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Abdelhadi S, Tzatzarakis E, Hermann M, Orth V, Vedder K, Briscoe J, Reissfelder C, Șandra-Petrescu F. The impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection, a retrospective cohort study. Int J Colorectal Dis 2024; 39:126. [PMID: 39105987 PMCID: PMC11303457 DOI: 10.1007/s00384-024-04699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Anastomotic stenosis (AS) is a common complication after colorectal resection. However, the predisposing factors for stricture formation are not fully understood. Previous studies have shown anastomotic leakage (AL) to be a risk factor for the occurrence of AS. Therefore, we aim to investigate the impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection. METHODS Consecutive patients with AL following elective, sphincter preserving, colorectal resection, with or without diversion ostomy, between January 2009 and March 2023 were identified from a prospectively collected database. The characteristics of the anastomotic leakage, patient baseline and operative characteristics as well as the postoperative outcomes were analyzed using univariate and multivariate logistic regression to identify factors associated with the occurrence of post-leakage AS. RESULTS A total of 129 patients developed AL and met the inclusion criteria. Among these, 28 (21.7%) patients were diagnosed with post-leakage AS. There was a significantly higher frequency of patients with neoadjuvant radiotherapy (18% vs 3%; p = .026) and hand-sewn anastomoses (39% vs 17%; p = .011) within the AS group. Furthermore, the extent of the anastomotic defect was significantly higher in the AS group compared with the non-AS group (50%, IQR 27-71 vs. 20%, IQR 9-40, p = 0.011). Similar findings were observed between the study groups regarding age, sex, BMI, ASA score, medical comorbidities, diagnosis, surgical procedure, surgical approach (open vs. minimally invasive), and anastomotic fashioning (side-to-end vs. end-to-end). On multivariate analysis, the extent of the anastomotic defect (OR 1.01; 95% CI 1.00-1.03; p = 0.034) and hand-sewn anastomoses (OR 2.68; 95% CI 1.01-6.98; p = 0.043) were confirmed as independent risk factors for post-leakage AS. No correlation could be observed between the occurrence of post-leakage AS and the ISREC grading of AL, the anastomotic height or the management of AL. Time to ostomy reversal was significantly longer in the AS group (202d, IQR 169-275 vs. 318d IQR 192-416, p = 0.014). CONCLUSION The extent of the anastomotic defect and hand-sewn anastomoses were confirmed as independent risk factors for the occurrence of post-leakage AS. No correlation could be observed between the ISREC grading of AL, the anastomotic height or AL management, and the occurrence of post-leakage AS.
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Affiliation(s)
- Schaima Abdelhadi
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Maike Hermann
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Vanessa Orth
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Katharina Vedder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jannis Briscoe
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- DKFZ Hector Cancer Institute at the University Medical Center, Mannheim, Germany
| | - Flavius Șandra-Petrescu
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Kouladouros K. Applications of endoscopic vacuum therapy in the lower gastrointestinal tract: Tips and tricks and a review of the literature. Best Pract Res Clin Gastroenterol 2024; 70:101927. [PMID: 39053980 DOI: 10.1016/j.bpg.2024.101927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/29/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
Endoscopic vacuum therapy (EVT) is an established technique for the treatment of rectal wall defects and especially anastomotic leaks. A wide range of EVT devices, both handmade and commercially available, allow for their successful placement even in small defects and difficult localizations. Reported success rates range between 85 and 97 %, while periintervenional morbidity is low and major adverse events are very rare. EVT has proven its effectiveness in the lower gastrointestinal tract and is now considered first line treatment for pelvic anastomotic leaks. This narrative review summarizes the current literature on EVT in the lower gastrointestinal tract, focusing on its indications, technical aspects and results, and offers tips and tricks for its clinical applications.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Wienholts K, Sharabiany S, de Wilt JHW, Hompes R, Tanis PJ. Reactivation leakages following stoma reversal after rectal cancer surgery: an underestimated problem. BJS Open 2024; 8:zrad150. [PMID: 38170893 PMCID: PMC10763996 DOI: 10.1093/bjsopen/zrad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Kiedo Wienholts
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Șandra-Petrescu F, Rahbari NN, Birgin E, Kouladouros K, Kienle P, Reissfelder C, Tzatzarakis E, Herrle F. Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers. J Clin Med 2023; 12:4933. [PMID: 37568336 PMCID: PMC10419945 DOI: 10.3390/jcm12154933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
(1) Background: A widely accepted algorithm for the management of colorectal anastomotic leakage (CAL) is difficult to establish. The present study aimed to evaluate the current clinical practice on the management of CAL among the German CHIR-Net centers. (2) Methods: An online survey of 38 questions was prepared using the International Study Group of Rectal Cancer (ISREC) grading score of CAL combined with both patient- and surgery-related factors. All CHIR-Net centers received a link to the online questionary in February 2020. (3) Results: Most of the answering centers (55%) were academic hospitals (41%). Only half of them use the ISREC definition and grading for the management of CAL. A preference towards grade B management (no surgical intervention) of CAL was observed in both young and fit as well as elderly and/or frail patients with deviating ostomy and non-ischemic anastomosis. Elderly and/or frail patients without fecal diversion are generally treated as grade C leakage (surgical intervention). A grade C management of CAL is preferred in case of ischemic bowel, irrespective of the presence of an ostomy. Within grade C management, the intestinal continuity is preserved in a subgroup of patients with non-ischemic bowel, with or without ostomy, or young and fit patients with ischemic bowel under ostomy protection. (4) Conclusions: There is no generally accepted therapy algorithm for CAL management within CHIR-Net Centers in Germany. Further effort should be made to increase the application of the ISREC definition and grading of CAL in clinical practice.
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Affiliation(s)
- Flavius Șandra-Petrescu
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
| | - Nuh N. Rahbari
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
| | - Emrullah Birgin
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
| | - Konstantinos Kouladouros
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
- Interdisciplinary Endoscopy, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Peter Kienle
- Surgical Department, Theresien Hospital, 68165 Mannheim, Germany
| | - Christoph Reissfelder
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
| | - Emmanouil Tzatzarakis
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
| | - Florian Herrle
- Surgical Department, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (N.N.R.); (E.B.); (K.K.); (C.R.); (E.T.); (F.H.)
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Schiffmann L, Becker M, Develing L, Varga-Szabo D, Scheidereiter-Krüger C, Zirngibl H, Seifert M, Biermann L, Schlüter C, Tumczak F, Weimann A, Jansen-Winkeln B, Wallstabe I, Schwandner F, Denecke S, Schafmayer C, Kamaleddine I, Stier A, Haegele K, Kindler M, Michling S, Horling EW, Denzer U. SEVTAR-A multicenter randomized controlled trial to investigate the impact of prophylactic endoluminal placed vacuum sponge for prevention of anastomotic leakage after low rectal resections. Front Surg 2023; 9:1099549. [PMID: 36860727 PMCID: PMC9968789 DOI: 10.3389/fsurg.2022.1099549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/30/2022] [Indexed: 02/15/2023] Open
Abstract
Background Low anterior resection for rectal cancer is commonly associated with a diverting stoma. In general, the stoma is closed 3 months after the initial operation. The diverting stoma reduces the rate of anastomotic leakage as well as the severeness of a potential leakage itself. Nevertheless, anastomotic leakage is still a life-threatening complication and might reduce the quality of life in the short and long term. In case of leakage, the construction can be converted into a Hartmann situation or it could be treated by endoscopic vacuum therapy or by leaving the drains. In recent years, endoscopic vacuum therapy has become the treatment of choice in many institutions. In this study, the hypothesis is to be evaluated, if a prophylactic endoscopic vacuum therapy reduces the rate of anastomotic leakage after rectal resections. Methods A multicenter parallel group randomized controlled trial is planned in as many as possible centers in Europe. The study aims to recruit 362 analyzable patients with a resection of the rectum combined with a diverting ileostoma. The anastomosis has to be between 2 and 8 cm off the anal verge. Half of these patients receive a sponge for 5 days, and the control group is treated as usual in the participating hospitals. There will be a check for anastomotic leakage after 30 days. Primary end point is the rate of anastomotic leakages. The study will have 60% power to detect a difference of 10%, at a one-sided alpha significance level of 5%, assuming an anastomosis leakage rate of 10%-15%. Discussion If the hypothesis proves to be true, anastomosis leakage could be reduced significantly by placing a vacuum sponge over the anastomosis for 5 days. Trial registration The trial is registered at DRKS: DRKS00023436. It has been accredited by Onkocert of the German Society of Cancer: ST-D483. The leading Ethics Committee is the Ethics Committee of Rostock University with the registration ID A 2019-0203.
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Affiliation(s)
- Leif Schiffmann
- Department of Visceral and General Surgery, Helios Klinikum Aue, Aue, Germany,Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany,Correspondence: Leif Schiffmann
| | - Matthias Becker
- Department of Visceral and General Surgery, Helios Weißeritztal-Kliniken GmbH—Klinikum Freital, Freital, Germany
| | - Leendert Develing
- Department of Visceral and General Surgery, University Hospital Wuppertal, Wuppertal, Germany
| | - David Varga-Szabo
- Department of Visceral and General Surgery, University Hospital Wuppertal, Wuppertal, Germany
| | | | - Hubert Zirngibl
- Department of Visceral and General Surgery, University Hospital Wuppertal, Wuppertal, Germany
| | - Michael Seifert
- Department of Visceral and General Surgery, Helios Klinikum Erfurt, Erfurt, Germany
| | - Lothar Biermann
- Department of Visceral and General Surgery, Joseph Hospital Warendorf, Warendorf, Germany
| | - Claudia Schlüter
- Department of Visceral and General Surgery, Joseph Hospital Warendorf, Warendorf, Germany
| | - Felicitas Tumczak
- Department of Visceral and General Surgery, University Hospital Wuppertal, Wuppertal, Germany
| | - Arved Weimann
- Department of Visceral and General Surgery, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral and General Surgery, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - Ingo Wallstabe
- Department of Gastroenterology, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Sandra Denecke
- Department of Visceral and General Surgery, University Hospital Wuppertal, Wuppertal, Germany
| | - Clemens Schafmayer
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Imad Kamaleddine
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Albrecht Stier
- Department of Visceral and General Surgery, Helios Klinikum Erfurt, Erfurt, Germany
| | - Katharina Haegele
- Department of Visceral and General Surgery, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - Michael Kindler
- Department of Visceral and General Surgery, Helios Weißeritztal-Kliniken GmbH—Klinikum Freital, Freital, Germany
| | - Sabine Michling
- Department of Visceral and General Surgery, Klinikum Kaufbeuren, Kaufbeuren, Germany
| | - Ernst-Wilhelm Horling
- Department of Visceral and General Surgery, Klinikum Kaufbeuren, Kaufbeuren, Germany
| | - Ulrike Denzer
- Department of Gastroenterology, Marburg University Hospital, Marburg, Germany
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