Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system.
ABSTRACT Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient by conventional endoscopic retrograde cholangiopancreaticography (ERCP) are difficult and, depending on the surgical procedure, in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients.
In a retrospective analysis of all DBE procedures at our department between November 2004 and June 2007, 11 patients were identified with various anatomic variations in whom ERCP was performed using a DBE.
In 72% of the patients, previous conventional ERCP examinations failed (8/11). In these patients, DBE-ERCP was successful in 63%. The overall success rate of DBE-ERCP in all patients was 64% (7/11 patients). In those patients, interventions such as papillotomy, calculus extractions, as well as stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite most of the DBE-ERCPs having included therapeutic interventions, no major complications occurred in our case series and minor side effects were restricted to meteorism and mild to moderate abdominal pain.
DBE-ERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary as well pancreatic system in the operated patient. However, it should be limited to selected patients, e.g., with contraindications for PTC, as it is a time-consuming as well as a cost-intensive procedure.
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ABSTRACT: Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.Digestive Endoscopy 05/2013; · 1.61 Impact Factor
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ABSTRACT: Background and AimEndoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is still challenging. We aimed to clarify the current status of ERCP in Japan in patients with surgically altered anatomy.Methods Questionnaire survey was conducted in 2012 at 11 participating facilities regarding ERCP in patients with surgically altered anatomy.ResultsA total of 490 ERCP procedures were carried out in 273 patients with surgically altered anatomy. The breakdown of surgical procedures was as follows: Roux-en-Y (R-Y) reconstruction (n = 154 [31.4%]), pancreaticoduodenectomy (PD) (n = 136 [27.8%]), hepaticojejunostomy (n = 103 [21.0%]), liver transplantation (n = 20 [4.1%]), Billroth II reconstruction (n = 69 [14.1%]), and interposition after total gastrectomy (n = 8 [1.6%]). The overall success rate of reaching the target site was 91.8% (450 of 490 ERCP procedures). According to reconstructive surgical procedures, the target site was reached in 138 of 154 procedures (89.6%) for R-Y reconstruction, 129 of 136 procedures (94.8%) for PD, 89 of 103 procedures (86.4%) for hepaticojejunostomy, 18 of 20 procedures (90.0%) for liver transplantation, 68 of 69 procedures (98.6%) for Billroth II reconstruction, and eight of eight procedures (100%) for interposition after total gastrectomy.Conclusions The success rate of reaching the target site was high in patients with Billroth II reconstruction and low in patients with hepaticojejunostomy. Although the success rate of endoscopic insertion for ERCP in patients with surgically altered anatomy was high, there are still cases in which it is difficult to achieve technical success.Digestive Endoscopy 04/2014; 26(S2). · 1.61 Impact Factor
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ABSTRACT: Background and AimIn patients with Roux-en-Y hepaticojejunostomy (HJ with R-Y) and Whipple resection, endoscopic retrograde cholangiopancreatography (ERCP) can be challenging. We report our experience with ERCP using balloon-assisted enteroscopy (BAE) (BAE-ERCP) in patients with HJ with R-Y, and Whipple resection.MethodsBAE-ERCP procedures were carried out in 62 patients (HJ with R-Y : Whipple resection = 34:28).ResultsOverall, the rates of reaching the anastomosis were 85.3% (29/34) in HJ with R-Y and 96.4% (27/28) in Whipple resection. In terms of HJ with R-Y, insertion success rate by standard single-balloon enteroscopy (SBE) was 89.3% (25/28). Insertion success rate by short BAE, including SBE and double-balloon enteroscopy (DBE), was 50% (3/6). There was a statistically significant difference of insertion success rate between standard long BE and short BE (P = 0.021). However, in the Whipple patients, insertion success rate by standard and short SBE was 93.8% (15/16) and 91.7% (11/12), respectively. Initial insertion success rate by short BAE in Whipple patients was significantly higher than in HJ with R-Y (91.7% vs 50%, P = 0.045). Therapeutic interventions included dilation of anastomosis stricture, stone extraction, endoscopic mechanical lithotripsy, biliary stent placement, stent extraction, endoscopic nasobiliary drainage, direct cholangioscopy, and electrohydraulic lithotripsy. Our HJ with R-Y series and Whipple series treatment success rate was 90% (18/20) and 95.0% (19/20), respectively.ConclusionsBAE-ERCP enabled ERCP to be carried out in patients with HJ. It is considered safe and feasible. Further experience and device improvement are needed.Digestive Endoscopy 04/2014; 26(S2). · 1.61 Impact Factor
American Journal of Gastroenterology
C ?2008 by Am. Coll. of Gastroenterology
Published by Blackwell Publishing
Double Balloon Enteroscopy: A Useful Tool
for Diagnostic and Therapeutic Procedures
in the Pancreaticobiliary System
Christian Maaser, M.D.,1∗Frank Lenze, M.D.,1∗Maja Bokemeyer,1Hansjoerg Ullerich, M.D.,1
Dirk Domagk, M.D.,1Matthias Bruewer, M.D.,2Andreas Luegering, M.D.,1Wolfram Domschke, M.D.,1
and Torsten Kucharzik, M.D.1
Departments of1Medicine B and2General Surgery, University of Muenster, Muenster, Germany
OBJECTIVES:Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously
operated patient by conventional endoscopic retrograde cholangiopancreaticography (ERCP) are
difficult and, depending on the surgical procedure, in many cases unsuccessful. We describe our
experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative
examination technique for these patients.
METHODS:In a retrospective analysis of all DBE procedures at our department between November 2004 and
June 2007, 11 patients were identified with various anatomic variations in whom ERCP was
performed using a DBE.
RESULTS:In 72% of the patients, previous conventional ERCP examinations failed (8/11). In these patients,
DBE-ERCP was successful in 63%. The overall success rate of DBE-ERCP in all patients was 64%
(7/11 patients). In those patients, interventions such as papillotomy, calculus extractions, as well as
stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite
most of the DBE-ERCPs having included therapeutic interventions, no major complications occurred
in our case series and minor side effects were restricted to meteorism and mild to moderate
CONCLUSIONS: DBE-ERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary
as well pancreatic system in the operated patient. However, it should be limited to selected patients,
e.g., with contraindications for PTC, as it is a time-consuming as well as a cost-intensive
(Am J Gastroenterol 2008;103:894–900)
Endoscopic diagnostic as well as therapeutic interventions,
especially in the pancreaticobiliary system of patients with
previous intestinal surgery, are often, even for the experi-
enced gastroenterologist, challenging and with no or lim-
ited success. One of the most common reasons is the in-
ability to reach the papilla vateri or biliary anastomosis
with the endoscope due to length of the necessary pas-
sage or angulation of the anastomosis (1–4). As a conse-
quence, percutaneous transhepatic cholangiographies (PTC)
or surgical interventions have to be performed in pa-
tients with biliary obstructions leading to a greater risk of
The introduction of double balloon enteroscopy into rou-
tine endoscopy in 2004 has clearly changed the manage-
∗Both authors contributed equally.
ment of mid-gut gastrointestinal bleeding as well as verifi-
cation of small bowel involvement in Crohn’s disease (5–
11). In addition to the examination of the mid-gut, the dou-
ble balloon enteroscope (DBE), due to its flexibility and
length on one hand, and the double balloon technique on
the other hand, allowing endoscopic advancement beyond
the maximal reach of the endoscope, might also be use-
ful in the operated patient requiring an endoscopic retro-
grade cholangiopancreaticography (ERCP). It is conceivable
that DBE-ERCP might be helpful in particular in patients
with an anatomic variation due to previous intestinal surgery
making it otherwise impossible to reach the papilla or the
biliary and pancreaticojejunal anastomoses with a normal
We here report on our experience with double balloon en-
teroscopy for diagnostic and therapeutic interventions in the
pancreaticobiliary system of patients with various difficult
postsurgical anatomic situations.
Double Balloon Enteroscopy and ERCP895
MATERIAL AND METHODS
Double balloon enteroscopy was introduced in the Depart-
ment of Medicine B in November 2004. From November
2004 until the end of June 2007, 840 double balloon entero-
scopies and 1,490 ERCPs have been performed. In a retro-
spective analysis, examinations that combined ERCP with
double balloon enteroscopy in previously abdominally op-
erated patients were reviewed. A total of 11 patients were
identified who had undergone double balloon ERCP (DBE-
ERCP; Table 1).
All examinations were performed by one of a team of
450P5/20 prototype or the therapeutic EN-450T5 endoscope
with a working length of 200 cm and a flexible overtube with
Table 1. Patient Characteristics
Indication for Surgery (Yr)
S.B.64/mPartial gastrectomy with
gastrojejunostomy and Roux-en-Y
Gastric neurinoma (2000)
Partial gastrectomy with
gastrojejunostomy and Roux-en-Y
Refractory peptic ulcers (1964)/Biliary
Total gastrectomy with Roux-en-Y
Gastric carcinoma (2004)
Partial gastrectomy with Billroth II
Refractory peptic ulcers (1990)
Partial gastrectomy with Billroth II
Gastric cancer (1976)
Chronic pancreatitis with suspected
Pylorus preserving Whipple
Gastrointestinal stroma tumor (2005)
Biliary stricture/chronic pancreatitis
Biliary stricture/primary sclerosing
Hepaticojejunostomy (side to side) with
Biliary stricture (2005)
Duodenum-preserving pancreatic head
resection in combination with
Biliary stricture (2005)
Choledocholithiasis (1) YesSphincterotomy/calculus
Cholangitis (1)YesDilation of anastomotic
B.A.67/mBiliary pancreatitis (1) YesSphincterotomy/papillary
G.B.68/mCholangiolithiasis (3)No (0/3)Sphincterotomy
DHC compression (3)
Yes (2/3) Sphincterotomy/plastic
stent placement (2×)
cholangitis with secondary
biliary cirrhosis (2)
L.K.69/mRecurrent cholangitis (1)No
S.M.44/fCholangitis (1)YesBile aspiration for
B.K.30/fChronic pancreatitis (1) Yes∗
∗Successful cannulation of pancreaticojejunal anastomosis.
The detailed system as well as the technique of insertion by
inflating and deflating the balloons has been described in de-
tail before by others (5, 12, 13).
Patient preparation consisted of a fasting period of at least
8 h before the examination. Analgosedation was performed
by IV administration of 50 mg pethidine once and diso-
privane in a dosage as needed for sedation. Patients were
monitored by continuous measurement of oxygen saturation
and pulse rate as well as intermittent measurement of blood
Double balloon enteroscopies combined with ERCP were
after receiving written consent from the patient regarding the
endoscopic procedure itself as well as treatment measures
896Maaser et al.
such as endoscopic sphincterotomy, stent implantation, and
Descriptive analysis was used to document the demographic
and clinical data of the patients.
Technical Aspects of DBE-ERCP
Preceding the examination, the earlier operative notes, if
available, were studied in order to get detailed information
regarding the type of surgery performed and to get an idea of
the anastomotic location (Fig. 1).
Entering the Afferent Loop
One of the major problems in patients with previous intesti-
nal surgery is identifying and entering the afferent loop in
order to reach the papilla or the hepatico/choledocho- and
pancreaticojejunal anastomosis. Careful inspection of the je-
junojejunal anastomosis is required to be able to identify the
afferent loop. As sometimes the anastomosis is only clearly
visible during withdrawal, intermittent withdrawal was per-
in whom identification of the anastomotic site was not easily
Figure 1. Schematic figures of the different types of surgery. (A) Normal anatomy; (B) partial gastrectomy with gastrojejunostomy and
Roux-en-Y reconstruction; (C) partial gastrectomy with Billroth II gastrojejunostomy; (D) total gastrectomy with Roux-en-Y reconstruc-
tion; (E) Whipple pancreaticoduodenectomy with Roux-en-Y reconstruction; (F) pylorus-preserving Whipple pancreaticoduodenectomy;
tion; (I) duodenum-preserving pancreatic head resection in combination with choledochojejunostomy; (J) gastric bypass with Roux-en-Y
attention to possible discontinuity and fusion of Kerckrings
folds, quantity of bile flow, as well as direction of bowel
motion, as movement in the afferent loop is antiperistaltic.
Most challenging are Roux-en-Y reconstructions, as the en-
teroscope has to manage the sharp angle of the jejunojejunal
anastomosis in order to access the afferent limb, which in
some patients represents an angle of up to 180 degrees. Once
entering the afferent loop, the enteroscope is inserted as deep
as possible followed by inflation of the enteroscope balloon
to stabilize the endoscope. Then, the overtube is advanced
beyond the anastomosis. Before advancing any further, the
overtube balloon has to be inflated and the double balloon
system has to be retracted as far as possible.
In the case of an intact papilla and duodenal stump, the
next difficult part is the sharp jejunal angle at the ligament
of Treitz, with the technique being similar to the technique
of entering the jejunojejunal anastomosis. In contrast, fur-
ther advancement in underlying hepatico-/choledocho- and
pancreaticojejunal anastomosis is easier due to a lack of the
jejunal angle at the ligament of Treitz.
Before cannulation of the biliary or pancreatic duct, the
double balloon system has to be retracted as far as possible,
which allows an easier advancement of endoscopic acces-
sories through the working channel as well as a more stable
position of the enteroscope’s tip due to a reduction in the
Double Balloon Enteroscopy and ERCP 897
Cannulation of the Papilla or Hepatico-/Choledocho- and
INTACT PAPILLA.Once the region of the papilla is
reached in the afferent limb, one has to keep in mind that
the landmarks of the papilla are inverted by 180◦compared
to their usual position in the nonoperated patient. Regarding
intubation of the papilla, the double balloon has two dis-
advantages compared to a side-viewing duodenoscope. The
enteroscope has no elevator and all procedures have to be
challenging. For cannulation and intervention, it is easier to
use the therapeutic EN-450T5 enteroscope, which has a 2.8-
mm working channel, as there are more accessories available
and the passage through the endoscope itself is smoother. In
some cases, due to nonavailability of the therapeutic entero-
scope, we had to use the diagnostic enteroscope, having a
working channel of 2.2 mm, with the disadvantage that spe-
cific accessories are not available or are provided only by
STOMOSES. While cannulation of the hepatico-/chole-
dochojejunal anastomosis is usually easier than cannulation
of an intact papilla, the endoscopic identification of the anas-
tomosis is often more difficult, as it can be hidden behind
a jejunal fold. Identification of the pancreaticojejunal anas-
tomosis, if required, can sometimes be time-consuming as
commonly some loop angles away from the biliary anasto-
and to cannulate than an end-to-side anastomosis.
Results of Endoscopic Procedures
DBE-ERCPs were performed in 11 patients with different
had an intact major papilla (37%); the other seven patients
had a biliodigestive anastomosis (63%).
In 8 of 11 patients, previous ERCP approaches with a
forward- and/or side-viewing endoscope had not been suc-
in the following examination (S.M.). In two patients (B.K.,
H.F.), DBE-ERCP was the initially performed examination
into the afferent limb was possible and the bile duct was
reached in 82% of the patients (9/11). In those with previ-
ously unsuccessful ERCPs employing forward- and/or side-
patients). Overall the success rate of DBE-ERCP in all pa-
tients was 64% (7/11 patients). In one patient, DBE-ERCP
was eventually successful after initial sphincterotomy during
a preceding examination also using the DBE-ERCP tech-
Cannulation in patients with an intact papilla was success-
ful in three of four patients (75%). In the fourth patient, can-
nulation was not possible as the papilla was not reached.
In patients with biliodigestive anastomosis, cannulation was
possible in four of seven patients (57%). In two patients, the
biliodigestive anastomosis was not reached, while in one pa-
tient cannulation was not possible.
In our case series, a broad spectrum of endoscopic in-
terventions have been successfully performed. Endoscopic
interventions included sphincterotomy, calculus extraction
(Fig. 2), biliary stent placement (Fig. 3), dilation of a bil-
iary anastomotic stricture (Fig. 4), biopsy of the papilla, and
bile aspiration for microbiologic analysis.
However, one has to note that only limited tools are avail-
able for endoscopic interventions using a DBE. Most of
the standard equipment that is employed for conventional
ERCPs cannot be used with a DBE mainly due to length
reasons. Limited accessories for DBE-ERCPs often require
improvization to allow endoscopic interventions. If, for in-
stance, a needle knife is not available, one can use a snare
instead, cutting off the loop and shortening the wire. Further-
ertheless sphincterotomy can be performed relatively safely
following stent insertion into the biliary duct and subsequent
cutting with a “needle knife” (prepared as described above)
alongside the stent. Generally, instillation of 2 mL silicon
oil into the working channel allows easier advancement of
endoscopic accessories through the tubing.
Though dilation balloons are now available for DBE-
ERCP, in our series, one biliary anastomotic stricture was
effectively dilated with a filling catheter as at the time of this
Figure 2. Calculus extraction in a patient with cholangiolithiasis
en-Y reconstruction (patient S.B.).
898 Maaser et al.
Figure 3. Biliary stent placement in a patient with biliary stenosis
after partial gastrectomy with Billroth II gastrojejunostomy (patient
intervention only the EN-450P5 enteroscope was available,
tial option is to advance the dilation balloon over a guidewire
through the overtube after removal of the enteroscope.
Figure 4. Dilation of a strictured choledochoduodenal anastomosis: (A) stricture of choledochoduodenal anastomosis (arrow); (B + C):
dilation with a filling catheter; (D): inserted guidewire after dilation (patient L.H.).
Proceeding After Failure of Endoscopic Examination
possible (4/11). In one patient (L.K.), endoscopically the bil-
iary anastomosis showed sludge within a very small anasto-
motic orifice indicative of a stricture. Surgical revision of the
anastomosis confirmed this suspicion. In another patient, af-
performed (W.H., 2 DBE-ERCP attempts), while in a further
patient after several unsuccessful double-balloon examina-
tions and unsuccessful PTC attempts for calculus extraction,
(D.H.), cannulation of the papilla was possible at the second
attempt after sphincterotomy had been performed during the
Reinterventions After Successful DBE-ERCP
Only one patient needed a second DBE-ERCP over a median
follow-up of 7.5 months (range 21 days to 24 months). The
second DBE-ERCP was necessary because of a plastic-stent
occlusion 21 days after intial endoscopic placement (D.H.).
cellular carcinoma. All other patients did not require another
ERCP or surgical intervention after successful DBE-ERCP
until the end of June 2007 (N = 6).
Common postinterventional complaints were abdominal
bloating, mild to moderate abdominal pain, as well as mild
symptoms of sore throat in a minority of patients. However,
Double Balloon Enteroscopy and ERCP 899
no major complications such as intestinal perforation, pan-
creatitis, or bleeding occurred.
ERCP is widely used for the management of pancreaticobil-
iary disorders with a success rate of about 90–95% in pa-
tients with normal gastric and pancreaticoduodenal anatomy.
In contrast, in patients with altered anatomy due to previ-
ous abdominal surgery, ERCPs are technically difficult and,
consequently, often unsuccessful. In this context, the endo-
scopist can be confronted with a broad spectrum of different
postsurgical anatomical situations, which require a detailed
knowledge of the different types of surgical procedures and
the location of anastomoses (Fig. 1). After Billroth II gas-
troenterostomy, ERCP success rates are as low as 52% (1,
2, 14–16), comparable to those in patients with prior pan-
creaticoduodenectomy (51%) (17). Even more challenging
are ERCPs in Roux-en-Y gastrojejunostomies, with reported
success rates ranging between 33% and 67% (2, 3). Accord-
ing to our experience, in about two-thirds of previously un-
successful ERCPs, DBE-ERCP proved to be an alternative
method to successfully perform diagnostic and therapeutic
procedures in the pancreaticobiliary systems (18–22). In the
ERCP was to perform a PTC or—if for various reasons not
be technically limited, due to the absence of dilated intrahep-
atic ducts, or contraindicated because of ascites or compro-
the pancreatic duct system, thus leaving surgery as the only
Employing DBE-ERCP, once the papilla or biliary anas-
tomosis is reached, the majority of endoscopic interventions
sphincterotomy, calculus extraction, stent implantation, and
dilation of anastomotic strictures. However, instrument man-
ufacturers should be requested to provide more adequate ac-
cessories for therapeutic DBE-ERCP in the near future. Ad-
ditionally, shorter double-balloon enteroscopes, which soon
will be available for routine clinical, may also improve the
success of endoscopic interventions.
Notably, no major complications such as perforation,
bleeding, or pancreatitis occurred in the total of 16 DBE-
ERCPs performed in our 11 patients. In a multicenter anal-
ysis including our department, the complication rate of
double-balloon enteroscopy in a total of 2,362 examinations
was 1.7%. The most frequent complications were bleeding
case of pancreatitis occurring after papillotomy using DBE
for cannulation of the blind loop in a patient with Roux-en-Y
At our department, a tertiary referral center, DBE-ERCPs
have been performed in only 11 patients over a time period
of 32 months, corresponding to less than 1.9% of all double-
balloon enteroscopies and 1.1% of all ERCPs performed.
Accordingly, it appears reasonable to restrict this technique
to a limited number of specialized centers to assure the best
expertise and success rate.
In conclusion, DBE-ERCP is a promising, alternative tool
to perform diagnostic and therapeutic procedures in the pan-
creaticobiliary system of selected, previously operated pa-
tients, especially in those with contraindications of PTC and
who are not yet candidates for reoperation.
What Is Current Knowledge
rDouble balloon enteroscopy is a useful diagnostic and
therapeutic tool for the small intestine.
rEndoscopic retrograde cholangiopancreaticography
(ERCP) in patients with previous intestinal surgery is
often challenging with no or only limited success.
What Is New Here
rDouble balloon enteroscopy is a useful tool opening
with postsurgical variations.
Reprint requests and correspondence: Christian Maaser, M.D.,
Department of Gastroenterology, Hospital of Lueneburg, Boegel-
strasse 1, D-21339 Lueneburg, Germany.
Received August 23, 2007; accepted October 24, 2007.
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CONFLICT OF INTEREST
Specific author contributions: Christian Maaser, Frank
Lenze, Torsten Kucharzik, and Wolfram Domschke were re-
sponsible for study design, data analysis, and script prepa-
ration. Maja Bokemeyer was responsible for the data collec-
tion. Endoscopic diagnosis and treatment were performed by
Torsten Kucharzik, Hansjoerg Ullerich, and Dirk Domagk.
Matthias Bruewer and Andreas Luegering were responsible
for patient recruitment and examination. All authors have
read and approved the submitted version of the manuscript.
Financial support: None.
Potential competing interests: None.