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Erschienen in: BMC Gastroenterology 1/2018

Open Access 01.12.2018 | Research article

Identification of risk factors for pancreatic pseudocysts formation, intervention and recurrence: a 15-year retrospective analysis in a tertiary hospital in China

verfasst von: Jie-hui Tan, Lei Zhou, Rong-chang Cao, Guo-wei Zhang

Erschienen in: BMC Gastroenterology | Ausgabe 1/2018

Abstract

Background

Pancreatic pseudocyst (PPC) is a common complication of acute and chronic pancreatitis. To our knowledge no study has systematically reported the risk factors for the formation, intervention and recurrence of PPC. Therefore, the present study aimed to investigate the potential risk factors for PPC, with regards to its formation, intervention and recurrence.

Methods

A database containing 5106 pancreatitis patients was retrospectively analyzed. As a result, a total of 4379 eligible patients were identified and divided into 2 groups: PPC group (group A, n = 759) and non-PPC group (group B, n = 3620). The PPC group was subdivided into 2 groups: intervention PPC (group C, n = 347) and resolution PPC (group D, n = 412). The differences in surgical complication and recurrence rates were compared among 347 PPC patients receiving different interventions, including surgical, endoscopic and percutaneous drainages. Furthermore, group C was subdivided into 2 groups: recurrent PPC (group E, n = 34) and non-recurrent PPC (group F, n = 313). All possible risk factors for PPC formation, intervention and recurrence were determined by multivariate regression analysis.

Results

In this study, PPC was developed in 17.3% (759/4379) of pancreatitis patients. The significant risk factors for PPC formation included alcoholic pancreatitis (OR, 6.332; 95% CI, 2.164–11.628; p = 0.031), chronic pancreatitis (CP) (OR, 5.822; 95% CI, 1.921–10.723; p = 0.006) and infected pancreatic necrosis (OR, 4.253; 95% CI, 3.574–7.339; p = 0.021). Meanwhile, the significant risk factors of PPC patients who received intervention were alcoholic pancreatitis (OR, 7.634; 95% CI, 2.125–13.558; p = 0.016), size over 6 cm (OR, 8.834; 95% CI, 2.017–16.649; p = 0.002) and CP (OR, 4.782; 95% CI, 1.897–10.173; p = 0.038). In addition, the recurrence rate in PPC patients treated with percutaneous drainage was found to be the highest (16.3%) among the three intervention groups. Furthermore, percutaneous drainage was the only risk factor of PPC recurrence (OR, 7.812; 95% CI, 3.109–23.072; p = 0.013) identified from this retrospective cohort study.

Conclusions

Alcoholic pancreatitis and CP are the main risk factors for PPC formation and intervention, but not PPC recurrence. A higher recurrence rate is found in PPC patients treated with percutaneous drainage, as compared to endoscopic and surgical interventions.
Abkürzungen
AP
Acute pancreatitis
CP
Chronic pancreatitis
IPN
Infected pancreatic necrosis
PPC
Pancreatic pseudocyst

Background

According to the revised Atlanta classification [1], acute fluid collections and pseudocyst formation are the most common complications in patients with acute and chronic pancreatitis. A cute peripancreatic fluid collections often lack a wall of granulation or fibrous tissue, which occurred in 30% to 50% of acute pancreatitis (AP) patients within 48 h of AP onset. More than 50% of AP cases disappear spontaneously, or develop into PPC surrounded by a well-defined wall [2]. PPC incidence ranged from 5 to 16% in AP patients, while 20–40% in patients with CP [36].
Large PPC is uaually known to cause compressive symptoms and a variety of treatment methods has been proposed such as conservative treatment (watchful monitoring), surgical drainage (open or laparoscopic), percutaneous drainage and endoscopic drainage. Traditionally, the indications for therapeutic intervention of PPC are more than 6 cm in size and persisted for more than 6 weeks. In practice, large pseudocysts are less likely to resolve spontaneously. However, prolonged observation of spontaneous PPC resolution may expose patients to unwarranted risks, including bleeding, perforation, jaundice and infection. Therefore, in order to design effective treatment strategies for patients with PPC, clinical studies should be performed on the basis of an appropriate plan of investigation reflecting the latest scientific and technical knowledge.
To our knowledge, after implementation of the 2012 revised Atlanta classification for AP, the number of retrospective studies focusing on PPC is relatively limited, and most of them has become obsolete. Given these circumstances, further studies are warranted to systematically sought out the incidence, risk factors and intervention effect for PPC. Accordingly, this study aimed to identify the potential risk factors for PPC, with regards to its formation, intervention and recurrence.

Methods

Patient identification and selection

A total of 5106 pancreatitis patients (4213 AP cases, 526 CP cases and 367 traumatic pancreatitis cases) hospitalized at NanFang Hospital, Southern Medical University from November 2003 to February 2018 were retrospectively analyzed. All patients were diagnosed and treated according to the guidelines of the Pancreatic Surgical Science Section of the Chinese Medical Association Surgery Branch in 2014, and were graded according to the 2012 revised Atlanta classification for AP. According to the 2012 revised Atlanta classification for AP, severity is classified as mild, moderate or severe. Mild acute pancreatitis has no organ failure, local or systemic complications. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure > 48 h [7]. All interventions were performed by or under the supervision of consultant surgeons and their assistants. PPC resection and cyst-enteric bypass were the primary treatment methods in these patients. The study protocol was approved by the ethics committee of the same hospital.
Among these patients, 4379 pancreatitis cases fulfilled the in-teamed standard and were divided into PPC group (group A, n = 759) and non-PPC group (group B, n = 3620). PPC was defined according to the revised Atlanta criteria. Group A was further divided into 2 groups: intervention PPC (group C, n = 347) and resolution PPC (group D, n = 412). Similarly, group C was divided into 2 groups: recurrent PPC (group E, n = 34) and non-recurrent PPC (group F, n = 313) (Fig. 1). All PPC patients were followed up for at least 6 weeks after diagnosis, while all intervention patients were followed up for at least 3 months after treatment.

Statistical analysis

All statistical analyses were performed with SPSS software (SPSS version 22.0, Chicago, IL, USA). Inter-group comparisons were determined by Pearson’s chi-square test, Student t test or Mann-Whitney U test, whenever appropriate. Univariate and multivariate logistic regression analyses were used to investigate the risk factors for the formation, intervention and recurrence of PPC. P values of less than 0.05 were considered statistically significant.

Results

The clinical characteristics of the 4379 pancreatitis patients are summarized in Table 1. PPC was developed in 17.3% (759/4379) of pancreatitis patients. Intriguingly, alcoholic etiology (OR, 6.332; 95% CI, 2.164–11.628; p = 0.031), CP (OR, 5.822; 95% CI, 1.921–10.723; p = 0.006) and infected pancreatic necrosis (IPN) (OR, 4.253; 95% CI, 3.574–7.339; p = 0.021) were revealed as significant risk factors for PPC formation (Table 1). Through multivariate analysis, the independent risk factors for PPC patients who required intervention were found to be alcoholic etiology (OR, 7.634; 95% CI, 2.125–13.558; p = 0.016), CP (OR, 4.782; 95% CI, 1.897–10.173; p = 0.038) and size over 6 cm (OR, 8.834; 95% CI, 2.017–16.649; p = 0.002) (Table 2). Additionally, there were statistically significant differences in the recurrence rates among endoscopic, surgical and percutaneous drainage groups, but not complications. The recurrence rate of PPC treated with percutaneous drainage was 16.3%, which ranked the highest among the three intervention groups (Table 3). Notably, percutaneous drainage (OR, 7.812; 95% CI, 3.109–23.072; p = 0.013) was the only independent risk factor for PPC recurrence, as assessed by multivariate analysis (Table 4).
Table 1
Univariate and multivariate regression analyses of risk factors associated with PPC formation
Variable
Univiarite analysis
Multivariate analysis
Total (n = 4379)
Group A (n = 759)
Group B (n = 3620)
P-value
OR (95% CI)
P-value
Age (years)
47.82 ± 15.31
47.33 ± 14.65
48.12 ± 15.74
0.523
  
Sex (male/female)
2788/1591
435/324
2253/1467
0.096
  
BMI
24.71 ± 4.85
24.28 ± 4.76
23.87 ± 5.13
0.329
  
Smoking (yes/no)
1343/3036
252/507
1091/2529
0.096
  
Comorbidity
 Hypertension
425
78
347
0.559
  
 Diabetes
505
83
412
0.724
  
 Respiratory diseases
214
35
179
0.698
  
 Liver diseases
147
34
113
0.061
  
Pancreatitis (acute/chronic)
3887/492
654/105
3233/387
0.013a
5.822 (1.921-10.723)
0.006a
Recurrent pancreatitis (yes/no)
861/3518
143/616
718/2917
0.565
  
Symptoms
 Pain
4334
748
3586
0.028a
1.557 (0.891-3.425)
0.067
 Fever
751
112
639
0.054
  
Etiology
 Biliary
1923
354
1569
0.096
  
 Alcoholic
785
163
622
0.005a
6.332 (2.164-11.628)
0.031a
 Trauma
304
42
262
0.093
  
 Hyperglycemia
342
49
293
0.126
  
 Post ERCP
577
84
493
0.059
  
 Idiopathic
448
67
381
0.161
  
Lab examination
 Amylase (U/L)
859.37 ± 612.35
831.22 ± 579.28
864.19 ± 634.56
0.574
  
 WBC (109/L)
13.79 ± 7.36
14.58 ± 8.24
12.46 ± 7.10
0.218
  
 CRP (mg/L)
82.63 ± 28.52
86.48 ± 32.67
78.44 ± 26.36
0.227
  
 TBIL (umol/L)
52.21 ± 33.62
54.37 ± 36.27
51.46 ± 31.70
0.232
  
IPN (%)
337 (7.7)
78 (10.3)
259 (7.2)
0.003a
4.253 (3.574-7.339)
0.021a
 Antibiotics (Yes/No)
3782/592
644/115
3138/477
0.152
  
 Somatostatin (Yes/No)
4201/178
725/34
3476/144
0.525
  
Data are expressed as n (%) or mean ± standard
aStatistically significant results (P < 0.050)
Table 2
Univariate and multivariate regression analyses of risk factors associated with PPC which needs intervention
Variable
Univiarite analysis
Multivariate analysis
Group C (n = 347)
Group D (n = 412)
P-value
OR (95% CI)
P-value
Age (years)
46.85 ± 15.19
48.04 ± 14.27
0.264
  
Sex (male/female)
193/154
242/170
0.387
  
BMI
24.59 ± 4.62
24.13 ± 4.83
0.614
  
Smoking (yes/no)
115/232
137/275
0.974
  
Comorbidity
 Hypertension
32/315
46/366
0.380
  
 Diabetes
39/308
44/368
0.806
  
 Respiratory diseases
13/336
22/390
0.289
  
 Liver diseases
14/333
20/392
0.586
  
Pancreatitis (acute/chronic)
285/62
369/43
0.003a
4.782 (1.897-10.173)
0.038a
Recurrent pancreatitis (yes/no)
68/279
75/337
0.625
  
Symptoms
 Pain
341
407
0.554
  
 Fever
48
64
0.510
  
Etiology
 Biliary
149
205
0.061
  
 Alcoholic
89
74
0.010a
7.634 (2.125-13.558)
0.016a
 Trauma
18
24
0.701
  
 Hyperglycemia
23
26
0.859
  
 Post ERCP
37
47
0.745
  
 Idiopathic
31
36
0.905
  
Lab examination
 Amylase (U/L)
912.47 ± 674.63
819.23 ± 626.37
0.172
  
 WBC (109/L)
14.71 ± 8.65
13.85 ± 8.23
0.384
  
 CRP (mg/L)
82.05 ± 28.39
88.72 ± 31.33
0.271
  
 TBIL (umol/L)
56.42 ± 34.71
52.93 ± 38.37
0.325
  
Time from pancreatitis to pseudocyst (weeks)
8.47 ± 1.78
9.12 ± 2.05
0.311
  
Location
  
0.043a
2.534 (0.892-3.665)
0.083
 Head
129
183
   
 Body/Tail
218
229
   
Number
  
0.037a
2.754 (0.821-4.378)
0.064
 Single
183
186
   
 Multiple
164
226
   
Size
  
0.011a
8.834 (2.017-16.649)
0.002a
  ≥ 6 cm
144
134
   
  < 6 cm
203
278
   
IPN
44
34
0.045a
1.811 (0.893-3.552)
0.056
 Antibiotics (Yes/No)
302/45
342/70
0.124
  
 Somatostatin (Yes/No)
331/16
394/18
0.872
  
Data are expressed as n (%) or mean ± standard
aStatistically significant results (P < 0.050)
Table 3
Comparison of complications of 347 PPC intervention patients according to different intervention methods
Total (n = 347)
Endoscopic
Surgical
Percutaneous drainage
P-value
48
164
135
 
Infection
5
13
22
0.076
Hemorrhage
2
5
5
0.914
Anastomotic/Percutaneous Leakage
3
4
7
0.342
Pancreatitis exacerbation
2
2
1
0.219
Organ failure
1
2
2
0.906
Mortality
1
1
3
0.464
Recurrence
4
8
22
0.004a
aStatistically significant results (P < 0.050)
Table 4
Univariate and multivariate regression analyses of risk factors associated with PPC recurrence
Variable
Univiarite analysis
Multivariate analysis
Group E (n = 34)
Group F (n = 313)
P-value
OR (95% CI)
P-value
Age(years)
47.33 ± 15.42
46.42 ± 14.82
0.317
  
Sex (male/female)
19/15
174/139
0.974
  
BMI
24.12 ± 4.34
24.69 ± 4.82
0.538
  
Smoking (yes/no)
8/26
107/206
0.210
  
Comorbidity
 Hypertension
4
28
0.589
  
 Diabetes
5
34
0.500
  
 Respiratory diseases
1
12
0.795
  
 Liver diseases
0
14
0.208
  
Pancreatitis (acute/chronic)
27/7
258/55
0.663
  
Recurrent pancreatitis (yes/no)
11/23
57/256
0.048a
2.017 (0.926-4.173)
0.063
Symptoms
 Pain
33
308
0.568
  
 Fever
8
40
0.085
  
Etiology
 Biliary
13
136
0.560
  
 Alcoholic
7
82
0.477
  
 Trauma
3
15
0.314
  
 Hyperglycemia
2
21
0.854
  
 Post ERCP
3
34
0.714
  
 Idiopathic
6
25
0.061
  
Lab examination
 Amylase (U/L)
958.26 ± 662.37
872.51 ± 652.46
0.142
  
 WBC (109/L)
13.67 ± 8.24
15.21 ± 8.32
0.254
  
 CRP (mg/L)
79.32 ± 27.61
83.23 ± 29.39
0.371
  
 TBIL (umol/L)
57.72 ± 33.69
56.10 ± 35.32
0.652
  
Time from pancreatitis to pseudocyst
8.74 ± 2.16
8.37 ± 1.85
0.725
  
Location
  
0.099
  
 Head
14
115
   
 Body/Tail
20
198
   
Number
  
0.325
  
 Single
15
168
   
 Multiple
19
145
   
IPN
8
36
0.045a
1.483 (0.875-3.262)
0.083
 Antibiotics (Yes/No)
31/3
271/42
0.449
  
 Somatostatin (Yes/No)
33/1
298/15
0.625
  
Intervention methods
  
0.004a
7.812 (3.109-23.072)
0.013a
 Endoscopic drainage (%)
4 (8.3%)
44 (91.7%)
   
 Surgical drainage (%)
8 (4.9%)
156 (95.1%)
   
 Percutaneous drainage (%)
22 (16.4%)
113 (83.6%)
   
Data are expressed as n (%) or mean ± standard
aStatistically significant results (P < 0.050)

Discussion

PPC, a begin complication of pancreatitis, can be predictors of a malignant outcome, especially among patients with severe AP. The two main indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications such as bleeding, infection, gastric outlet and biliary obstruction [8]. To date, the guidelines on minimally invasive management of PPC demonstrated a lack of consensus in clinical recommendations, and few recommendations have been graded according to the strength of supporting evidence. The identification and prediction of risk factors for PPC formation, intervention and recurrence may help to distinguish the high-risk PPC group from patients with pancreatitis. Thus, early detection and treatment can be considered for patients at high-risk of PPC. Additionally, identification of risk factors may reduce surgical adverse events, avoid delay in inappropriate interventions and improve the prognosis of PPC patients.
In the present study, data of 5106 pancreatitis patients was retrieved from a prospective database and was retrospectively analyzed. After reviewing the English-language articles published in PubMed with MeSH terms of “pancreatitis”, “pancreatic pseudocyst”, “pancreatic necrosis”, “infected pancreatic necrosis”, or “pancreatic fluid collections”, we believed that this study contained the largest population of PPC patients at a single center, reporting the risk factors of PPC formation, intervention and recurrence. Alcoholic and chronic pancreatitis remained the main risk factors for PPC formation and intervention. Although the recurrence rate of PPC treated with percutaneous drainage was ranked the highest, there was no difference in the rate of complications among the three types of interventions.
Biliary pancreatitis is ranked the most common cause of PPC among Asian countries, followed by alcoholic pancreatitis. However, more severe forms of AP and local complication, such as pseudocyst formation, have been associated with alcoholic AP compared to biliary AP [9]. Alcohol acts to worsen pancreatitis by its effects on pancreatic mitochondria to promote necrosis, which has been proved by in vitro experiments and clinical research [10, 11]. Besides, nonalcoholic acute pancreatitis is associated with a lower incidence of pseudocyst formation when compared with acute alcoholic pancreatitis. Alcoholism etiology has been reported as one of the risk factors for pancreatic fluid collections [12]. On the other hand, a high incidence of pseudocyst formation has been found among patients with CP. A multicenter study from China reported that 26.25% of CP patients are more likely to develop pseudocysts [13]. PPC due to CP, is often accompanied by secondary complications, including duodenal and/or biliary obstruction, splenic vein thrombosis and rarely infection [14]. These complications are primarily treated by surgery and less amenable to endoscopic therapy, especially for common bile duct stricture, main pancreatic duct obstruction and pseudocysts [15]. Furthermore, alcoholism exhibits a worse effect on pancreatic function and is the most common cause of CP. These findings suggest the importance of alcoholic pancreatitis and CP as new combinational risk factor for PPC formation.
IPN, a local complication of severe AP, is commonly accompanied with PPC, due to the collection of pancreatic necrotic tissues by PPC. Typically, pancreatic necrosis is a late complication of AP, resulting in considerable morbidity and mortality. The necrotic pancreatic tissues can remain solid or liquefy, and remain sterile or become infected. Among the patients with necrotizing pancreatitis, 33% of them may develop infected necrosis. The prevalence of organ failure in necrotizing pancreatitis is 54% and even higher among patients with infected necrosis [16]. To the best of our knowledge, no studies have reported on the association between IPN and PPC. The present study revealed that IPN was significantly correlated with PPC formation (OR, 4.253; 95% CI, 3.574–7.339; p = 0.021). Therefore, it is noted that an active and effective treatment for IPN can prevent the development of PPC, improve the prognosis of pancreatitis patients, and even lower the morbidity and mortality rate.
The surgical techniques and timing of treatment for PPC are still in debate. Most previous studies have shown that PPC larger than 5 or 6 cm are less likely to resolve spontaneously. The intervention for patients with a small pseudocyst and mild symptoms can be delayed for a further 3 months, since the spontaneous resolution of PPC may still occur [17]. A prolonged period of “wait-and-see” policy for more than 6 weeks is suggested for patients with asymptomatic pseudocyst, especially for a single lesion [6]. Spontaneous resolution has occurred in 40% to 50% of PPC patients with no major complications during the period of active observation. As a consequence, intervention is warranted if the patient is symptomatic, a progressive increase in PPC size or if complications occur [18]. However, it has been reported that a delay of surgical intervention in PPC may contribute to higher incidences of postoperative complications, readmission, morbidity, and mortality. Moreover, the increasing application of nonsurgical interventions may require a further evaluation [19]. The concept of practice is that the wait-and-see policy should be carried out for more than 4 to 6 weeks until the appearance of spontaneous remission, unless PPC is associated with other symptoms or complications. Generally, chronic pseudocyst encapsulated with a thicker and more well-defined wall than acute pseudocyst [20]. The surgical intervention is usually performed on PPC with a wall thickness of greater than 1 mm. In addition, patients with first-attack AP and fluid collections at discharge should be examined by ultrasonography at a 3-month follow-up, in order to detect the presence of asymptomatic complications such as PPC.
Thus far, there have been no prospective studies comparing the effects of different intervention techniques (i.e. endoscopic drainage, percutaneous drainage and surgical drainage) on the complication and recurrence rates of PPC. The success rate of PPC after endoscopic drainage is considerably variable, most likely due to the presence of heterogeneity among patient populations and intervention types [21]. Surgery is no longer used as a sole treatment for PPC, ever since the emergence of alternative first-line therapy at most centers. Although both endoscopic and surgical drainages have demonstrated comparable success rates, there is a lack of published data regarding the optimal intervention for PPC patients [22]. Some patients may require multiple endoscopic procedures, and the decision to pursue endoscopic therapy depends on patient preference, underlying medical conditions and whether an additional endoscopic procedure is feasible. In addition, percutaneous drainage has been applied in patients with acute pseudocyst or the presence of physiologic exhaustion or comorbid conditions that prevent surgical intervention [23]. Percutaneous drainage provides a convenient alternative to patients, practitioners and physicians. However, several studies reported an equal effectiveness of percutaneous, endoscopic and surgical drainage [22, 24, 25]. In the present study, surgical drainage has the lowest recurrence rate as compared to endoscopic and percutaneous drainages (OR, 7.812; 95% CI, 3.109–23.072; p = 0.013). For the complication and recurrence rates of PPC among the three intervention groups, surgery is considered as the last remedial step (Figs. 2 and 3). Despite a higher recurrence rate of PPC in percutaneous drainage group, especially for children, PPC can often be managed without surgery, regardless of its size or complexity [26].
The advancement of new techniques in endoscopic and laparoscopic approaches have reduced the postoperative morbidity and mortality rates of PPC patients. Given that severe complications may occur after the procedure (Fig. 2), endoscopic drainage is recommended to be performed at tertiary-care center, by a surgeon with expertise in pancreatic surgery [27]. Both laparoscopic and open pancreatic cystgastrostomy have high primary success rates than endoscopic internal drainage, although repeated endoscopic cystgastrostomy offers a better success rate for selected PPC patients [28]. There have been various surgical approaches for treating PPC, but none of them are used as gold standards, as the choice of treatment is much dependent on the surgeon‘s experience and the clinical characteristics of patient. For patients with symptomatic CP, a multidisciplinary approach appears to have low threshold to surgical intervention, since long-term pain relief is accomplished more often after surgical treatment than after endoscopic treatment [29]. Surgical treatment for PPC patients consistes of open and laparoscopic approaches and includes the following: open drainage, cystogastrostomy, cystojejunostomy, distal pancreatectomy, PPC resection and pancreato-jejunostomy [30]. The laparoscopic approach to cystogastrostomy for PPC is associated with a shorter operating time, a smoother and more rapid postoperative recovery, and a shorter length of hospital stay compared to open surgery. Hence, the laparoscopic approach should be considered as the preferred treatment modality for PPC, when laparoscopic expertise is available [31].

Conclusion

Alcoholic and chronic pancreatitis may serve as the major risk factors for PPC formation and intervention. Moreover, percutaneous drainage is the only independent risk factor for PPC recurrence. The main limitations of this study include its retrospective design and single-institution nature. Therefore, future multi-institutional prospective studies are warranted to provide additional evidence supporting the risk factors for PPC, and the research results should be incorporated into clinical practice guidelines.

Funding

The study was supported by Guangdong Natural Science Foundation (2015A030313279) & Guangdong Science and Technology Planning Project (2014A030304022) & Guangdong Science and Technology Planning Project (2015A030302026) & Southern Medical University Clinical Research Start-up Planning Project (LC2016PY011). The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Ethics approval for the study was granted by the Medical Ethics Committees of Southern Medical University Nanfang Hospital, and details can be provided by the corresponding author on reasonable request. Consent to participate is not applicable.
Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Metadaten
Titel
Identification of risk factors for pancreatic pseudocysts formation, intervention and recurrence: a 15-year retrospective analysis in a tertiary hospital in China
verfasst von
Jie-hui Tan
Lei Zhou
Rong-chang Cao
Guo-wei Zhang
Publikationsdatum
01.12.2018
Verlag
BioMed Central
Erschienen in
BMC Gastroenterology / Ausgabe 1/2018
Elektronische ISSN: 1471-230X
DOI
https://doi.org/10.1186/s12876-018-0874-z

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