M Lakehal

Centre Hospitalier Universitaire de Rennes, Roazhon, Brittany, France

Are you M Lakehal?

Claim your profile

Publications (24)25.01 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: En materia de trasplantes, el órgano es el quid de la cuestión. Sin él, no hay injerto. Cuando está disponible, debe ser perfecto desde los puntos de vista anatómico y funcional, pues la vida del receptor depende de ello. Esto requiere una extracción y conservación minuciosas. En el 90% de los casos, los órganos se extraen de un donante en estado de muerte encefálica y en dos tercios de los casos se trata de una extracción multiorgánica: corazón, pulmones, hígado, riñones, páncreas, intestino, hueso, córneas, vasos y, a veces, piel o incluso cara. La operación es compleja y en ella se reúnen varios equipos, por lo que hay que ser muy rápido. Por fortuna, está perfectamente sistematizada. Cualquier cirujano debe conocer sus detalles, porque es probable que algún día tenga que participar en una, con independencia de dónde ejerza. Evitar la pérdida de un órgano debido a un error técnico o a un desconocimiento de las reglas comunes es una de las misiones de esta exposición. Un artículo de técnicas quirúrgicas debe leerse intentando vivir la atmósfera que rodea al procedimiento. En este caso, hay que imaginar que la intervención tiene una dimensión especial. Una familia está en estado de duelo y un ser humano ha aceptado donar. La intervención del médico, que se realiza sobre un «muerto» va a dar la vida. Por último, hay que recordar que un «buen extractor» suele reconocerse por el conocimiento que tiene de la extracción de los órganos que no trasplanta.
    EMC - Cirugía General. 01/2014; 14(1):1–18.
  • [Show abstract] [Hide abstract]
    ABSTRACT: En materia de trasplantes, el órgano es el quid de la cuestión. Sin él, no hay injerto. Cuando está disponible, debe ser perfecto desde los puntos de vista anatómico y funcional, pues la vida del receptor depende de ello. Esto requiere una extracción y conservación minuciosas. En el 90% de los casos, los órganos se extraen de un donante en estado de muerte encefálica y en dos tercios de los casos se trata de una extracción multiorgánica: corazón, pulmones, hígado, riñones, páncreas, intestino, hueso, córneas, vasos y, a veces, piel o incluso cara. La operación es compleja y en ella se reúnen varios equipos, por lo que hay que ser muy rápido. Por fortuna, está perfectamente sistematizada. Cualquier cirujano debe conocer sus detalles, porque es probable que algún día tenga que participar en una, con independencia de dónde ejerza. Evitar la pérdida de un órgano debido a un error técnico o a un desconocimiento de las reglas comunes es una de las misiones de esta exposición. Un artículo de técnicas quirúrgicas debe leerse intentando vivir la atmósfera que rodea al procedimiento. En este caso, hay que imaginar que la intervención tiene una dimensión especial. Una familia está en estado de duelo y un ser humano ha aceptado donar. La intervención del médico, que se realiza sobre un «muerto» va a dar la vida. Por último, hay que recordar que un «buen extractor» suele reconocerse por el conocimiento que tiene de la extracción de los órganos que no trasplanta.
    EMC - Técnicas Quirúrgicas - Aparato Digestivo. 01/2014; 30(2):1–18.
  • [Show abstract] [Hide abstract]
    ABSTRACT: In trapiantologia, il trapianto è il protagonista. Senza organo da trapiantare, non vi è nessun trapianto. E, quando esso è disponibile, deve essere anatomicamente e funzionalmente perfetto. Ne dipende la vita del ricevente. Ciò sottolinea la minuziosità con la quale esso deve essere prelevato e conservato. Nove volte su dieci, i trapianti sono prelevati da un donatore in stato di morte encefalica e due volte su tre la procedura riguarda prelievi multiorgano: cuore, polmoni, fegato, reni, pancreas, intestino, osso, cornee, vasi e, a volte, cute o, anche, faccia. L’intervento è complesso. Esso riunisce diverse equipe e deve avvenire molto rapidamente. È, fortunatamente, regolato perfettamente. Ogni chirurgo deve conoscerne il dettaglio, poiché vi si troverà probabilmente di fronte un giorno, quale che sia il luogo dove esercita. Evitare la perdita di un organo la cui origine era un errore tecnico o un misconoscimento delle regole comuni rappresenta una delle missioni di questa esposizione. Un capitolo di tecniche chirurgiche si legge tentando di vivere l’atmosfera che circonda la procedura. Allora, immaginate che il vostro gesto abbia una dimensione inusuale. Una famiglia è in lutto, un uomo ha accettato di donare e il vostro coinvolgimento, che certamente riguarda una «morte», donerà la vita. Per terminare, tenete a mente che un «buon prelevatore» si riconosce spesso per la comprensione che ha del prelievo degli organi che non trapianterà lui stesso.
    EMC - Tecniche Chirurgiche Vascolare. 01/2014; 19(1):1–16.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Il 1o marzo del 1963, Thomas Starzl tenta, a Denver, Colorado, il primo trapianto di fegato. Intervento «dell’impossibile», che termina «in tragedia» per un’emorragia incontrollabile. Questo insuccesso non scoraggerà il chirurgo che, basandosi su un programma di sperimentazione animale di diversi anni, finirà per imporre il «suo» trapianto come il solo trattamento efficace delle malattie gravi del fegato. I primi successi del trapianto detto «classico» ortotopico, con circolazione extracorporea, daranno il via ai miglioramenti tecnici: trapianto senza bypass, trapianto a partire da fegati ridotti, trapianto per due a partire da un innesto in situ o ex vivo, trapianto con emitrasposizione cavoportale, trapianto ausiliare eterotopico e, poi, ortotopico e, infine, trapianto a partire da un emifegato prelevato su un donatore vivente. Un’avventura chirurgica appassionante che dura da circa 50 anni.
    EMC - Tecniche Chirurgiche Addominale. 01/2013; 19(3):1–27.
  • [Show abstract] [Hide abstract]
    ABSTRACT: El 1 de marzo de 1963, Thomas Starzl intentó en Denver, Colorado, el primer trasplante de hígado. Esta operación, «casi imposible», terminó «en tragedia» debido a una hemorragia incoercible. Este fracaso no desalentó al cirujano, quien, apoyado en un programa de experimentación animal de varios años, terminó por imponer «su» trasplante como el único tratamiento eficaz de las enfermedades graves del hígado. Los primeros éxitos del trasplante denominado «clásico» ortotópico, con circulación extracorpórea, fueron el punto de partida de diversas mejoras técnicas: trasplante sin circulación extracorpórea, trasplante a partir de hígados reducidos, trasplante para dos personas a partir de un injerto dividido in situ o ex vivo, trasplante con hemitransposición cavoporta, trasplante auxiliar heterotópico y después ortotópico y, por último, trasplante a partir de un hemihígado extraído de un donante vivo. Se trata de una aventura quirúrgica apasionante que tiene ya cerca de 50 años de historia.
    EMC - Técnicas Quirúrgicas - Aparato Digestivo. 01/2013; 29(3):1–28.
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores. OBJECTIVE: To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation. METHODS: Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing. RESULTS: Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8±3.1% vs. 76±2.9% (P=0.29) and overall graft survival was 77.6±3.4% vs. 82.8±2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1±4.4% vs. 73.5±4.5%, P=0.42), while that of HCC patients decreased (65.3±5.3% vs. 86.8±4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009). CONCLUSION: The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.
    Gastroentérologie Clinique et Biologique 09/2012; · 0.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this article is to report our experience concerning the indications and results for combined liver-kidney transplantation in our centre. From July 1991 to October 2006, 26 patients underwent combined liver-kidney transplantation in our establishment. This group comprised 16 men and 10 women with a mean age of 50.1 years (range: 19 to 68 years). The main indications were as follows: hepatorenal polycystic disease, type I hyperoxaluria, cirrhosis associated with end-stage renal failure. The median follow-up was 62.73 (+/-50.9) months. Only two patients of this series died, one at 70 months from gastric cancer, and the other at 89 months from cerebral metastases. Nine patients developed surgical complications (29%). Liver function was normal in the 24 surviving patients. Only one case of loss of renal graft was observed at 12 years and this patient is currently on dialysis. The mean creatinine level in these patients (apart from the dialysed patient) at the last follow-up visit was 120.3 (+/-30.43)micromol/l. Combined liver-kidney transplantation can be performed with acceptable morbidity and mortality and excellent long-term results.
    Progrès en Urologie 05/2008; 18(4):245-50. · 0.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Acute rejection is still a common complication of hepatic transplantation. The diagnosis, based on the histological examination of the graft, may be difficult to confirm in the setting of combined hepatitis C virus infection. The presence of C4d in the portal capillaries could facilitate differentiation between acute rejection and relapsed hepatitis C. The deposit of C4d provides evidence of activation of humoral immunity. To attempt to confirm this hypothesis, we searched for the presence of C4d in posttransplant hepatic biopsies. Thirty-six biopsies from 34 patients were analyzed retrospectively. The samples had been requested for one of the following reasons: suspected rejection, relapsed hepatitis C infection, or systematic check-up 1 year after the transplant. C4d expression was common in biopsies classified as acute rejection (33%) and chronic rejection (100%). C4d was never detected in the event of recurrent hepatitis C infection without rejection. These results, which are comparable to recently published data, give credence to the theory that C4d could be used as a marker for rejection following hepatic transplantation.
    Transplantation Proceedings 10/2006; 38(7):2333-4. · 0.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Hepatocellular carcinoma (HCC) is the most frequent primitive cancer of the liver. It mostly develops on cirrhotic livers. Orthotopic liver transplantation is the only treatment that definitively addresses both the metachronous occurrence risk of HCC and the underlying disease. Under Milan criteria, i.e. less than 3 nodules of 3 cm max in diameter, or 1 nodule of 5 cm maximum, OLT has been shown effective and provides with survival rates almost equal to those obtained with HCC free cirrhotic patients. In Rennes, 195 patients with early HCC on cirrhotic livers have been transplanted from January 1995 to June 2005. Global and disease free 8 years patient survival rates were 73 and 70%, respectively. These results were significantly altered when the recipient was female, the cirrhosis due to C virus and the patient of B blood group. Despite these excellent results, the principal limit to the application of transplantation for HCC remains the long period of time patients have to wait for a graft. During this period of time, growth of the tumour may drop the patient out of Milan criteria and subsequently from the waiting list. The role of chemoembolisation, liver resection and thermal ablation while the patient is waiting for a graft remains debatable.
    Cancer/Radiothérapie 12/2005; 9(6-7):458-63. · 1.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Potential antiviral properties of cyclosporine against hepatitis C virus have been highlighted in several publications. Therefore, we investigated the effect of a switch from tacrolimus to cyclosporine in a liver transplant recipient with recurrent hepatitis C who did not respond to antiviral therapy. The patient received a liver transplant for hepatitis C cirrhosis. Initial immunosuppressive treatment was based on tacrolimus. Because of viral activity, a combined therapy was initiated 20 months later including interferon and ribavirine. Then, due to a lack of virological and biochemical response, tacrolimus was replaced by cyclosporine (Neoral), while maintaining the same antiviral therapy. Decreases in the viral load and transaminases levels were observed.
    Transplantation Proceedings 01/2005; 37(6):2871-2. · 0.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: In the absence of cadaveric grafts, a living donor liver transplant program was started in Algeria in February 2003. The aim of this study is to report the preliminary results. From February 2003 to September 2004, eight adult-to-adult living related liver transplantations were performed. The donors were six women and two men of mean age of 25 years (range, 18 to 48 years). Right hepatectomy was performed in seven patients and left hepatectomy in one patient. The recipients were four women and four men of mean age 33 years (range, 16 to 56 years). Follow-up ranged from 1 month to 18 months (median 7 months). All donors survived the procedure. In the immediate postoperative period, two donors experienced complications. One donor underwent reoperation for hemorrhage and one suffered partial portal vein thrombosis, which was treated medically. The eight donors are alive at home without any late complications. One recipient died on postoperative day 43 due to sepsis. Among the seven other recipients, two experienced complications: one bilioma in relation to a biliary-intestinal fistula and one thrombosis of the splenic vein with a left portal embolus. At present the seven recipients are alive with normal liver function and without complications. Our results are comparable to other reports suggesting that adult-to-adult living related liver transplantation is feasible with no mortality and low morbidity in donors. However, it is important to develop a cadaveric liver transplant program.
    Transplantation Proceedings 01/2005; 37(6):2873-4. · 0.95 Impact Factor
  • P Compagnon, M Lakehal, K Boudjema
    [Show abstract] [Hide abstract]
    ABSTRACT: We describe a simple and safe technique of cholédocho-jejunostomy using a Roux-en-Y jéjunal limb, to repair immediately biliary tract injuries, even when the conduits are thin.
    Annales de Chirurgie 05/2003; 128(3):191-4. · 0.35 Impact Factor
  • P. Compagnon, M. Lakehal, K. Boudjema
    [Show abstract] [Hide abstract]
    ABSTRACT: We describe a simple and safe technique of cholédocho-jejunostomy using a Roux-en-Y jéjunal limb, to repair immediately biliary tract injuries, even when the conduits are thin.
    Annales de Chirurgie 01/2003; 128(3):191-194. · 0.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Herein we report a technique that allows a rapid and selective clamping of the left and right glissonian sheats and that secures the opening of the main fissure. The posterior face of segment IV capsula is opened immediately above the hilum on the left side of the gallbladder fossa. The tip of a right angled dissector is gently pushed in the liver substance from front to back while maintained against the hilar plate, until it arises in the caudate process just below the pedicle. A tape is used to encircle the Glisson sheath. Its inferior extremity can be picked up either on the right or the left side of the liver pedicle in order to clamp the right or the left portal pedicle, respectively. Both clamping precisely mark the anterior limit of the main fissure. Using a Kelly forceps, a second tape is introduced in the Couinaud space, between the inferior vena cava and segment one. The inferior extremity of this tape is then picked up above the Glisson sheat and allows to hang the posterior limit of the main fissure which can be securely approached. The two tapes technique cannot be applied when liver is fibrotic or when biliary ducts are dilated.
    Annales de Chirurgie 03/2002; 127(2):149-53. · 0.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Herein we report a technique that allows a rapid and selective clamping of the left and right glissonian sheats and that secures the opening of the main fissure.The posterior face of segment IV capsula is opened immediately above the hilum on the left side of the gallbladder fossa. The tip of a right angled dissector is gently pushed in the liver substance from front to back while maintained against the hilar plate, until it arises in the caudate process just below the pedicle. A tape is used to encircle the Glisson sheath. Its inferior extremity can be picked up either on the right or the left side of the liver pedicle in order to clamp the right or the left portal pedicle, respectively. Both clamping precisely mark the anterior limit of the main fissure.Using a Kelly forceps, a second tape is introduced in the Couinaud space, between the inferior vena cava and segment one. The inferior extremity of this tape is then picked up above the Glisson sheat and allows to hang the posterior limit of the main fissure which can be securely approached.The two tapes technique cannot be applied when liver is fibrotic or when biliary ducts are dilated.
    Annales de Chirurgie. 01/2002; 127(2):149-153.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.
    World Journal of Surgery 09/2001; 25(10):1284-1288. · 2.23 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years. Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome. The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed. The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively. The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.
    Annals of Surgery 09/1999; 230(2):266-75. · 6.33 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2). Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.
    European Journal of Cardio-Thoracic Surgery 03/1998; 13(2):184-8; discussion 188-9. · 2.67 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgery was performed on 6 patients after unsuccessful chemoradiotherapy for squamous cell cancer of the esophagus. The operation was very difficult due to post-irradiation sequelae in 5. The postoperative period was uneventful in 4 patients. Median intensive care unit stay and hospitalization were 5 and 47 days, respectively. Survival after surgery reached 44 months in 1 patient (59 months after diagnosis). Outcome was better in patients who had surgery after recurrence rather than after nonresponse to chemoradiotherapy. Salvage esophagectomy can be beneficial, in selected patients, after unsuccessful chemoradiotherapy for cancer of the esophagus by providing longer survival and better quality of life despite operative and postoperative morbidity.
    Digestive Surgery 02/1998; 15(3):224-6. · 1.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. Methods: Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n=19) or ligature (n=2). Results: Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1–30) and 17 days (3–57), respectively. Among the 13 survivors, pulmonary infections (n=2) and cervical fistulae (n=5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. Conclusion: The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.
    European Journal of Cardio-thoracic Surgery - EUR J CARDIO-THORAC SURG. 01/1998; 13(2):184-189.

Publication Stats

163 Citations
25.01 Total Impact Points

Institutions

  • 1996–2006
    • Centre Hospitalier Universitaire de Rennes
      • Service des maladies du foie
      Roazhon, Brittany, France
  • 1999
    • Groote Schuur Hospital
      Kaapstad, Western Cape, South Africa