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Manoharan J, Albers MB, Bartsch DK. [Individualized approach for MEN1-associated duodenopancreatic neuroendocrine neoplasms]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:207-215. [PMID: 38180518 DOI: 10.1007/s00104-023-01994-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Multiple endocrine neoplasia type 1 (MEN1)-associated duodenopancreatic neuroendocrine neoplasms (dpNEN) represent the most frequent syndrome-associated cause of death, but the adequate treatment is sometimes considered controversial. OBJECTIVE Presentation of possible diagnostic and therapeutic options for MEN1-associated dpNENs. MATERIAL AND METHODS In this review article retrospective case studies, expert recommendations, national and international guidelines as well as personal experiences were analyzed and evaluated. RESULTS Due to early detection programs and the use of the most modern imaging techniques, dpNEN are nowadays diagnosed much earlier. Nonfunctional pNENs currently represent the most frequent dpNENs with about 70%, followed by gastrinomas and insulinomas. Regardless of their functional activity, dpNENs with a size of > 2 cm are generally an indication for surgery. The choice of the optimal treatment strategy, however, in most cases remains the subject of controversial discussions, although nowadays surgery should always be performed in an organ-preserving and minimally invasive way when feasible. Recurrences or new dpNENs are expected in more than 60% of cases, necessitating a reoperation in up to 40% of these cases. Duodenopancreatic resections and reoperations can be carried out safely by experienced practitioners and with an acceptable level of risk. CONCLUSION The planning of treatment requires careful consideration of the suitable timing, the extent of the operation, the risk of recurrence and potential morbidities. Furthermore, preserving pancreatic function and the quality of life is of utmost importance. In view of the complexity of the disease, MEN1 patients should be treated in specialized centers.
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Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland.
| | - Max B Albers
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral‑, Thorax- und Gefäßchirurgie, Philipps Universität Marburg, 35043, Marburg, Deutschland
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2
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Imamura M, Komoto I, Taki Y. How to treat gastrinomas in patients with multiple endocrine neoplasia type1: surgery or long-term proton pump inhibitors? Surg Today 2023; 53:1325-1334. [PMID: 36473964 PMCID: PMC10678812 DOI: 10.1007/s00595-022-02627-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/08/2022] [Indexed: 12/12/2022]
Abstract
In patients with multiple endocrine neoplasia type 1 syndrome (MEN 1) and Zollinger-Ellison syndrome (ZES), gastrinomas arise from the duodenum, about 60% are multiple, and about 15% of patients have coexisting pancreatic gastrinomas, which can be localized by the selective arterial secretagogue injection test (SASI test). The guidelines (GLs) by the Japanese Neuroendocrine Tumor Society (JNETS) recommend surgical resection for functioning duodenopancreatic neuroendocrine tumors (NETs), including gastrinomas, in patients with MEN1 (Grade A, 100% agreement among members). Conversely, the GLs of the National Comprehensive Cancer Network (NCCN) in the USA recommend observation and treatment with proton pump inhibitors (PPIs) or exploratory surgery for occult gastrinomas. An international Consensus Statement (ICS) from the European Union (EU) also does not recommend resection of gastrinomas in patients with MEN1, despite some surgeons having reported surgery being curative for gastrinomas in MEN1 patients. In this review, we discuss the serious side effects and tumorigenic effects of the prolonged use of PPIs and the safety and curability of surgery, supported by our results of curative surgery for gastrinomas in 20 patients with MEN1 over 30 years. We conclude that surgery should be the first-line treatment for gastrinomas in MEN1 patients.
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Affiliation(s)
- Masayuki Imamura
- Neuroendocrine Tumor Center, Kansai Electric Power Hospital, 2-1-7, Fukushima, Fukushima-Ku, Osaka City, 553-0003, Japan.
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawaharacho, Sakyo-Ku, Kyoto City, 606-8507, Japan.
| | - Izumi Komoto
- Department of Surgery, Kansai Electric Power Hospital, 2-1-7, Fukushima, Fukushima-Ku, Osaka City, Japan
| | - Yoshiro Taki
- Department of Surgery, Kansai Electric Power Hospital, 2-1-7, Fukushima, Fukushima-Ku, Osaka City, Japan
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3
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Manoharan J, Albers M, Bartsch DK. [Indication and Surgical Procedures for MEN1-associated Duodenopancreatic Neuroendocrine Neoplasms]. Zentralbl Chir 2023; 148:483-491. [PMID: 37604166 DOI: 10.1055/a-2103-3525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The optimal therapy of duodenopancreatic neuroendocrine neoplasia (dpNEN), which occurs in the context of multiple endocrine neoplasia type 1, is still a major challenge and is controversial. Due to the rarity of the disease, there is a lack of prospective randomised studies, so that most recommendations regarding the surgical indication and procedure are based on retrospective case series. In summary, surgical therapy is indicated for non-functional dpNEN > 2 cm, suspected malignancy and functionally active dpNEN. Enucleation or formal pancreatic resections with or without lymphadenectomy may be considered. The aim of therapy should be to eliminate hormone-associated symptoms and prevent an aggressive metastatic disease. At the same time, pancreatic function and quality of life should be preserved in the mostly young patients by resections that save as much parenchyma as possible.
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Affiliation(s)
- Jerena Manoharan
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Max Albers
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
| | - Detlef K Bartsch
- Klinik für Visceral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Deutschland
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4
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Kimura N, Hirata Y, Iwashiro N, Kijima H, Takayasu S, Yamagata S, Sakihara S, Uchino S, Ohara M. Multiple endocrine neoplasia type 1 with Zollinger-Ellison syndrome: clinicopathological analysis of a Japanese family with focus on menin immunohistochemistry. Front Endocrinol (Lausanne) 2023; 14:1221514. [PMID: 37867522 PMCID: PMC10588651 DOI: 10.3389/fendo.2023.1221514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Background Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by the occurrence of multiple epithelial neuroendocrine tumors (NETs) and non-NETs in various organs. MEN1 encodes a 610-amino acid-long tumor suppressor protein, menin. The optimal treatment for multiple tumors, identification of the most critical tumors for patient prognosis, and menin immunohistochemistry findings remain controversial. Therefore, we aimed to elucidate these issues through a histological analysis of tumors and tumor-like lesions in a Japanese family, comprising a father and his two sons, who had MEN1 with Zollinger-Ellison syndrome (ZES). Patients and methods All family members had a germline alteration in exon 10, c.1714-1715 del TC of MEN1, and exhibited multiple synchronous and metachronous tumors. The patients had pulmonary NETs, hyperparathyroidism, hypergastrinemia, pituitary adenomas, pancreaticoduodenal NETs, adrenocortical adenoma with myelolipoma, nodular goiter of the thyroid, lipomas, and angiofibroma. Most tumors were resected and histologically examined. We compared their clinical courses and tumor histology, and conducted menin immunohistochemistry (IHC). Results Two patients died of pulmonary NET G2. One patient who underwent pancreaticoduodenectomy was cured of ZES; however, the two other patients who did not undergo pancreaticoduodenectomy suffered persistent ZES despite treatment with octreotide. Menin IHC revealed varying NET intensities, ranging from positive to negative stains. Conclusion Pancreaticoduodenectomy is the most effective treatment for ZES. Long-term follow-up is essential for pulmonary NET G2 owing to the risk of distant metastasis and/or multiplicity. Moreover, the variability of menin IHC in MEN1-related tumors may indicate the pattern of tumor formation rather than the diagnostic utility of menin in MEN1.
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Affiliation(s)
- Noriko Kimura
- Department of Clinical Research, National Hospital Organization Hakodate Hospital, Hakodate, Hokkaido, Japan
- Department of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Hokkaido, Japan
| | - Yasuji Hirata
- Department of Hematology and Oncology, National Hospital Organization Hakodate Hospital, Hakodate, Hokkaido, Japan
| | - Nozomu Iwashiro
- Department of Surgery, National Hospital Organization Hakodate Hospital, Hakodate, Hokkaido, Japan
| | - Hiroshi Kijima
- Department of Pathology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shinobu Takayasu
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine and Hospital, Hirosaki, Aomori, Japan
| | - Satoshi Yamagata
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine and Hospital, Hirosaki, Aomori, Japan
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, NY, United States
| | - Satoru Sakihara
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine and Hospital, Hirosaki, Aomori, Japan
- Division of Diabetes and Endocrinology, Aomori Rosai Hospital, Aomori, Japan
| | - Shinya Uchino
- Department of Endocrine Surgery, Noguchi Thyroid Clinic and Hospital Foundation, Beppu, Oita, Japan
| | - Masanori Ohara
- Department of Surgery, National Hospital Organization Hakodate Hospital, Hakodate, Hokkaido, Japan
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5
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Hofland J, Falconi M, Christ E, Castaño JP, Faggiano A, Lamarca A, Perren A, Petrucci S, Prasad V, Ruszniewski P, Thirlwell C, Vullierme MP, Welin S, Bartsch DK. European Neuroendocrine Tumor Society 2023 guidance paper for functioning pancreatic neuroendocrine tumour syndromes. J Neuroendocrinol 2023; 35:e13318. [PMID: 37578384 DOI: 10.1111/jne.13318] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 08/15/2023]
Abstract
This ENETS guidance paper aims to provide practical advice to clinicians for the diagnosis, treatment and follow-up of functioning syndromes in pancreatic neuroendocrine tumours (NET). A NET-associated functioning syndrome is defined by the presence of a clinical syndrome combined with biochemical evidence of inappropriately elevated hormonal levels. Different hormonal syndromes can be encountered in pancreatic NET patients, including insulinoma, gastrinoma as well as the rare glucagonoma, VIPoma, ACTHoma, PTHrPoma, carcinoid syndrome, calcitoninoma, GHRHoma and somatostatinoma. The recommendations provided in this paper focus on the biochemical, genetic and imaging work-up as well as therapeutic management of the individual hormonal syndromes in well-differentiated, grade 1-3, functioning NET with the primary tumour originating in the pancreas, and for specific subtypes also in the duodenum.
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Affiliation(s)
- Johannes Hofland
- Department of Internal Medicine, Section of Endocrinology, ENETS Centre of Excellence, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Massimo Falconi
- Pancreatic Surgery and Transplantation Unit, Pancreas Translational and Clinical Research Centre, ENETS Center of Excellence, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Emanuel Christ
- ENETS Centre of Excellence for Neuroendocrine and Endocrine Tumours, University Hospital Basel, Basel, Switzerland
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Justo P Castaño
- Maimonides Biomedical Research Institute of Córdoba, Córdoba, Spain
- Department of Cell Biology, Physiology, and Immunology, University of Córdoba, Córdoba, Spain
- Hospital Universitario Reina Sofía, Córdoba, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, ENETS Centre of Excellence, Sapienza University of Rome, Rome, Italy
| | - Angela Lamarca
- Department of Oncology - OncoHealth Institute, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Department of Medical Oncology, The Christie NHS Foundation, Manchester, Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Simona Petrucci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
- Medical Genetics and Advanced Cell Diagnostics Unit, Sant Andrea University Hospital, Rome, Italy
| | - Vikas Prasad
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Philippe Ruszniewski
- Department of Pancreatology, FHU MOSAIC, Université Paris Cité - APHP Hôpital Beaujon, Clichy, France
| | | | - Marie-Pierre Vullierme
- Centre Hospitalier Annecy Genevois (CHANGE), Université Paris-Cité, Praticien Hospitalier Imagerie Médicale, Annecy, France
| | - Staffan Welin
- Department of Endocrine Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Phillips-University Marburg and University Hospital Gießen Marburg GmbH, Marburg, Germany
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Ito T, Ramos-Alvarez I, Jensen RT. Successful Lifetime/Long-Term Medical Treatment of Acid Hypersecretion in Zollinger-Ellison Syndrome (ZES): Myth or Fact? Insights from an Analysis of Results of NIH Long-Term Prospective Studies of ZES. Cancers (Basel) 2023; 15:1377. [PMID: 36900170 PMCID: PMC10000208 DOI: 10.3390/cancers15051377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023] Open
Abstract
Analysis of the efficacy/pharmacology of long-term/lifetime medical treatment of acid hypersecretion in a large cohort of ZES patients in a prospective study. This study includes the results from all 303 patients with established ZES who were prospectively followed and received acid antisecretory treatment with either H2Rs or PPIs, with antisecretory doses individually titrated by the results of regular gastric acid testing. The study includes patients treated for short-term periods (<5 yrs), patients treated long-term (>5 yrs), and patients with lifetime treatment (30%) followed for up to 48 years (mean 14 yrs). Long-term/lifelong acid antisecretory treatment with H2Rs/PPIs can be successfully carried out in all patients with both uncomplicated and complicated ZES (i.e., with MEN1/ZES, previous Billroth 2, severe GERD). This is only possible if drug doses are individually set by assessing acid secretory control to establish proven criteria, with regular reassessments and readjustments. Frequent dose changes both upward and downward are needed, as well as regulation of the dosing frequency, and there is a primary reliance on the use of PPIs. Prognostic factors predicting patients with PPI dose changes are identified, which need to be studied prospectively to develop a useful predictive algorithm that could be clinically useful for tailored long-term/lifetime therapy in these patients.
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Affiliation(s)
- Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, International University of Health and Welfare, 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan
| | | | - Robert T. Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA
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Robin L, Sauvanet A, Walter T, Najah H, Falconi M, Pattou F, Gaujoux S. Recurrence after surgical resection of nonmetastatic sporadic gastrinoma: Which prognostic factors and surgical procedure? Surgery 2023; 173:1144-1152. [PMID: 36781315 DOI: 10.1016/j.surg.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/29/2022] [Accepted: 12/30/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND The only curative treatment of gastrinoma is complete resection, but its surgical management remains controversial and prognostic factors of sporadic nonmetastatic gastrinoma are poorly known. METHODS This was a retrospective study including all patients who underwent elective surgery for nonmetastatic sporadic gastrinoma between 2000 and 2020 in 15 hospitals. The primary and secondary outcomes were overall survival and disease-free survival predictive factors. RESULTS In total, 108 patients were included, of which 68 (63%) were duodenal, 19 (18%) pancreatic, and 21 (19%) primary lymph node gastrinomas, with no major difference in clinical presentation. Among the 68 duodenal gastrinomas, 26% (n = 18) underwent pancreaticoduodenectomy (PD) and 74% (n = 50) underwent duodenotomy with the excision of duodenal wall tumors and lymphadenectomy (DUODX + LN). Overall, the median overall survival was 173 months, and the 5-year overall survival was 94%, with no predictive factors identified. The median disease-free survival was 93 months, and the 5-year disease-free survival was 63%. Tumor size >2 cm (P = .00001), grade (P = .00001), and pancreatic tumor location (P = .0001) were predictive factors of recurrence; however, in multivariate analysis, only tumor size >2 cm (P = .005) and grade (P = .013) were independent predictors of recurrence. Age, sex, preoperative gastrin level, lymphadenectomy <10 resected lymph nodes, and metastatic lymph nodes on surgical specimens were not predictors of recurrence. For duodenal gastrinomas, surgical procedures (PD versus DUODX + LN) did not have a significant effect on overall survival and disease-free survival. CONCLUSION Sporadic nonmetastatic gastrinomas had an excellent overall survival. Recurrence is frequent and influenced by tumor size and grade. Regarding sporadic duodenal gastrinoma, duodenotomy with excision of duodenal wall tumors with lymphadenectomy could be considered a valid surgical option, in the absence of clear oncologic superiority of PD.
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Affiliation(s)
- Léa Robin
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Paris, France; Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France; School of Medicine, Sorbonne University, Paris, France
| | - Alain Sauvanet
- Department of Hepato-Biliary and Pancreatic Surgery, Beaujon Hospital, AP-HP, Clichy, France; School of Medicine, Paris University, Paris, France
| | - Thomas Walter
- Service d'Oncologie Médicale et Hépato-gastro-entérologie, Hospices Civil de Lyon, France; School of Medicine, Lyon University, Lyon, France
| | - Haythem Najah
- Department of Digestive and Endocrine Surgery, CHU de Bordeaux, Groupe Hospitalier Sud, Hôpital Haut-Lévêque, Centre Magellan, Pessac, France
| | - Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy; Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Università Vita-Salute, Milan, Italy; Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - François Pattou
- Univ Lille, Inserm, CHU Lille, Institut Pasteur Lille, U1190 Translational Research for Diabetes, European Genomic Institute for Diabetes, Integrated Center of Obesity, France; Department of General and Endocrine Surgery, Lille University Hospital, France
| | - Sébastien Gaujoux
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Paris, France; Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France; School of Medicine, Sorbonne University, Paris, France.
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Krug S, Schrader J, Rinke A. Updates on Diagnostic and Therapeutic Management of Gastrointestinal and Pancreatic NET. Cancers (Basel) 2022; 14:cancers14112628. [PMID: 35681608 PMCID: PMC9179388 DOI: 10.3390/cancers14112628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 05/21/2022] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sebastian Krug
- Clinic for Internal Medicine I, Martin-Luther University Halle/Wittenberg, Ernst-Grube-Strasse 40, D 06120 Halle, Germany
- Correspondence: ; Tel.: +49-345-557-2661
| | - Jörg Schrader
- Medical Department, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D 20246 Hamburg, Germany;
| | - Anja Rinke
- Department of Gastroenterology and Endocrinology, University Hospital Marburg, Baldinger Strasse, D 35043 Marburg, Germany;
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