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4. Deep learning-based recognition of key anatomical structures during robot-assisted minimally invasive esophagectomy

Author

den Boer, R.B., Jaspers, T.J.M., de Jongh, C., Pluim, J.P.W., van der Sommen, F., Boers, T., van Hillegersberg, R., Van Eijnatten, M.A.J.M., Ruurda, J.P., den Boer, R.B., Jaspers, T.J.M., de Jongh, C., Pluim, J.P.W., van der Sommen, F., Boers, T., van Hillegersberg, R., Van Eijnatten, M.A.J.M., and Ruurda, J.P.

Abstract

Objective: To develop a deep learning algorithm for anatomy recognition in thoracoscopic video frames from robot-assisted minimally invasive esophagectomy (RAMIE) procedures using deep learning. Background: RAMIE is a complex operation with substantial perioperative morbidity and a considerable learning curve. Automatic anatomy recognition may improve surgical orientation and recognition of anatomical structures and might contribute to reducing morbidity or learning curves. Studies regarding anatomy recognition in complex surgical procedures are currently lacking. Methods: Eighty-three videos of consecutive RAMIE procedures between 2018 and 2022 were retrospectively collected at University Medical Center Utrecht. A surgical PhD candidate and an expert surgeon annotated the azygos vein and vena cava, aorta, and right lung on 1050 thoracoscopic frames. 850 frames were used for training of a convolutional neural network (CNN) to segment the anatomical structures. The remaining 200 frames of the dataset were used for testing the CNN. The Dice and 95% Hausdorff distance (95HD) were calculated to assess algorithm accuracy. Results: The median Dice of the algorithm was 0.79 (IQR = 0.20) for segmentation of the azygos vein and/or vena cava. A median Dice coefficient of 0.74 (IQR = 0.86) and 0.89 (IQR = 0.30) were obtained for segmentation of the aorta and lung, respectively. Inference time was 0.026 s (39 Hz). The prediction of the deep learning algorithm was compared with the expert surgeon annotations, showing an accuracy measured in median Dice of 0.70 (IQR = 0.19), 0.88 (IQR = 0.07), and 0.90 (0.10) for the vena cava and/or azygos vein, aorta, and lung, respectively. Conclusion: This study shows that deep learning-based semantic segmentation has potential for anatomy recognition in RAMIE video frames. The inference time of the algorithm facilitated real-time anatomy recognition. Clinical applicability should be assessed in prospective clinical studies.

Published
2023

5. Deep learning-based recognition of key anatomical structures during robot-assisted minimally invasive esophagectomy

Author

Fysica Radiotherapie Research, MS CGO, Cancer, den Boer, R B, Jaspers, T J M, de Jongh, C, Pluim, J P W, van der Sommen, F, Boers, T, van Hillegersberg, R, Van Eijnatten, M A J M, Ruurda, J P, Fysica Radiotherapie Research, MS CGO, Cancer, den Boer, R B, Jaspers, T J M, de Jongh, C, Pluim, J P W, van der Sommen, F, Boers, T, van Hillegersberg, R, Van Eijnatten, M A J M, and Ruurda, J P

Published
2023

6. Computer-aided anatomy recognition in intrathoracic and -abdominal surgery: a systematic review

Author

den Boer, R.B., de Jongh, C., Huijbers, W.T.E., Jaspers, T. J.M., Pluim, J.P.W., van Hillegersberg, R., van Eijnatten, M., Ruurda, J.P., den Boer, R.B., de Jongh, C., Huijbers, W.T.E., Jaspers, T. J.M., Pluim, J.P.W., van Hillegersberg, R., van Eijnatten, M., and Ruurda, J.P.

Abstract

BACKGROUND: Minimally invasive surgery is complex and associated with substantial learning curves. Computer-aided anatomy recognition, such as artificial intelligence-based algorithms, may improve anatomical orientation, prevent tissue injury, and improve learning curves. The study objective was to provide a comprehensive overview of current literature on the accuracy of anatomy recognition algorithms in intrathoracic and -abdominal surgery.METHODS: This systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Pubmed, Embase, and IEEE Xplore were searched for original studies up until January 2022 on computer-aided anatomy recognition, without requiring intraoperative imaging or calibration equipment. Extracted features included surgical procedure, study population and design, algorithm type, pre-training methods, pre- and post-processing methods, data augmentation, anatomy annotation, training data, testing data, model validation strategy, goal of the algorithm, target anatomical structure, accuracy, and inference time.RESULTS: After full-text screening, 23 out of 7124 articles were included. Included studies showed a wide diversity, with six possible recognition tasks in 15 different surgical procedures, and 14 different accuracy measures used. Risk of bias in the included studies was high, especially regarding patient selection and annotation of the reference standard. Dice and intersection over union (IoU) scores of the algorithms ranged from 0.50 to 0.98 and from 74 to 98%, respectively, for various anatomy recognition tasks. High-accuracy algorithms were typically trained using larger datasets annotated by expert surgeons and focused on less-complex anatomy. Some of the high-accuracy algorithms were developed using pre-training and data augmentation.CONCLUSIONS: The accuracy of included anatomy recognition algorithms varied substantially, ranging from moderate

Published
2022

10. Examining the Distribution and Impact of Single-Nucleotide Polymorphisms in the Capsular Locus of Streptococcus pneumoniae Serotype 19A

Author

Arends, D. W., primary, Miellet, W. R., additional, Langereis, J. D., additional, Ederveen, T. H. A., additional, van der Gaast–de Jongh, C. E., additional, van Scherpenzeel, M., additional, Knol, M. J., additional, van Sorge, N. M., additional, Lefeber, D. J., additional, Trzciński, K., additional, Sanders, E. A. M., additional, Dorfmueller, H. C., additional, Bootsma, H. J., additional, and de Jonge, M. I., additional

Published
2021
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12. Examining the Distribution and Impact of Single-Nucleotide Polymorphisms in the Capsular Locus of Streptococcus pneumoniae Serotype 19A

Author

Immuno/reuma onderzoek 8 (Trzcinski), Infection & Immunity, Epi Infectieziekten Team 1, MMB Research line 1, Cluster B, Child Health, Arends, D. W., Miellet, W. R., Langereis, J. D., Ederveen, T. H.A., van der Gaast–de Jongh, C. E., van Scherpenzeel, M., Knol, M. J., van Sorge, N. M., Lefeber, D. J., Trzcinski, K., Sanders, E. A.M., Dorfmueller, H. C., Bootsma, H. J., de Jonge, M. I., Immuno/reuma onderzoek 8 (Trzcinski), Infection & Immunity, Epi Infectieziekten Team 1, MMB Research line 1, Cluster B, Child Health, Arends, D. W., Miellet, W. R., Langereis, J. D., Ederveen, T. H.A., van der Gaast–de Jongh, C. E., van Scherpenzeel, M., Knol, M. J., van Sorge, N. M., Lefeber, D. J., Trzcinski, K., Sanders, E. A.M., Dorfmueller, H. C., Bootsma, H. J., and de Jonge, M. I.

Published
2021

19. The additive value of restaging-CT during neoadjuvant chemotherapy for gastric cancer

Author

Arts Assistenten CTC, MS CGO, Cancer, MS Radiologie, Divisie Beeld & Oncologie, Gertsen, E. C., de Jongh, C., Brenkman, H. J.F., Mertens, A. C., Broeders, I. A.M.J., Los, M., Boerma, D., ten Bokkel Huinink, D., van Leeuwen, L., Wessels, F. J., van Hillegersberg, R., Ruurda, J. P., Arts Assistenten CTC, MS CGO, Cancer, MS Radiologie, Divisie Beeld & Oncologie, Gertsen, E. C., de Jongh, C., Brenkman, H. J.F., Mertens, A. C., Broeders, I. A.M.J., Los, M., Boerma, D., ten Bokkel Huinink, D., van Leeuwen, L., Wessels, F. J., van Hillegersberg, R., and Ruurda, J. P.

Published
2020

21. The contribution of genetic variation of streptococcus pneumoniae to the clinical manifestation of invasive pneumococcal disease

Author

Cremers, A.J.H., Mobegi, Fredrick, Van Der Gaast-De Jongh, C., Van Weert, M., Van Opzeeland, F.J., Vehkala, M., Knol, M.J., Bootsma, H.J., Välimäki, N., Croucher, N.J., Meis, J.F., Bentley, S., Van Hijum, S.A.F.T., Corander, J., Zomer, A.L., Ferwerda, G., De Jonge, M.I., Cremers, A.J.H., Mobegi, Fredrick, Van Der Gaast-De Jongh, C., Van Weert, M., Van Opzeeland, F.J., Vehkala, M., Knol, M.J., Bootsma, H.J., Välimäki, N., Croucher, N.J., Meis, J.F., Bentley, S., Van Hijum, S.A.F.T., Corander, J., Zomer, A.L., Ferwerda, G., and De Jonge, M.I.

Abstract

© 2018 The Author(s). Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. Background. Different clinical manifestations of invasive pneumococcal disease (IPD) have thus far mainly been explained by patient characteristics. Here we studied the contribution of pneumococcal genetic variation to IPD phenotype. Methods. The index cohort consisted of 349 patients admitted to 2 Dutch hospitals between 2000-2011 with pneumococcal bacteremia. We performed genome-wide association studies to identify pneumococcal lineages, genes, and allelic variants associated with 23 clinical IPD phenotypes. The identified associations were validated in a nationwide (n = 482) and a post-pneumococcal vaccination cohort (n = 121). The contribution of confirmed pneumococcal genotypes to the clinical IPD phenotype, relative to known clinical predictors, was tested by regression analysis. Results. Among IPD patients, the presence of pneumococcal gene slaA was a nationwide confirmed independent predictor of meningitis (odds ratio [OR], 10.5; P = .001), as was sequence cluster 9 (serotype 7F: OR, 3.68; P = .057). A set of 4 pneumococcal genes co-located on a prophage was a confirmed independent predictor of 30-day mortality (OR, 3.4; P = .003). We could detect the pneumococcal variants of concern in these patients' blood samples. Conclusions. In this study, knowledge of pneumococcal genotypic variants improved the clinical risk assessment for detrimental manifestations of IPD. This provides us with novel opportunities to target, anticipate, or avert the pathogenic effects related to particular pneumococcal variants, and indicates that information on pneumococcal genotype is important for the diagnostic and treatment strategy in IPD. Ongoing surveillance is warranted to monitor the clinical value of information on pneumococcal variants in dynamic microbial and susceptible host populations.

Published
2018

24. Can health status questionnaires be used as a measure of physical activity in COPD patients?

Author

Demeyer, H, Dueñas-Espín, I, De Jongh, C, Louvaris, Z, Hornikx, M, Gimeno-Santos, E, Loeckx, M, Vogiatzis, I, Janssens, W, Hopkinson, NS, Rabinovich, RA, Karlsson, N, Garcia-Aymerich, J, Troosters, T, PROactive consortium, and Groningen Research Institute for Asthma and COPD (GRIAC)

Subjects
Male, Pulmonary and Respiratory Medicine, Gerontology, Copd patients, Health Status, Respiratory System, Psychological intervention, Physical activity, OBSTRUCTIVE PULMONARY-DISEASE, Pulmonary Disease, Chronic Obstructive, 03 medical and health sciences, 0302 clinical medicine, Surveys and Questionnaires, Health care, Humans, Medicine, In patient, 030212 general & internal medicine, Exercise, Aged, Sedentary lifestyle, business.industry, 11 Medical And Health Sciences, A300, medicine.disease, FRAMEWORK, Obstructive lung disease, 3. Good health, respiratory tract diseases, LIFE, 030228 respiratory system, FUNCTIONAL STATUS, Female, Basic needs, business, PROactive consortium
Abstract

Acting to address the amount of physical activity of patients with chronic obstructive pulmonary disease (COPD) is recommended as part of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations [1]. A level lower than approximately 5000 steps for day (sedentary lifestyle index) is associated with significantly increased health risks [2, 3]. Actively screening to identify patients below this threshold could be an important step towards targeting interventions to increase physical activity. Potential screening tools include activity monitors (objective assessment) or self-reported questionnaires (subjective assessment) to measure the amount of physical activity [4]. The latter method, which is feasible in clinical practice, may not result in an accurate representation in an individual patient, as questionnaire responses tend to misclassify physical activity [5]. Although more accurate and widely used in research, activity monitoring is not yet commonly included in patients' routine assessment. Several health status questionnaires in routine clinical use contain a domain or dimension related to physical activity [6]. In the analytical framework of Leidy [7], functional performance has been defined as the physical, psychological, social, occupational and spiritual activities that people actually do in the normal course of their lives to meet basic needs, fulfil usual roles, and maintain their health and wellbeing. A review by Kocks et al . [8] proposed that these questionnaires could be used in the measurement of functional performance (defined as “what a patient is actually doing”) and that this would be a more practical alternative to physical activity monitoring. Whether this approach is sufficiently valid as a representation of physical activity levels in clinical practice remains to be established. Health status questionnaires provide only limited insight into the physical activity of patients with COPD The PROactive Consortium members are as follows. Nathalie Ivanoff: Almirall, Barcelona, Spain; Niklas Karlsson and Solange Corriol-Rohou: AstraZeneca AB, Molndal, Sweden; Ian Jarrod: British Lung Foundation, London, UK; Damijen Erzen: Boehringer Ingelheim, Nieder-Ingelheim, Germany; Mario Scuri and Roberta Montacchini: Chiesi Farmaceutici S.A. Parma, Italy; Paul McBride: Choice Healthcare Solutions, Hitchin, UK; Nadia Kamel: European Respiratory Society, Lausanne, Switzerland; Margaret Tabberer: GlaxoSmithKline, Uxbridge, UK; Thierry Troosters, Wim Janssens and Fabienne Dobbels,: Katholieke Universiteit Leuven, Leuven, Belgium; Judith Garcia-Aymerich, Municipal Institute of Medical Research, Barcelona, Spain; Pim de Boer: Netherlands Lung Foundation, Amersfoort, The Netherlands; Karoly Kulich and Alastair Glendenning: Novartis, Basel, Switzerland; Michael I. Polkey and Nick S. Hopkinson: Royal Brompton and Harefield NHS Foundation Trust, London, UK; Ioannis Vogiatzis: Thorax Research Foundation, Athens, Greece; Enkeleida Nikai: UCB, Brussels, Belgium; Thys van der Molen and Corina De Jong: University Medical Center, Groningen, The Netherlands; Roberto A. Rabinovich and Bill MacNee: University of Edinburgh, Edinburgh, UK; Milo A. Puhan and Anja Frei: University of Zurich, Zurich, Switzerland.

Published
2016

42. Aspergillus sinusitis in cancer patients.

Author

Viollier, Anne-Francoise, Peterson, Douglas E., De Jongh, Carlos A., Newman, Kathryn A., Gray, William C., Sutherland, John C., Moody, Mark A., Schimpff, Stephen C., Viollier, A F, Peterson, D E, De Jongh, C A, Newman, K A, Gray, W C, Sutherland, J C, Moody, M A, and Schimpff, S C

Published
1986
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48. ASO Visual Abstract: The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)-Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry.

Author

Kooij CD, de Jongh C, Kingma BF, van Berge Henegouwen MI, Gisbertz SS, Chao YK, Chiu PW, Rouanet P, Mourregot A, Immanuel A, Mala T, van Boxel GI, Carter NC, Li H, Fuchs HF, Bruns CJ, Giacopuzzi S, Kalff JC, Hölzen JP, Juratli MA, Benedix F, Lorenz E, Egberts JH, Haveman JW, van Etten B, Müller BP, Grimminger PP, Berlth F, Piessen G, van den Berg JW, Milone M, Luketich JD, Sarkaria IS, Sallum RAA, van Det MJ, Kouwenhoven EA, Brüwer M, Harustiak T, Kinoshita T, Fujita T, Daiko H, Li Z, Ruurda JP, and van Hillegersberg R

Abstract

Competing Interests: Disclosures: An Intuitive Robotic Clinical Research Grant was provided in 2018 to support the setup of the registry for a duration of 1 year. No funding was requested nor received for the current study.

Published
2025
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49. The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry.

Author

Kooij CD, de Jongh C, Kingma BF, van Berge Henegouwen MI, Gisbertz SS, Chao YK, Chiu PW, Rouanet P, Mourregot A, Immanuel A, Mala T, van Boxel GI, Carter NC, Li H, Fuchs HF, Bruns CJ, Giacopuzzi S, Kalff JC, Hölzen JP, Juratli MA, Benedix F, Lorenz E, Egberts JH, Haveman JW, van Etten B, Müller BP, Grimminger PP, Berlth F, Piessen G, van den Berg JW, Milone M, Luketich JD, Sarkaria IS, Sallum RAA, van Det MJ, Kouwenhoven EA, Brüwer M, Harustiak T, Kinoshita T, Fujita T, Daiko H, Li Z, Ruurda JP, and van Hillegersberg R

Subjects
Humans, Male, Female, Middle Aged, Prospective Studies, Aged, Minimally Invasive Surgical Procedures methods, Follow-Up Studies, Prognosis, Postoperative Complications epidemiology, Esophagectomy methods, Esophageal Neoplasms surgery, Esophageal Neoplasms pathology, Robotic Surgical Procedures methods, Registries
Abstract

Background: Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted in centers worldwide, with ongoing refinements to enhance results. This study aims to assess the current state of RAMIE worldwide and to identify potential areas for improvement., Methods: This descriptive study analyzed prospective data from esophageal cancer patients who underwent transthoracic RAMIE in Upper GI International Robotic Association (UGIRA) centers. Main endpoints included textbook outcome rate, surgical techniques, and perioperative outcomes. Analyses were performed separately for intrathoracic (Ivor-Lewis) and cervical anastomosis (McKeown), divided into three time cohorts (2016-2018, 2019-2020, 2021-2023). A sensitivity analysis was conducted with cases after the learning curve (> 70 cases)., Results: Across 28 UGIRA centers, 2012 Ivor-Lewis and 1180 McKeown procedures were performed. Over the time cohorts, textbook outcome rates were 39%, 48%, and 49% for Ivor-Lewis, and 49%, 63%, and 61% for McKeown procedures, respectively. Fully robotic procedures accounted for 66%, 51%, and 60% of Ivor-Lewis procedures, and 53%, 81%, and 66% of McKeown procedures. Lymph node yield showed 27, 30, and 30 nodes in Ivor-Lewis procedures, and 26, 26, and 34 nodes in McKeown procedures. Furthermore, high mediastinal lymphadenectomy was performed in 65%, 43%, and 37%, and 70%, 48%, and 64% of Ivor-Lewis and McKeown procedures, respectively. Anastomotic leakage rates were 22%, 22%, and 16% in Ivor-Lewis cases, and 14%, 12%, and 11% in McKeown cases. Hospital stay was 13, 14, and 13 days for Ivor-Lewis procedures, and 12, 9, and 11 days for McKeown procedures. In Ivor-Lewis and McKeown, respectively, the sensitivity analysis revealed textbook outcome rates of 43%, 54%, and 51%, and 47%, 64%, and 64%; anastomotic leakage rates of 28%, 18%, and 15%, and 13%, 11%, and 10%; and hospital stay of 11, 12, and 12 days, and 10, 9, and 9 days., Conclusions: This study demonstrates favorable outcomes over time in achieving textbook outcome after RAMIE. Areas for improvement include a reduction of anastomotic leakage and shortening of hospital stay., Competing Interests: Disclosure: Mark van Berge Henegouwen: Consulting or advisory role: Viatris, Johnson & Johnson, BBraun, Stryker, Medtronic. Philippe Rouanet, Anne Mourregot, Gijs van Boxel, Marc van Det, Ewout A. Kouwenhoven: Consulting or advisory role: Intuitive Surgical. Peter Grimminger: Consulting or advisory role: Intuitive Surgical, Medicaroid. Guillaume Piessen: Consulting or advisory role: BMS, Nestlé, Astellas Pharma, Daiichi; travel or accommodation: Medtronic, MSD. Inderpal Sarkaria: Teaching, consulting, research grants, co-founder and/or advisory: CMR, Intuitive, Medtronic, Stryker, OTL, Activ Surgical, AMSI, VAIM, Oncolys. Takahiro Kinoshita: Honorarium for lectures for Intuitive Surgical. Jelle Ruurda: Consulting or advisory role: Intuitive Surgical, Medtronic. Richard van Hillegersberg: Consulting or advisory role: Intuitive Surgical, Medtronic, Olympus. Cas de Jongh: Research grant in 2018 for a period of 1 year to make a start with establishing the UGIRA Esophageal Registry, provided by Intuitive (this is mentioned in the manuscript). Philip Chiu: Cornerstone Robotics Co. Ltd; serves as a Board member with stock options. Nicholas Carter: Proctor for Intuitive Surgical teaching robotic surgery to other hospitals. Christiane Bruns: Advisory board, Medtronic; oral presentations, AstraZeneca; grant support, Sirtex; Editorial Board, MedUpdate; research grant, Stryker. James Luketich: Owns stock in Intuitive Surgical but this represents <5% of his investments and does not influence his research. Suzanne Gisbertz: J&J (money paid to institution, not to her personally); Medicaroid (money paid to institution, not to her personally); Olympus (money paid to institution, not to her personally). Cezanne D. Kooij, B. Feike Kingma, Yin-Kai Chao, Arul Immanuel, Tom Mala, Hecheng Li, Hans F. Fuchs, Simone Giacopuzzi, Jörg C. Kalff, Jens-Peter Hölzen, Mazen A. Juratli, Frank Benedix, Eric Lorenz, Jan-Hendrik Egberts, Jan W. Haveman, Boudewijn van Etten, Beat P. Müller, Felix Berlth, Jan W. van den Berg, Marco Milone, Rubens A.A. Sallum, Matthias Brüwer, Tomas Harustiak, Takeo Fujita, Hiroyuki Daiko, and Zhigang Li have declared no conflicts of interest that may be relevant to the contents of this study., (© 2024. The Author(s).)

Published
2025
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50. Impact of pre-treatment waiting intervals on short-term postoperative outcomes in neoadjuvant chemotherapy followed by gastrectomy: A population-based study using the Dutch Upper Gastrointestinal Cancer Audit (DUCA) data.

Author

Wang J, de Jongh C, Wu Z, de Groot EM, Markar SR, Brenkman HJF, van Hillegersberg R, and Ruurda JP

Abstract

Introduction: The pre-treatment waiting interval of gastric cancer patients receiving neoadjuvant chemotherapy (nCT) followed by gastrectomy includes pre-nCT (diagnosis to nCT) and preoperative (diagnosis to surgery) waiting intervals. This study aimed to investigate the impact of these two distinct intervals on short-term postoperative outcomes., Methods: Patients (cT1-4aN0-3M0) who underwent nCT plus gastrectomy were included using the Dutch national DUCA-database. Multivariate logistic regression was used to determine the impact of the two waiting intervals upon short-term postoperative outcomes: pre-nCT waiting intervals (≤5, 5-8 and 8-12 weeks) and preoperative waiting intervals (≤17, 17-22, and >22 weeks)., Results: Between 2010 and 2021, 1242 patients were included. Compared to the pre-nCT waiting interval ≤5 weeks, the longer intervals (5-8 and 8-12 weeks) were not associated with worse 30-day mortality (p-value = 0.707; p-value = 0.900), overall complications (p-value = 0.733; p-value = 0.453), pulmonary complications (p-value = 0.250; p-value = 0.238), gastrointestinal complications (p-value = 0.396; p-value = 0.992), re-interventions (p-value = 0.407; p-value = 0.072) and 30-day readmission (p-value = 0.992; p-value = 0.664). Compared to the preoperative waiting interval ≤17 weeks, the longer intervals (17-22 and > 22 weeks) were also not associated with worse 30-day mortality (p-value = 0.926; p-value = 0.732), overall complications (p-value = 0.286; p-value = 0.510), pulmonary complications (p-value = 0.912; p-value = 0.351), gastrointestinal complications (p-value = 0.765; p-value = 0.882), re-interventions (p-value = 0.617; p-value = 0.800) and 30-day readmission (p-value = 0.592; p-value = 0.782)., Conclusion: A longer pre-nCT or preoperative waiting interval is not associated with worse short-term postoperative outcomes in Western gastric cancer patients undergoing nCT plus gastrectomy., (Copyright © 2025. Published by Elsevier Ltd.)

Published
2025
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