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Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Long-term Fecal Incontinence, Recurrence, Satisfaction, and Regret After the Transobturator Postanal Sling Procedure. Female Pelvic Med Reconstr Surg 2021; 27:244-248. [PMID: 31425371 DOI: 10.1097/spv.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to assess long-term outcomes after the transobturator postanal sling (TOPAS) procedure for the treatment of fecal incontinence. Long-term recurrence, satisfaction and regret after transobturator postanal sling procedure support the ongoing use of this procedure for patients with fecal incontinence. METHODS Both a retrospective review of medical records and a prospective telephone survey were conducted. For the retrospective review of medical records, all patients who underwent the TOPAS procedure at our institution were eligible. Medical records were reviewed to assess for symptom resolution, retreatment, and complications. For the prospective telephone survey, patients who were conversant in English and had a valid contact information were eligible and were asked to complete questions on satisfaction, the Patient Global Impression of Improvement, the Wexner Symptom Severity Score, the Fecal Incontinence Qualify of Life Scale, and the modified Decision Regret Scale. RESULTS A total of 134 patients met the inclusion criteria for the retrospective medical record review. Patients were followed in clinic for a median of 24.0 months (interquartile range, 6.0-53.0). Overall, 75.4% reported improvement in fecal incontinence. There were 37 (27.6%) who required subsequent treatment for fecal incontinence. There were 67 patients eligible for the prospective telephone survey, of whom 46 (68.7%) agreed to participate. Median time between surgery and the telephone survey was 63.5 months (interquartile range, 36.0-98.0). Among these participants, 54.3% were satisfied and 60.9% would recommend the procedure to someone else. No adverse events were identified with long-term follow-up. CONCLUSIONS Our findings suggest that the TOPAS procedure remains a safe and effective therapy for the treatment of fecal incontinence with favorable long-term outcomes.
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Mege D, Meurette G, Brochard C, Damon H, Lambrescak E, Faucheron JL, Wyart V, Lehur PA, Sielezneff I, Siproudhis L, Mion F, Etienney I, Houivet E, Bridoux V, Leroi AM. Sacral nerve modulation for faecal incontinence: influence of age on outcomes and complications. A multicentre study. Colorectal Dis 2019; 21:1058-1066. [PMID: 30985984 DOI: 10.1111/codi.14649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/02/2019] [Indexed: 02/08/2023]
Abstract
AIM Faecal incontinence is frequent in the elderly. Little is currently known about the efficacy of sacral nerve modulation (SNM) in the elderly. The present study aimed to assess the impact of age on the outcome of SNM and on the surgical revision and explantation rates by comparing the results of a large data set of patients. METHOD Prospectively collected data from patients who underwent an implant procedure between January 2010 and December 2015 in seven French centres were retrospectively evaluated. In total, 352 patients [321 women; median age (range): 63 (24-86) years] were included. Clinically favourable and unfavourable outcomes, and surgical revision and explantation rates, were compared according to the age of the patients. RESULTS A similar outcome was observed when comparing patients < 70 years and ≥ 70 years (a favourable outcome in 79.2% and 76.2%, respectively, P = 0.89). The probability of a successful treatment as a function of time was similar for the two age groups (< 70 years and ≥ 70 years, P = 0.54). The explantation and revision rates were not influenced by age (explantation rate: 17% in patients < 70 years vs 14% in patients ≥ 70 years, P = 0.89; and revision rate: 42% in patients < 70 years vs 40% in patients ≥ 70 years, P = 0.89). The probability of explantation as a function of time was similar for the two age groups (P = 0.82). The limitations of this study were its retrospective status, the rate of loss at follow-up and different durations of patient follow-up. CONCLUSIONS Our results suggest that patients ≥ 70 years suffering from faecal incontinence benefit from SNM with a similar risk as a younger population.
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Affiliation(s)
- D Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - G Meurette
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France
| | - C Brochard
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, CHU Pontchaillou, CIC1414, INPHY, INSERM U1241, Université de Rennes 1, Rennes, France
| | - H Damon
- Digestive Physiology, University Hospital of Lyon, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - E Lambrescak
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - J-L Faucheron
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - V Wyart
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France
| | - P-A Lehur
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France.,Department of General Surgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - I Sielezneff
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - L Siproudhis
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, CHU Pontchaillou, CIC1414, INPHY, INSERM U1241, Université de Rennes 1, Rennes, France
| | - F Mion
- Digestive Physiology, University Hospital of Lyon, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - I Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - E Houivet
- Biostatistics Unit, INSERM CIC 1404, Rouen, France
| | - V Bridoux
- Department of Digestive Surgery, Normandie Univ, UNIROUEN Inserm U1073, Rouen University Hospital, Rouen, France
| | - A-M Leroi
- Department of Digestive Physiology and CIC-CRB 1404, Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Rouen, France
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Brochard C, Mege D, Bridoux V, Meurette G, Damon H, Lambrescak E, Faucheron JL, Trilling B, Lehur PA, Wyart V, Sielezneff I, Mion F, Etienney I, Leroi AM, Siproudhis L. Is Sacral Nerve Modulation a Good Option for Fecal Incontinence in Men? Neuromodulation 2019; 22:745-750. [PMID: 31318471 DOI: 10.1111/ner.13017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women. METHOD Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women. RESULTS A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively). CONCLUSION Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.
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Affiliation(s)
- Charlène Brochard
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
| | - Diane Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - Valérie Bridoux
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Henri Damon
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Elsa Lambrescak
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Jean-Luc Faucheron
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Bertrand Trilling
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Paul-Antoine Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France.,Department of General Surgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - Vincent Wyart
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Igor Sielezneff
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - François Mion
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Isabelle Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Anne-Marie Leroi
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Laurent Siproudhis
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
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Goldman HB, Lloyd JC, Noblett KL, Carey MP, Castaño Botero JC, Gajewski JB, Lehur PA, Hassouna MM, Matzel KE, Paquette IM, de Wachter S, Ehlert MJ, Chartier-Kastler E, Siegel SW. International Continence Society best practice statement for use of sacral neuromodulation. Neurourol Urodyn 2018; 37:1823-1848. [PMID: 29641846 DOI: 10.1002/nau.23515] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
AIMS Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. METHODS Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. RESULTS The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. CONCLUSIONS These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.
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Affiliation(s)
- Howard B Goldman
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica C Lloyd
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karen L Noblett
- Axonics Modulation Technologies and Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Marcus P Carey
- Division of Urogynaecology, Frances Perry House, Parkville, Victoria, Australia
| | | | - Jerzy B Gajewski
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul A Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Universite de Nantes, Nantes, France
| | - Magdy M Hassouna
- Division of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Klaus E Matzel
- Division of Coloproctology, University of Erlangen, Erlangen, Germany
| | - Ian M Paquette
- Department of Surgery, Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stefan de Wachter
- Department of Urology, University Hospital Antwerpen, University of Antwerpen, Belgium
| | | | - Emmanuel Chartier-Kastler
- Department of Urology, Academic Hospital Pitié-Salpétrière, Medical School Sorbonne Université, Paris, France ECK
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Rydningen MB, Dehli T, Wilsgaard T, Lindsetmo RO, Kumle M, Stedenfeldt M, Norderval S. Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation. Colorectal Dis 2017; 19:274-282. [PMID: 27463362 DOI: 10.1111/codi.13472] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/30/2016] [Indexed: 12/17/2022]
Abstract
AIM The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. METHOD This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. RESULTS Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P = 0.04), body mass index (BMI) (P = 0.03) and pain during PNE (P = 0.046) but not to the extent of the sphincter defect (P = 0.1). Responders had a higher St Mark's score than nonresponders (P = 0.046). CONCLUSIONS The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.
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Affiliation(s)
- M B Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Dehli
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Wilsgaard
- Department of Community Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - R O Lindsetmo
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - M Kumle
- Department of Radiology, University Hospital of North Norway, Tromsoe, Norway.,Narvik University College, Narvik, Norway
| | - M Stedenfeldt
- National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
| | - S Norderval
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway.,National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
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Bielefeldt K. Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration. World J Gastrointest Pharmacol Ther 2016; 7:294-305. [PMID: 27158546 PMCID: PMC4848253 DOI: 10.4292/wjgpt.v7.i2.294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/23/2016] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the nature and severity of AE related to sacral neurostimulation (SNS).
METHODS: Based on Pubmed and Embase searches, we identified published trials and case series of SNS for fecal incontinence (FI) and extracted data on adverse events, requiring an active intervention. Those problems were operationally defined as infection, device removal explant or need for lead and/or generator replacement. In addition, we analyzed the Manufacturer and User Device Experience registry of the Federal Drug Administration for the months of August - October of 2015. Events were included if the report specifically mentioned gastrointestinal (GI), bowel and FI as indication and if the narrative did not focus on bladder symptoms. The classification, reporter, the date of the recorded complaint, time between initial implant and report, the type of AE, steps taken and outcome were extracted from the report. In cases of device removal or replacement, we looked for confirmatory comments by healthcare providers or the manufacturer.
RESULTS: Published studies reported adverse events and reoperation rates for 1954 patients, followed for 27 (1-117) mo. Reoperation rates were 18.6% (14.2-23.9) with device explants accounting for 10.0% (7.8-12.7) of secondary surgeries; rates of device replacement or explant or pocket site and electrode revisions increased with longer follow up. During the period examined, the FDA received 1684 reports of AE related to SNS with FI or GI listed as indication. A total of 652 reports met the inclusion criteria, with 52.7% specifically listing FI. Lack or loss of benefit (48.9%), pain or dysesthesia (27.8%) and complication at the generator implantation site (8.7%) were most commonly listed. Complaints led to secondary surgeries in 29.7% of the AE. Reoperations were performed to explant (38.2%) or replace (46.5%) the device or a lead, or revise the generator pocket (14.6%). Conservative management changes mostly involved changes in stimulation parameters (44.5%), which successfully addressed concerns in 35.2% of cases that included information about treatment results.
CONCLUSION: With reoperation rates around 20%, physicians need to fully disclose the high likelihood of complications and secondary interventions and exhaust non-invasive treatments, including transcutaneous stimulation paradigms.
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Duelund-Jakobsen J, Worsoe J, Lundby L, Christensen P, Krogh K. Management of patients with faecal incontinence. Therap Adv Gastroenterol 2016; 9:86-97. [PMID: 26770270 PMCID: PMC4699277 DOI: 10.1177/1756283x15614516] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.
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Affiliation(s)
- Jakob Duelund-Jakobsen
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Tage-Hansens Gade 2, 8000 Aarhus C, Denmark
| | - Jonas Worsoe
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Lilli Lundby
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Peter Christensen
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
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