Malignant Liver Tumors E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1707

Veröffentlichungsjahr: 2011

Beschreibung

This comprehensive and critical review of current and established treatment modalities for malignant liver tumors is designed to help you sort through the proliferation of competitive approaches and choose the best treatment options for your patient. Dr. Clavien and his contributors consider all the options - radiological, surgical, pharmaceutical, and emerging/novel therapies - and help you find the best single or combined therapy. Building on the success of the previous edition, this extremely thorough revision: * features a new section on Guidelines for Liver Tumors, where you will find specific strategies for treating common liver malignancies; the guidelines were prepared by the Associate Editors and take into account national and international society guidelines * reflects actual practice by taking a multidisciplinary approach, with contributions from international experts who have extensive experience with this patient population * achieves comprehensive and balanced coverage by having each chapter reviewed by the Editor, Deputy Editor, two Associate Editors, and at least one external reviewer * includes 16 new chapters that cover liver anatomy, histologic changes in the liver, epidemiology and natural history of HCC, CCC and colorectal liver metastases, strategies of liver resection, and economic aspects as well as novel therapies * facilitates the kind of daily interaction among hepatologists, hepatic surgeons, medical oncologists, radiotherapists, and interventional radiologists that is essential when treating patients with complex liver malignancies In 44 chapters organized into six major sections, the book covers the full range of liver tumors. The perfect blend of evidence and experience, Malignant Liver Tumors: Current and Emerging Therapies, 3rd Edition, illuminates the path to better patient care.

Leseprobe

Contents

Contributors

Preface

Acknowledgments

Abbreviations

Section 1 Introduction

1 From Promethean to Modern TimesKuno Lehmann, Stefan Breitenstein, and Pierre-Alain Clavien

From myths to mysteries

Of inquisitive anatomists and courageous surgeons

The era of liver transplantation

Surgical oncology: breaking down the limits

Self-assessment questions

References

Self-assessment answers

2 Hepatic Anatomy and TerminologySteven M. Strasberg

Overview

Surgical anatomy for liver resections

GALLBLADDER AND extrahepatic bile ducts and arteries

Self-assessment questions

References

Self-assessment answers

Section 2 Epidemiology and Diagnosis

Introduction,Chung-Mau Lo

3 Histology and Pathology of Normal and Diseased LiverValerie Paradis and Achim Weber

Introduction

Histology of normal liver

Steatosis

Fibrosis and cirrhosis

“ Typical f eatures ” of nontumoral liver according to the type of malignant tumor

Impact of diseased liver on surgical management of patients with malignant liver tumors

Self-assessment questions

References

Self-assessment answers

4 Pathology of Primary and Secondary Malignant Liver TumorsKay Washington

Primary Epithelial Tumors of the Liver

Primary hepatic sarcomas

Primary hepatic lymphoma

Secondary tumors

Carcinoma of the gallbladder

Self-assessment questions

References

Self-assessment answers

5 Epidemiology, Etiology, and Natural History of Hepatocellular CarcinomaWei-Chen Lee and Miin-Fu Chen

Epidemiology

Etiology

Natural history of HCC

Self-assessment questions

References

Self-assessment answers

6 Epidemiology, Etiology, and Natural History of CholangiocarcinomaPeter Neuhaus, Ulf P. Neumann, and Daniel Seehofer

Epidemiology

Etiology

Natural history

Self-assessment questions

References

Self-assessment answers

7 Epidemiology, Etiology, and Natural History of Colorectal Liver MetastasesRobert J. Porte

Epidemiology and e tiology

Natural history

Determination of p rognosis

Self-assessment questions

References

Self-assessment answers

8 Tumor Markers in Primary and Secondary Liver TumorsKetsia B. Pierre and Ravi S. Chari

Tumor markers in primary liver cancer

Tumor markers in metastatic liver cancer

Self-assessment questions

References

Self-assessment answers

9 Modalities for Imaging Liver TumorsDominik Weishaupt and Thomas F. Hany

Introduction

Ultrasound

Computed tomography

Positron emission tomography/computed tomography imaging

Magnetic resonance imaging

Catheter-assisted angiography, computed tomography during hepatic arteriography and during arterial portography

Cholangiography

Self-assessment questions

References

Self-assessment answers

Section 3 Systemic and Regional Therapies

IntroductionRavi S. Chari

10 Systemic Treatment of Hepatobiliary TumorsPanagiotis Samaras, Michael A. Morse, and Bernhard C. Pestalozzi

Liver metatatases from colorectal cancer

Unresectable hepatocellular carcinoma

Cancer of the biliary tract

Neuroendocrine tumors

Rare liver tumors in adults

Self-assessment questions

References

Self-assessment answers

11 External Beam Radiation Therapy for Liver TumorsRakesh Reddy and A. Bapsi Chakravarthy

Advances in the delivery of radiation

Colorectal cancer metastatic to the liver

Conclusion

Self-assessment questions

References

Self-assessment answers

12 Internal Radiation Therapy for Liver TumorsAhsun Riaz, Laura Kulik, Michael Abecassis, and Riad Salem

Introduction

Vascular anatomy of the liver and its tumors

History of internal radiation

Yttrium-90 microspheres

Pretreatment evaluation

Other radionuclides

Complications of internal radiation

Role of radioembolization in the management of primary liver tumors

Role of radioembolization in the management of secondary liver tumors

Conclusion

Self-assessment questions

References

Self-assessment answers

13 Transarterial Embolization for Patients with Hepatocellular CarcinomaJordi Bruix, Carmen Ayuso, and Maria I. Real

Therapeutic strategy in patients with hepatocellular carcinoma and role of transarterial chemoembolization

Techniques to obstruct the hepatic artery blood flow

Therapeutic efficacy of transarterial (chemo)embolization: impact on tumor progression and survival

Transarterial embolization as coadjuvant treatment prior to resection and transplantation

Conclusion

Self-assessment questions

References

Self-assessment answers

14 Selective Continuous Intra-arterial Chemotherapy for Liver TumorsFidel D. Huitzil-Melendez, Stefan Breitenstein, and Nancy Kemeny

Background

Pump mechanics

Technical considerations

Technical complications

Clinical applications

Conclusion

Self-assessment questions

References

Self-assessment answers

15 Isolated Hepatic Perfusion and Percutaneous Hepatic PerfusionCharles K. Heller, III, James F. Pingpank, and Steven K. Libutti

Isolated hepatic perfusion

Percutaneous hepatic perfusion

Conclusion

Self-assessment questions

References

Self-assessment answers

Section 4 Resection, Ablation or Transplantation for Liver Tumors

IntroductionJean-Nicolas Vauthey and Tadatoshi Takayama

16 Liver Resection of Primary Tumors: Hepatocellular Carcinoma, Cholangiocarcinoma, and Gallbladder CancerTadatoshi Takayama and Masatoshi Makuuchi

Liver anatomy

Liver resection

Hepatocellular carcinoma

Cholangiocarcinoma

Gallbladder carcinoma

Self-assessment questions

References

Self-assessment answers

17 Liver Resection of Colorectal Liver MetastasesDaria Zorzi, Yun Shin Chun, and Jean-Nicolas Vauthey

Preoperative considerations and work-up

Selection of surgical candidates

Surgical techniques

Methods to improve resectability

Conclusion

Self-assessment questions

References

Self-assessment answers

18 Laparoscopic Liver ResectionLuca Vigand and Daniel Cherqui

Feasibility: technique and indications

Evaluation of laparoscopic liver resection

Reproducibility

Conclusion

Self-assessment questions

References

Self-assessment answers

19 Repeat Resection for Liver TumorsMickael Lesurtel and Henrik Petrowsky

Introduction

Technical considerations

Repeat hepatic resection for metastatic colorectal cancer

Repeat hepatic resection for hepatocellular carcinoma

Self-assessment questions

References

Self-assessment questions

20 Cryoablation of Liver TumorsSivakumar Gananadha and David L. Morris

History

Mechanism of cryodestruction

Indications

Which ablative therapy?

Preoperative work-up

Equipment

Technique

Minimally invasive approach

Monitoring

Postoperative course and follow-up

Complications

Clinical results

Prognostic factors after cryotherapy

Combined modality therapies using cryoablation

Advantages and limitations

Self-assessment questions

References

Self-assessment answers

21 Thermal Ablation of Liver Tumors by Radiofrequency, Microwave, and Laser TherapyM. B. Majella Doyle and David C. Linehan

Radiofrequency thermal ablation

Temperature and cell death

Microwave thermal ablation

Laser thermal ablation

Self-assessment questions

References

Self-assessment answers

22 Ethanol and Other Percutaneous Injection Modalities in the Treatment of Liver TumorsMichael A. Heneghan and Andrew D. Yeoman

Mechanism of action

Acetic acid injection

Patient selection

Contraindications

Procedure

Complications of therapy

Follow-up imaging

Clinical results

Hot saline injection

Comparison of percutaneous ethanol injection and radiofrequency ablation

Combined transcatheter arterial embolization/radiofrequency ablation and percutaneous ethanol injection

Percutaneous ethanol injection of metastatic disease

Intralesional chemotherapy

Cost

The future of percutaneous therapy

Conclusion

Self-assessment questions

References

Self-assessment answers

23 Transplantation for Liver TumorsFrangois Durand, Claire Francoz, and Jacques Belghiti

Introduction

Liver transplantation for hepatocellular carcinoma

Liver transplantation for cholangiocarcinoma

Transplantation for liver metastases of neuroendocrine tumors

Liver transplantation for hepatic epithelioid hemangioendothelioma

Liver transplantation for other liver malignancies

Conclusions and perspectives

Self-assessment questions

References

Self-assessment answers

24 Preventing Recurrence of Hepatocellular Carcinoma after Curative ResectionStefan Breitenstein, Dimitris Dimitroulis, and Beat Müllhaupt

Introduction

Interferon

Iodine-131-labelled lipiodol

Retinoids

Other potential approaches for secondary prevention

Conclusion

Self-assessment questions

References

Self-assessment answers

Section 5 Guidelines for Liver Tumor Treatment

IntroductionStefan Breitenstein and Pierre-Alain Clavien

25 Strategies for Safer Liver SurgeryPhilipp Dutkowski, Olivier de Rougemont, and Pierre-Alain Clavien

Introduction

Strategies to evaluate risk factors before surgery

Strategies to recognize liver capacity before surgery

Liver regeneration

Strategies to increase liver volume

Strategies to protect liver function

Conclusion

Self-assessment questions

References

Self-assessment answers

26 Hepatocellular CarcinomaTadatoshi Takayama

Introduction

Staging systems

Treatment guidelines

Conclusion

Self-assessment questions

References

Self-assessment answers

27 CholangiocarcinomaJacques Belghiti and Charles B. Rosen

Introduction

Intrahepatic cholangiocarcinoma

Hilar cholangiocarcinoma

Distal cholangiocarcinoma

Conclusion

Self-assessment questions

References

Self-assessment answers

28 Gallbladder CancerJuan Hepp and Chung-Mau Lo

Introduction

Summary of evidence and recommendations

Diagnosis and treatment

Treatment strategies and prognosis based on tumor stage

Therapeutic algorithm based on presentation

Acknowledgements

Self-assessment questions

References

Self-assessment answers

29 Colorectal Liver MetastasesPhuong L. Doan, Jean-Nicolas Vauthey, Martin Palavecino, and Michael A. Morse

Initial evaluation and diagnosis

Treatment (Figure 29.1)

Surveillance

Self-assessment questions

References

Self-assessment answers

Section 6 Emerging Therapies

IntroductionMichael A. Morse and Josep M. Llovet

30 Viral-Based Therapies for Primary and Secondary Liver CancerMenghua Dai, Lorena Gonzalez, and Yuman Fong

Introduction

History of viral therapy

Strategies for viral therapy

Viruses

Conclusion

Self-assessment questions

References

Self-assessment answers

31 Signaling Pathways and Rationale for Molecular Therapies in Hepatocellular CarcinomaAugusto Villanueva, Clara Alsinet, and Josep M. Llovet

Introduction

Molecular pathogenesis of hepatocellular carcinoma

Molecular-targeted therapies: a novel approach in the management of hepatocellular carcinoma

Future research

Self-assessment questions

References

Self-assessment answers

32 Novel Therapies Targeted at Signal Transduction in Liver TumorsFidel D. Huitzil-Melendez, Ghassan K. Abou-Alfa, and Michael A. Morse

Introduction

Receptor tyrosine kinase in hepatocellular carcinoma

Angiogenesis as a therapeutic target in liver cancer

Conclusion

Self-assessment questions

References

Self-assessment answers

33 Induction of Apoptosis in Liver TumorsMarkus Selzner and Pierre-Alain Clavien

Apoptosis

Necrosis

Inhibition of the apoptotic pathway in cancer cells

Strategies to induce apoptosis in tumor cells

Conclusion

Self-assessment questions

References

Self-assessment answers

34 Antiangiogenic Agents for Liver TumorsMathijs Vogten, Emile E. Voest, and Inne H.M. Borel Rinkes

Angiogenesis: a new target for cancer therapy

Angiogenesis: vessel proliferation

Tumor growth is dependent on angiogenesis

Angiogenesis in liver tumors

Antiangiogenic agents

Endogenous antiangiogenic compounds

Combination of antiangiogenic drugs with conventional treatment modalities

Future perspectives

Self-assessment questions

References

Self-assessment answers

35 Integrative Oncology: Alternative and Complementary TreatmentsBarrie R. Cassileth and Jyothirmai Gubili

Introduction

Alternative medical systems

Conclusion

Self-assessment questions

References

Self-assessment answers

Section 7 Special Tumors, Population, and Special Considerations

IntroductionStefan Breitenstein and Pierre-Alain Clavien

36 Liver Metastases from Endocrine TumorsClayton D. Knox and C. Wright Pinson

Introduction

Primary tumors

Imaging for diagnosis, staging, and follow-up

Treatment

Conclusion

Self-assessment questions

References

Self-assessment answers

37 Uncommon Primary and Metastatic Liver TumorsStefan Breitenstein, Ashraf Mohammad El-Badry, and Pierre-Alain Clavien

Uncommon primary tumors of the liver

Liver metastases of noncolorectal non- neuroendocrine origin

Self-assessment questions

References

Self-assessment answers

38 Liver Tumors in Special PopulationsTadahiro Uemura, Akhtar Khan, and Zakiyah Kadry

Liver tumors in nonalcoholic steatohepatitis

Liver tumors in high cardiovascular risk patients: cardiac stratification for hepatic resection

Hepatic tumors in immunosuppressed patients

Liver tumors during pregnancy

Self-assessment questions

References

Self-assessment answers

39 Malignant Liver Tumors in ChildrenXavier Rogiers and Ruth De Bruyne

Hepatoblastoma

Hepatocellular carcinoma

Angiosarcoma

Undifferentiated (embryonal) sarcoma

Embryonal rhabdomyosarcoma

Other tumors

Metastatic lesions

Self-assessment questions

References

Self-assessment answers

40 Liver Tumors in AsiaNorihiro Kokudo, Sumihito Tamura, and Masatoshi Makuuchi

Historical background

Hepatocellular carcinoma

Cholangiocellular carcinoma

Other primary liver tumors

Secondary liver tumors

Self-assessment questions

References

Self-assessment answers

41 Liver Tumors in South AmericaLucas McCormack and Eduardo de Santibanes

Development of hepatic surgery and liver transplantation

Common hepatic tumors

Self-assessment questions

References

Self-assessment answers

42 Liver Tumors in AfricaMichael C. Kew

Introduction

Epidemiology

Clinical presentation

Natural history, prognosis, and causes of death

Diagnosis

Pathology

Treatment

Etiology and pathogenesis

Self-assessment questions

References

Self-assessment answers

43 Anesthetic Management of Liver SurgeryMarco P. Zalunardo

Preoperative evaluation

Liver transplantation

Intraoperative management

Hemostatic management

Special considerations

Self-assessment questions

References

Self-assessment answers

44 Qualitative and Economic Aspects of Liver SurgeryRene Vonlanthen, Ksenija Slankamenac, and Christian Ernst

Quality measurement in surgical care

Economic aspects of hepato-pancreato- biliary surgery

Self-assessment questions

References

Self-assessment answers

Index

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Library of Congress Cataloging-in-Publication Data

Malignant liver tumors : current and emerging therapies / edited by Pierre-Alain Clavien ; deputy editor, Stefan Breitenstein ; associate editors, Jacques Belghiti... [et al.].-3rd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978–1–4051–7976–8

1. Liver-Cancer-Treatment. I. Clavien, Pierre-Alain.

[DNLM: 1. Liver Neoplasms-therapy. WI 735 M251 2010]

RC280.L5L578 2010

616.99’436-dc22

2009029874

Preface

Very few areas in medicine offer as many controversies as the management of liver tumors. Since the publication of the first two editions of the book, in 1999 and 2004 respectively, many novel diagnostic and therapeutic tools have become available. This has brought tremendous excitement and hope for curing previously lethal diseases. However, the recent proliferation of innovative and competitive approaches, often marketed prior to conclusive demonstration of their efficacy, has also brought confusion about which therapeutic modalities to select for a particular case [1].

Today, the success of treating a patient with hepatic malignancy is often linked to the appropriate use of various treatments, combining neoadjuvant and adjuvant modalities with surgery. Thus, the best approach for a patient with an hepatic tumor is achieved by a multidisciplinary team comprising a medical oncologist, hepatologist, hepatic surgeon, radiotherapist, and interventional radiologist. The availability of such specialists in a center per se is not enough for success. Of vital importance is the daily interaction of those specialists, which is mandatory in order to provide optimal treatment for each patient presenting with a complex liver malignancy [2].

Since most innovative approaches are still experimental and often technically demanding, patients presenting with hepatic tumors should optimally be managed in centers with a strong commitment to research. Patients often need to travel long distances to reach such centers. Therefore, for adequate long-term management of these patients, it is imperative to establish a close collaboration between specialized centers and local oncologists, as well as other physicians.

To this end, the third edition of Malignant Liver Tumors has been extensively revised compared to the two previous editions, including a new format, new associate editors, and 16 new chapters containing guidelines for the treatment of each specific type of malignancy. However, the goal remains similar in providing a comprehensive and critical approach to current and established therapeutic modalities, while critically evaluating promising new avenues. The book was written by a multidisciplinary panel of international experts, each with extensive experience in this population of patients. Each chapter was reviewed by the Editor, Deputy Editor, two Associate Editors, and at least one external reviewer to achieve comprehensive and balanced coverage of each topic, to minimize redundancy among chapters, and to provide appropriate cross-references. While each chapter can be read separately, the book was written with the intention that the chapters be read sequentially.

The first and second editions received many positive comments published in several surgical, oncologic, and gastrointestinal journals, testifying to the interdisciplinary interest in the field. Besides many eulogistic comments, such as “best book in the area” [3], the most relevant criticism of the second edition appeared in the New England Journal of Medicine: “If I were a physician who was consulting this book for advice on how to treat my patient, I would be impressed by how many treatment options my patient had, but I would have no idea how to pick up the best one” [4]. To address this pertinent comment we added an entire new section (Section 5) on “Guidelines for liver tumor treatment,” covering the most common liver malignancies: hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), gallbladder cancer, and colorectal liver metastases. These guidelines were prepared by the Associate Editors, taking into account other guidelines prepared by international or national societies, which should now offer a specific strategy to treat a patient with a specific condition through algorithms.

Each chapter has been updated, often by the original authors. Sixteen new chapters have been added. The book starts with a new chapter (Chapter 1) on the history of liver tumors and their therapies. The next chapter (Chapter 2) is also new, covering the liver anatomy and the consensus terminology for the various types of liver resection. A new emphasis is also given to histologic changes in the liver related to underlying conditions such as steatosis and cirrhosis, as well as neoadjuvant chemotherapies, which are increasingly used in clinical practice (Chapter 4). Three new chapters (Chapters 5–7) cover the epidemiology and the natural history of HCC, CC, and colorectal liver metastases, respectively. Novel developments have occurred in the field of internal radiation therapy of liver tumors, which is covered in Chapter 12. Strategies for liver resection are newly covered in two separate chapters (Chapters 16 and 17), one for HCC and gallbladder cancer, and another for colorectal metastases. Among the emerging therapies, novel therapies, targeted at specific signaling pathways, appear to be the most promising, and a new chapter has been included which covers relevant signaling pathways in liver tumors (Chapter 31). Finally, a new chapter has been included to cover the economic aspects of the treatment of liver tumors (Chapter 44).

This book also has an important educational purpose, and therefore we include 5–10 questions after each chapter. This will enable the reader to test his or her understanding of the main information in each chapter.

I hope that this third edition of Malignant Liver Tumors: Current and Emerging Therapies will prove useful, and will provide timely information and guidelines for the management of this difficult population of patients.

P.-A.C.

References

1 Clavien PA, Petrowsky H, deOliveira ML, Graf R. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med 2007;356:1545–59.

2 Clavien PA, Mullhaupt B, Pestalozzi B. Do we need a center approach to treat patients with liver diseases? Forum on Liver Transplantation. J Hepatol 2006;44:639–42.

3 Morris DL. Book review. Br J Surg 2000;87:1117.

4 Di Bisceglie AM. Book review. N Engl J Med 2004;350:203.

Contributors

Michael Abecassis, MD

Professor

Division of Organ Transplantation

Department of Surgery

Northwestern University

Chicago, IL, USA

Ghassan K. Abou-Alfa, MD

Department of Medicine

Division of Gastrointestinal Oncology

Memorial Sloan-Kettering Cancer Center

New York, NY, USA

Clara Alsinet, PhD

Barcelona-Clinic-Liver-Cancer (BCLC) Group,

Institut d’ Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)

Centro de Investigaciones Biomédicas en Red (CIBEREHD)

Liver Unit, Hospital Clínic

Barcelona, Spain

Carmen Ayuso, MD

Senior Consultant

Barcelona-Clinic-Liver-Cancer (BCLC) Group

Department of Radiology

Hospital Clínic, University of Barcelona

Centro de Investigaciones Biomédicas en Red

Institut d’ Investigacions Biomèdiques August Pi

i Sunyer (IDIBAPS)

Barcelona, Spain

Jacques Belghiti, MD

Professor of Surgery

Department of Hepatobiliary Surgery

Hospital Beaujon

Clichy, France

Inne H.M. Borel Rinkes, MD, PhD

Professor of Surgery

Department of Surgery

University Medical Center

Utrecht, The Netherlands

Stefan Breitenstein, MD

Department of Surgery

Swiss Hepato-Pancreato-Biliary and

Transplantation Center

University Hospital Zurich

Zurich, Switzerland

Jordi Bruix, MD

Senior Consultant

Barcelona-Clinic-Liver-Cancer (BCLC) Group

Liver Unit

Hospital Clínic, University of Barcelona

Centro de Investigaciones Biomédicas en Red

Institut d’ Investigacions Biomèdiques August Pi

i Sunyer (IDIBAPS)

Barcelona, Spain

Barrie R. Cassileth, MS, PhD

Integrative Medicine Service

Memorial Sloan-Kettering Cancer Center

New York, NY, USA

A. Bapsi Chakravarthy, MD

Associate Professor

Department of Radiation Oncology

Vanderbilt University

Nashville, TN, USA

Ravi S. Chari, MD

Professor of Surgery and Cancer Biology

Vanderbilt University Medical Center

Nashville, TN, USA

Miin-Fu Chen, MD, FACS

Department of General Surgery

Chang-Gung Memorial Hospital

Chang-Gung University Medical School

Taoyuan, Taiwan

Daniel Cherqui, MD

Professor of Surgery

Chief Department of Digestive and Hepatobiliary

Surgery

Hôpital Henri Mondor – Universit é Paris

Cr é teil, France

Yun Shin Chun, MD

Department of Surgical Oncology

The University of Texas M.D. Anderson Cancer

Center

Houston, TX, USA

Pierre-Alain Clavien, MD, Phd

Professor

Department of Surgery

Swiss Hepato-Pancreato-Biliary and

Transplantation Center

University Hospital Zurich

Zurich, Switzerland

Menghua Dai, MD

Department of Surgery

Memorial Sloan-Kettering Cancer Center

New York, NY, USA

Olivier de Rougemont, MD

Department of Surgery

Swiss Hepato-Pancreato-Biliary and

Transplantation Center

University Hospital Zurich

Zurich, Switzerland

Eduardo de Santibañes MD, PhD, FACS

Professor of Surgery

Hepatobiliopancreatic and Liver Transplant Unit

Hospital Italiano

Buenos Aires, Argentina

Ruth De Bruyne, MD

Department of Pediatrics

Section of Pediatric Gastroenterology

University Medical Center Ghent

Ghent, Belgium

Dimitrios Dimitroulis, MD