reimplantation for aortic root replacement

Guglielmo Stefanelli1 | Fabrizio Pirro1 | Emilio Chiurlia1 |

2 2,3
Alessandro Bellisario | Luca Weltert

1
Department of Cardiac Surgery and
Cardiology, Hesperia Hospital, Modena, Italy
2
Department of Cardiac Surgery, European
Hospital, Rome, Italy
3
Department of Biostatistics, San Camillus
International University of Health Sciences,
Rome, Italy
Correspondence
Guglielmo Stefanelli, Department of Cardiac
Surgery and Cardiology, Hesperia Hospital, via
Arquà 80, Modena, Italy.
Email: guglielmostefanelli@gmail.com
Abstract
Objective: To compare the early and midterm clinical outcomes of patients under-
going two different surgical procedures (stentless biological Bentall [SBB] vs. valve‐
sparing David Reimplantation [VSDR]) for aortic root dilatation, with or without
concomitant aortic valve pathology.
Methods: A population of 106 patients underwent aortic root replacement from
2004 to 2015 at our unit. Mean age at operation was 63.1 ± 10 years. The patients
were retrospectively assigned to 2 groups according to surgical procedure. David
operation was carried out in 52 patients (group A‐VSDR) and stentless biological
Bentall in 54 patients (group B‐SBB). Preoperative characteristics were similar in the
2 cohorts, except for age and EuroSCORE. Mean follow‐up time was 7.09 years
(0.26–14.50 years), and 96% complete. Patients were evaluated and analyzed for
intra‐operative results and long‐term clinical outcomes.
Results: Intraoperative mortality was 0% in both groups. Overall survival probability
at 11 years was 91.8% in group A and 73.8% in group B (p = .004). Cardiac mortality
at 11 years was similar in the 2 groups (p = .116). Freedom from structural valve
deterioration at 11 years was 88.8% (VSDR) and 90.6% (SBB) [p = .689]. Freedom
from reoperation at 11 years did not differ between the groups (83.6% VSDR vs.
98.5% SBB, p = .574). Freedom from major adverse cardiac and cerebrovascular
events at 11 years was 76.7% (VSDR) versus 80.1% (SBB) (p = .542). Mean gradient
at last follow‐up was lower in VSDR group (8.13 vs. 11.70 mmHg, p < .001).
Conclusions: David reimplantation and stentless biological Bentall procedures
achieve excellent and comparable results at midterm follow‐up. David operations
provide superior hemodynamic performance preserved over time and may be pre-
ferred in younger, active patients.

KEYWORDS
aortic root surgery, Bentall operation, David operation

Abbreviations: ABE, acute bacterial endocarditis; ACC, aortic cross clamping; A I, aortic valve insufficiency; AO, aortic; BAV, bicuspid aortic valve; BSA, body surface area; CABG, coronary
artery bypass graft; CPB, cardiopulmonary bypass; EF, ejection fraction; ICU LOS, intensive care unit length of stay; LVEDD, left ventricular end‐diastolic diameter; MACCE, major adverse
cardiac and cerebrovascular events; NYHA, New York Heart Association; ΔP, left‐ventricle‐aorta gradient; SVD, structural valve deterioration.

J Card Surg. 2022;37:781–788. wileyonlinelibrary.com/journal/jocs © 2022 Wiley Periodicals LLC | 781


782 | STEFANELLI
1 | INTRODUCTION
1
The Bentall operation, as first described in the late 1960s and later
modified by Kochoukos 2 in the “button‐ Bentall” technique, remains
the standard procedure for patients with dilated aortic root asso-
ciated with aortic valve pathology. Due to increasing patient's re-
quest for biological devices, most Bentall procedures are now
performed using a tube vascular graft including an aortic bioprosth-
esis. As alternative to biological Bentall, and in addition to homograft
and Ross procedure, aortic valve sparing operation, first proposed by
3 4
David and Yacoub, although surgically more demanding, offers
excellent short‐ and long‐term results, due to improved hemody-
namic performance and durability, provided the indication and sur-
gical technique are accurate. In this retrospective study we aimed to
analyze two groups of patients affected by aneurismal dilatation of
the aortic root, isolated or associated with aortic valve pathology,
who underwent aortic root replacement either by David valve sparing
procedure technique or by Bentall operation using a factory‐
produced or a self‐assembled stentless bioprosthetic conduit, and to
evaluate the outcomes and the drawbacks related to each of these
surgical options. The choice of a stentless bioroot for the Bentall
procedure instead of the commonly used stented one, aimed to im-
prove the hemodynamic performance and durability, by avoiding the
rigid strut of a stented prosthesis and by allowing a bigger im-
plant size.
2 | M E TH O D S
2.1 | Population
Between 2004 and 2015, a cohort of 106 patients underwent re-
placement of the aortic root for dilatation of the ascending aorta
isolated or in association with aortic valve disease at our unit by a
single surgeon.
Patients without significant (>45 mm) aortic root dilatation and
patients with aortic valve stenosis were excluded from the study.
Patients in the Bentall group with acute aortic dissection and patients
with acute bacterial endocarditis (ABE) were excluded from our
analysis since they do not fit with the comparator group of the David
procedure. All patients received a preoperative evaluation by echo-
cardiography and computed tomography. The study was approved by
the Institutional Ethical Committee (EC #0011/2019). Preoperative,
intraoperative, and postoperative data were collected from the hos-
pital medical records and informed consent to use their data was
obtained from all patients. Follow‐up of patients consisted of one
time point evaluation of postoperative events. Endpoints of our
analysis included early/in‐hospital mortality, late overall and cardiac
mortality, rate of major adverse cardiac and cerebrovascular events
(MACCE) and ABE at follow‐up, which were compared between the
David and Bentall groups of patients. The incidence of structural
valve deterioration (SVD) and valve‐related reoperation was also
evaluated, along with hemodynamic performance over time.
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ET AL.
Guidelines reported by Akins et al. were used to define the endpoints
of the analysis.5
2.2 | Surgical technique
All procedures were performed by a single surgeon in a single in-
stitution. Patients older than 75 years, or having retracted, thickened,
and partly calcified aortic leaflets, or with dilatation of the aortic
annulus >35 mm or affected by aortic valve ABE were not considered
good candidates for David reimplantation, and underwent a biological
Bentall procedure. All operations were performed by median ster-
notomy, moderately hypothermic cardiopulmonary bypass (CPB) and
cardiac arrest obtained by antegrade and retrograde Custodiol™
(Dr. Franz Köhler Chemie GmbH) cardioplegic solution, after aortic
cross‐clamping (ACC). Cardiocirculatory arrest at 25°C and brain
protection by selective perfusion of neck vessels was adopted in
cases of aortic arch replacement. Reimplantation operation was
performed as originally described by David in 52 patients. As a first
step, after transverse aortotomy, resection of the aortic sinuses was
carried out, followed by accurate dissection of the peri‐annular soft
tissue. Aortic leaflet repair, required in 14 patients, was achieved at
this time, and consisted mostly of one or more cusp plication by
central 5‐0 polypropylene stitch or by cusp resuspension using
continuous 7‐0 gore‐tex suture. Next, the native aortic valve was
implanted inside a straight tube woven graft using 15 braided U
stitches for the annulus and 3 polypropylene continuous sutures for
the outflow. A water test to check the aortic valve competence was
performed and, if necessary, further gestures on aortic leaflets were
accomplished to obtain optimal valve competence. Reimplantation of
the coronary ostia and Teflon reinforced distal aortic anastomosis
completed the procedure. A residual aortic insufficiency greater than
mild or with asymmetrical regurgitant jet at a postprocedural trans-
esophageal echocardiography control were considered signs of pro-
cedural failure; indeed these circumstances did not occur in any of
our patients. The modified biological Bentall operation was carried
out in 54 patients, using a Shelhigh NR‐2000 (Shelhigh, Inc.) in 24
patients, and a self‐made bioconduit, constructed by inclusion of a 3F
equine pericardial stentless prosthesis (Medtronic, Dublin, Ireland)
into a Hemashield (Getinge, Göteborg, Sweden) straight tube graft in
30 patients. (Supporting Information Video). In all 54 cases the bio‐
conduit was secured to the native aortic annulus by three different
surgical techniques, namely: interrupted, multiple U braided stitches
reinforced with supra‐annular Teflon pledgets, or alternatively by a
single or by three running polypropylene sutures reinforced with a
strip of pericardium (Figure 1).
2.3 | Statistical analysis
Categorical variables were presented as numbers and percentages
and were analyzed by Pearson's χ2 or Fisher's exact test. Continuous
variables were expressed as mean ± SD or median with interquartile
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STEFANELLI ET AL. | 783

FIGURE 1 Stentless bio‐root assembly

range. Normality of the data was assessed using the Shapiro–Wilk TABLE 1 Preoperative patients characteristics
test. Differences between groups were compared using Student's t Bentall David
test for normally distributed continuous variables whereas for non- Mean/N° Mean/N°
normally distributed continuous variables the Mann–Whitney U test (SD/%) (SD/%) p
was used. The Kaplan–Meier method was used to plot graphs, with Age 67 (±9.68) 59 (±8.76) <.001
confidence intervals drawn as thinner lines for sake of visual clarity, Gender (male) 40 (74.1%) 44 (84.6%) <.001
number at risk is plotted in the lower row, and all curves are cut when
BSA 1.82 (±0.19) 1.88 (±0.19) .151
10% of total patients at risk is reached. The Log Rank method was
used after testing for the proportional hazard assumption to verify NYHA III–IV 15 (27.8%) 12 (23.1%) .087

significance of differences between curves. Cox regression was then Log EUROSC % 12.98 (±9.95) 8.16 (±3.64) .001
used to test the impact of different covariates on study endpoints. All EF_PRE 57 (±7.62) 56 (±7.58) .43
p values of <.05 were considered statistically significant. All statistical
LVEDD_PRE 54 (±8.5) 52 (±5.9) .164
analyses were performed using JMP® Version 13.1.0 and SAS Soft-
ware, Version 9.4 (SAS Institute Inc.). AV 6 (11.1%) 6 (±11.5) .945

AO. DISSECT. 0 (0%) 0 (0%) n.a

MARFAN 0 (0%) 0 (0%) n.a

3 | RESULTS
ABE_PRE 0 (0%) 0 (0%) n.a

3.1 | Early results REDO_pre 4 (7.4%) 4 (7.7%) .95

Abbreviations: ABE, acute bacterial endocarditis; AO, aortic; BAV,

Patients were retrospectively assigned to two groups, according to
the surgical procedure. Group A had a David Reimplantation opera-
tion (n = 52; average 5 pts/year) and group B had a stentless biolo-
gical Bentall operation (n = 54; average 5.2 pts/year). Table 1
summarizes the preoperative patient details demonstrating sig-
nificant differences between the two groups related to lower age at
surgery in group A (p < .001), higher logistic EuroSCORE in group B
(p = .001), but the number of patents in New York Heart Association
(NYHA) Class III–IV did not differ (p = .09) and ejection fraction was
similar between the groups (p = .43). A bicuspid aortic valve was
present in 12 patients, including 6 patients of group A (11.50%) and
in 6 patients of group B (11.10%). A total of 8 patients had undergone
a previous cardiac operation, including 4 in group A (7.70%) and 4 in
group B (7.40%). Intraoperative patient details and hospital discharge
data are presented in Table 2. The mean aortic graft size was sub-
stantially different (30.5 ± 1.9 mm in group A and 27.6 ± 2.2 mm in
bicuspid aortic valve; BSA, body surface area; EF, ejection fraction;
LVEDD, left ventricular end‐diastolic diameter; NYHA, New York Heart
Association.
group B [p < .001]). Concomitant aortic valve repair occurred for 14
patients in group A (26.9%). Hemashield straight vascular prosthesis
(Getinge) was used for all cases in group A, whereas 30 patients of
group B received a self‐assembled 3F bioconduit using a Vascutek
Gelweave straight vascular prosthesis (Terumo Aortic). In the two
cases requiring aortic arch replacement, a Shelhigh pericardial valve
conduit was used for the Bentall procedure and concomitant aortic
arch reconstruction. CPB and ACC times were significantly longer in
group A compared to group B. Incidence of reexploration for bleeding
was not different between the two groups; overall length of stay in
the intensive care unit was similar as well. Trivial to mild aortic in-
sufficiency at discharge was reported in 7 patients of group A (13.4%)
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784 | STEFANELLI ET AL.

T A B L E 2 Intraoperative and hospital discharge patients TABLE 3 Follow‐up data

characteristics
Bentall David
Bentall David Mean/N° Mean/N°
Mean/N° Mean/N° (SD/%) (SD/%) p
(SD/%) (SD/%) p Overall deaths (actual) 12 (22.2%) 2 (3.8%) .002
ASSOC. PROC. 14 (25.9%) 8 (15.4%) .002
Cardiac deaths (actual) 5 (9.3%) 1 (1.9%) .102
CABG 7 (13%) 8 (15.4%) .720
NYHA follow‐up I–II 49 (90.7%) 49 (92.6%) 1.000
MITRAL 5 (9.09%) 0 (0%) .025
NYHA follow‐up III–IV 5 (8.3%) 4 (7.4%) .345
AORTIC ARCH 2 (3.6%) 0 (0%) .49
ΔPmed follow‐up 11.74 (±4.83) 8.13 (±1.54) <.001
AO GRAFT_SIZE 27.63 (±2.2) 30.46 (1.92) <.001
AOI (mild) follow‐up 14 (25.9%) 18 (3.8%) .003
CUSP REPAIR 0 (0%) 14 (26.9%) <.001
ABE (actual) 1 (1.85%) 1 (1.92%) .977
ECC 138 (±61) 169 (±18) <.001
SVD (actual) 4 (7.4%) 2 (3.8%) .428
AXCL 106 (±32) 139 (±15) <.001
Valve Rel. REop 2 (3.7%) 3 (5.8%) .616
ICU_LOS 34 (±24) 29 (±110) .717 (actual)

Re Expl. For 4 (7.4%) 6 (11.5%) .224 Valve RelComplic. 2 (3.6%) 0 (0%) .232
bleeding (actual)

Deep sternal 1 (1.85%) 1 (1.9%) 1.00 MACCE (actual) 10 (18.5%) 6 (11.5%) .634
infection
Note: ΔP = left‐ventricle‐aorta gradient.
PMK implant 1 (1.85%) 2 (3.8%) .06 Abbreviations: ABE, acute bacterial endocarditis; AOI, aortic insufficiency;
MACCE, major adverse cardiac and cerebrovascular events; NYHA, New
Acute renal failure 0 (0%) 1 (1.9%) .07
York Heart Association; SVD, structural valve deterioration.
HOSP death 0 (0%) 0 (0%) .161

ΔPmax DIS 18.75 (±5.71) 13.71 (±1.92) <.001

ΔPmed DIS 11.04 (±6.82) 8.45 (±1.5)
AOI trivial to 4 (7.4%) 7 (13.5%)
mild DIS
Note: ΔP = left‐ventricle‐aortic gradient.
Abbreviations: AOI, aortic valve insufficiency; AXCL, aortic cross
clamping; CABG, coronary artery bypass graft; Dis, discharge; ECC,
extracorporeal circulation; ICU LOS, intensive care unit length of stay;
PMK, pace‐maker.
and in 4 patients of group B (7.4%, p = .03). Permanent pacemaker
implantation was necessary for 2 patients in group A and 1 patient in
group B (p = .06). Acute renal failure necessitating of continuous
veno‐venous ultrafiltration occurred in one patient of group A and in
no patients in group B (p = .07). Mean transvalvular aortic gradient
evaluated by echocardiography at hospital discharge was lower in
group A while early perioperative mortality was 0% in both groups.
3.2 | Late results
Median follow‐up time was 7.09 years (range: 0.26–14.51 years)
corresponding to 352 patient‐years, and follow‐up was 96% com-
plete. No substantial difference in follow up time was present be-
tween the two cohorts. To gain all follow‐up data, all patients were
contacted by the same researcher using a brief questionnaire and
echocardiography data and clinical examinations were gathered from
the patient's cardiologist or from referring hospitals, with specific
requirements regarding a full assessment of the aortic valve
.009 parameters. All death causes were carefully assessed at the best of
the possibility accessing medical records of patients when available.
.03
The follow‐up consisted of one time point evaluation of post-
operative events. Follow‐up data are presented in Table 3. Sixteen
patients died during follow‐up including 2 patients from group A
(3.8%) and 14 patients from group B (22.2%, p = .002). In group A,
1 patient died for noncardiac causes and another died suddenly for
malignant arrhythmia a few months after operation. In group B,
1 patient died for acute myocardial infarction 10 years after the
operation, 1 patient died for aortic dissection 3 years after the op-
eration, 1 patient with uncontrolled diabetes died a few months after
the operation due to severe acute hypoglycemia, and 9 patients died
due to noncardiac causes, mostly because of cancer or aging. Late
mortality related to direct cardiac causes was not statistically dif-
ferent between the two groups (1.9% vs. 9.3%, p = .102). Overall
actuarial survival probability was 100% at 5 years and 91.8% at 11
years for David procedures versus 77.7% at 5 years and 73.8% at 11
years for stentless Bentall procedures (p = .004; Figure 2A). Freedom
from cardiac‐related mortality at 11 years was 96.7% for group A
versus 90.4% for group B (p = .116; Figure 2B).
Cox regression analysis in such a relatively small cohort does not
grant solid results, however, patients undergoing the Bentall proce-
dure seems to be at higher risk of late overall death (p = .016). Logistic
EuroSCORE (p < .001), body surface area BSA (p = .038), and NYHA
class at follow‐up (p < .001) seems to be risk factors for late cardiac
and noncardiac death in both groups. Age at operation (p = .015) and
concomitant mitral valve surgery (p = .015) were risk factors for
overall death. Duration of CPB resulted an additional risk factor for

STEFANELLI ET AL.
FIGURE 2 Overall and cardiac death
FIGURE 3 Freedom from endocarditis and major adverse cardiac and cerebrovascular events (MACCE) at follow‐up
late cardiac mortality (p < .001). Reported adverse events were too
few to make solid inference and plot meaningful freedom curves:
ABE occurred during follow‐up in two cases, one in each group. In
both cases the reoperation of aortic valve replacement was un-
eventful (Figure 3A).
Freedom from MACCE at 11 years was 76.7% versus 80.1%
(p = .542) (Figure 3B).
Mild aortic valve insufficiency at follow‐up was diagnosed by
echocardiography for 2 patients in group A (3.80%) and 14 patients in
group B (25.9% p = .003). In group A, it was central and remained quite
stable over time. SVD was considered present with an echocardio-
graphy diagnosis of mean aortic valve gradient >20 mmHg or aortic
insufficiency greater than moderate. Aortic insufficiency was severe for
two patients in group A and both received an aortic valve replacement.
The four patients in group B with SVD continue to be followed because
they are in good clinical condition and the aortic valve pathology still
moderate. Freedom from SVD at 11‐year follow‐up was similar
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| 785
between the groups (88.8% in group A vs. 90.6% in group B, p = .689)
(Figure 4A). Five patients underwent a reoperation during follow‐up to
replace the aortic valve. Three patients in group A (5.8%) were re-
operated, 1 patient after ABE and 2 patients for SVD. Two patients in
group B (3.7%) were reoperated, respectively 1 patient after ABE and 1
patient for SVD. This last patient had received a Bentall procedure with
a Shelhigh conduit and underwent a successfull trans‐catheter aortic
valve implant 10 years later. Albeit with the limitations inherent to such
a low rate of events, incidence of reoperation was not significantly
different between the 2 groups (p = .574) (Figure 4B). As expected,
trans‐valvular mean gradient at follow‐up control was significantly lower
in patients receiving a David procedure compared to Bentall
(8.13 ± 1.54 mmHg vs. 11.74 ± 4.83 mmHg, p < .001), confirming a bet-
ter function of the spared native aortic valve (Figure 5).
Finally, overall clinical condition of patients according to NYHA
class evaluation at follow‐up did not differ significantly between the
two groups.
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786 | STEFANELLI ET AL.

FIGURE 4 Freedom from structural valve deterioration and valve‐related reoperation during follow‐up

FIGURE 5 Peak and mean gradients at hospital discharge and at last follow‐up (FU)

4 | DISC US SION
A stentless bio‐Bentall operation may represent, in young and active
patients who wish to avoid anticoagulation,6–9 a valid alternative to
homograft, often difficult to supply in most cardiac units,10 and to the
Ross operation11 that requires a certain amount of surgical training
and skill. Valve sparing procedures, introduced by David3 and
4
Yacoub in the early 1990s, remain a valid alternative to Bentall in
selected cases, and have proven excellent long‐term results in several
reported large series of patients.12 However, compared to Bentall,
aortic valve sparing surgery is more technically demanding and re-
sults are closely related to a correct indication. We analyzed a cohort
of patients affected by aortic root and ascending aorta dilatation who
underwent surgical repair by David reimplantation or by biological
stentless Bentall procedure. Criteria for assignment of patients to
either technique have been illustrated in the Methods section. We
aimed to investigate possible differences at long‐term follow‐up
between the patients undergoing the two surgical techniques, related
to overall and cardiac mortality rate, incidence of MACCE, ABE, SVD,
and valve‐related reoperation, and finally to compare hemodynamic
performance over time. It is not surprising that age at operation,
logistic EuroSCORE, and patient BSA, as well as NYHA class and CPB
duration resulted significant predictors of late overall and cardiac
mortality in both groups. Indeed, the overall late mortality was sig-
nificantly higher in the biological Bentall group, and this could be
explained by the older age and worse clinical status of the patients
from this cohort. SVD and incidence of valve‐related reoperation at
long‐term follow‐up was instead similar in the two groups of patients.
Occurrence of MACCE and ABE during follow‐up was not sig-
nificantly different between the two groups. Conversely, significantly
better hemodynamic performance at last follow‐up was reported in
the group of patients receiving a David procedure and was well stable
over time. While several authors have reported their results com-
paring aortic valve sparing operation versus the Bentall procedure
using composite mechanical and biological aortic grafts,13–15 only a
few papers published in literature analyze the long‐term outcomes
after David reimplantation versus Bentall operation performed with
sole bioprosthetic valve conduits. Two recent publications compare
David versus only biological Bentall operation. The first was a paper
from Esaki et al.16 from Emory University. They reported a 7‐year
retrospective review by propensity score matching analysis based on
20 preoperative characteristics resulting in 123 pairs out of 282 and
425 patients undergoing David or biological Bentall operation, re-
spectively. Not different from our experience, they concluded that

STEFANELLI ET AL.
both procedures resulted in similar early and late mortality and
morbidity, without a difference in valve durability. In another retro-
17
spective, propensity score‐matched study Gaudino et al. analyzed
the results of 749 consecutive patients from two institutions un-
dergoing either biological Bentall or aortic reimplantation for aneur-
ysmal dilatation of the aortic root associated to aortic valve
pathology at a mean follow‐up of 28 months. They concluded that
both surgical techniques provide excellent results. In our series, pa-
tients undergoing valve sparing procedure had a straight tube graft
implant in all cases, according to David observations concerning the
most appropriate type of prosthesis.18 The entire group of patients
receiving a biological Bentall underwent a stentless aortic valve im-
plant. The rationale of using a stentless valve is to optimize the he-
modynamic performance by implanting a larger prosthesis. In our
earlier experience, we used the ready‐to‐use Shelhigh conduit.19,20
Subsequently we assembled a bioconduit, constructed by inclusion of
a 3F stentless valve into a straight tube graft, as previously described
by Stewart et al.21 We have recently published our experience with
226 consecutive patients receiving a 3F valve implantation between
2007 and 2015, and reported excellent intermediate outcomes of
this user‐friendly prosthesis designed as a tubular structure and
constructed from three equal sections of equine pericardium.22
Unfortunately the 3F prosthesis production was interrupted by
Medtronic for commercial strategies.
4.1 | Study limitations
The retrospective design, the relatively small population size, the
one‐time point only evaluation of postoperative events follow‐up and
the single‐surgeon experience are major limitations in this study.
Moreover the direct comparability of the two cohorts might be
biased due to difference in aortic leaflet quality. Conversely, the si-
milar number of patients operated per year in both groups and the
same surgical technique adopted in all David operations, associated
with 96% completeness of follow‐up, may reduce the confounding
biases often present in similar analyses
5 | C ONC LUS I ON S
In cases of aortic root dilatation with or without aortic valve pa-
thology, reimplantation operation by David technique and biological
Bentall procedure using a stentless prosthesis are both associated
with low early and late cardiac‐related mortality and morbidity, good
valve durability, and reduced rate of valve‐related reoperation.
Superior hemodynamic performance preserved over time after David
procedure makes this surgical option more advisable in younger and
more active patients, provided that the indication is undoubtedly
correct and the surgical technique is accurate.
FUNDING I NFORMA TI ON
Funding information is not available.
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| 787
CONFLIC T OF INTERESTS
The authors declare no conflict of interest.
ORC I D
Guglielmo Stefanelli http://orcid.org/0000-0002-7789-0967
Luca Weltert http://orcid.org/0000-0001-6094-8280
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