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Zandieh G, Yazdaninia I, Afyouni S, Shaghaghi M, Borhani A, Mohseni A, Shaghaghi S, Liddell R, Kamel IR. Spectrum of Imaging Findings and Complications After Hepatic Transarterial Chemoembolization for Liver Tumors. J Comput Assist Tomogr 2024:00004728-990000000-00305. [PMID: 38595176 DOI: 10.1097/rct.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT This study reviews the spectrum of imaging findings and complications after transarterial chemoembolization (TACE) for the treatment of primary liver tumors (hepatocellular carcinoma, cholangiocarcinoma) and liver metastases. The review encompasses a spectrum of imaging criteria for assessing treatment response, including the modified Response Evaluation Criteria in Solid Tumors guidelines, tumor enhancement, and apparent diffusion coefficient alterations.We discuss the expected posttreatment changes and imaging responses to TACE, describing favorable and poor responses. Moreover, we present cases that demonstrate potential complications post-TACE, including biloma formation, acute cholecystitis, abscesses, duodenal perforation, arterial injury, and nontarget embolization. Each complication is described in detail, considering its causes, risk factors, clinical presentation, and imaging characteristics.To illustrate these findings, a series of clinical cases is presented, featuring diverse imaging modalities including computed tomography, magnetic resonance imaging, and digital subtraction angiography.
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Affiliation(s)
- Ghazal Zandieh
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Iman Yazdaninia
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Shadi Afyouni
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Mohamadreza Shaghaghi
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Ali Borhani
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Alireza Mohseni
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
| | - Shiva Shaghaghi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Robert Liddell
- Division of Vascular and Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD
| | - Ihab R Kamel
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, John's Hopkins University, Baltimore, MD
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Lo YC, Hsu PW, Chew FY, Chen HY. Special presentation of bronchobiliary fistula after transcatheter arterial chemoembolization: A case report. Medicine (Baltimore) 2022; 101:e31596. [PMID: 36401479 PMCID: PMC9678547 DOI: 10.1097/md.0000000000031596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
RATIONALE Transcatheter arterial chemoembolization (TACE) is a widely adopted treatment for advanced stage hepatocellular carcinoma (HCC). Nevertheless, several complications may occur, such as hepatic artery injury, nontarget embolization, pulmonary embolism, hepatic abscess, biloma, biliary strictures, and hepatic failure. However, bronchobiliary fistula is rarely mentioned before. PATIENT CONCERNS A 65-year-old man with HCC underwent the TACE procedure, and then he encountered fever, dyspnea, abdominal pain, and abundant yellowish purulent bronchorrhea. DIAGNOSIS Bronchobiliary fistula was diagnosed based on the computed tomography (CT) scan of his chest, which revealed the right lower lobe of his lung was connected to a hepatic cystic lesion. INTERVENTIONS Percutaneous transhepatic cystic drainage was performed, and we obtained yellowish bile, showing the same characteristics as the patient's bronchorrhea. OUTCOMES We kept drainage of his biloma and provided supportive care as the patient wished. Unfortunately, the patient passed away due to progressive right lower lobe pneumonia 2 weeks later. LESSONS This case exhibits a typical CT scan image that was helpful for the diagnosis of post-TACE bronchobiliary fistula. Post-TACE bronchobiliary fistula formation hypothesis includes biliary tree injuries with subsequent biloma formation and diaphragmatic injuries. Moreover, the treatment of bronchobiliary fistula should be prompt to cease pneumonia progression. Therefore, we introduce this rare complication of post-TACE bronchobiliary fistula in hopes that future clinicians will keep earlier intervention in mind.
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Affiliation(s)
- Yuan-Chun Lo
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Ping-Wen Hsu
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Fatt-Yang Chew
- Department of Medical Imaging, China Medical University Hospital, Taiwan
| | - Hung-Yao Chen
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- * Correspondence: Hung-Yao Chen, Center for Digestive Medicine, Department of Internal Medicine, China Medical University, Taichung, Taiwan, No. 2, Yude Road, North District, Taichung City 40447, Taiwan (e-mail: )
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Zhu M, Li G, Chen Y, Gong G, Guo W. Clinical features and treatment of hepatic abscesses with biloma formation after transcatheter arterial chemoembolization. Arab J Gastroenterol 2022; 23:32-38. [DOI: 10.1016/j.ajg.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 05/20/2021] [Accepted: 12/09/2021] [Indexed: 11/27/2022]
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Hall AD, White SB, Rilling WS. Biliary-Caval Fistula following Y90 Radioembolization. Semin Intervent Radiol 2021; 38:488-491. [PMID: 34629719 DOI: 10.1055/s-0041-1735605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The safety of radioembolization with yttrium-90 ( 90 Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following 90 Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.
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Affiliation(s)
- Alexander D Hall
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah B White
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William S Rilling
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Hudgi AR, Peng H, Sridhar S, Yap JE. Iatrogenic biloma: a rare and delayed complication of a life-saving transarterial hepatic embolisation. BMJ Case Rep 2021; 14:e244814. [PMID: 34413048 PMCID: PMC8378345 DOI: 10.1136/bcr-2021-244814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Amit R Hudgi
- Internal Medicine, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - Haoran Peng
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - Subbaramia Sridhar
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - John Erikson Yap
- Division of Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, Georgia, USA
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Imaging Changes and Clinical Complications After Drug-Eluting Bead Versus Conventional Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma: Multicenter Study. AJR Am J Roentgenol 2020; 217:933-943. [PMID: 33245680 DOI: 10.2214/ajr.20.24708] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND. Drug-eluting bead transarterial chemoembolization (DEB-TACE) has emerged as an alternative to conventional TACE (cTACE) for treatment of hepatocellular carcinoma (HCC), although selection between the approaches remains controversial. OBJECTIVE. The purpose of this study was to compare DEB-TACE and cTACE in the treatment of patients with unresectable HCC in terms of hepatobiliary changes on imaging and clinical complications. METHODS. This retrospective study included 1002 patients (871 men, 131 women; mean age, 59 ± 12 years) from three centers who had previously untreated unresectable HCC and underwent DEB-TACE with epirubicin (780 procedures in 394 patients) or cTACE with ethiodized oil mixed with doxorubicin and oxaliplatin (1187 procedures in 608 patients) between May 2016 and November 2018. Among these patients 83.4% had hepatitis B-related liver disease, 57.6% had Barcelona Clinic Liver Cancer (BCLC) stage A or B HCC, and 42.4% had three or more nodules. Mean tumor size was 6.3 ± 4.2 cm. Hepatobiliary changes and tumor response were evaluated with CT or MRI 1 month after TACE. Clinical records were reviewed for adverse events. RESULTS. Bile duct dilatation (p < .001) and portal vein narrowing (p = .006) on imaging and liver failure (p = .03) and grade 3 abdominal pain (p < .001) in clinical follow-up occurred at higher frequency in the DEB-TACE group (15.5%, 4.6%, 2.3%, and 6.1%) than in the cTACE (7.4%, 1.6%, 0.7%, and 2.1%) group. Higher frequency of bile duct dilation in patients who underwent DEB-TACE was observed in subgroup analyses that included patients with BCLC stage A or B HCC (p = .001), with cirrhosis (p < .001), without cirrhosis (p = .04), and without main portal vein tumor thrombus (p = .002). Total bilirubin level 1 month after treatment was 1.5 ± 2.4 mg/dL (95% CI, 1.2-1.8 mg/dL) for DEB-TACE versus 1.3 ± 2.0 mg/dL (95% CI, 1.1-1.5 mg/dL) for cTACE (p = .02). The cTACE and DEB-TACE groups did not differ in other manifestations of postembolization syndrome or systemic toxicity (p > .05). Local tumor disease control rates did not differ between the cTACE and DEB-TACE groups (1 month, 96.7% vs 98.5%, p = .06; 3 months, 81.8% vs 82.4%, p = .87), but overall DCR was significantly higher in the cTACE than in the DEB-TACE group (1 month, 87.5% vs 80.0%, p = .001; 3 months, 78.5% vs 72.1%, p = .02). CONCLUSION. Compared with cTACE, DEB-TACE was associated with greater frequency of hepatobiliary injury and severe abdominal pain. CLINICAL IMPACT. Greater caution and closer follow-up are warranted for patients who undergo DEB-TACE for unresectable HCC than for those who undergo cTACE.
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Kolli S, Shahnazarian V, Gurram H, Reddy M, Gurram K. A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy Confirming Autoimmune Hepatitis. Cureus 2020; 12:e11059. [PMID: 33224655 PMCID: PMC7676497 DOI: 10.7759/cureus.11059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bilomas are unexpected post-procedural complications of cholecystectomies, hepatic resections, endoscopic retrograde cholangiopancreatography, and-rarely-liver biopsies. While uncommon, this should remain high on the differential in a patient presenting with sudden postop sepsis even in the absence of significant liver injury. Diagnosis involves coordination between interventional radiology, gastroenterology, and internal medicine. This involves a precise clinical history, invasive radiological techniques, and advanced interventional endoscopic solutions for diagnosis and treatment. This is a case of a biloma that occurred as a consequence of a post-hepatic biopsy and resulted in fungal infection, rather than its more common bacterial counterpart. Due to the unusual circumstances, a more circuitous route to the correct diagnosis and treatment was undertaken.
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Kobayashi S, Kozaka K, Gabata T, Matsui O, Koda W, Okuda M, Okumura K, Sugiura T, Ogi T. Pathophysiology and Imaging Findings of Bile Duct Necrosis: A Rare but Serious Complication of Transarterial Therapy for Liver Tumors. Cancers (Basel) 2020; 12:cancers12092596. [PMID: 32932894 PMCID: PMC7565329 DOI: 10.3390/cancers12092596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Bile duct necrosis (BDN) is rare but serious complication of transarterial therapy for liver tumors. During development of BDN, ischemia of the peribiliary vascular plexus (PBP) induces the disruption of the bile duct epithelial protection mechanism, causing necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN starts, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On CT images, BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Clinicians should be aware that although BDN and biloma can usually be treated conservatively, in the presence of symptoms such as moderate or severe infection or interval growth of the biloma, prompt treatment is essential to avoid lethal abscess formation and sepsis. Abstract Bile duct necrosis (BDN) with biloma formation is a type of ischemic bile duct injury that is one of the serious complications associated with transarterial therapies, such as transcatheter chemoembolization therapy (TACE), and radioembolization for hepatocellular carcinoma (HCC) and hepatic arterial infusion chemotherapy (HAIC) for metastatic liver cancer from colorectal carcinoma. In terms of the occurrence of BDN and subsequent biloma formation, ischemic injury to the peribiliary vascular plexus (PBP), the supporting vessel of bile duct epithelium, is thought to be intimately associated. In this paper, we first describe the anatomy, blood supply, and function of the intrahepatic bile duct, and then illustrate the pathophysiology of BDN, and finally present the imaging findings of BDN. Under the process of BDN formation, ischemia of the PBP induces the disruption of the bile duct epithelial protection mechanism that causes coagulation and fibrinoid necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN occurs, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On pre-contrast and contrast-enhanced computed tomography (CT), BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Differentiation of imaging findings on CT and ultrasound (US)/magnetic resonance (MR) imaging/MR cholangiopancreatography (MRCP) is important for correct diagnosis of BDN.
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Liu J, Wu Y, Xu E, Huang Q, Ye H, Tan L, Zheng R, Zeng Q, Li K. Risk factors of intrahepatic biloma and secondary infection after thermal ablation for malignant hepatic tumors. Int J Hyperthermia 2020; 36:980-985. [PMID: 31544547 DOI: 10.1080/02656736.2019.1660422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: This study aimed to evaluate the risk factors of biloma formation and secondary infection after thermal ablation for malignant hepatic tumors. Patients and methods: A total of 58 patients with 68 bilomas after thermal ablation were recruited as the complication group, and 61 patients with 72 lesions without major complications were selected randomly as the control group. The potential risk factors for biloma formation were analyzed with the chi-square test and multivariate logistic regression analysis. To determine the optimum management method for biloma, patients with secondary infection were included for the subgroup analysis of risk factors. Results: A history of transcatheter arterial chemoembolization (TACE) treatment (odds ratio [OR]: 3.606, 95% confidence interval [CI]: 1.165-11.156, p = .026) and tumor location (OR: 37.734, 95% CI: 13.058-109.034, p = .000) were independent predictors of biloma formation. Among the 58 patients with biloma, 49 (84.5%) showed no symptoms (i.e., the asymptomatic group), while the remaining 9 (15.5%) developed symptoms related to secondary infections (i.e., the symptomatic group). There were significant differences in the history of biliary manipulation (p = .031) between the symptomatic and asymptomatic groups. Conclusion: A history of TACE treatment and the distance from the biliary tract were independent predictors of biloma formation after thermal ablation. Therefore, protecting the bile duct (i.e., cooling of the bile duct and combing thermal ablation with chemical ablation) should be considered for high-risk patients. Moreover, active monitoring and management should be performed for patients with bilomas who underwent biliary surgery before.
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Affiliation(s)
- Jia Liu
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Yuxuan Wu
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Erjiao Xu
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Qiannan Huang
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Huolin Ye
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Lei Tan
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Rongqin Zheng
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Qingjing Zeng
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
| | - Kai Li
- Department of Ultrasound, Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , PR China
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Würstle S, Göß A, Spinner CD, Huber W, Algül H, Schlag C, Schmid RM, Weber A, Obermeier A, Schneider J. A retrospective clinical and microbial analysis of 32 patients with bilomas. BMC Gastroenterol 2019; 19:50. [PMID: 30947689 PMCID: PMC6450004 DOI: 10.1186/s12876-019-0968-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bilomas are defined collections of bile fluids mainly caused by iatrogenic injuries of the bile duct system. Owing to the infrequency of this disease, studies addressing bilomas are rare. METHODS By using an endoscopic database, this retrospective study identified 32 patients with bilomas treated between 2004 to 2015, in order to analyse aetiology, clinical presentation, spectrum of pathogens, and resolution rate of bilomas. RESULTS 65.6% of the study population (21/32) developed bilomas after surgery and 21.9% (7/32) after endoscopic retrograde cholangiography (ERC). Icterus, fever, and abdominal pain were the leading symptoms. 93.9% (46/49) of microbiological bile cultures revealed a positive microbiology. The predominant microorganisms were the group of Enterobacteriaceae (43.0%, 52/121), followed by Enterococcus spp. (32.2%, 39/121), and Candida spp. (9.1%, 11/121). Multiresistant bacteria like Enterobacteriaceae were isolated from one quarter of all patients. Single or multimodal treatment resulted in an overall complication rate of 4.8% (9/188). Clinical follow-up analysis showed a complete resolution rate of 78.3% for interventional therapy and 80% in the non-interventional group. CONCLUSIONS Pathogen spectrum of bilomas mainly comprises the group of Enterobacteriacae and Enterococcus spp., with a high proportion of multiresistant bacteria. Different interventional approaches are available for biloma drainage, which seem to be safe and effective for most patients. TRIAL REGISTRATION German Clinical Trials Register DRKS00015208 , retrospectively registered.
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Affiliation(s)
- S Würstle
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany.
| | - A Göß
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - C D Spinner
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - W Huber
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - H Algül
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - C Schlag
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - R M Schmid
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - A Weber
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
| | - A Obermeier
- Klinikum rechts der Isar, Technische Universität München, Klinik für Orthopädie und Sportorthopädie, Implantat-assoziierte Infektforschung, Munich, Germany
| | - J Schneider
- Klinikum rechts der Isar, Technische Universität München, Innere Medizin II, Ismaningerstrasse 22, 81675, Munich, Germany
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