!!
"#$%#&'!()&*!+$(#,,+*&%'!-!+$(#,,.$%'!/+0)&*%1'!2!
!"#$%&'"#()*+,"-")./.%'(-(0&1+,,,!#,23,4#5".&(,
61#7(%1,81,9:(#(1,
E*;(.-,?*#(,"/?&''"(#1,
F,4/?.&'1,81,G")1#,H,
6?:(-%)1#,8IJ88(,
K",?"?(''1,,
L-)#.8&%$.-,•! M&/1+,#"#1+B,,,N,81+,M3,?*#(,"/?&''"(#1+3,,
•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`,?"-%#*"+B,%:.'"-;(.%"#%(-./1,8(+)"',•! !3+*'4!!!!!!5!!!6#&/*%!7!8!+1'!9!'%#,%$%10!:%!;!!!!!!5!!!"+#?!:%!&)@*:*/%'!),%/)!>>>!!ABC4!3>D!9!EF5;;=!,
2.$.-+,*?(8*/(.'.;(0&1+,•! G1@*:%1@%9!,8(a%('1,T,"??#*%(1#b,,,
,,,,,,,,b,,4G,+.&71-),(-%'&+,"71%,'1+,"&)#1+,M3,?*#("/?&''"(#1+,,,,,,,,,b,,+*#(1+,/.-.%1-)#(0&1+B,81,?1$),1c1%$Y,,,,, - rares, 0,5 -1/100 000 hbts* - 0,2% des cancers GI - 6% des T. péri ampullaires ,
•! HI%!P,+&]1),d;*!V"?#O+,Ze,"-+W,/"(+,"&++(,]1&-1,V!4fW,,,,,,,,,,,,,,,,d;1,/*8("-,"&,8(";-.+$%,P,_Z"-+,!
•! J.$$%'!K!L%$$%'!•! M.(#,+N.1!7!&*'O#%!9!!.'g"8*-./").+1,Y"/('("'1B,
!#*+1-)"$.-,%'(-(0&1,
,,,U,/.81+,81,8*%.&71#)1,+.-),:"5()&1'+,P,,,P5!!(+N%10'!'Q$(0.$+NO#%'!!!
,F5!!:)(*'0+I%!:+1'!#[email protected]%'0%!:%!MHR!A'#&/%*,,+1@%D,
,,,,,,,,,,,,,U5!!:)@.#/%&0%!%1:.'@.(*O#%!L.&0#*0%S!!
,,,,,,,,,,,Q,?.,Qeee,;"+)#.+%.?(1+,h3,,,,
!#*+1-)"$.-,%'(-(0&1,
•!,,L%)O#1,P,ie,T,je,k,"&,/./1-),8&,8(";-.+$%,,,,,R,,?#.;#1++(Y,/"(+,?1&),l&%)&1#3,,,,,R,,(+.'*,,,,,R,.&,"++.%(*,T,P,?#(),VQi,kW,,,,,,,,,,,,,,,,,,,,,,,,,,,,,P,,"/"(;#(++1/1-),VUQ,k,T,XQ,kW,,,,,,,,,,,,,,,,,,,,,,,,,,,,,P,,:*/.##";(1,8(;1+$71,m3,A*'*-",m3,4-*/(1,,,L%)O#1,[,"-*/(1,[,"+):*-(1R"/"(;#(++1/1-),m3,n7.%")1[[[,
•!,,G*+(%&'1,?"'?"5'1,,,
!"$1-)+,+g/?)./"$0&1+,P,
T*+I1.'N@!:*U@*,%!@+&!,)'*.1!:%!(%N0%!0+*,,%!!,,,,,V?"?(''()1^B,'():("+1B,+g-8#./1,8IJ?(^W,
,
R! M,#'*%#&'!%?+$%1'[[[,
!!V#+1:!/.,#$*1%#'%W!+((+&0%1+1@%X!!?"-%#*"+^B,5"+,%:.'*8.0&1^B,8&.8*-&/^,
,
L-71+$;"$.-+,,
•! C%:.;#"?:(1,•! +%"--1#,
L-71+$;"$.-+,,
•! [email protected]&+(Z*%!P,+(;-1+,(-8(#1%)+,,[[[,
,,,,,,,,,,,,,,,,R,,%:.'1+)"+1,,,,,,,,,,,,,,,,,R,,-(71"&,81,'I.5+)"%'1,,,,,,,,,,,,,,,,,R,,-"),81,'I.5+)"%'1^,,,,,,,,,,,,,,,,,,,,b,'():("+1P,"++.%("$.-,T,&-1,'():("+1,5('("(#1P,j,T,Sek,,,,,,,,,,,,,,,,,,,,,b,8*)1%$.-,)&/1+,"/?&''"(#1+,P,QSk,).,Sikb,,,,,,,,,,,,,
L-71+$;"$.-+,,
*Chen W-X. Hepatobiliary Pancreat Dis Int. 2008;7:649-53. * Skordilis P. BMC Surg. 2002;1:1-8. * Chen C-H. J Clin Ultrasound. 2009;37:18-25.
•! 6@+11%&9!!,,,R,,(&.@%''#'!(+1@&)+NO#%!>>>!,,,,R,,,'*I1%'!*1:*&%@0'!9!!,,,,,,,b8('")"$.-,%"-"'"(#1,5('("(#1,,,,,,,,,,,1),,?"-%#*"$0&1,m33.#(1-)"$.-[[,,,,,,5!!!%1/+Z*''%$%10!:%'!.&I+1%'!:%!!!!!!!!!!!!/.*'*1+I%!!!,,,T)0%@N.1!:%'!0#$%#&'!+$(#,,+*&%'!X!!WS!!!!!!!M%#!!(%&L.&$+10!!
!!!!!!!!!!!!!!!!!!!!!!!
L-71+$;"$.-+,,
L-71+$;"$.-+,,•! Y1:.'@.(*%9!!
!!!!!5!7!/*'*.1!,+0)&+,%!>>>!!!!!!5!+1+,Q'%!:#!&%,*%L!$#O#%#?!(+(*,,+*&%!!!!!!5!!:*[)&%1@*+N.1!%10&%!\)1*1!%0!!@+1@%&!>>>!!!!!!!!!!!!!!!!!!!!!!!!!!
!!G10&+5:#.:)1+,%'!4!SZk,,,7*;*)"-)1+B,-.8&'"(#1+B,,,,&'%*#.R5.1.--"-)1+,
!G10&+5+$(#,,+*&%'4!P]=!!!T@!>!:*U@*,%!,5./5"-)1+,,
!R.&$%'!$*?0%'4!8^=,
L-71+$;"$.-+,,•! Y1:.'@.(*%9!!
!!!!!5!7!/*'*.1!,+0)&+,%!>>>!!!!!!5!+1+,Q'%!:#!&%,*%L!$#O#%#?!(+(*,,+*&%!!!!!!5!T*[)&%1@*+N.1!%10&%!\)1*1!%0!!@+1@%&!>>>!!!!!!5!,)'*.1'!:%!!(%N0%!0+*,,%!A5F@$D!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!G10&+5:#.:)1+,%'!4!F8=,,,,,7*;*)"-)1+B,-.8&'"(#1+B,,,,&'%*#.R5.1.--"-)1+,
!G10&+5+$(#,,+*&%'4P]=!!!T@!>!:*U@*,%!,5./5"-)1+,,
!R.&$%'!$*?0%'4!8^=,
!!!!!5!,)'*.1'!:%!!(%N0%!0+*,,%!A5F@$D!!!
!H''.@*+N.1!7!:%'!(.,Q(%'!:#.:)1+#?!.#!+:)1.$%'!9!!!!!!!!5!!MHR!9!K!]
f"&\,[,1),Y"&\,R,
H$(.#,%!(.'05$*I&+N.1! H$(#,,.$%!%1:.!(+(*,,+*&%!!
,,,,,,,,,,,,,,L-71+$;"$.-+,,
b,,Y"%('1+,mmm33,Y.#/1+,(-)#"R8&.8*-"'1+,,,,b,[8(a%('1+,m33,Y.#/1+,(-)#"R.88(1--1+,P,,,
,,,,,,,,,,,,,,,,,+?:(-%)*#.)./(1,,?"#Y.(+B,#*?*)1#,,'1+,@\,,,,
!`!,*$*0%'9!,,,R,?#*'O71/1-)+,,81,?1$)1,)"(''1B,$++&+,(-8*+,,,,R,8(a%&')*+,81,#1?*#";1,8&,+()1,1\"%),81,?#*'O71/1-)3,,,,R,?"#Y.(+,+(/?'1,%g).'.;(1,?"#,5#.++";1,,,,,,,,,,,,,,,,,,,,,)"&\,*'17*,81,L+#?!1)I+NL'!9!F85!8
L-71+$;"$.-+,,
•!!!YY9!R,%?+$%1!,%!(,#'!(%&L.&$+10!>>>!5!!(&*1@*(+,!*10)&b0!9!!,
QR,,)&/1,(-)#"R"/?&''"(#1,[[[,SR,,,+)";(-;,'.%"'P,,,,,,,R,,1-7":(++1/1-),?"#(*)"',VMWP,iQ,T,oQk,,,,,,R,,1-7":(++1/1-),;"-;'(.--"(#1,P,p"5('()*,81,ZU,T,ji,k,V2W,,
UR,,1\)1-+(.-,(-)#"%"-"'"(#1,81,'",)&/1,XR,,1\)1-+(.-,#"??.#),)&/1R7"(++1"&\,V1\$#?"5('()*W,ZR,5(.?+(1+[[[,,,,,,!
L-71+$;"$.-+,,YY9!!
,`!#(-%(?"',(-)*#q),P,,,
QR,,)&/1,(-)#"R"/?&''"(#1,SR,,,+)";(-;,'.%"'P,,,,,,,R,,1-7":(++1/1-),?"#(*)"',V+)")&),MW,,,,,,R,,1-7":(++1/1-),;"-;'(.--"(#1,P,p"5('()*,81,ZU,T,ji,k,V+)")&),2W,,
UR,,1\)1-+(.-,71#+,'1,%"-"',5('("(#1,.&,?"-%#*"$0&1,XR,,1\)1-+(.-,#"??.#),)&/1R7"(++1"&\,V1\$#?"5('()*W,,,,,,!5!c&*%10%!/%&'!,%!0Q(%!:%!@Z*&I*%!A+$(#,,%@0.$*%4!TMdD!
L-71+$;"$.-+,,YY9!!
,`!#(-%(?"',(-)*#q),P,,,
QR,,)&/1,(-)#"R"/?&''"(#1,SR,,,+)";(-;,'.%"'P,,,,,,,R,,1-7":(++1/1-),?"#(*)"',V+)")&),MW,,,,,,R,,1-7":(++1/1-),;"-;'(.--"(#1,P,p"5('()*,81,ZU,T,ji,k,V+)")&),2W,,
UR,,1\)1-+(.-,71#+,'1,%"-"',5('("(#1,.&,?"-%#*"$0&1,XR,,1\)1-+(.-,#"??.#),)&/1R7"(++1"&\,V1\$#?"5('()*W,,,,,,!!3+*'!9!:*'[email protected]!%10&%!"P!%0!"F!!:*U@*,%S!!
L-71+$;"$.-+,,YY9!!
,A(-(+.-81+,,:"&)1,Y#*0&1-%1,1-,(-)#"8&%)"'P,,
R,,)&/1+,(-)#"R"/?&''"(#1+[[[,,R,,?1$)1+,)&/1+B,)&/1,81,8*5&),`,*)"),81,'",+.&+R/&0&1&+1,,,,,,mm,(-)*#q),P,"??#.%:1,1-8.+%.?(0&1,[[[,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,V!4fB,
L-71+$;"$.-+,,GC3!%0!\*,*5GC3!9!,R,+(;-1+,(-8(#1%)+,,,,,b,.5+)#&%$.-,5('("(#1,V?#*%(+(.-,oUkW,,,,b[,8('")"$.-,r(#+&-;(1--1,,
,R,+(;-1+,8I.#(1-)"$.-P,1/?#1(-)1,E\,,R,+,'I"/?&'./1,P,8(a%('1,m,?1$)1+,)&/1+,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,P,-"),'():("+1^,M&/1^,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,R,1\"/1-,"&\('("(#1,"7"-),&-,)#"()1/1-),%:(#(%"',,,,,,,!
,,
Kim JH. AJR 2002;178: 909-14.
L-71+$;"$.-+P,%.-%'&+(.-+,,•!!B+!'*0#+N.1!+1+0.$*O#%!:%!,e+$(.#,%!:%!f+0%&4!,+!(%N0%!0+*,,%!:%'!0#$%#&'!!!!!&%1:%10!,%#&!:)0%@N.1!:*U@*,%!+#''*!\*%1!%1!)@Z.I&+(Z*%4!!+#!'@+11%&!.#!!!!!%1!GC3!WWS!!C%0%1N''%$%10!@+1+,+*&%>>>!!!!!!!!!!!!!!!*Chang S. Abdom Imaging. 2007;33:457-62. *Kim TU. Eur J Radiol. 2008;66:48-64. ,
•!!T*,+0+N.1!\*5@+1+,+*&%!9!)/.@+0&*@%!:e+$(#,,.$%!!
•!!YY!K!'@+11%&!%0!GC3!%0!\*,*5GC3!(.#&!,%!:*+I1.'N@!>!!
•!!YY!!+((.&0%!#1!>!9!:*+I1.'N@!Z*'0.,.I*O#%4!:)0%@N.1!"S!*10&+5+$(#,,+*&%'!>>>!!
•!!YY!g!$%*,,%#&!'0+I*1I!"h!,.@+,!!!!!!!!!!!*$(+@0!'#&!,%'!*1:*@+N.1'!>>>!!•!!3+*'!(.#&!#1!:*+I1.'N@!(&)@*'!%0!L.&$%,4!!!
!!!!!!!!+((&.@Z%!$#,N$.:+,%!A)@Z.4!'@+11%&4!GC34!%1:.'@.(*%4!YY!+/%@!a?D!!!!!!!!!+''.@*)%!7!#1%[email protected]@%&0+N.1!MT4!!!!!!!!"p-,81,-1,?"+,+.&/1s#1,'1,/"'"81,T,&-1,%:(#(1,"5&+(71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,VM3,@*-(;-1B,M3,81,8*5&)W,.&,?"+,+&a+"-)13,
,,
t.--*1+,"-"?"):,
•! ^
t.--*1+,"-"?"):P,%'"++(p%"$.-,
w,,V8eW,P,)&/1,'(/()*1,"&,+?:(-%)1#,8IJ88(,,,w,V8QW,P,)&/1,(-p')#"-),'",+`/&0&1&+1,8&.8*-"'1,w,V8SW,P,)&/1,(-p')#"-),'",/&+%&'"#(+,?#.?#(",8&.8*-"'1,,w,,V?"-%x[yW,P,)&/1,(-p')#"-),'1,?"-%#*"+3,
M2A,V4z99,SeQeW,
9'"++(p%"$.-,z"?.-"(+1,
60+0#0!"!
t.--*1+,"-"?"):P,%'"++(p%"$.-,
,,,,,,,R,,Y.-%$.-,8&,+)"81,M,,,,,,R,,?#*%.%1[[[,,
,,,,,R,,5"+,?.,'1+,MQB,,,,,,,,,,/"(+,#(+0&1,81,2[,*'17*,m33,Sek,,,,,,,R,Zek,,?.,'1+,)&/1+,MURMX,,,,,,
M2A,V4z99,SeQeW,
C-7":(++1/1-),;"-;'(.--"(#1,,,
t.--*1+,"-"?"):,
R,,MUBMXB,2[,R!,,;#"81,:(+).'.;(0&1,V?1&,T,(-8(c*#1-%(*,[[[WB,66EB,EK,R!,,1-7":(++1/1-),'g/?:.R7"+%&'"(#1,R!,,1-;"(-1/1-),?*#(-1#71&\,,R!,,+.&+R)g?1,:(+).'.;(0&1,
f"%)1+,?#.-.+$0&1+,?#*8(%$Y+,81,+(1,,
•! 6.&+R)g?1+,:(+).'.;(0&1+,bP,,
,,,,,,R,,(-)1+$-"',,,,,,,R,,?"-%#*").5('("(#1,V?#*8./(-"-)W,,,,,,,R,/(\)1,,,,,,,,,,,mmmmmmmmmmm3,81,?#.-.+$%,8(c*#1-)3,,
t.--*1+,4-"?):,
*Kimura W,. Jpn J Cancer Res. 1994;85:161-6.
!#.-.+$%,`,+.&+R)g?1,:(+).'.;(0&1,
!'&+(1+,+*#(1+P,,,
Mg?1,?"-%#*").5('("(#1,b,P,,,,R,?'&+,/"&7"(+,?#.-.+$%,`)g?1,(-)1+$-"',,,,R,?'&+,/"&7"(+1,+(1,,,,,R,?'&+,81,2[,,,R,,Y"%)1,(-8*?1-8"-),81,+(1bB,EKbb,,,tI"&)#1+,+*#(1+,P,Mg?1,?"-%#*").5('("(#1,{,)g?1,(-)1+$-"',,,
`D+E&!&2!)1!>!,,R,,,?"+,81,t6,1-)#1,'1+,S,+.&+R)g?1+B,,,R,,,/q/1,+(,'",/*8("-1,81,+(1,1+),81,SS,/.(+,C",_e,/.(+,?.,'1,)g?1,,,,,,,(-)1+$-"'3,
*Kimura W,. Jpn J Cancer Res. 1994;85:161-6. *Schirmacher. BMC Cancer. 2008;8:251 * Carter JT,. J Am Coll Surg. 2008;207:210–8. *, ** Kim WS. J Surg Oncol. 2012;105:266-72. *Morini S,. Pancreas. 2013;42:60-6.
Howe JR. Ann Surg. 1998;228:87-94. Zhou H. Am J Surg Pathol. 2004;28:875–82.
,,
•! ,U,+.&+R;#.&?1+,B,+1'.-,'I1\?#1++(.-,81+,%g).v*#"$-1+,"&,-(71"&,81,'",)&/1b3,,,,,,!!!!!!!5!djk>`9DSeRmmmmmmmmmmmmmmm,)g?1,?"-%#*").5('("(#1,P,,,,,,,,,R,9DiR`djF,.&,9Di[`djF,mmmm33,,)g?1,(-)1+$-"',,,,,,,,,R,9Di5`9DSe5,mmmmmmmmmmmmmmm33,/(\)1,,,,,,
L=9,
*Morini S.,Pancreas. 2013;42:60–6.
`!djk!9!!Z+\*0#%,,%$%10!%?(&*$)!(+&!,%'!)(*0Z),*#$'!@+1+,+*&%'!!!!!!!!!!!!!!!djk>!9!!^P4;=!l!0Q(%'!Ma!!!!!!!!!!!!!!!!`!djF
9Di, 9DSe,
Mg?1,(-)1+$-"',
Mg?1,!@,
B%!djk>!l!djF
,!.&.(,%1s1,L=9^,
Yun and Seo BMC Gastroenterology (2015) 15:165
M#"()1/1-),%:(#(%"',
•! M#"()1/1-),%:(#(%"'{,+)"-8"#8,,•! M#"()1/1-),#"8(%"',{,1\*#O+1,,,,,,,R,TMd!"71%,.&,+"-+,?#*+1#7"$.-,?g'.#(0&1{,+)"-8"#8[[[,,,,,,R,"++.%(*1,T,&-,%";1,;"-;'(.--"(#1,'.%.#*;(.-"'3,,,,,,R,"71%,/"#;1+,+"(-1+,VEeW3,,,,,R,,#*)"5'(++1/1-),81+,%.-$-&()*+,?"-%#*"$0&1B,5('("(#1,1),8(;1+$713,,!!!!!!,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
M#"()1/1-),
,,A1(''1,*7"'&"$.-,,,,,,M#),,?'&+,%.-+1#7")1,,,,,,,4/?&''1%)./(1,,,,?.,,)&/1+,'.%"'(+*1+,,,,,,,,VMQB,,?1$)1,)"(''1W,
,,,,,,,,,,,,,t!9,,,,,,,R,'.QB,+&]1)+,d;*+,,,,,,,R,/.#)"'()*,VSR,ZkW,,,,,,,,R,/.#5(8()*P,SiRXZk, *Palta M. Ann Surg Oncol. 2012;19:1535-40.
M#"()1/1-),
,,A1(''1,*7"'&"$.-,,,,,,M#),,?'&+,%.-+1#7")1,,,,,,,4/?&''1%)./(1,,,,?.,,)&/1+,'.%"'(+*1+,,,,,,,,,,,,,1),?1$)1+,
,,,,,,,,,,,,,t!9,,,,,,,R,'.QB,+&]1)+,d;*+,,,,,,,R,/.#)"'()*,VS,R,ZkW,,,,,,,,R,/.#5(8()*P,SiRXZk, t*71'.??1/1-),81,'I1-8.+%.?(1,
,,,,,,,K*+(.-+,"&,+)"81,?#*%.%1,,,,,,,,,,,,,,,,,,,,,,,,,V!4fB,
t&.8*-.?"-%#*")1%)./(1,%*?:"'(0&1P,,,!! ,M"&\,81,#*+*%"5('()*,*'17*,,,,,,,R,1-7":(++1/1-),'.%.#*;(.-"',/.(-+,,,,,,,,,,#*8:(5().(#1,[[[,!! ,!1&,81,8(a%&')*+,)1%:-(0&1+P,/"()#(+1,,,,,,R,/"(+,)"&\,*'17*,81,p+)&'1+,,,,,,,,?"-%#*"$0&1+,VSZkW,,!! ,6(1,T,Z,"-+,{,,,,,,,,_ek,Riek,+(,2R,,,,,,,,Uek,+(,2[3,,
M#"()1/1-),%:(#(%"',
4/?&''1%)./(1,%:(#(%"'1,V="'+)18B,QjooWP,
,
R! ?"?(''1%)./(1,P,)&/1+,T,8*71'.??1/1-),/&0&1&\,
R! "/?&''1%)./(1,.&,8&.8*-.?"?(''1%)./(1B,1/?.#)"-),P,,,
,,,,,,,,,,,,,,,b,).)"'()*,8&,+?:(-%)1#,8IJ88(,,,,,,,,b,5"+,%:.'*8.0&1,,,,,,,,b,)1#/(-"(+.-,8&,r(#+&-;,,,,,,,,b,?.#$.-,81,?"#.(,8&.8*-"'1,,,,,,,,b,#*(/?'"-)"$.-,81+,S,%"-"&\,1-,,,,,,,,,,,,,%"-.-,81,Y&+(',
M#"()1/1-),%:(#(%"',
M#"()1/1-),%:(#(%"',4/?&''1%)./(1,%:(#(%"'1,,,,,
V="'+)18B,QjooW,,
M#"()1/1-),%:(#(%"',4/?&''1%)./(1,%:(#(%"'1,,,,,
V="'+)18B,QjooW,,
4/?&''1%)./(1,%:(#(%"'1,,,,,V="'+)18B,QjooW,
,
M#"()1/1-),%:(#(%"',
b,
4/?&''1%)./(1,%:(#(%"'1,,,,,V="'+)18B,QjooW,
,
M#"()1/1-),%:(#(%"',
•!,,/.#)"'()*,-&''1,•!,/.#5(8()*,+?*%(p0&1,P,:*/.##";(1+,,,,,,,,,,,,,VQe,T,QZkW,,,,,,,,,,,,,,,,,,,,,,?"-%#*"$)1+,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,p+)&'1,8&.8*-"'1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,•!,*7()1,'1+,+*0&1''1+,Y.-%$.--1''1+,81,'",t!9,•!,,(-8(%"$.-+P,,,,,b,)&/1+B,M(+B,MQB,-.-,(-p')#"-)1+B,}},,S%/,,,,,b,5(1-,8(c*#1-%(*1+,,,,b,)1##"(-,P,+&]1)+,d;*+B,Y"$;&*+B,%./.#5(8()*+m3,,,,,b,)&/1+,#1/.-)"-),&-,?1&,T,'I,CC,8"-+,,,,,,,,,,,,,'1,%"-"',5('("(#1,(-)#"R?"-%#*"$0&1,,•!,Zek,81,#*%(8(71,+(,D%,(-p')#"-),'",+`/&0&1&+1,,,,,
M#"()1/1-),"8]&7"-),
JAMA, July 11, 2012—Vol 308, No. 2
R,Seee,T,Seej,P,Qee,%1-)#1+,VC.?1B,4&+)#"'(1B,z"?.-,1),9"-"8"3W,R!,XSj,?"$1-)+,(-%'&+,?#*+1-)"-),&-1,)&/1,?*#(R"/?&''"(#1,R,8.-),F^k!+$(#,,.$%'B,o_,%"-%1#+,G@!,(-)#"?"-%#*"$0&1,1),UZ,"&)#1+,%"-%1#+3,R!,J!P,6
M#"()1/1-),"8]&7"-), JAMA, July 11, 2012—Vol 308, No. 2
P;;!
P;E,P;P,
XSj,
M#"()1/1-),"8]&7"-), JAMA, July 11, 2012—Vol 308, No. 2
M#"()1/1-),"8]&7"-), JAMA, July 11, 2012—Vol 308, No. 2
6
!@,C"!L-)1+$-"',+.&+R)g?1,
,,"&%&-1,8(c*#1-%1,
,1-)#1,"/?&''./1+,81,+.&+,)g?1,(-)1+$-"',,1),,
"/?&''./1+,81,+.&+R)g?1,?"-%#*").5('("(#13,,~&1,%1&\R%(,"(1-),#1&,&-1,9M,.&,-.-3,
,,,,
,9.-%'&+(.-+,
,•! K1+,"/?&''./1+,+.-),/(1&\,%.--&+,"&].I:&(,+,'1,?'"-,
?"):.;*-(0&1,1),:(+).?#.-.+$0&13,•! KICC,8.(),q)#1,8*71'.??*1,?.,/(1&\,8*?(+)1#,'1+,Y.#/1+,81,8*5&),
1),?#.?.+1#,?'&+,81,)#"()1/1-),%.-+1#7")1,V"/?&''1%)./(1W3,,•! KI*)&81,"-"?"):,817#"(),-.&+,+?*%(p1#,T,'I"71-(#,'1+,+.&+R)g?1+,
?"-%#*").5('("(#1,1),(-)1+$-"',%"#,%1&\R%(,.-),&-1,(/?'(%"$.-,?#.-.+$0&1,8*/.-)#*13,,
•! L'+,?1&71-),"&].I:&(,.#(1-)1#,71#+,&-1,8*/"#%:1,?'&+,"8*0&")1B,-.)"//1-),1-,%1,0&(,%.-%1#-1,'I(-8(%"$.-,.&,'1,%:.(\,8I&-1,%:(/(.):*#"?(13,,
,•! K1,/"#0&";1,L=9,817#"(),'&(,"&++(,.#(1-)1#,71#+,81+,?#.).%.'1+,81,
%:(/(.):*#"?(1,?'&+,1a%"%1+3,,
6
M#"()1/1-),"8]&7"-), JAMA, July 11, 2012—Vol 308, No. 2
,A*8("-1,81,+(1,P,,4/?&''./1+,{,ZU3Q,/.(+,C"!US3_,/.(+,?.,'1+,"&)#1+,%"-%1#+,V%:.'"-;(.%"#%(-./1+,1),"&)#1+,)&/1+,?*#("/?&''"(#1+,VoZk,9LB,Qi3XR/.-):+WÄ,"-8,(-)#"?"-%#1"$%5('18&%)%"#%(-./"+BSe3o/.-):+VoZk9LBQi3eRSi3Z/.-):+ÄS,S{Sj3oUÄ!3eeQ3@BM:1/18("-+(7"'$/1+Y.#.5+1#7"$.-r"+UZ3S/.-):+VoZk9LB,Si3SRXU3e,/.-):+WÄ,Y.#,l&.#."%(',?'&+,Y.'(-(%,"%(8B,Uj3o,/.-):+,VoZk,9LB,SX3_RZ_3e,/.-):+WÄ,"-8,Y.#,;1/%()"5(-1B,XZ3i,/.-):+,VoZk,9LB,U_3ZR/.-):+W3,M:1,:"|"#8,#"$.,Y.#,l&.#."%(',?'&+,Y.'(-(%,"%(8,7+,.5+1#7"$.-,(+,e3oZ,VoZk,9LB,e3ieRQ3SjÄ,Å"'8,S{e3QQÄ,!{3iXW,"-8,Y.#,;1/%()"5(-1B,e3ii,VoZk,9LB,e3ZiRQ3eZÄ,Å"'8,S{S3_oÄ,!{3QeWÄ,"8]&+)18,).,l&.#."%(',?'&+,Y.'(-(%,"%(8B,e3io,VoZk,9LB,e3ZjRQ3ejÄ,Å"'8,S{S3S_Ä,!,{3QUWÄ,"-8,Y.#,;1/%()"5(-1B,e3ie,VoZk,9LB,e3ZQRe3oiÄ,Å"'8,S{X3_ZÄ,!,{3eUW3,
,A18("-,+(7"',Y.#,):1,"/?&''"#g,?"-%#1").5('("#g,;#.&?,r"+,Z_3e,/.-):+,"-8,XU3Q,/.-):+,Y.#,):1,"/?&''"#g,(-)1+$-"',;#.&?,V!{3SjW3,,
,9.-%'&+(.-+,
,•! K1+,"/?&''./1+,-1,817#"(1-),?'&+,q)#1,%.-+(8*#*+,%.//1,
&-1,1-$)*,"-")./.%'(-(0&1,T,?"#)3,,•! C)&81,"-"?"):,817#"(),-.&+,+?*%(p1#,T,'I"71-(#,'1+,+.&+R
)g?1+,?"-%#*").5('(("#1,1),(-)1+$-"'3,,•! C),%.-+(8*#1#,'1+,"/?&''./1+,!@,%.//1,81+,)&/1+,