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Almadi MA, Lu Y, Alali AA, Barkun AN. Peptic ulcer disease. Lancet 2024; 404:68-81. [PMID: 38885678 DOI: 10.1016/s0140-6736(24)00155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 06/20/2024]
Abstract
Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Yidan Lu
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada.
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2
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Abel WF, Soliman YY, Wasserman RD, Reddy S, Sangay ARV, Monkemuller KE, Kesar V, Yeaton P, Kesar V. Endoscopic ultrasound-guided gastrojejunostomy for benign gastric outlet obstruction (GOO): a retrospective analysis of patients and outcomes. Surg Endosc 2024; 38:3849-3857. [PMID: 38831212 DOI: 10.1007/s00464-024-10897-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/02/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has been well utilized in treating malignant gastric outlet obstructions (GOO) given its efficacy and lower risk profile compared to surgery. However, its efficacy and potential for use in patients with benign GOO who are poor surgical candidates is not well documented. The aim of this study was to examine the role of EUS-GJ in treatment of benign GOO in select patients. PATIENTS AND METHODS This is a single-center, open-label, retrospective descriptive study that included all consecutive patients undergoing EUS-GJ to treat benign causes of GOO. Direct antegrade and direct retrograde methods were utilized. RESULTS A total of 18 patients were included, 38.9% female with an average age of 63.3 years. Extrinsic GOO was present in (10 of 18) 55.5% of patients and intrinsic etiology was present in (8 of 18) 45.5% of patients. Technical success was achieved in 100% (18 of 18) patients and clinical success was achieved in 94% (17 of 18) patients. In total, 13 patients had follow-up endoscopy, 2 patients were treated relatively recently in time, 1 patient was lost to follow-up, and 2 patients died of other chronic illnesses. Stents remained in place for a median of 286 days (range 88-1444 days). In patients whose stents were removed, 75% (3 of 4) had extrinsic etiologies of GOO. CONCLUSIONS This study reports a favorable long-term patency with excellent technical and clinical success of EUS-GJ in patients with benign GOO. Despite the limitations of sample size and retrospective nature, it adds to the extremely limited literature of EUS-GJ in management of patients with benign GOO.
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Affiliation(s)
- William F Abel
- Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA.
- PGY-3 Internal Medicine Resident, Virginia Tech Carilion Internal Medicine Residency, 1906 Belleview Avenue, Roanoke, VA, 24014, USA.
| | - Youssef Y Soliman
- Division of Gastroenterology, Cancer Treatment Centers of America, Phoenix, AZ, USA
| | - Reid D Wasserman
- Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
| | - Shravani Reddy
- Division of Gastroenterology, Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
| | | | - Klaus E Monkemuller
- Division of Gastroenterology, Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
| | - Varun Kesar
- Division of Gastroenterology, Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
| | - Paul Yeaton
- Division of Gastroenterology, Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
| | - Vivek Kesar
- Division of Gastroenterology, Department of Internal Medicine, Virginia Tech Carilion, Roanoke, VA, USA
- Division of Gastroenterology, Interventional Gastroenterology, Virginia Tech Carilion School of Medicine, 1906 Belleview Avenue, Roanoke, VA, 24014, USA
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3
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Canakis A, Irani SS. Endoscopic Treatment of Gastric Outlet Obstruction. Gastrointest Endosc Clin N Am 2024; 34:111-125. [PMID: 37973223 DOI: 10.1016/j.giec.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Mailstop: C3-GAS, Seattle, WA 98101, USA.
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4
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Maharshi S, Sharma D, Sharma SS, Sharma KK, Pokharna R, Nijhawan S. Aetiology and clinical spectrum of gastric outlet obstruction in North West India. Trop Doct 2023; 53:433-436. [PMID: 37350082 DOI: 10.1177/00494755231183989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Our study to evaluate the aetiological and clinical spectrum of gastric outlet obstruction (GOO) in North-west India showed malignant cause (54.9%) was more common than benign (45.1%). Common causes of malignancy were gall bladder (37.5%), gastric (31.8%) and pancreatic carcinoma (19.6%); commonest benign causes were opioid abuse (29%), peptic ulcer disease (21.6%), ingestion of corrosives (20.2%) and chronic pancreatitis (12.3%).
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Deepak Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Kamlesh Kumar Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Rupesh Pokharna
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
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5
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Chittajallu V, Omar YA, Simons-Linares CR, Chahal P. Endoscopic balloon dilation management for benign duodenal stenosis. Surg Endosc 2023; 37:3610-3618. [PMID: 36624215 DOI: 10.1007/s00464-022-09844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS Benign duodenal stenosis (BDS) is most commonly caused by peptic ulcer disease (PUD). Endoscopic balloon dilation (EBD) is the recommended initial management despite limited supporting literature. Our study investigated the etiologic spectrum of BDS and its response to endoscopic dilation. METHODS We performed a cohort study of a prospectively maintained database of BDS at our large tertiary academic center between 2002 and 2018. All patients who underwent EBD were analyzed. Dilation was performed using through-the-scope balloons. Technical and clinical successes of initial and repeat EBD were compared. Descriptive statistics, univariate, and multivariate analysis were performed. RESULTS The study included 86 patients with 54.7% female gender. Etiologies included 39 patients with PUD (45.3%), 19 patients with Crohn's disease (22.1%), 23 patients had idiopathic etiologies (26.7%), and 5 patients were listed as other etiologies (5.8%). Proximal stricture location (1st part of duodenum) occurred in 66% of females, whereas distal duodenal involvement was seen in 63.6% of males (p value 0.007). Usage of PPI was associated with 3.6 times higher clinical success rate (p value 0.04). Technical (97.4%) and clinical (77.8%) successes for index dilations in PUD were not significantly better than those of non-PUD patients (p values 0.99, 0.52). CONCLUSION EBD has both a high technical and clinical success for BDS regardless of etiology and should be considered over initial surgical intervention due to low risk profile. Males tend to have more distal duodenal involvement, and PPI usage is an independent predictor for clinical success.
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Affiliation(s)
- Vibhu Chittajallu
- Digestive Health Institute, University Hospitals Cleveland, Cleveland, OH, USA.
| | - Yazan Abu Omar
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Prabhleen Chahal
- Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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6
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Montoro-Huguet MA. Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus. Nutrients 2022; 14:4819. [PMID: 36432505 PMCID: PMC9697263 DOI: 10.3390/nu14224819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.
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Affiliation(s)
- Miguel A. Montoro-Huguet
- Unit of Gastroenterology, Hepatology & Nutrition, University Hospital San Jorge, 22005 Huesca, Spain;
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- Aragón Health Sciences Institute (IACS), 50009 Zaragoza, Spain
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7
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Adverse events associated with EGD and EGD-related techniques. Gastrointest Endosc 2022; 96:389-401.e1. [PMID: 35843754 DOI: 10.1016/j.gie.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
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8
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Sharma B, Birk J. Endoscopic Dilation of Corrosive Strictures: Is It Safe? Dig Dis Sci 2022; 67:2706-2707. [PMID: 34739623 DOI: 10.1007/s10620-021-07298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Bashar Sharma
- Division of Gastroenterology and Hepatology, University of Connecticut, Farmington, CT, USA
| | - John Birk
- Division of Gastroenterology and Hepatology, University of Connecticut, Farmington, CT, USA.
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9
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Bush N, Bhattacharjee S, Sachan A, Gupta R, Rana S. Perforations from Endoscopic Dilation of Corrosive Strictures in Adults: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:3200-3209. [PMID: 34739625 DOI: 10.1007/s10620-021-07295-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/08/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Endoscopic dilation is an important therapeutic option for treatment of corrosive strictures. Its safety is unclear with variable perforation rates in previous studies. We aimed to evaluate its safety with regard to perforations and the effect of dilator type to perforation risk. METHODS A systematic review of published literature from inception to April 24, 2021, using PubMed and EMBASE databases was conducted. Studies in adult subjects (mean age ≥ 18 years) reporting perforation rates of endoscopic dilation of corrosive esophageal and/or gastric strictures were included. Pooled cumulative perforation rates were computed as primary outcome. Secondary outcomes included, perforation with each dilator subtypes, surgical or conservative modes of management and mortality. Random effect meta-analysis was used to estimate the frequency of each of these outcomes. Variables were reported as percentages with 95% CI. RESULTS A total of 712 subjects (N) who underwent 4840 dilations (n) were noted in the 15 studies that were included. Of which, eight were retrospective, while the remaining seven were prospective. On meta-analysis, the cumulative pooled perforation rate was 1% (1-2%) of the number of dilations (n%). The perforation rates with SG (1%, 0-3%) and balloon (1%, 0-5%) dilators were similar (p value < 0.01). 45/64 (59%, 11-94%) perforations were subjected to surgery while the remaining 14/64 (41%, 6-89%) was managed conservatively. Choice of management strategy was biased to the norms of the treating team. About 3/712 patients (0%, 0-2%) succumbed following perforation. CONCLUSION Perforation from endoscopic dilation of corrosive strictures occurs rarely, and there is no significant difference in perforation risk related to the type of dilator.
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Affiliation(s)
- Nikhil Bush
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Samiksha Bhattacharjee
- Department of Clinical Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Anurag Sachan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Surinder Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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10
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Cunningham BS, Alexander CP. Spontaneous Gastric Perforation in a Child and Endoscopic Balloon Dilation for Postoperative Gastric Stenosis. JPGN REPORTS 2022; 3:e199. [PMID: 37168896 PMCID: PMC10158354 DOI: 10.1097/pg9.0000000000000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/20/2022] [Indexed: 05/13/2023]
Affiliation(s)
- Bethany S. Cunningham
- From the Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Penn State Milton S Hershey Children’s Hospital, Hershey, PA
| | - Chandran P. Alexander
- From the Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Penn State Milton S Hershey Children’s Hospital, Hershey, PA
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11
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Can computed tomography-antral wall thickness predict response to endoscopic balloon dilation in patients with caustic-induced gastric outlet obstruction? Indian J Gastroenterol 2022; 41:190-197. [PMID: 35190977 DOI: 10.1007/s12664-021-01208-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/03/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Caustic-induced gastric outlet obstruction (GOO) remains one of the important causes of long-term morbidity in patients with caustic ingestion. Though endoscopic balloon dilation is an effective modality, response to caustic GOO is poorer as compared to peptic stricture. Computed tomography (CT)-antral wall thickness (AWT) has not been previously explored to predict the procedural success in patients with caustic GOO. METHODS In a retrospective single-center study of prospectively maintained database, all patients with symptomatic caustic GOO who underwent CT scan prior to endoscopic balloon dilation were included. Gastric AWT was measured at the site of maximum visible thickness on CT scan. Details regarding caustic ingestion and endoscopic dilation were retrieved. Patients were divided into two groups, based on CT-AWT (< or ≥9 mm) and compared for outcome measures. RESULTS Mean age of included patients (n=35) was 33.51 ± 13.65 years and 22 were male. Procedural success was achieved in 29 (82.85%) patients. Number of mean dilation sessions required were 5.28 ± 2.96 for achieving procedural success. The mean CT-AWT was 10.73 ± 2.80 mm (range 4-18 mm). There was no significant association between the CT-AWT and the number of dilations and procedural success. On univariate analysis, size of the first balloon used was a predictor of refractory stricture (p=0.011). However, no other factors predicted either refractory stricture or procedural success. CONCLUSION There is no additional role of CT-AWT in predicting response to endoscopic balloon dilation or to predict refractory stricture in patients with caustic GOO.
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12
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Limdi JK. Editorial commentary on the Indian Journal of Gastroenterology-March-April 2022. Indian J Gastroenterol 2022; 41:115-118. [PMID: 35522371 DOI: 10.1007/s12664-022-01261-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jimmy K Limdi
- Section of Inflammatory Bowel Diseases, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, UK.
- University of Manchester, Manchester, UK.
- Manchester Metropolitan University, Manchester, UK.
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13
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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14
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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15
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Jue TL, Storm AC, Naveed M, Fishman DS, Qumseya BJ, McRee AJ, Truty MJ, Khashab MA, Agrawal D, Al-Haddad M, Amateau SK, Buxbaum JL, Calderwood AH, DeWitt J, DiMaio CJ, Fujii-Lau LL, Gurudu SR, Jamil LH, Kwon RS, Law JK, Lee JK, Pawa S, Sawhney MS, Thosani NC, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 2021; 93:309-322.e4. [PMID: 33168194 DOI: 10.1016/j.gie.2020.07.063] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.
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Affiliation(s)
- Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam Naveed
- Advent Health Medical Group, Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Autumn J McRee
- Division of Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark J Truty
- Department of Surgical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Mohammed Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Audrey H Calderwood
- Department of Gastroenterology and Hepatology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Suryakanth R Gurudu
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health, Royal Oak, Michigan, USA
| | - Richard S Kwon
- Department of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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16
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Liang C, Tan Y, Lu J, Le M, Liu D. Endoscopic incision for treatment of benign gastrointestinal strictures. Expert Rev Gastroenterol Hepatol 2020; 14:445-452. [PMID: 32380885 DOI: 10.1080/17474124.2020.1766966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Benign gastrointestinal strictures are common, and can be congenital or acquired (anastomotic, corrosive, induced by Crohn's disease or endoscopic treatments, etc.). Patients usually present with stricture-related symptoms such as vomiting, dysphagia, dyschezia, abdominal pain, which impair their quality of life. Endoscopic balloon dilation (EBD) is the first-line treatment for most of the benign strictures; however, long-term efficacy is suboptimal, and the recurrence rate can be up to 38%. Endoscopic incision (EI) was firstly reported for treatment of congenital membranous stricture, and then applied to other benign gastrointestinal strictures. AREA COVERED In the present review, we provided a comprehensive review of EI for the treatment of benign gastrointestinal strictures, mainly focus on the technical details, indication, safety, and efficacy of EI. The present review is expected to provide tips for operators who are going to perform EI. EXPERT OPINION EI can serve as an alternative method for treatment of gastrointestinal strictures, the best indications are congenital membranous stricture and short-segmental (<1 cm) anastomotic strictures refractory to EBD. EI may also be attempted for strictures induced by other reasons. Combination with other endoscopic methods such as EBD, local steroid injection, stent placement, may improve the efficacy of EI.
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Affiliation(s)
- Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Jiaxi Lu
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Meixian Le
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
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17
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James TW, Greenberg S, Grimm IS, Baron TH. EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction. Gastrointest Endosc 2020; 91:537-542. [PMID: 31759034 PMCID: PMC7039740 DOI: 10.1016/j.gie.2019.11.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/03/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIMS Benign gastric outlet obstruction (GOO) has typically been managed surgically. However, many patients are poor operative candidates because of comorbidities. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has previously demonstrated efficacy as a definitive treatment for benign and malignant GOO; however, limited data exist on use as a bridge to resolution of the obstruction in an attempt to avoid or delay definitive surgery. METHODS A retrospective series of consecutive patients who underwent EUS-GE between January 2013 and July 2019 for benign GOO at a tertiary referral center were included in the study. The primary outcome was the rate of definitive surgery; secondary outcomes included technical success and rate of adverse events. RESULTS During the study period, 22 patients with benign GOO underwent EUS-GE (40% female; mean age, 54.2 years). The mean procedure time was 66 minutes, and technical success was achieved in 21. Five patients developed recurrent GOO while the LAMS was in place after a mean dwell time of 228 days; 1 patient was converted to surgical GE. LAMSs were removed electively in 18 patients after GOO resolution and a mean dwell time of 270 days; 1 patient developed a recurrent GOO after LAMS removal and was converted to surgical GE. The rate of recurrent GOO after LAMS removal was 5.6%. Three severe adverse events occurred in the cohort. CONCLUSIONS EUS-GE was able to prevent surgery for GOO in 83.3% of cases. LAMSs needed to stay in place for a mean of 8.5 months to allow resolution of GOO, and there was a low rate of recurrent GOO (5.6%) after LAMS removal. Prospective, randomized trials comparing surgical and endoscopic anastomoses are needed in patients with benign causes of GOO.
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Affiliation(s)
- Theodore W. James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - Sydney Greenberg
- Department of Medicine, University of North Carolina, Chapel Hill
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
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18
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Zare E, Raeisi H, Honarvar B, Lankarani KB. Long-term Results of Endoscopic Balloon Dilatation for Gastric Outlet Obstruction Caused by Peptic Ulcer Disease. Middle East J Dig Dis 2019; 11:218-224. [PMID: 31824625 PMCID: PMC6895853 DOI: 10.15171/mejdd.2019.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastric outlet obstructions (GOO) is a disabling complication of peptic ulcer disease (PUD). The introduction of endoscopic through the scope balloon dilatation (EBD) has eased the management but there are few reports on the long term results of this modality of treatment on patients’ symptoms. METHODS Over a period of 4 years from January 2012 to December 2015 in two major referral hospitals affiliated to Shiraz university, medical endoscopy reports were reviewed retrospectively to identify those who received EBD for the treatment of GOO due to PUD .All of these patients were recalled and their current status were evaluated. RESULTS 22 consecutive patients with symptomatic GOO secondary to benign stricture underwent endoscopic balloon dilatation by a single operator. Of them, 14 had balloon dilatation twice and 6 had ballooning three times. The interval between the first referral and the last follow-up was 25.2 ± 10.3 (min: 4.8 max:43.4) months. The averages of maximum balloon size were 14.4 ± 5 mm in the first session, 14.3 ± 3.1mm in the second session, and 16 ± 2.4 mm in the third session. 73% of the patients had a significant improvement in clinical symptom with two sessions of EBD and did not require repeat dilatation. CONCLUSION EBD is a safe and efficient method in the management of GOO with good long term results.
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Affiliation(s)
- Ehsan Zare
- Gastroenterology and Hepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | - Hadi Raeisi
- Department of Biostatistics, Shahre Kord University of Medical Sciences, Shahrekord, Islamic Republic of Iran
| | - Behnam Honarvar
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | - Kamran B Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
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19
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Tringali A, Giannetti A, Adler DG. Endoscopic management of gastric outlet obstruction disease. Ann Gastroenterol 2019. [PMID: 31263354 DOI: 10.20524/aog.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti)
| | - Aurora Giannetti
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti).,Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (DI.BI.M.I.S.), University of Palermo, Palermo, Italy (Aurora Giannetti)
| | - Douglas G Adler
- Gastroenterology, and Hepatology Department, University of Utah School of Medicine, Salt Lake City, Utah USA (Douglas G. Adler)
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20
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Tringali A, Giannetti A, Adler DG. Endoscopic management of gastric outlet obstruction disease. Ann Gastroenterol 2019; 32:330-337. [PMID: 31263354 PMCID: PMC6595925 DOI: 10.20524/aog.2019.0390] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/07/2019] [Indexed: 12/14/2022] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient’s prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti)
| | - Aurora Giannetti
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti).,Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (DI.BI.M.I.S.), University of Palermo, Palermo, Italy (Aurora Giannetti)
| | - Douglas G Adler
- Gastroenterology, and Hepatology Department, University of Utah School of Medicine, Salt Lake City, Utah USA (Douglas G. Adler)
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21
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Endoscopic balloon dilation for benign gastric outlet obstruction: Does etiology matter? Gastrointest Endosc 2018; 88:909-911. [PMID: 30449403 DOI: 10.1016/j.gie.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/09/2018] [Indexed: 12/11/2022]
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