Background: Postoperative management of patients undergoing visceral surgery can present challenging clinical situations with significant morbidity and mortality. Interventional radiological techniques offer quick, safe, and effective minimally invasive treatment options in the postoperative management of visceral surgery. Summary: Most commonly done procedures include – but are not limited to – fluid or abscess drainage, biliary diversion, bleeding embolization, and re-canalization of a thrombosed vessel. While bleeding from side branches after hepatobiliary and pancreatic surgeries can be managed by coil embolization, the hepatic arterial injury should be managed by stent-graft placement. Hepatic venous complications can require a transhepatic or transjugular approach, whereas the transjugular intrahepatic portosystemic shunt approach has a higher clinical success rate in patients with portal vein thrombosis. Biliary leakages require multidisciplinary management, and interventional radiology can offer an efficient treatment, especially in patients with biliodigestive anastomosis. Key Messages: Interventional radiology provides a broad spectrum of procedures in the management of patients with recent visceral surgery.

In the case of adverse events, postoperative management after major abdominal surgery can become challenging. In order to avoid an increase in postoperative morbidity and mortality, all treatment options – including operative and nonoperative – should be available at any time in the perioperative period. Independent of the type of surgery, the most frequent complications are related to infection or bleeding, whereas some surgical procedures have unique complications [1, 2]. High-volume centers have been shown to have lesser postoperative complications [3, 4]. However, complex and challenging visceral procedures in certified centers require high expertise in interventional radiology (IR).

Complication management should be performed in an interdisciplinary and transparent manner with the involvement of the responsible surgeon. In particular, the potential options with the associated therapeutic chances and morbidities should be discussed in multidisciplinary boards. In life-threatening situations, a quick meeting by the CT console and referral of the patient directly to the operation room or angiography suite prevents the time delay. In general, complications that occur after a longer time interval after surgery are particularly indicative of an interventional approach. With the technical developments and advancements in minimally invasive procedures, IR management has become one of the mainstay options for various postoperative situations in clinically stable patients that do not require immediate redo surgery and also in unstable patients when surgical options are limited [5, 6]. Here, we present a comprehensive review of interventional techniques that should be part of the armamentarium for postoperative management after abdominal surgery.

Image-guided aspiration and drainage is an established technique for treating collections of various organs/anatomical spaces [7]. The indications, techniques, guiding imaging modalities, and management of catheter drainage differ slightly from center to center. It is used to sample or drain the percutaneous accessible collections in patients who do not require immediate surgical management. Ultrasound and CT are the primary imaging modalities to guide drainage procedures [7]. Other modern, less commonly used imaging modalities include magnetic resonance imaging and cone beam CT [8, 9].

With advancements in noninvasive imaging modalities, diagnostic arteriography has been replaced mainly by CT or MR angiography and is reserved for cases with equivocal findings in imaging or when angiographic treatment is indicated [10, 11]. Although bleeding is the most common indication for vascular intervention during the postsurgical period, arterial or venous stenosis and thrombosis can also be managed interventionally. Catheter-directed thrombectomy or thrombolysis can be utilized in patients with thrombosis, and balloon angioplasty or stent placements are further options for the treatment of stenosis. With support of modern materials, such as microcatheter systems, selective catheterization and embolization help preserve as much healthy tissue as possible. The choice of embolic agents depends on the indication and location of vascular pathology. The most commonly used agents are gelatin sponge, microparticles, metallic coils, vascular plugs, or cyanoacrylates [12]. Considering most patients would be followed in surgical wards after the procedures, effective communication on postprocedural care with primary and consulting services and nursing staff education is essential. A well-structured procedural note should provide clear instructions and guidelines for nursing staff, including specific situations to alert the physicians.

Postoperative management is primarily directed by the visceral surgeon. In the case of instability or significant blood loss, patients must undergo immediate surgical revision. In modern patient-tailored medicine, the routine clinical practice strives for interdisciplinary management that includes radiologic intervention in a variety of settings.

Interventional Management after Surgery of the Upper Gastrointestinal Tract

In the following, the focus is on surgery of the upper gastrointestinal tract, including gastric surgery, hepatobiliary and pancreatic surgery. It should be noted that the potential complications and their management have quite a few parallels.

Interventional Management after Gastric and Bariatric Surgery

Interventional therapies can be management options during the postoperative period of benign etiologies such as perforated gastric ulcers, bariatric surgeries, or malign diseases like stomach cancer, lymphoma, or gastrointestinal stromal tumors. Bariatric surgery gained popularity with the increasing prevalence of obesity. Although there are several techniques defined – the most common being Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding – postoperative complications of obesity surgery can be summarized in two major groups: bleeding and anastomosis insufficiency [13]. The most common complication following bariatric surgery is extraluminal leakage, reported in up to 6% of the cases [14]. Although this will be treated mainly by repetitive surgeries and/or endoscopic stent-graft placement, IR usually supports management with CT- or US-guided drainage of infectious collections. Additionally, endoscopic vacuum therapy is a promising alternative option with a fistulous orifice closure rate of 81.6% [15].

Another serious complication of bariatric surgery is bleeding and has been reported to occur in less than 1% of the surgeries mentioned above [16]. However, in patients with a confirmed postoperative leakage, the bleeding rates can increase up to 10% [17]. Once clinically suspected through fresh blood in drainages or the presence of hypovolemic symptoms, multiphase CT imaging is needed to identify and localize the potential bleeding. Bleeding localization is dependent on the surgical technique used; the most common bleeding site being the stapler-line bleeding after sleeve gastrectomy, and bleeding or pseudoaneurysm formation in branches of the gastroduodenal artery, especially after an Roux-en-Y gastric bypass operation [18]. CT angiography has 84.8% sensitivity and 96.9% of specificity to identify the bleeding focus in patients with gastrointestinal bleeding [19]. Initial studies with helical CT showed that bleeding rate of 0.5 mL/min can be detected with CT [20]. In case of intraluminal bleeding, endoscopic management is the initial treatment option [21]. In patients with extraluminal bleeding or failed endoscopy for intraluminal bleeding confirmed with CT, bleeding can be primarily managed via angiographic approach using coils for a vascular occlusion [17].

Interventional Management after Hepatobiliary and Pancreatic Surgery

Hepatobiliary complications mainly occur after liver resection, liver transplantation, and cholecystectomy but can also be seen after minimally invasive biliary procedures and pancreatic or gastric surgery due to proximity. Despite the refinements in surgical technique and improvements in patient care, pancreatic resections are still associated with significant morbidity and mortality. The reported overall complication rates are up to 45–68%, and serious complication rates at 25% according to the literature [22, 23]. Pancreatic fistulas are seen approximately after 20% of pancreatic surgeries with most of the serious complications related to free pancreatic enzymes [23]. Additionally, vascular resection during pancreatic surgery has been shown to increase postoperative morbidity, including bleeding complications [24]. The most common complications requiring interventional management after hepatobiliary and pancreatic surgeries are intra-abdominal fluid collections and abscesses, biliary complications, injury to the hepatic artery, portal or hepatic veins.

Hepatic arterial injury is a potentially fatal complication of hepatobiliary and pancreatic surgeries. It can be seen in up to 10% of liver or pancreatic surgeries [25-27]; however, it may be lower in high-volume centers [28]. Early bleeding within 48 h after surgery can usually be managed by re-operation, and interventional treatment can address delayed bleeding (e.g., due to arterial erosion). In most cases, bleeding is delayed and results from accompanied anastomosis leakage or postsurgical infectious collections, which destruct the arterial wall [29]. In more than half of the cases, bleeding is either from pancreatic anastomosis or splanchnic arteries [26]. Sentinel bleeding is an important indicator of a subsequent serious bleeding. CT is crucial to confirm a diagnosis and guide interventional treatment. Management of hepatic arterial injury should aim to control the bleeding with preservation of the liver’s arterial supply. Although accompanying pathologies generally require a definitive surgery to correct the anastomosis problem, surgery in acute conditions is associated with significant morbidity and mortality. Additionally, the bleeding site may not be visualized due to dense adhesions, inflammation, and hematoma [30, 31].

Initial reports on interventional management of hepatic arterial bleeding have reported high technical success rates for embolization of the hepatic artery with coils. However, there was a significant risk for hepatic infarction and failure, even if the second inflow to the liver via portal vein was patent [32]. This risk is higher in patients who underwent a major liver resection or liver transplantation [33, 34]. Studies have shown that embolization of the hepatic artery resulted in either re-transplantation or death in patients with recent liver transplantation. To overcome this problem, embolization of the pseudoaneurysm sac has been suggested in patients without active extravasation. However, probably due to fragile vessel wall and ongoing inflammation, a coil package usually fails to produce a durable embolization with re-bleeding rates up to 100% having been reported [35].

With improvements in catheter and delivery system technology, low-profile stent-graft systems have been developed, which allow for the treatment of small and tortuous arteries, such as visceral arteries, with stent-grafts (shown in Fig. 1). Initial studies have reported promising results in patients with hepatic arterial bleeding [36, 37]. Several case series have reported high technical and clinical success after stent-graft implantation. Stent-grafts also offer faster exclusion of the vascular pathology than coils, which is especially important in patients with hemorrhagic shock. However, stent-grafts are associated with a considerable risk of patency loss, especially in cases with stent-graft implantation to distal arteries. Previous studies have reported up to a 55% stent-graft occlusion during follow-up [38]. Early imaging follow-ups have shown partial thrombosis or edge stenoses within the stent-grafts, which indicates that the stent-graft occlusion is an ongoing process and allows development of collaterals to the liver [39]. Also, endothelization of covered stents takes longer than bare metal stents [40]. As a result, stent-graft occlusion is mostly asymptomatic. Nevertheless, a dual antiplatelet regimen should be pursued for at least 6 months followed by life-long ASA, when possible. Furthermore, other branches of the celiac trunk should be preserved to maintain collaterals during deployment of the stent-graft, which is especially important in patients with major resection, like after pancreatectomy; there is a conflict in overstenting the left gastric artery regarding a potential gastric ischemia.

Fig. 1.

a CT images obtained due to bloody drainage 13 days after Whipple operation due to pancreatic carcinoma show pseudoaneurysm (white arrowhead) of the common hepatic artery in a patient with postoperative pancreatic fistula. b Emergent celiac angiography shows pseudoaneurysm (dashed arrow) and wall irregularities at the common hepatic artery. c Control angiography after the deployment of a stent-graft shows complete exclusion of the pseudoaneurysm from circulation. d Follow-up CT image in coronal view reveals no residual filling in the pseudoaneurysm and patency of the stent-graft.

Fig. 1.

a CT images obtained due to bloody drainage 13 days after Whipple operation due to pancreatic carcinoma show pseudoaneurysm (white arrowhead) of the common hepatic artery in a patient with postoperative pancreatic fistula. b Emergent celiac angiography shows pseudoaneurysm (dashed arrow) and wall irregularities at the common hepatic artery. c Control angiography after the deployment of a stent-graft shows complete exclusion of the pseudoaneurysm from circulation. d Follow-up CT image in coronal view reveals no residual filling in the pseudoaneurysm and patency of the stent-graft.

Close modal

In patients with bleeding from small side branches, coil embolization is the preferred technique. Due to the risk of re-bleeding through the collaterals, both inflow and outflow (front- and backdoor) vessels should be embolized. In patients with coagulation problems, liquid embolic agents could be preferred; however, the risk of pancreatitis should be considered in patients with partial pancreatectomy.

Hepatic arterial thrombosis is the most common vascular complication of liver transplantation [41]. The onset depends on the etiology and can be seen months after transplantation. Early thrombosis is usually related to surgical technique and should be managed with prompt surgical correction or with re-transplantation. The clinical presentation can range from delayed bile leaks, perihepatic fluid collections, sepsis, to acute fulminant hepatic failure [29]. In patients with hepatic arterial thrombosis, selective catheterization of the hepatic arterial stump with a microcatheter and infusion of thrombolytics can restore the flow, and balloon dilatation and stenting should follow in case of underlying stenosis [42]. In patients with concomitant steal syndrome, the vessel that causes the steal (splenic or gastroduodenal artery) can be embolized in the same session [43]. Possible complications of endovascular treatment of hepatic arterial thrombosis are dissection or rupture of the hepatic artery, or bleeding from the anastomosis.

Clinical presentation of hepatic arterial stenosis is usually milder and later than thrombosis. Technical and clinical success rates have been reported up to 90% after balloon angioplasty and 1-year patency rates around 60–80% [44]. In patients with suboptimal results after balloon angioplasty, stent implantation can be deployed. In liver transplantation patients treated with metallic stents, 1-year patency rates are around 50% [45].

Portal vein stenosis is a rare complication seen after 3% of liver transplantations [46]. Clinical symptoms are related to increased portal pressure and can lead to bleeding from varices, splenomegaly, and ascites. Portal access can be obtained either via percutaneous puncture of the intrahepatic portal branches or with the transjugular intrahepatic portosystemic shunt (TIPS) approach. Although balloon angioplasty could be utilized in these patients, due to postsurgical fibrotic changes, re-stenosis and need for a second procedure is high. A recent systematic review of 393 patients who had interventional treatment due to portal vein stenosis after liver transplantation showed higher technical success and lower re-stenosis rates after primary stenting in relation to angioplasty alone [47].

Portal vein thrombosis can be seen after splenectomy or laparoscopic surgeries. Although systemic anticoagulation for at least 6 months is the recommended treatment, interventional recanalization should be pursued in patients with impending intestinal ischemia [48]. A randomized trial showed higher recanalization rates after interventional treatment (37% vs. 71%, p < 0.001), despite the higher thrombus burden in the interventional arm at baseline [49]. However, a treatment approach was at the discretion of each center, and the optimal interventional treatment sequence is still not clear. In patients with significant ascites or complete thrombosis of intrahepatic portal branches, the TIPS approach should be preferred. Additionally, due to better outflow after TIPS, this approach might offer a more durable recanalization [50]. Despite the risk of re-thrombosis of TIPS, a previous randomized trial evaluating anticoagulation after TIPS in patients with cirrhotic portal vein thrombosis showed that anticoagulation did not result in significant increase in recanalization rate [51].

Although it is rare, with an incidence of 1% after liver transplantation, inferior vena cava stenosis can be seen due to problems in surgical technique or the development of a fibrous scar at the anastomosis [52]. Hepatic venous stenosis at the level of anastomosis could accompany in cases with a fibrous scar. Patients present with refractory ascites, pleural effusion, edema at lower extremities, and an increase in hepatic and renal markers. Catheter-directed pressure measurements should be done on both sides of the anastomosis with balloon angioplasty being the initial option for treatment. In patients with resistant stenosis, a bare metal stent can be placed (shown in Fig. 2) [53].

Fig. 2.

a Hepatic arteriography of a patient with increase in transaminases after liver transplantation shows decreased arterial perfusion and widespread spasm in hepatic artery branches. Microcatheter was left in place for overnight prostaglandin infusion. b Follow-up CT image shows deterioration of hepatic flow with development of sinusoidal obstruction syndrome. Portal vein (asterisk) is not opacified in late venous phase. c Transjugular intrahepatic portal shunt (TIPS) was decided to bridge patient for a second liver transplantation. Portography shows dilatation of preanastomotic portal vein with filiform filling of intrahepatic branches and opacification of collaterals (arrowhead). d After creation of TIPS (black dashed arrow), portal flow is redirected through the shunt, and collaterals are no longer visible. A slight stenosis is visible at the level of anastomosis (arrow). e Coronal CT image after second transplantation shows stenosis in inferior vena cava central to the anastomosis, f which is successfully treated with a stent.

Fig. 2.

a Hepatic arteriography of a patient with increase in transaminases after liver transplantation shows decreased arterial perfusion and widespread spasm in hepatic artery branches. Microcatheter was left in place for overnight prostaglandin infusion. b Follow-up CT image shows deterioration of hepatic flow with development of sinusoidal obstruction syndrome. Portal vein (asterisk) is not opacified in late venous phase. c Transjugular intrahepatic portal shunt (TIPS) was decided to bridge patient for a second liver transplantation. Portography shows dilatation of preanastomotic portal vein with filiform filling of intrahepatic branches and opacification of collaterals (arrowhead). d After creation of TIPS (black dashed arrow), portal flow is redirected through the shunt, and collaterals are no longer visible. A slight stenosis is visible at the level of anastomosis (arrow). e Coronal CT image after second transplantation shows stenosis in inferior vena cava central to the anastomosis, f which is successfully treated with a stent.

Close modal

Pseudoaneurysms of the hepatic vein or inferior vena cava are very rare after intra-abdominal surgeries but can present very late due to low pressure within the venous system. Embolization of the aneurysmal sac can be done in cases of small aneurysms, and stent-graft placement or embolization of the neck with vascular plugs are treatment options in large aneurysms [54, 55].

Biliary leakage after hepatobiliary surgery is rare but associated with increased morbidity and mortality [56]. Its incidence has increased due to more patients undergoing laparoscopic surgery and with operation of patients who would have been accepted as ineligible for surgery before. Biliary leakage can be seen up to 4% after open pancreatic surgeries [57]. The most common location of injury is the common bile duct after cholecystectomy, followed by ducts of Luschka (subvesical bile duct). In patients with liver transplantation, leakage usually occurs at the anastomosis of bile ducts or from hepaticojejunostomy but can also occur from the cut liver surface after living-donor transplantation [58]. Similarly, bile leakage can be seen from a cut liver surface or an insufficiently controlled bile duct stump, and due to injury to major bile ducts in patients with liver resection [59].

Biliary leakages should be managed by a multidisciplinary team involving surgeons, gastroenterologists, and interventional radiologists. The location and character of the leak, the possibility of further surgeries, and the time interval since the biliary injury should be considered for a treatment decision. Although endoscopic treatment is also an option in these patients, this approach is limited in patients with reconstruction of the biliary system. Early leaks (within 3 days) could be operated upon; however, an increased mortality rate of reoperation needs to be considered. In these patients, preoperative drainage of the biliary system could help surgeons not only to visualize obscure leaks but also serve as a scaffold for further anastomoses.

In patients with biliary leakage after hepatic resection, due to intense abdominal fibrosis and ongoing inflammation, surgical management is typically not preferred. Interventional management of these cases involves drainage of the biliary system and bilomas by percutaneous transhepatic biliary drainage [60]. This intervention helps decrease pressure within the biliary tract, redirect bile from the defect to enhance the healing process, stabilize the clinical condition of the patient, and control the infectious source (shown in Fig. 3). Although early self-limiting hemobilia has been reported in up to 20% of the cases treated interventionally, the rate of bleeding complications requiring additional measures is reported at around 2.5% [61]. Imaging-guided percutaneous drainage of bilomas should be done if immediate surgical repair is not indicated. Untreated bilomas could lead to peritonitis, sepsis, and extensive abdominal fibrosis [62].

Fig. 3.

a CT image of a patient history of renal and pancreas transplantation 14 years ago who underwent emergent operation due to duodenal perforation shows a large subhepatic collection (asterisk) with enhancing walls. Percutaneous drainage of the collection revealed a biloma. b Percutaneous transhepatic cholangiography shows leakage at common bile duct (arrow). Arrowhead shows the leakage in the biloma, which was treated by percutaneous transhepatic biliary drainage (PTBD). c Control cholangiography 2.5 months after the initial procedure showed no residual leakage, and catheter was removed. d Follow-up CT image shows complete resolution of biloma.

Fig. 3.

a CT image of a patient history of renal and pancreas transplantation 14 years ago who underwent emergent operation due to duodenal perforation shows a large subhepatic collection (asterisk) with enhancing walls. Percutaneous drainage of the collection revealed a biloma. b Percutaneous transhepatic cholangiography shows leakage at common bile duct (arrow). Arrowhead shows the leakage in the biloma, which was treated by percutaneous transhepatic biliary drainage (PTBD). c Control cholangiography 2.5 months after the initial procedure showed no residual leakage, and catheter was removed. d Follow-up CT image shows complete resolution of biloma.

Close modal

In patients with transections or uncrossable obstructions, external drainage may be needed. When possible, an internal-external drainage catheter should be placed. In patients with persistent leakage or accompanying stenosis, the catheter can be upsized gradually (e.g., from 8 to 14 French). Residual stenosis can be dilated with a compliant balloon. In patients with isolated bile duct injury, embolization with fibrin or histoacryl can be done. Fistulous communications can be embolized with coils or liquid agents, and in patients with localized injury of the common bile duct, placement of a stent-graft could seal the leak [63].

Intra-abdominal fluid collections represent the most common indication for interventional management. In cases where the procedure can be easily guided with ultrasound, US-guided drainage placement offers radiation-free real-time guidance. Additionally, considering the serious clinical condition of these patients, especially when sepsis is accompanying, these procedures can be done bedside using US. Collections located deep in the abdomen or ones that cannot be visualized sufficiently with US can be drained under CT guidance (shown in Fig. 4). Although the trocar technique could provide faster drainage, a stepwise dilatation with Seldinger technique is particularly safer and thus recommended. Contrast injections after catheter placement can be used to diagnose an underlying fistula. Previous reports have shown technical and clinical success rates of percutaneous drainage up to 97 and 79%, after pancreatic surgeries [64, 65].

Fig. 4.

Axial (a) and coronal (b) CT image of a patient with septic findings after distal pancreatectomy shows a fluid collection (asterisks) in the surgical area. The stomach located anterior to the collection, which restricts visualization of collection with ultrasound. c Catheterization of the collection with a needle under CT fluoroscopy. d Control CT image at the end of the procedure shows correct placement of the catheter.

Fig. 4.

Axial (a) and coronal (b) CT image of a patient with septic findings after distal pancreatectomy shows a fluid collection (asterisks) in the surgical area. The stomach located anterior to the collection, which restricts visualization of collection with ultrasound. c Catheterization of the collection with a needle under CT fluoroscopy. d Control CT image at the end of the procedure shows correct placement of the catheter.

Close modal

Lymphatic complications after pancreatic surgery are rarely encountered, and conservative treatment with dietary modifications is effective in most cases. In cases with persistent leakage, percutaneous lymphangiography and embolization could help seal the leakage [66].

Interventional Management after Surgery of the Lower Gastrointestinal Tract

IR provides a quick, effective, and minimally invasive approach in the management of the lower GI tract, such as anastomosis insufficiency and gastrointestinal bleedings after colorectal surgery. Patients with partial or total colonic resections can develop diverse complications such as fluid collections due to insufficiencies and bleeding on the anastomosis surface. Anastomosis leakages can be seen in up to 7% of colonic surgeries and should be managed surgically [67]. IR can help as a bridging treatment to cool down a septic situation in the patient, e.g., by abscess drainage, until the definitive surgical revision can be carried out [68]. A close follow-up, an intensive, multidisciplinary approach, and an aggressive drainage strategy such as placement of large-bore systems and repetitive flushing of the catheters should be endorsed [69].

In case surgery or endoscopy is not primarily expedient, interventional radiological methods can help locate or even stop the bleeding [70, 71]. After marking the bleeding source with a catheter-directed injection of methylene blue, the bleeding segment can be surgically resected [72]. Once acute arterial bleeding is proven in CT, the main principles in intestinal bleeding embolization are applicable; proximal embolization should be avoided due to the extensive gastrointestinal collateral network. Moreover, further broad embolization with particles or liquid embolic agents should be avoided due to potential risks of mucosal ischemia [71].

Both the superior mesenteric artery and the inferior mesenteric artery should be angiographically checked in detail for potential anastomoses with the aim of excluding any backdoor supply to the bleeding branch [73]. After catheterization of the target vessel with a microcatheter, coils should be preferred for an adequate embolization, covering the distal and proximal parts of the extravasation site (shown in Fig. 5) [74].

Fig. 5.

Coronal arterial-phase (a) and axial venous-phase (b) CT images of a patient with renal transplantation who underwent hemicolectomy and ileal resection due to peritonitis-related intestinal perforation show contrast extravasation from sigmoid colon (dashed arrow) with venous pooling. Angiographies from inferior mesenteric artery (c) and after superselective catheterization (d) confirm active bleeding (arrowheads). e Control angiography after superselective coil embolization of the injured vessel proximal and distal due to bleeding (front- and backdoor technique) shows complete cessation of hemorrhage.

Fig. 5.

Coronal arterial-phase (a) and axial venous-phase (b) CT images of a patient with renal transplantation who underwent hemicolectomy and ileal resection due to peritonitis-related intestinal perforation show contrast extravasation from sigmoid colon (dashed arrow) with venous pooling. Angiographies from inferior mesenteric artery (c) and after superselective catheterization (d) confirm active bleeding (arrowheads). e Control angiography after superselective coil embolization of the injured vessel proximal and distal due to bleeding (front- and backdoor technique) shows complete cessation of hemorrhage.

Close modal

Interventional radiological techniques offer quick, safe, and effective minimally invasive treatment options in diverse clinical conditions of visceral surgery patients.

The authors have no conflicts of interest to declare.

The authors did not receive any funding for this manuscript.

Sinan Deniz, Osman Öcal, and Florian Streitparth: conception and design of the study, drafting or revision of the manuscript, and approval of the final version of the manuscript. Florian Kühn, Martin Kurt Angele, and Jens Werner: revision of the manuscript and approval of the final version of the manuscript.

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