1
|
Postpyloric Feeding Access in Infants and Children: A State of the Art Review. J Pediatr Gastroenterol Nutr 2022; 75:237-243. [PMID: 35696699 DOI: 10.1097/mpg.0000000000003518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.
Collapse
|
2
|
Hasan Y, Ali A, Sayed AE, Levin A, Gerke H, Jhun HY, Mokadem M, Abiad RE, Jesudoss R, Polyak S, Sahar N. Direct endoscopic placement of percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) using ultra-thin endoscopes - long-term outcomes from a U.S. tertiary referral center. Surg Endosc 2022; 36:4233-4238. [PMID: 34642797 DOI: 10.1007/s00464-021-08757-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/27/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire. METHODS A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension. RESULTS Fifty-eight patients underwent PEG-J placement (median age 61 years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44 min for new PEG-J tube placement (range 26-103) and 20 min for placement of a J-tube extension through an existing PEG tube (range 9-86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1-9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20 min (range 2-62). No major adverse events were encountered. CONCLUSION PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.
Collapse
Affiliation(s)
- Yazan Hasan
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Asad Ali
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Amer El Sayed
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Avraham Levin
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Henning Gerke
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Hye Yeon Jhun
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Mohamad Mokadem
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Rami El Abiad
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Randhir Jesudoss
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Steven Polyak
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA
| | - Nadav Sahar
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52240, USA.
| |
Collapse
|
3
|
Ripamonti C, Gemlo BT, Bozzetti F, De Conno F. Role of Enteral Nutrition in Advanced Cancer Patients: Indications and Contraindications of the Different Techniques Employed. TUMORI JOURNAL 2018; 82:302-8. [PMID: 8890960 DOI: 10.1177/030089169608200402] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the last 20 years there has been great progress regarding total parenteral nutrition and enteral nutrition for patients who cannot take food by mouth or cannot swallow, or so that controlled feeding can be established in anorexic and malnourished patients. The use and the role of artificial nutrition is still controversial in advanced cancer patients. Such controversies often are due to the fact that these patients have a survival expectancy that varies from one to several months. The present review describes the most frequent techniques used for enteral nutrition (nasoenteral tubes, gastrostomy and jejunostomy), their indications, contraindications and complications, and gives an indication regarding which patients may really benefit from enteral nutrition taking into consideration not only the potential advantages but also the discomfort and distress related to enteral nutrition and the different techniques that are employed.
Collapse
Affiliation(s)
- C Ripamonti
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
| | | | | | | |
Collapse
|
4
|
Rosenberger LH, Newhook T, Mauro DM, Hennessy SA, Sawyer RG. Jejunal tube extensions via percutaneous endoscopic gastrostomy and delayed small-bowel perforations: a case series. Gastrointest Endosc 2012; 75:683-7. [PMID: 22243831 PMCID: PMC3288174 DOI: 10.1016/j.gie.2011.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 10/06/2011] [Indexed: 01/24/2023]
Affiliation(s)
- Laura H. Rosenberger
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy Newhook
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David M. Mauro
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
| | - Sara A. Hennessy
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert G. Sawyer
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
5
|
Campbell SA, Daley CA. Endoscopically Assisted Nasojejunal Feeding Tube Placement: Technique and Results in Five Dogs. J Am Anim Hosp Assoc 2011; 47:e50-5. [DOI: 10.5326/jaaha-ms-5514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interest in noninvasive feeding tube placement in companion animals led to the adaption of a human technique utilizing endoscopy to place nasojejunal feeding tubes. Data from medical records in which nasojejunal feeding tubes were attempted were reviewed. Feeding tubes were attempted and successfully placed in five dogs within a median of 35 min. Feeding tubes remained in place for approximately 7 days. Complications included facial irritation (5/5), sneezing (5/5), fractured facial sutures (4/5), vomiting (3/5), diarrhea (3/5), crimping of feeding tube (3/5), regurgitation (1/5), epistaxis (1/5), clogging of the feeding tube (2/5), and oral migration with premature removal of the feeding tube (1/5). The deployment technique used in this study was found to be cumbersome. Despite minor complications, endoscopy can be used to rapidly and accurately place nasoenteric feeding devices.
Collapse
|
6
|
Abdelgadir MA, Mahadi SEI, Nasr AO, Ahmed ME. Role of jejunostomy feeding catheter as a model for nutritional support. Int J Surg 2010; 8:439-43. [DOI: 10.1016/j.ijsu.2010.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/19/2010] [Accepted: 05/18/2010] [Indexed: 01/10/2023]
|
7
|
Wildi SM, Gubler C, Vavricka SR, Fried M, Bauerfeind P. Transnasal endoscopy for the placement of nasoenteral feeding tubes: does the working length of the endoscope matter? Gastrointest Endosc 2007; 66:225-9. [PMID: 17643693 DOI: 10.1016/j.gie.2006.12.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 12/26/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. OBJECTIVE To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. DESIGN Randomized controlled study. SETTING University Hospital of Zurich, Switzerland. PATIENTS Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. MAIN OUTCOME MEASUREMENTS Success rates of endoscopic placement of enteral feeding tubes. RESULTS A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001). LIMITATIONS In rare cases, the randomization list could not be followed correctly. CONCLUSIONS This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.
Collapse
Affiliation(s)
- Stephan M Wildi
- Current affiliations: Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital of Zurich, Switzerland
| | | | | | | | | |
Collapse
|
8
|
Lin CH, Liu NJ, Lee CS, Tang JH, Wei KL, Yang C, Sung KF, Cheng CL, Chiu CT, Chen PC. Nasogastric feeding tube placement in patients with esophageal cancer: application of ultrathin transnasal endoscopy. Gastrointest Endosc 2006; 64:104-7. [PMID: 16813813 DOI: 10.1016/j.gie.2005.12.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2004] [Accepted: 12/28/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with esophageal cancer often present with dysphagia and malnutrition. Obstructive symptoms may improve after radiotherapy and chemotherapy. Nutrition support via a nasogastric tube (NG) or gastrostomy is very important during treatment. The newly developed ultrathin endoscope (Olympus, GIF-N230, outer diameter: 6 mm) has a smaller diameter than the standard endoscope and can be introduced into the esophagus via the nasal cavity. This article reports on the use of an ultrathin endoscope for NG placement for patients with esophageal cancer who presented with dysphagia and failed traditional NG tube placement. METHODS A consecutive series of 40 patients with esophageal cancer were referred to our hospital from November 2001 to October 2002 for endoscopic placement of NG tubes due to failure of traditional methods of NG placement. An ultrathin endoscope was used to advance the guidewire into the stomach via the nasal cavity. After withdrawal of the scope, the NG tube was inserted over the guidewire under fluoroscopy. OBSERVATIONS A total of 71 procedures were performed in 40 patients (37 males, 3 females), age 57 +/- 15 years (range, 37-91 y). Seventy procedures (99%) were successful in completing NG tube placement by using an ultrathin transnasal endoscope. Only one procedure failed because the esophageal lumen was completely occluded and the guidewire was not able to be passed through the obstructed site. The average duration that the NG tube was left in place was 49 +/- 35 days (range, 2-144 days). No procedure-related complications, such as bleeding or perforation, occurred. CONCLUSIONS Using ultrathin transnasal endoscopy to place an NG tube for esophageal cancer patients is effective and safe. It simplifies the procedures and increases the success rate.
Collapse
Affiliation(s)
- Cheng-Hui Lin
- Division of Digestive Therapeutic Endoscopy, Department of Hepatogastroenterology, Chang Gung Memorial Hospital, Linkou, 5 Fu-Shin Street, Kweishan, Taoyuan, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Bajaj JS, Shaker R. Another indication for transnasal, unsedated upper-GI endoscopy. Gastrointest Endosc 2005; 62:667-8. [PMID: 16246676 DOI: 10.1016/j.gie.2005.04.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 04/28/2005] [Indexed: 02/08/2023]
|
10
|
Külling D, Bauerfeind P, Fried M. Transnasal versus transoral endoscopy for the placement of nasoenteral feeding tubes in critically ill patients. Gastrointest Endosc 2000; 52:506-10. [PMID: 11023568 DOI: 10.1067/mge.2000.107729] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nasoenteral feeding tube placement with the Seldinger technique using transoral endoscopy is a tedious procedure. This study compared the transoral approach with a new technique that uses a transnasal endoscope without the need for a mouth-to-nose wire transfer. METHODS Critically ill patients requiring nasoenteral feeding tube placement were randomly assigned to the transoral technique using a standard upper endoscope (n = 80) or the transnasal method using a 5.3 mm fiberscope (n = 80). Procedure time, medication requirement, technical difficulty, patient tolerance, and radiologic tube position were assessed. RESULTS The two groups were similar with regard to baseline medication, endoscopic findings, as well as overall technical difficulty and patient tolerance. The transnasal technique required less procedure time (median 8.0 versus 12.0 minutes, p < 0.001) and less relaxant medication (p = 0.029). Furthermore, it caused fewer circulatory (p = 0.040) and respiratory (p = 0.016) alterations regardless of the application of sedative or relaxant medication. The transnasal endoscope was inferior with respect to passage through the pylorus (p = 0.003) and duodenum (p = 0.020). These differences were significant in univariate hypothesis testing. Bonferroni correction for multiple testing of data removed the significance at p > 0.0031. Both techniques achieved similar rates of successful tube placement in the small bowel (86% versus 84%, p = 0.82). CONCLUSION Transnasal endoscopy allows accurate placement of nasoenteral feeding tubes in critically ill patients and is superior to transoral endoscopy in terms of procedure time, medication requirement, and safety.
Collapse
Affiliation(s)
- D Külling
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Zürich, Switzerland.
| | | | | |
Collapse
|
11
|
Chaurasia OP. Percutaneous endoscopic gastrojejunostomy tube placement. Gastrointest Endosc 1998; 47:433-4. [PMID: 9609451 DOI: 10.1016/s0016-5107(98)70235-4] [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: 02/07/2023]
|
12
|
|
13
|
Leichus L, Patel R, Johlin F. Percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) tube placement: a novel approach. Gastrointest Endosc 1997; 45:79-81. [PMID: 9013175 DOI: 10.1016/s0016-5107(97)70307-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- L Leichus
- Department of Medicine, University of Iowa College of Medicine, Iowa City, USA
| | | | | |
Collapse
|
14
|
Affiliation(s)
- W L Berger
- Medical College of Wisconsin, Milwaukee, USA
| | | | | |
Collapse
|
15
|
Kimmey MB, Al-Kawas FH, Gannan RM, Saeed ZA, Carr-Locke DL, Edmundowicz SA, Jamidar PA, Stein TN. Technology Assessment status evaluation: endoscopic feeding tubes. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1995; 42:612-4. [PMID: 8674942 DOI: 10.1016/s0016-5107(95)70026-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
16
|
Affiliation(s)
- W N Baskin
- University of Illinois College at Rockford, USA
| | | |
Collapse
|
17
|
Affiliation(s)
- O P Chaurasia
- Division of Gastroenterology, University of California, Irvine Medical Center, Orange 92668, USA
| | | |
Collapse
|
18
|
Swaroop VS, Dhir V, Vazifdar K, Shinde S. Nasoenteric tube placement using Savary-Gilliard guide wire for postoperative gastric retention following transhiatal esophagectomy. Gastrointest Endosc 1995; 41:180-1. [PMID: 7721017 DOI: 10.1016/s0016-5107(05)80617-0] [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: 02/08/2023]
|
19
|
Shukla NK, Goel AK, Seenu V, Nanda R, Deo SV, Kriplani AK. Endoscopically guided placement of nasogastric tubes in patients with esophageal carcinoma with absolute dysphagia: report of a 3-year experience. J Surg Oncol 1994; 56:217-20. [PMID: 8057645 DOI: 10.1002/jso.2930560403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Esophageal cancer often leads to total or near-total dysphagia, necessitating placement of nasogastric tubes for nutritional support. In patients with failed blind intubation or even failed fluoroscopic-guided tube placement, endoscopic guidance has a role to play. The catheter-over-guidewire technique is simple, safe, and easy to use. Over a period of 3 years, it was used in 28 patients who had esophageal cancer with absolute dysphagia. Successful placement of Levin tubes was achieved in 21 (75%) of these patients. Failure was more common in upper third lesions. The procedure was done on an outpatient basis, and no procedure-related complications were recorded in this series. To summarize, endoscopically assisted nasogastric tube placement is a useful option in esophageal cancer when blind intubation has failed, and it should be considered in preference to fluoroscopic assistance if endoscopic facilities are available.
Collapse
Affiliation(s)
- N K Shukla
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi
| | | | | | | | | | | |
Collapse
|
20
|
Bumpers HL, Luchette FA, Doerr RJ, Hoover EL. A simple technique for insertion of PEJ via PEG. Surg Endosc 1994; 8:121-3. [PMID: 8165482 DOI: 10.1007/bf00316623] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Percutaneous endoscopic jejunostomy provides good access for enteral nutrition in those patients at high risk for aspiration and poor tolerance of gastric feeding. Positioning the jejunostomy tube through the PEG tube and into the duodenum can be difficult and time consuming. We describe a simple method for gaining rapid control of the jejunal tube and its duodenal insertion.
Collapse
Affiliation(s)
- H L Bumpers
- Department of Surgery, State University of New York, Buffalo School of Medicine and Biomedical Sciences 14215
| | | | | | | |
Collapse
|
21
|
Abstract
Contrary to total parenteral nutrition with its relatively recent introduction into modern clinical medicine, enteral nutrition has a long and colorful history. Prior to development of fiberoptic endoscopy, physicians attempting to feed patients who could not or would not eat were limited to the blind placement of intestinal tubes or radiologically assisted placement of these devices. Previous to these modern attempts, the use of nutrient enemas was attempted for which there was evidence of occasional success. With the introduction of fiberoptic flexible endoscopy, guidance of tubes into the upper intestinal tract under direct vision became feasible. The manner in which tubes were positioned, advanced, or manipulated are myriad and attest to the ingenuity of clinicians. A revolution in endoscopic intervention occurred with the introduction of the percutaneous endoscopic gastrostomy in 1980. This provided secure access to the stomach without a laparotomy. This technique was also modified to allow decompression of the stomach with feeding distally into the small intestine and also direct puncture and placement of tubes into the small intestine. The most recent advance in enteral nutrition is taking place at the present time with the introduction of laparoscopic techniques in the creation of gastrostomies and jejunostomies.
Collapse
Affiliation(s)
- T A Stellato
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
22
|
Affiliation(s)
- R G Mitchell
- Department of Gastroenterology, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27157
| | | | | | | |
Collapse
|
23
|
|
24
|
Affiliation(s)
- B S Lewis
- Mt. Sinai Medical Center, New York, New York
| |
Collapse
|