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Zhang C, Li Y, Song M, Sun Z, Han X, Ren J, Jiao D. False-negative factors of percutaneous transluminal clamp biopsy for suspected malignant biliary stricture: 194 cases analyzed from a single center. Insights Imaging 2024; 15:108. [PMID: 38609579 PMCID: PMC11014833 DOI: 10.1186/s13244-024-01675-y] [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: 11/20/2023] [Accepted: 02/18/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE To study the predictive factors of false negatives in the diagnosis of biliary stricture (BS) by percutaneous transluminal clamp biopsy (PTCB). METHOD From January 2016 to January 2021, 194 patients with a high suspicion of malignant tumors due to BS underwent PTCB during biliary drainage at our department. The final diagnosis was confirmed by postoperative pathology, other tissue or cell evidence, or medical imaging follow-up. Univariate and multivariate regression analyses were performed on the pathological results, summarizing the independent risk factors for false-negative value (FNV) to help further clinical diagnosis and treatment. RESULTS Of the 194 cases, 176 and 18 cases were finally diagnosed as malignant and benign BS, respectively, compared to 144 and 50 cases by PTCB, including 32 false-negative cases. The sensitivity, specificity, false-positive value, and FNV of PTCB were 81.8%, 100%, 0%, and 18.2%, respectively. Multivariate analysis showed that non-cholangiocarcinoma BS was an independent risk factor for FNV of PTCB (odds ratio 7.5 (95% CI 1.74-32.6), p < 0.01). CONCLUSION PTCB is an effective minimally invasive interventional technique for BS diagnosis. Non-cholangiocarcinoma BS is an independent risk factor for FNV. CRITICAL RELEVANCE STATEMENT Identifying factors that are predictive of false-negative results by percutaneous transluminal clamp biopsy in the setting of biliary stricture may have a guiding effect on clinical practice. KEY POINTS • Factors predictive of false negatives in the diagnosis of biliary stricture etiology by PTCB may aid in the interpretation of results. • Non-cholangiocarcinoma BS is an independent risk factor for FNV on PTCB. • PTCB is an effective minimally invasive interventional technique for BS diagnosis.
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Affiliation(s)
- Chengzhi Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Yipu Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Mengyao Song
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Zhanguo Sun
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Jianzhuang Ren
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Interventional Therapy Institute of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China.
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Gaballah M, Worede F, Alexander C, Arkader A, Cahill AM, Acord MR. Novel method to biopsy aneurysmal bone cysts in children. Skeletal Radiol 2023; 52:2479-2486. [PMID: 37191930 DOI: 10.1007/s00256-023-04360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE The thin and friable septations composing aneurysmal bone cysts (ABC) may be challenging to target for percutaneous biopsy. The purpose of this study was to describe and evaluate a novel method of ABC biopsy using endomyocardial biopsy forceps as an attempt to capture larger fragments of tissue for diagnosis. METHODS AND MATERIALS This was a retrospective study performed over a 17-year period. Patients <18 years old who underwent percutaneous biopsy for a presumed ABC, based on pre-procedure imaging, were included. Medical records were reviewed to identify age, sex, lesion location, biopsy procedure details, complications, and pathology results. A diagnostic biopsy was defined as conclusive histologic confirmation. Inconclusive findings or findings suggestive of but not diagnostic of an ABC were treated as non-diagnostic, even if imaging and clinical findings were characteristic. Biopsy device selection and quantity of tissue obtained was at the discretion of the pediatric interventional radiologist. Fisher's exact test was used to compare the diagnostic yield of standard biopsies to those employing biopsy forceps. RESULTS Twenty-three biopsies were performed in 18 patients (11 female) with a median age of 14.7 years (IQR 10.6-15.6). Lesions were located in the extremities (7, 30.4%), chest (6, 26.1%), pelvis (5, 21.7%), spine (4, 17.4%), and mandible (1, 4.3%). Specimens were obtained using a 13- or 15-gauge bone coring needle (11, 47.8%); 14-, 16-, or 18-gauge soft tissue needle (6, 26.1%); or a combination of bone and soft tissue (4, 17.4%) needles. Endomyocardial biopsy forceps were utilized in 7 cases (30.4%), 2 in which it was the only device used. Overall, a conclusive pathologic diagnosis was made in 13/23 (56.5%) biopsies. Of the diagnostic biopsies, 1 was a unicameral bone cyst and all others were ABCs. No malignancy was identified. Compared to the standard approach, the use of forceps was more likely to result in a diagnostic biopsy (40.0% vs 100.0%, p = 0.008). There were no complications. CONCLUSIONS Endomyocardial biopsy forceps offer an additional, novel technique to biopsy presumed ABCs and may improve diagnostic yield.
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Affiliation(s)
- Marian Gaballah
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Fikadu Worede
- Department of Medicine, Mercy Catholic Medical Center, Darby, PA, 19023, USA
| | - Caitlin Alexander
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Anatomic Pathology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Alexandre Arkader
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Acord
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Cortese F, Acquafredda F, Mardighian A, Zurlo MT, Ferraro V, Memeo R, Spiliopoulos S, Inchingolo R. Percutaneous insertion of a novel dedicated metal stent to treat malignant hilar biliary obstruction. World J Gastrointest Oncol 2022; 14:1833-1843. [PMID: 36187389 PMCID: PMC9516644 DOI: 10.4251/wjgo.v14.i9.1833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/11/2022] [Accepted: 08/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Percutaneous bilateral biliary stenting is an established method for the management of unresectable malignant hilar biliary obstruction.
AIM To evaluate the efficacy and safety of a novel uncovered biliary stent, specifically designed for hilar reconstruction.
METHODS This, single-center, retrospective study included 18 patients (mean age 71 ± 11 years; 61.1% male) undergoing percutaneous transhepatic Moving cell stent (MCS) placement for hilar reconstruction using the stent-in-stent technique for malignant biliary strictures, between November 2020 and July 2021. The Patients were diagnosed with cholangiocarcinoma (12/18; 66.6%), gallbladder cancer (5/18; 27.7%), and colorectal liver metastasis (1/18; 5.5%). Primary endpoints were technical (appropriate stent placement) and clinical (relief from jaundice) success. Secondary endpoints included stent patency, overall survival, complication rates and stent-related complications.
RESULTS The technical and clinical success rates were 100% (18/18 cases). According to Kaplan-Meier analysis, the estimated overall patient survival was 80.5% and 60.4% at 6 and 12 mo respectively, while stent patency was 90.9% and 68.2% at 6 mo and 12 mo respectively. The mean stent patency was 172.53 ± 56.20 d and median stent patency was 165 d (range 83-315). Laboratory tests for cholestasis significantly improved after procedure: mean total bilirubin decreased from 15.2 ± 6.0 mg/dL to 1.3 ± 0.4 mg/dL (P < 0.001); mean γGT decreased from 1389 ± 832 U/L to 114.6 ± 53.5 U/L (P < 0.001). One periprocedural complication was reported. Stent-related complications were observed in 5 patients (27.7%), including 1 occlusion (5.5%) and 1 stent migration (5.5 %).
CONCLUSION Percutaneous hilar bifurcation biliary stenting with the MCS resulted in excellent clinical and technical success rates, with acceptable complication rates. Further studies are needed to confirm these initial positive results.
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Affiliation(s)
- Francesco Cortese
- Interventional Radiology Unit, Miulli Hospital, Acquaviva Delle Fonti 70124, Italy
| | - Fabrizio Acquafredda
- Interventional Radiology Unit, Miulli Hospital, Acquaviva Delle Fonti 70124, Italy
| | - Andrea Mardighian
- Interventional Radiology Unit, Miulli Hospital, Acquaviva Delle Fonti 70124, Italy
| | - Maria Teresa Zurlo
- Interventional Radiology Unit, Miulli Hospital, Acquaviva Delle Fonti 70124, Italy
| | - Valentina Ferraro
- Unit of Hepatobiliary Surgery, Miulli hospital, Acquaviva Delle Fonti 70124, Italy
| | - Riccardo Memeo
- Unit of Hepatobiliary Surgery, Miulli hospital, Acquaviva Delle Fonti 70124, Italy
| | - Stavros Spiliopoulos
- 2nd Radiology Department, National and Kapodistrian University of Athens, Chaidari Athens 12461, Greece
| | - Riccardo Inchingolo
- Interventional Radiology Unit, Miulli Hospital, Acquaviva Delle Fonti 70124, Italy
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Tian Y, An J, Zou Z, Dong Y, Wu J, Chen Z, Niu H. Percutaneous transluminal forceps biopsy with an adjustable curved sheath for obstructive jaundice. MINIM INVASIV THER 2022; 31:1096-1102. [PMID: 35616175 DOI: 10.1080/13645706.2022.2079381] [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: 10/18/2022]
Abstract
PURPOSE To evaluate the feasibility and safety of percutaneous transluminal forceps biopsy (PTFB) with an adjustable curved sheath in patients with obstructive jaundice. MATERIAL AND METHODS Forty-two patients who underwent PTFB with an adjustable curved sheath were analyzed retrospectively. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were calculated for all populations and in different situations. Technical success and safety were evaluated. RESULTS The technical success rate was 100%. Thirty-five of 42 cases were diagnosed malignant diseases, the sensitivity of PTFB with an adjustable curved sheath was 74.29% (26/35), the specificity was 100%, the positive predictive value was 100%, the negative predictive value was 43.75% (7/16), and the accuracy rate was 78.57% (33/42). There was a better sensitivity for bile duct malignancies when compared with non-bile duct malignancies (p = 0.012). No statistical difference was found in the sensitivity of the upper part of the biliary tree and the lower part of the biliary tree, and none in the sensitivity of different approaches (left vs. right). The complication rate was 11.90%, and no serious complications were observed. CONCLUSIONS PTFB with an adjustable curved sheath is an effective and safe technique, without being limited by approaches and obstruction sites.
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Affiliation(s)
- Ye Tian
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Jianli An
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Zibo Zou
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Yanchao Dong
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Jingpeng Wu
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Zhuo Chen
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
| | - Hongtao Niu
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, P. R. China
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Inchingolo R, Acquafredda F, Posa A, Nunes TF, Spiliopoulos S, Panzera F, Praticò CA. Endobiliary biopsy. World J Gastrointest Endosc 2022; 14:291-301. [PMID: 35719901 PMCID: PMC9157693 DOI: 10.4253/wjge.v14.i5.291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/22/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
The differential diagnosis between benign and malignant biliary strictures is challenging and requires a multidisciplinary approach with the use of serum biomarkers, imaging techniques, and several modalities of endoscopic or percutaneous tissue sampling. The diagnosis of biliary strictures consists of laboratory markers, and invasive and non-invasive imaging examinations such as computed tomography (CT), contrast-enhanced magnetic resonance cholangiopancreatography, and endoscopic ultrasonography (EUS). Nevertheless, invasive imaging modalities combined with tissue sampling are usually required to confirm the diagnosis of suspected malignant biliary strictures, while pathological diagnosis is mandatory to decide the optimal therapeutic strategy. Although EUS-guided fine-needle aspiration biopsy is currently the standard procedure for tissue sampling of solid pancreatic mass lesions, its diagnostic value in intraductal infiltrating type of cholangiocarcinoma remains limited. Moreover, the "endobiliary approach" using novel slim biopsy forceps, transpapillary and percutaneous cholangioscopy, and intraductal ultrasound-guided biopsy, is gaining ground on traditional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography endobiliary forceps biopsy. This review focuses on the available endobiliary techniques currently used to perform biliary strictures biopsy, comparing the diagnostic performance of endoscopic and percutaneous approaches.
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Affiliation(s)
- Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Fabrizio Acquafredda
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Alessandro Posa
- Department of Radiology, Policlinico Universitario “A. Gemelli“, Rome 00186, Italy
| | - Thiago Franchi Nunes
- Interventional Radiology Unit, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Francesco Panzera
- Interventional Gastroenterology Unit, Madonna Delle Grazie Hospital, Matera 75100, Italy
| | - Carlos Alberto Praticò
- Unité d’Endoscopie Digestive, Hôpital Privé “Armand Brillard” 3/5 avenue Watteau, Nogent-sur-Marne 94130, France
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Systematic review and meta-analysis of percutaneous transluminal forceps biopsy for diagnosing malignant biliary strictures. Eur Radiol 2021; 32:1747-1756. [PMID: 34537877 DOI: 10.1007/s00330-021-08301-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To perform a systematic review and meta-analysis to determine the diagnostic performance of percutaneous transluminal forceps biopsy (PTFB) for differentiating malignant from benign biliary stricture. METHODS A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted to identify original articles published between January 2001 and January 2021 reporting the diagnostic accuracy of PTFB. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS Fourteen studies involving 1762 patients met the inclusion criteria and were included in the meta-analysis. The meta-analysis summary estimates of PTFB for diagnosis of malignant biliary strictures were as follows: sensitivity 81% (95% confidence interval [CI], 78-81%); specificity 100% (95% CI, 98-100%); diagnostic odds ratio 85.34 (95% CI, 38.37-189.81). The area under the curve of PTFB was 0.948 in the diagnosis of malignant biliary strictures. The diagnostic sensitivity was higher in intrinsic (85%) than in extrinsic (73%) biliary strictures. The pooled rate of all complications was 10.3% (95% CI, 7.0-14.2%), including a major complication rate of 3.1%. CONCLUSION These data demonstrate that PTFB is sensitive and highly specific for diagnosing malignancy in biliary strictures. PTFB should be incorporated into future guidelines for tissue sampling in biliary cancer, especially in cases with failed endoscopic management. KEY POINTS • PTFB had a good overall diagnostic performance for differentiating malignant from benign biliary strictures, with a meta-analysis summary estimate of 81% for sensitivity and 100% for specificity. • PTFB had higher sensitivity for cholangiocarcinoma (85%) than for other cancers (73%). • PTFB had a 100% technical success rate and a 10.3% rate for complications, including a 3.1% rate for major complications.
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Camacho JC, Brody LA, Covey AM. Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know. Semin Intervent Radiol 2021; 38:300-308. [PMID: 34393340 DOI: 10.1055/s-0041-1731269] [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: 10/25/2022]
Abstract
Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.
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Affiliation(s)
- Juan C Camacho
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill-Cornell Medical Center, New York, New York
| | - Lynn A Brody
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill-Cornell Medical Center, New York, New York
| | - Anne M Covey
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill-Cornell Medical Center, New York, New York
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Zhang H, Huo C, Guo Y, Zhu K, Li F, Huang J. Tissue sampling for biliary strictures using novel elbow biopsy forceps. Sci Rep 2021; 11:10895. [PMID: 34035351 PMCID: PMC8149446 DOI: 10.1038/s41598-021-90197-4] [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] [Received: 01/04/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
We aim to evaluate the safety and feasibility of novel elbow biopsy forceps with a prebent head for sampling biliary strictures in our institution. A total of 24 patients (15 males and 9 females) with biliary stricture who underwent biliary biopsy during endoscopic retrograde cholangiopancreatography (ERCP) using novel elbow biopsy forceps from June 2019 to August 2020 were retrospectively included. The novel biopsy forceps had a head angulation of 30 degrees and were able to cannulate the bile duct and approach the biliary strictures easily to obtain adequate samples. The technical success rate, incidence of adverse events, and consistency of pathological and surgical specimens were assessed. This device was used successfully in all patients. A total of 52 biopsy specimens were obtained from 24 patients, and all specimens could be used for histopathological examination. Seventeen patients were diagnosed with malignancy based on biopsies, and all of them underwent surgical treatment. The histopathological findings of the biopsy specimens were in accordance with the postoperative pathology diagnoses. One of the seven patients was diagnosed with a benign lesion that was proven to be malignant during surgical treatment in the follow-up period. Two patients experienced a single episode of acute pancreatitis and recovered shortly after appropriate treatment. No patients experienced biliary perforation or biliary bleeding. Biopsy using novel elbow forceps in patients with biliary stenosis is feasible and safe. The novel device and related biopsy technique may be widely applied for biliary disease differentiation.
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Affiliation(s)
- Huahui Zhang
- Graduate School of Dalian Medical University, Dalian, China
| | - Chunyan Huo
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China
| | - Yongxin Guo
- Graduate School of Dalian Medical University, Dalian, China
| | - Keyuan Zhu
- Graduate School of Dalian Medical University, Dalian, China
| | - Fengdong Li
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China
| | - Jin Huang
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China.
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