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Goudarzi Y, Monirvaghefi K, Aghaei S, Amiri SS, Rezaei M, Dehghanitafti A, Azarpey A, Azani A, Pakmehr S, Eftekhari HR, Tahmasebi S, Zohourian Shahzadi S, Rajabivahid M. Effect of genetic profiling on surgical decisions at hereditary colorectal cancer syndromes. Heliyon 2024; 10:e34375. [PMID: 39145015 PMCID: PMC11320152 DOI: 10.1016/j.heliyon.2024.e34375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 07/06/2024] [Accepted: 07/09/2024] [Indexed: 08/16/2024] Open
Abstract
Hereditary colorectal cancer syndromes, such as Lynch syndrome and familial adenomatous polyposis (FAP), present significant clinical challenges due to the heightened cancer risks associated with these genetic conditions. This review explores genetic profiling impact on surgical decisions for hereditary colorectal cancer (HCRC), assessing options, timing, and outcomes. Genotypes of different HCRCs are discussed, revealing a connection between genetic profiles, disease severity, and outcomes. For Lynch syndrome, mutations in the MLH1, MSH2, MSH6, and PMS2 genes guide the choice of surgery. Subtotal colectomy is recommended for patients with mutations in MLH1 and MSH2, while segmental colectomy is preferred for those with MSH6 and PMS2 mutations. In cases of metachronous colon cancer after segmental colectomy, subtotal colectomy with ileorectal anastomosis is advised for all mutations. Surgical strategies for primary rectal cancer include anterior resection or abdominoperineal resection (APR), irrespective of the specific mutation. For rectal cancer occurring after a previous segmental colectomy, proctocolectomy with ileal pouch-anal anastomosis (IPAA) or APR with a permanent ileostomy is recommended. In FAP, surgical decisions are based on genotype-phenotype correlations. The risk of desmoid tumors post-surgery supports a single-stage approach, particularly for certain APC gene variants. Juvenile Polyposis Syndrome (JPS) surgical decisions involve genetic testing, polyp characteristics with attention to vascular lesions in SMAD4 mutation carriers. However, genetic profiling does not directly dictate the specific surgical approach for JPS. In conclusion this review highlights the critical role of personalized surgical plans based on genetic profiles to optimize patient outcomes and reduce cancer risk. Further research is needed to refine these strategies and enhance clinical guidelines.
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Affiliation(s)
- Yasaman Goudarzi
- Department of Medical Science, Shahroud Branch, Islamic Azad University, Iran
| | - Khaterehsadat Monirvaghefi
- Department of Adult Hematology & Oncology, School of Medicine, Ayatollah Khansari Hospital, Arak University of Medical Sciences, Arak, Iran
| | - Salar Aghaei
- Faculty of Medicine, Medical University of Kurdistan, Sanandaj, Iran
| | - Seyed Siamak Amiri
- Department of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mahdi Rezaei
- Clinical Research Department, Pasteur Institute of Iran, Tehran, Iran
| | - Atefeh Dehghanitafti
- Department of General Surgery, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Ali Azarpey
- Emory University School of Medicine, Atlanta, GA, USA
| | - Alireza Azani
- Department of Medical Genetics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | | | - Hamid Reza Eftekhari
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Safa Tahmasebi
- Student Research Committee, Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mansour Rajabivahid
- Department of Internal Medicine, Valiasr Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
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Lincoln AG, Benton SC, Piggott C, Sheikh SR, Beggs AD, Buckley L, DeSouza B, East JE, Sanders P, Lim M, Sheehan D, Snape K, Hanson H, Greenaway JR, Burn J, Nylander D, Hawkins M, Lalloo F, Green K, Lee TJ, Walker J, Matthews G, Rutherford T, Sasieni P, Monahan KJ. Risk-stratified faecal immunochemical testing (FIT) for urgent colonoscopy in Lynch syndrome during the COVID-19 pandemic. BJS Open 2023; 7:zrad079. [PMID: 37668669 PMCID: PMC10478750 DOI: 10.1093/bjsopen/zrad079] [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: 01/13/2023] [Revised: 05/29/2023] [Accepted: 06/20/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Lynch syndrome is a hereditary cancer disease resulting in an increased risk of colorectal cancer. Herein, findings are reported from an emergency clinical service implemented during the COVID-19 pandemic utilizing faecal immunochemical testing ('FIT') in Lynch syndrome patients to prioritize colonoscopy while endoscopy services were limited. METHODS An emergency service protocol was designed to improve colonoscopic surveillance access throughout the COVID-19 pandemic in England for people with Lynch syndrome when services were extremely restricted (1 March 2020 to 31 March 2021) and promoted by the English National Health Service. Requests for faecal immunochemical testing from participating centres were sent to the National Health Service Bowel Cancer Screening South of England Hub and a faecal immunochemical testing kit, faecal immunochemical testing instructions, paper-based survey, and pre-paid return envelope were sent to patients. Reports with faecal haemoglobin results were returned electronically for clinical action. Risk stratification for colonoscopy was as follows: faecal haemoglobin less than 10 µg of haemoglobin/g of faeces (µg/g)-scheduled within 6-12 weeks; and faecal haemoglobin greater than or equal to 10 µg/g-triaged via an urgent suspected cancer clinical pathway. Primary outcomes of interest included the identification of highest-risk Lynch syndrome patients and determining the impact of faecal immunochemical testing in risk-stratified colonoscopic surveillance. RESULTS Fifteen centres participated from June 2020 to March 2021. Uptake was 68.8 per cent amongst 558 patients invited. For 339 eligible participants analysed, 279 (82.3 per cent) had faecal haemoglobin less than 10 µg/g and 60 (17.7 per cent) had faecal haemoglobin greater than or equal to 10 µg/g. In the latter group, the diagnostic accuracy of faecal immunochemical testing was 65.9 per cent and escalation to colonoscopy was facilitated (median 49 versus 122 days, χ2 = 0.0003, P < 0.001). CONCLUSION Faecal immunochemical testing demonstrated clinical value for Lynch syndrome patients requiring colorectal cancer surveillance during the pandemic in this descriptive report of an emergency COVID-19 response service. Further longitudinal investigation on faecal immunochemical testing efficacy in Lynch syndrome is warranted and will be examined under the 'FIT for Lynch' study (ISRCTN15740250).
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Affiliation(s)
- Anne G Lincoln
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Sally C Benton
- Department of Clinical Biochemistry and NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Carolyn Piggott
- Department of Clinical Biochemistry and NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Shama Riaz Sheikh
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Andrew D Beggs
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Leah Buckley
- Clinical Genetics, St Michael’s Hospital, Bristol, UK
| | - Bianca DeSouza
- Clinical Genetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Pete Sanders
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Michael Lim
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Donal Sheehan
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Katie Snape
- South West Thames Regional Genetics Service, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Helen Hanson
- South West Thames Regional Genetics Service, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - John R Greenaway
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - John Burn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Menna Hawkins
- Family Cancer Clinic, St Mark’s Hospital, London, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Kate Green
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Thomas J Lee
- Gastroenterology Research, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Julie Walker
- Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
| | - Gillian Matthews
- Gastroenterology, County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | - Terry Rutherford
- Gastroenterology, County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | - Peter Sasieni
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Kevin J Monahan
- Family Cancer Clinic, St Mark’s Hospital, London, UK
- Faculty of Medicine, Imperial College, London, UK
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Houwen BB, Vleugels JL, Pellisé M, Rivero-Sánchez L, Balaguer F, Bisschops R, Tejpar S, Repici A, Ramsoekh D, Jacobs MA, Schreuder RM, Kamiński MF, Rupińska M, Bhandari P, van Oijen MG, Koens L, Bastiaansen BA, Tytgat KM, Fockens P, Dekker E, Hazewinkel Y. Real-time diagnostic accuracy of blue light imaging, linked color imaging and white-light endoscopy for colorectal polyp characterization. Endosc Int Open 2022; 10:E9-E18. [PMID: 35047330 PMCID: PMC8759942 DOI: 10.1055/a-1594-1693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background and study aims Fujifilm has developed a novel ELUXEO 7000 endoscope system that employs light-emitting diodes (LEDs) at four different wavelengths as light sources that enable blue light imaging (BLI), linked color imaging (LCI), and high-definition white-light endoscopy (HD-WLE). The aim of this study was to address the diagnostic accuracy of real-time polyp characterization using BLI, LCI and HD-WLE (ELUXEO 7000 endoscopy system). Patients methods This is a prespecified post-hoc analysis of a prospective study in which 22 experienced endoscopists (> 2,000 colonoscopies) from eight international centers participated. Using a combination of BLI, LCI, and HD-WLE, lesions were endoscopically characterized including a high- or low-confidence statement. Per protocol, digital images were created from all three imaging modalities. Histopathology was the reference standard. Endoscopists were familiar with polyp characterization, but did not take dedicated training for purposes of this study. Results Overall, 341 lesions were detected in 332 patients. Of the lesions, 269 histologically confirmed polyps with an optical diagnosis were included for analysis (165 adenomas, 27 sessile serrated lesions, and 77 hyperplastic polyps). Overall, polyp characterization was performed with high confidence in 82.9 %. The overall accuracy for polyp characterization was 75.1 % (95 % confidence interval [CI] 69.5-80.1 %), compared with an accuracy of 78.0 % (95 % CI 72.0-83.2 %) for high confidence assignments. The accuracy for endoscopic characterization for diminutive polyps was 74.7 % (95 %CI 68.4-80.3 %), compared with an accuracy of 78.2 % (95 % CI 71.4-84.0 %) for high-confidence assignments. Conclusions The diagnostic accuracy of BLI, LCI, and HD-WLE by experienced endoscopist for real-time polyp characterization seems limited (NCT03344289).
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Affiliation(s)
- Britt B.S.L. Houwen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - Jasper L.A. Vleugels
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clinic of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut dʼInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Liseth Rivero-Sánchez
- Department of Gastroenterology, Hospital Clinic of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut dʼInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clinic of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut dʼInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Sabine Tejpar
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Italy,Department of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Rozzano, Italy
| | - D. Ramsoekh
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location VU University Medical Centre, VU University Amsterdam, Amsterdam, the Netherlands
| | - M. A.J.M Jacobs
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location VU University Medical Centre, VU University Amsterdam, Amsterdam, the Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Michal F. Kamiński
- Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Maria Rupińska
- Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - M. G.H. van Oijen
- Department of Medical Oncology, Amsterdam University Medical Center, location Academic Medical Centre, University of Amsterdam, the Netherlands
| | - L. Koens
- Department of Pathology, Amsterdam University Medical Center, location Academic Medical Centre, University of Amsterdam, the Netherlands
| | - Barbara A.J. Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - K. M.A.J. Tytgat
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, the Netherlands
| | - Yark Hazewinkel
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Radboud University of Nijmegen, Nijmegen, The Netherlands
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4
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Rivero-Sánchez L, Gavric A, Herrero J, Remedios D, Alvarez V, Albéniz E, Gordillo J, Puig I, López-Vicente J, Huerta A, López-Cerón M, Salces I, Peñas B, Parejo S, Rodriguez E, Herraiz M, Carretero C, Gimeno-Garcia AZ, Saperas E, Alvarez C, Arnau-Collell C, Ortiz O, Sánchez A, Jung G, Balaguer F, Pellisé M. The "diagnose and leave in" strategy for diminutive rectosigmoid polyps in Lynch syndrome: a post hoc analysis from a randomized controlled trial. Endoscopy 2022; 54:27-34. [PMID: 33271604 DOI: 10.1055/a-1328-5405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The "diagnose-and-leave-in" policy has been established to reduce the risks and costs related to unnecessary polypectomies in the average-risk population. In individuals with Lynch syndrome, owing to accelerated carcinogenesis, the general recommendation is to remove all polyps, irrespective of size, location, and appearance. We evaluated the feasibility and safety of the diagnose-and-leave-in strategy in individuals with Lynch syndrome. METHODS : We performed a post hoc analysis based on per-polyp data from a randomized, clinical trial conducted by 24 dedicated colonoscopists at 14 academic centers, in which 256 patients with confirmed Lynch syndrome underwent surveillance colonoscopy from July 2016 to January 2018. In vivo optical diagnosis with confidence level for all detected lesions was obtained before polypectomy using virtual chromoendoscopy alone or with dye-based chromoendoscopy. Primary outcome was the negative predictive value (NPV) for neoplasia of high-confidence optical diagnosis among diminutive (≤ 5 mm) rectosigmoid lesions. Histology was the reference standard. RESULTS Of 147 rectosigmoid lesions, 128 were diminutive. In 103 of the 128 lesions (81 %), the optical diagnostic confidence was high and showed an NPV of 96.0 % (95 % confidence interval [CI] 88.9 %-98.6 %) and accuracy of 89.3 % (95 %CI 81.9 %-93.9 %). By following the diagnose-and-leave-in policy, we would have avoided 59 % (75/128) of polypectomies at the expense of two diminutive low grade dysplastic adenomas and one diminutive sessile serrated lesion that would have been left in situ. CONCLUSION In patients with Lynch syndrome, the diagnose-and-leave-in strategy for diminutive rectosigmoid polyps would be feasible and safe.
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Affiliation(s)
- Liseth Rivero-Sánchez
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Aleksandar Gavric
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,University Medical Centre Ljubljana, Department of Gastroenterology and Hepatology Ljubljana, Slovenia
| | - Jesús Herrero
- Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Biomédica Galicia Sur, CIBERehd, Gastroenterology, Ourense, Spain
| | - David Remedios
- Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Biomédica Galicia Sur, CIBERehd, Gastroenterology, Ourense, Spain
| | - Victoria Alvarez
- Complexo Hospitalario de Pontevedra, Digestive Department, Pontevedra, Spain
| | - Eduardo Albéniz
- Complejo Hospitalario de Navarra, Digestive System Service, Endoscopy Unit, Navarrabiomed, Universidad Pública de Navarra, IdiSNa, Pamplona, Spain
| | - Jordi Gordillo
- Hospital de la Santa Creu i Sant Pau, Gastroenterology Unit, Barcelona, Spain
| | - Ignasi Puig
- Althaia, Xarxa Assistencial Universitària de Manresa, Gastroenterology Department, Manresa, Spain
| | - Jorge López-Vicente
- Hospital Universitario de Móstoles, Digestive System Service, Móstoles, Madrid, Spain
| | - Alain Huerta
- Hospital Galdakao-Usansolo, Department of Gastroenterology, Galdakao, Spain
| | - María López-Cerón
- Hospital Universitario 12 de Octubre, Digestive System Service, Madrid, Spain
| | - Inmaculada Salces
- Hospital Universitario 12 de Octubre, Digestive System Service, Madrid, Spain
| | - Beatriz Peñas
- Hospital Universitario Ramon y Cajal, Department of Gastroenterology, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sofía Parejo
- Hospital Universitario Ramon y Cajal, Department of Gastroenterology, Madrid, Spain
| | - Enrique Rodriguez
- Hospital Universitario Ramon y Cajal, Department of Gastroenterology, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Maite Herraiz
- University of Navarra Clinic-IdiSNA, Gastroenterology Department, Pamplona, Spain
| | - Cristina Carretero
- University of Navarra Clinic-IdiSNA, Gastroenterology Department, Pamplona, Spain
| | - Antonio Z Gimeno-Garcia
- Hospital Universitario de Canarias, Gastroenterology Department, Santa Cruz de Tenerife, Spain
| | - Esteban Saperas
- Hospital General de Catalunya, Gastroenterology Department, Sant Cugat del Vallès, Spain
| | | | - Coral Arnau-Collell
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Oswaldo Ortiz
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Ariadna Sánchez
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Gerhard Jung
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Francesc Balaguer
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - María Pellisé
- Hospital Clinic de Barcelona, Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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