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Lopetuso LR, Deleu S, Godny L, Petito V, Puca P, Facciotti F, Sokol H, Ianiro G, Masucci L, Abreu M, Dotan I, Costello SP, Hart A, Iqbal TH, Paramsothy S, Sanguinetti M, Danese S, Tilg H, Cominelli F, Pizarro TT, Armuzzi A, Cammarota G, Gasbarrini A, Vermeire S, Scaldaferri F. The first international Rome consensus conference on gut microbiota and faecal microbiota transplantation in inflammatory bowel disease. Gut 2023; 72:1642-1650. [PMID: 37339849 PMCID: PMC10423477 DOI: 10.1136/gutjnl-2023-329948] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/16/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Several randomised clinical trials (RCTs) performing faecal microbiota transplantation (FMT) for the management of inflammatory bowel disease (IBD), particularly for ulcerative colitis, have recently been published, but with major variations in study design. These include differences in administered dose, route and frequency of delivery, type of placebo and evaluated endpoints. Although the overall outcomes appear to be promising, they are highly dependent on both donor and recipient factors. OBJECTIVE To develop concensus-based statements and recommendations for the evaluation, management and potential treatment of IBD using FMT in order to move towards standardised practices. DESIGN An international panel of experts convened several times to generate evidence-based guidelines by performing a deep evaluation of currently available and/or published data. Twenty-five experts in IBD, immunology and microbiology collaborated in different working groups to provide statements on the following key issues related to FMT in IBD: (A) pathogenesis and rationale, (B) donor selection and biobanking, (C) FMT practices and (D) consideration of future studies and perspectives. Statements were evaluated and voted on by all members using an electronic Delphi process, culminating in a plenary consensus conference and generation of proposed guidelines. RESULTS AND CONCLUSIONS Our group has provided specific statements and recommendations, based on best available evidence, with the end goal of providing guidance and general criteria required to promote FMT as a recognised strategy for the treatment of IBD.
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Affiliation(s)
- Loris Riccardo Lopetuso
- IBD Unit, CEMAD Centro Malattie dell'Apparato Digerente, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Sara Deleu
- Department of Chronic Diseases & Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Lihi Godny
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Valentina Petito
- IBD Unit, CEMAD Centro Malattie dell'Apparato Digerente, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Pierluigi Puca
- IBD Unit, CEMAD Centro Malattie dell'Apparato Digerente, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Federica Facciotti
- Dipartimento di Biotecnologie e Bioscienze, University of Milan-Bicocca, Milano, Italy
| | - Harry Sokol
- INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, Saint Antoine Hospital, Gastroenterology Department, Sorbonne Universite, Paris, France
| | - Gianluca Ianiro
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Luca Masucci
- Department of Laboratory Sciences and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Maria Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Samuel Paul Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Ailsa Hart
- IBD Unit, Saint Mark's Hospital, Harrow, UK
| | - Tariq H Iqbal
- Microbiome Treatment Center, University of Birmingham, Birmingham, UK
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Maurizio Sanguinetti
- Department of Laboratory Sciences and Infectious Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medizinische Universitat Innsbruck, Innsbruck, Austria
| | - Fabio Cominelli
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Theresa T Pizarro
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Alessandro Armuzzi
- Deparment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Giovanni Cammarota
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Antonio Gasbarrini
- IBD Unit, CEMAD Centro Malattie dell'Apparato Digerente, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Séverine Vermeire
- Department of Chronic Diseases & Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Franco Scaldaferri
- IBD Unit, CEMAD Centro Malattie dell'Apparato Digerente, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
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Fliss-Isakov N, Aviv Cohen N, Bromberg A, Elbert G, Anbar R, Ron Y, Hirsch A, Thurm T, Maharshak N. Crohn's Disease Exclusion Diet for the Treatment of Crohn's Disease: Real-World Experience from a Tertiary Center. J Clin Med 2023; 12:5428. [PMID: 37629470 PMCID: PMC10455757 DOI: 10.3390/jcm12165428] [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: 07/05/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
The Crohn's Disease (CD) exclusion diet (CDED) has been shown to induce remission in pediatric and adult patients with CD. In this retrospective cohort study, we describe our real-world experience with the CDED at the inflammatory bowel disease (IBD) unit of the Tel Aviv Medical Center between 2018-2021. CD patients with multiple clinical presentations and disease phenotypes who initiated the diet were included. Indications for treatment, medical and nutritional data were collected from dietician clinic visits and medical records. Clinical and biomarker responses were determined. The CDED was recommended to 220 CD patients. Seventy-two patients were included in the analysis for a clinically active disease (n = 48) or for remission maintenance (n = 24). Among patients with a clinically active disease, 62.5% of patients achieved clinical remission at week 6 and at week 12. A positive association between high adherence to the CDED and clinical remission at week 12 was observed (adjusted OR = 7.6, 95% CI 1.07-55.2, p = 0.043). Among patients treated for remission maintenance, remission at week 12 was maintained among 83.3% of patients. We conclude that the CDED may be a promising intervention for multiple CD presentations and indications. These findings should be further validated in larger, prospective, controlled studies.
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Affiliation(s)
- Naomi Fliss-Isakov
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Nathaniel Aviv Cohen
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Ahuva Bromberg
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Nutrition and Dietetics Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Gal Elbert
- Nutrition and Dietetics Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Ronit Anbar
- Nutrition and Dietetics Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Yulia Ron
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Ayal Hirsch
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Tamar Thurm
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Nitsan Maharshak
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
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He H, Liu C, Chen M, Guo X, Li X, Xiang Z, Liao F, Dong W. Effect of Dietary Patterns on Inflammatory Bowel Disease: A Machine Learning Bibliometric and Visualization Analysis. Nutrients 2023; 15:3442. [PMID: 37571379 PMCID: PMC10420952 DOI: 10.3390/nu15153442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
AIMS This study aimed to analyze the related research on the influence of dietary patterns on IBD carried out over the past 30 years to obtain the context of the research field and to provide a scientific basis and guidance for the prevention and treatment of IBD. METHODS The literature on the effects of dietary patterns on inflammatory bowel disease published over the past three decades was retrieved from the Web of Science Core Collection (WoSCC) database. CiteSpace, VOSviewer, the R software (version 4.3.0) bibliometrix package, the OALM platform, and other tools were used for the analyses. RESULTS The growth of scientific papers related to this topic can be divided into two stages: before and after 2006. Overall, the growth of the relevant literature was in line with Price's literature growth curve. Subrata Ghosh and Antonio Gasbarrini are the authors with the highest academic influence in the field, and Lee D.'s research results are widely recognized by researchers in this field. Among the 72 countries involved in the study, the United States contributed the most, while China developed rapidly with regard to research being carried out in this area. From a regional perspective, countries and institutions in North America, Europe, and East Asia have made the most significant contributions to this field and have the closest cooperation. Among the 1074 articles included in the study, the most influential ones tended to consider the mechanism of the effect of dietary patterns on IBD from the perspective of the microbiome. Multiple tools were used for keyword analysis and mutual verification. The results showed that NF-κB, the Mediterranean diet, fatty acids, fecal microbiota, etc., are the focus and trends of current research. CONCLUSIONS A Mediterranean-like dietary pattern may be a good dietary habit for IBD patients. Carbohydrates, fatty acids, and inulin-type fructans are closely related to IBD. Fatty acid, gut microbiota, NF-κB, oxidative stress, and endoplasmic reticulum stress are the hot topics in the study of the effects of dietary patterns on IBD and will be emerging research trends.
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Affiliation(s)
- Haodong He
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Chuan Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Meilin Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Xingzhou Guo
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Xiangyun Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Zixuan Xiang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
| | - Fei Liao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
- Wuhan University Shenzhen Research Institute, Wuhan 430060, China
| | - Weiguo Dong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430060, China; (H.H.); (C.L.); (M.C.); (X.G.); (X.L.); (Z.X.)
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Gubatan J, Kulkarni CV, Talamantes SM, Temby M, Fardeen T, Sinha SR. Dietary Exposures and Interventions in Inflammatory Bowel Disease: Current Evidence and Emerging Concepts. Nutrients 2023; 15:579. [PMID: 36771288 PMCID: PMC9921630 DOI: 10.3390/nu15030579] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Diet is intimately linked to the gastrointestinal (GI) tract and has potent effects on intestinal immune homeostasis. Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the GI tract. The therapeutic implications of diet in patients with IBD have received significant attention in recent years. In this review, we provide a contemporary and comprehensive overview of dietary exposures and interventions in IBD. Epidemiological studies suggest that ultra-processed foods, food additives, and emulsifiers are associated with a higher incidence of IBD. Exclusion and elimination diets are associated with improved symptoms in patients with IBD, but no effects on objective markers of inflammation. Specific dietary interventions (e.g., Mediterranean, specific carbohydrate, high fiber, ketogenic, anti-inflammatory diets) have been shown to reduce symptoms, improve inflammatory biomarkers, and quality of life metrics to varying degrees, but these studies are limited by study design, underpowering, heterogeneity, and confounding. To date, there is no robust evidence that any dietary intervention alone may replace standard therapies in patients with IBD. However, diet may play an adjunct role to induce or maintain clinical remission with standard IBD therapies. The results of novel dietary trials in IBD such as personalized fiber, intermittent fasting, and time-restricted diets are eagerly awaited.
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Affiliation(s)
- John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
- Chan Zuckerberg Biohub, San Francisco, CA 94158, USA
| | - Chiraag V. Kulkarni
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sarah Melissa Talamantes
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Michelle Temby
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Touran Fardeen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sidhartha R. Sinha
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
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5
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Chen B, Han Z, Geng L. Mendelian randomization analysis reveals causal effects of food intakes on inflammatory bowel disease risk. Front Immunol 2022; 13:911631. [PMID: 36211374 PMCID: PMC9536736 DOI: 10.3389/fimmu.2022.911631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Traditional observational studies have indicated a link between specific food intakes and inflammatory bowel disease (IBD), but the nature of such links remains unknown. We sought to assess the potential causal relationship between food intakes and IBD risk using Mendelian randomization methods. This study used summary statistics data from large-scale genome-wide association studies (GWAS) on food intakes, Crohn’s disease (CD), and ulcerative colitis (UC). In the primary analysis, we used the inverse variance-weighted method to determine whether specific food was causal for CD and UC. In addition, we also ran four other Mendelian randomization methods, including MR Egger, weighted median, maximum likelihood, and weighted mode as a complement. The primary analysis showed that high consumption of poultry (OR, 3.696; 95% CI, 1.056–12.937; p = 0.041) and cereal (OR, 2.449; 95% CI, 1.094–5.482; p = 0.029) had a significant causal association with CD, while high oily fish intake level was found to be statistically significantly associated with the risk of UC (OR, 1.482; 95% CI, 1.002–2.194; p = 0.049). This MR study provides evidence of a potential causal link between certain food intake and CD and UC.
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Affiliation(s)
- Bingxia Chen
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- *Correspondence: Bingxia Chen,
| | - Zemin Han
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lanlan Geng
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
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Gubatan J, Boye TL, Temby M, Sojwal RS, Holman DR, Sinha SR, Rogalla SR, Nielsen OH. Gut Microbiome in Inflammatory Bowel Disease: Role in Pathogenesis, Dietary Modulation, and Colitis-Associated Colon Cancer. Microorganisms 2022; 10:1371. [PMID: 35889090 PMCID: PMC9316834 DOI: 10.3390/microorganisms10071371] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 12/11/2022] Open
Abstract
The gut microbiome has increasingly been recognized as a critical and central factor in inflammatory bowel disease (IBD). Here, we review specific microorganisms that have been suggested to play a role in the pathogenesis of IBD and the current state of fecal microbial transplants as a therapeutic strategy in IBD. We discuss specific nutritional and dietary interventions in IBD and their effects on gut microbiota composition. Finally, we examine the role and mechanisms of the gut microbiome in mediating colitis-associated colon cancer.
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Affiliation(s)
- John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Theresa Louise Boye
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, DK-2730 Copenhagen, Denmark; (T.L.B.); or (O.H.N.)
| | - Michelle Temby
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Raoul S. Sojwal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Derek R. Holman
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Sidhartha R. Sinha
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Stephan R. Rogalla
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.T.); (R.S.S.); (D.R.H.); (S.R.S.); (S.R.R.)
| | - Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, DK-2730 Copenhagen, Denmark; (T.L.B.); or (O.H.N.)
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Lederer AK, Huber R. The Relation of Diet and Health: You Are What You Eat. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:7774. [PMID: 35805428 PMCID: PMC9266141 DOI: 10.3390/ijerph19137774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 12/10/2022]
Abstract
The intake of food is more than just a necessary process for ensuring the functionality of the human body [...].
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Affiliation(s)
- Ann-Kathrin Lederer
- Center for Complementary Medicine, Department of Medicine II, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
- Department of General, Visceral and Transplantation Surgery, University Medical Center, 55131 Mainz, Germany
| | - Roman Huber
- Center for Complementary Medicine, Department of Medicine II, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
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