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Li X, Ouyang J, Dai J. Current Gallstone Treatment Methods, State of the Art. Diseases 2024; 12:197. [PMID: 39329866 PMCID: PMC11431374 DOI: 10.3390/diseases12090197] [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: 06/21/2024] [Revised: 08/18/2024] [Accepted: 08/21/2024] [Indexed: 09/28/2024] Open
Abstract
This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.
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Affiliation(s)
- Xiangtian Li
- The Second Clinical Medical College, Southern Medical University, Guangzhou 510280, China;
| | - Jun Ouyang
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, National Virtual, Reality Experimental Education Center for Medical Morphology (Southern Medical University), National Key Discipline of Human Anatomy School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China;
| | - Jingxing Dai
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, National Virtual, Reality Experimental Education Center for Medical Morphology (Southern Medical University), National Key Discipline of Human Anatomy School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China;
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Ding C, Yang JF, Yang B, Lu W, Wang X, Zhou YF, Zhang XF. A pancreaticogastric fistula related to intraductal papillary mucinous neoplasm of the pancreas developed during follow-up: A case report and literature review. J Dig Dis 2024; 25:140-146. [PMID: 38433115 DOI: 10.1111/1751-2980.13255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Cong Ding
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Jian Feng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Bin Yang
- Department of Radiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
| | - Wen Lu
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Xia Wang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Yi Feng Zhou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Xiao Feng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
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Abstract
Despite advances in noninvasive techniques for imaging the pancreaticobiliary system, several disease processes including indeterminate biliary strictures as well as neuroendocrine tumors, inflammatory pseudotumors, and complex cysts of the pancreas remain difficult to characterize. New endoscopic imaging technologies have emerged to address these challenges. Cholangioscopy and intraductal ultrasound (IDUS) are powerful tools to characterize subtle biliary concretions and strictures. Confocal Laser Endomicroscopy (CLE) and Optical Coherence Tomography (OCT) are emerging approaches for the most difficult biliary lesions. Contrast harmonic endoscopic ultrasound (CH-EUS), elastography, and 3D-EUS are improving the approach to subtle pancreatic lesions, particularly in the context of indeterminate tissue sampling. Pancreatoscopy, pancreatic IDUS, and intracystic CLE hold promise to further improve the assessment of pancreatic cysts. We aim to comprehensively review the emerging clinical evidence for these innovative endoscopic imaging techniques.
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de Jong DM, Poley JW, Bruno MJ, de Jonge PJF. Uncommon cause of cholangitis due to a migrated pancreatic stone into the common bile duct. VideoGIE 2020; 5:667-669. [PMID: 33319137 PMCID: PMC7730134 DOI: 10.1016/j.vgie.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- David M de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan W Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Okamoto M, Kamitani Y, Iwamoto T, Hayashi A, Maeda K, Yanagitani A, Tanaka K. Obstructive cholangitis by mucus from an intraductal papillary mucinous neoplasm with pancreatobiliary fistula treated by endoscopic septotomy and direct peroral cholangioscopy: a case report. Clin J Gastroenterol 2019; 12:495-499. [PMID: 30963408 DOI: 10.1007/s12328-019-00973-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/23/2019] [Indexed: 12/22/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) occasionally form a fistula to adjacent organs, resulting in obstructive jaundice and cholangitis due to mucus obstruction. Although some procedures such as endoscopic nasobiliary drainage are attempted, they often do not work adequately because of high mucus viscosity. Herein, we report the case of an 87-year-old man with obstructive cholangitis treated by endoscopic septotomy and mucus suction with direct peroral cholangioscopy using conventional endoscopy. The patient incidentally showed a branched-type IPMN in the pancreatic head on computed tomography (CT) approximately 10-years ago. Although the patient's tumor had grown slowly and he occasionally developed cholangitis, he did not want surgery. He was admitted to our hospital because of cholangitis by mucus obstruction with a PB fistula. Endoscopic retrograde cholangiopancreatography (ERCP) and septotomy were performed. Septotomy made the duodenal papilla a large orifice, thereby facilitating spontaneous drainage of mucus. In addition, conventional endoscopy with a large working channel enabled direct access into the orifice and smooth mucus suction, thereby alleviating his cholangitis. In conclusion, septotomy and direct peroral cholangioscopy using conventional endoscopy could be useful to control biliary tract infection and obstructive jaundice due to mucus obstruction from an IPMNs with PB fistula.
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Affiliation(s)
- Masaru Okamoto
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, 730 Ezu, Tottori, 680-0901, Tottori, Japan.
| | - Yu Kamitani
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Taku Iwamoto
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Akihiro Hayashi
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kazunori Maeda
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Atsushi Yanagitani
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kiwamu Tanaka
- Department of Gastroenterology, Tottori Prefectural Central Hospital, Tottori, Japan
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Reuterwall M, Lubbe J, Enochsson L, Lundell L, Konradsson M, Swahn F, Del Chiaro M, Löhr M, Arnelo U. The clinical value of ERCP-guided cholangiopancreatoscopy using a single-operator system. BMC Gastroenterol 2019; 19:35. [PMID: 30808288 PMCID: PMC6390318 DOI: 10.1186/s12876-019-0953-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 02/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Single-operator, per-oral cholangiopancreatoscopy (SOPCP) enables direct biliopancreatic ductal visualization, targeted tissue sampling, and therapeutic intervention. At Karolinska University Hospital, SOPCP was introduced early and has since been extensively utilized according to a standardized protocol. We analysed the clinical value of SOPCP in the diagnosis and treatment of biliopancreatic diseases in a single high volume center. METHODS All SOPCP procedures performed between March 2007 and December 2014 were retrospectively reviewed. Each procedure's diagnostic yield and therapeutic value was evaluated using a predefined 4 grade scale; 1 - no diagnostic or therapeutic value, 2 - information gained did not impact clinical decision-making and in case of a therapeutic intervention, did not alter the clinical course of the patient, 3 - information gained had an impact on clinical decision-making and in the case of a therapeutic intervention, assisted subsequent disease management, and finally, 4 - information gained was essential and critical for clinical decision-making and in case of a therapeutic intervention, solved the clinical problem requiring no further therapeutic actions. Descriptive statistics were used to analyse results, with uni- and multivariate analyses completed to assess risk of adverse events. RESULTS During the study period, 365 SOPCP procedures were performed. We found SOPCP of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases. CONCLUSION SOPCP offers direct access to the biliopancreatic ducts for both diagnostic and therapeutic purposes, adding significant clinical value in 64% of cases. TRIAL REGISTRATION As this is a purely observational and retrospectively registered study in which the assignment of the medical intervention was not at the discretion of the investigator, it has not been registered in a registry.
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Affiliation(s)
- Marcus Reuterwall
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden.
| | - Jeanne Lubbe
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden.,Division of Surgery, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Lars Enochsson
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
| | - Magnus Konradsson
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
| | - Frederik Swahn
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Marco Del Chiaro
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
| | - Matthias Löhr
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, CLINTEC, Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 114 86, Stockholm, Sweden
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De Luca L, Repici A, Koçollari A, Auriemma F, Bianchetti M, Mangiavillano B. Pancreatoscopy: An update. World J Gastrointest Endosc 2019; 11:22-30. [PMID: 30705729 PMCID: PMC6354109 DOI: 10.4253/wjge.v11.i1.22] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 02/06/2023] Open
Abstract
Per-oral pancreatoscopy (POPS) is an endoscopic procedure to visualize the main pancreatic duct. POPS specifically has the advantage of direct visualization of the pancreatic duct, allowing tissue acquisition and directed therapies such as stones lithotripsy. The aim of this review is to analyze and summarize the literature around pancreatoscopy. Pancreatoscopy consists of the classic technique of the mother-baby method in which a mini-endoscope is passed through the accessory channel of the therapeutic duodenoscope. Pancreatoscopy has two primary indications for diagnostic purpose. First, it is used for visualization and histological diagnosis of intraductal papillary mucinous neoplasms. In these cases, POPS is very useful to assess the extent of malignancy and for the study of the intraductal papillary mucinous neoplasm in order to guide the surgery resection margins. Second, it is used to determine pancreatic duct strictures, particularly important in cases of chronic pancreatitis, which is associated with both benign and malignant strictures. Therefore POPS allows differentiation between benign and malignant disease and allows mapping the extent of the tumor prior to surgical resection. Also tissue sampling is possible, but it can be technically difficult because of the limited maneuverability of the biopsy forceps in the pancreatic ducts. Pancreatoscopy can also be used for therapeutic purposes, such as pancreatoscopy-guided lithotripsy in chronic painful pancreatitis with pancreatic duct stones. The available data for the moment suggests that, in selected patients, pancreatoscopy has an important and promising role to play in the diagnosis of indeterminate pancreatic duct strictures and the mapping of main pancreatic duct intraductal papillary mucinous neoplasms. However, further studies are necessary to elucidate and validate the pancreatoscopy role in the therapeutic algorithm of chronic pancreatitis.
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Affiliation(s)
- Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Piazzale Cinelli, Pesaro 61121, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Humanitas University, Pieve Emanuele 20090, Italy
| | - Adea Koçollari
- Gastroenterology Unit, University Medical Center “Mother Theresa” Hospital, Tirana 1000, Albania
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Benedetto Mangiavillano
- Humanitas University, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
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Ren X, Zhu CL, Qin XF, Jiang H, Xia T, Qu YP. Co-occurrence of IPMN and malignant IPNB complicated by a pancreatobiliary fistula: A case report and review of the literature. World J Clin Cases 2019; 7:102-108. [PMID: 30637259 PMCID: PMC6327132 DOI: 10.12998/wjcc.v7.i1.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/06/2018] [Accepted: 12/08/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile duct (IPNB) is pathologically similar to intraductal papillary mucinous neoplasm (IPMN). However, there are several significant differences between them. The rate of IPMN associated with extrapancreatic malignancies has been reported to range from 10%-40%, and it may occasionally be complicated with the presence of fistulas. IPMN associated with malignant IPNB is extremely rare and only nine cases have been reported in the literature.
CASE SUMMARY We report a 52-year-old man who presented with recurrent cholangitis for nine months. Computed tomography and magnetic resonance cholangiopancreatography showed the common bile duct stricture with dilated pancreatobiliary duct without other abnormal findings. The underlying pathogenesis could not be identified based on the radiologic images. Endoscopic retrograde cholangiopancreatography revealed a pancreatobiliary fistula with dilated main pancreatic duct, biliary stricture with dilated biliary tree, and mucus discharge from the enlarged orifice of the major papilla. The patient underwent SpyGlass cholangiopancreatoscopy due to a suspected mucin-producing biliary neoplasm and indeterminate main pancreatic duct dilatation. Multiple papillary growing neoplasms with vascular images, with the extent of lesions spreading in the biliopancreatic ductal lumens, were identified by SpyGlass. In addition, the presence of a pancreatobiliary fistula was also identified. The patient was diagnosed as having benign IPMN and malignant IPNB with focal invasion by postoperative pathology. Furthermore, varying histological subtypes were present in both IPMN and IPNB. Pylorus-preserving pancreaticoduodenectomy was performed on the patient with excellent results during the 52 month follow-up period.
CONCLUSION We deemed that pancreatography and SpyGlass allowed for an efficient diagnosis of IPMN with pancreatobiliary fistula, whereas the etiology could not be identified by radiologic imaging.
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Affiliation(s)
- Xu Ren
- Digestive Disease Hospital of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Province, China
| | - Chun-Lan Zhu
- The Second Digestive Department, Digestive Disease Hospital of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Provice, China
| | - Xu-Fu Qin
- The Second Digestive Department, Digestive Disease Hospital of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Provice, China
| | - Hong Jiang
- Department of Pathology of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Provice, China
| | - Tian Xia
- Digestive Disease Hospital of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Province, China
| | - Yong-Ping Qu
- Digestive Endoscopy Center, Digestive Disease Hospital of Heilongjiang Provincial Hospital, Harbin 150001, Heilongjiang Provice, China
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Arnelo U, Siiki A, Swahn F, Segersvärd R, Enochsson L, del Chiaro M, Lundell L, Verbeke CS, Löhr JM. Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN). Pancreatology 2014; 14:510-4. [PMID: 25287157 DOI: 10.1016/j.pan.2014.08.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Even when advanced cross-sectional imaging modalities have been employed, endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMN) is often required in order to assess the final character and extent of lesions. The current study addresses the use of SpyGlass single-operator peroral pancreatoscopy in suspected IPMN. DESIGN A prospective, non-randomized exploratory cohort study. SETTING Single-center. PATIENTS AND INTERVENTION A prospective study-cohort of 44 consecutive patients in a single tertiary referral center who underwent ERCP and peroral pancreatoscopy, was prospectively collected between July 2007 and March 2013 because of a radiological signs of IPMN. These IPMN-findings were discovered incidentally in 44% of the cases. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy (specificity & sensitivity) and complications. RESULTS The targeted region of the pancreatic duct was reached with the SpyGlass system in 41 patients (median age 65 years, 41% female). Three patients were excluded from analysis because of failed deep cannulation of the pancreatic duct. Brush cytology was taken in 88% and direct biopsies in 41%. IPMN with intermediate or high-grade dysplasia was the main final diagnosis (76%) in 22 patients who had surgery. Out of the 17 patients with a final diagnosis of MD-IPMN, 76% were correctly identified by pancreatoscopy. Of the 9 patients with a final diagnosis of BD-IPMN, the pancreatoscopy identified 78% of the cases correctly.The incidence of post-ERCP pancreatitis was 17%. Pancreatoscopy was found to have provided additional diagnostic information in the vast majority of the cases and to affect clinical decision-making in 76%. LIMITATIONS Single-center study. CONCLUSIONS Single-operator peroral pancreatoscopy contributed to the clinical evaluation of IPMN lesions and influenced decision-making concerning their clinical management. The problem of post-procedural pancreatitis needs further attention.
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Affiliation(s)
- Urban Arnelo
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden.
| | - Antti Siiki
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden; Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Fredrik Swahn
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Ralf Segersvärd
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Lars Enochsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Marco del Chiaro
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Lars Lundell
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - Caroline S Verbeke
- Division of Pathology, Dept. of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - J-Matthias Löhr
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
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