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Takahashi K, Iwama T, Tanaka K, Miyazawa Y, Kuroda S, Horiuchi M, Saito S, Muto M, Sakatani A, Ando K, Ueno N, Kashima S, Moriichi K, Tanabe H, Okumura T, Fujiya M. Risk Factors for Post-Colorectal Endoscopic Submucosal Dissection Bleeding and Efficacy of Carbazochrome Sodium Sulfonate: A Multicenter Retrospective Cohort Study. Digestion 2024:1-10. [PMID: 38763127 DOI: 10.1159/000539367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 05/12/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Carbazochrome sodium sulfonate (CSS) is a hemostatic agent that reduces capillary permeability and enhances capillary resistance. However, its specific effects on colorectal endoscopic submucosal dissection (ESD) outcomes remain uncertain. This study aimed to assess the risk factors for post-ESD bleeding and the effect of CSS on colorectal ESD outcomes. METHODS First, we retrospectively analyzed the risk factors for post-ESD bleeding using data from 1,315 lesions in 1,223 patients who underwent ESD for superficial colorectal neoplasms at eight institutions. Second, patients were divided into CSS and non-CSS groups using propensity score matching, and their outcomes from colorectal ESD were analyzed. RESULTS The risk factors for post-colorectal ESD bleeding were identified as age of ≥70 years, tumor located in the rectum, tumor size of ≥40 mm, and post-ESD defect unclosure in both univariate and multivariate analyses. The CSS and non-CSS groups each consisted of 423 lesions after propensity score matching. The post-colorectal ESD bleeding rate was 3.5% (15/423) and 3.3% (14/423) in the CSS and non-CSS groups, respectively, indicating no significant differences. Among patients with the high-risk factors for post-ESD bleeding, the administration of CSS also did not demonstrate a significant reduction in the post-ESD bleeding rate compared to the non-CSS group. CONCLUSION CSS administration is ineffective in preventing post-colorectal ESD bleeding in both the general population and individuals at a high risk for such bleeding. Our results indicate the necessity to reconsider the application of CSS for preventing post-colorectal ESD bleeding.
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Affiliation(s)
- Keitaro Takahashi
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takuya Iwama
- Department of Gastroenterology, Asahikawa City Hospital, Asahikawa, Japan
| | - Kazuyuki Tanaka
- Department of Gastroenterology, Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - Yuki Miyazawa
- Department of Gastroenterology, Nayoro City General Hospital, Nayoro, Japan
| | - Shohei Kuroda
- Department of Gastroenterology, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Masashi Horiuchi
- Department of Gastroenterology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Seisuke Saito
- Department of Gastroenterology, Furano Kyokai Hospital, Furano, Japan
| | - Momotaro Muto
- Department of Internal Medicine, Engaru-Kosei General Hospital, Engaru, Japan
| | - Aki Sakatani
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Katsuyoshi Ando
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Shin Kashima
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroki Tanabe
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
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Song S, Dou L, Liu Y, Zhang Y, He S, Wang G. A strategy combining endoscopic hand-suturing with clips for closure of rectal defects after endoscopic submucosal dissection with or without myectomy (with video). Gastrointest Endosc 2024; 99:614-624.e2. [PMID: 37993061 DOI: 10.1016/j.gie.2023.11.015] [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: 07/12/2023] [Revised: 10/11/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND AND AIMS Endoscopic hand-suturing (EHS) has been preliminarily demonstrated to be effective in closing defects after endoscopic submucosal dissection (ESD), but it is not easily performed. We proposed a strategy combining EHS with clips (EHS-Clips) and explored its effectiveness in closing rectal defects after ESD or ESD with myectomy (ESD-ME). METHODS In this observational study, data from patients with rectal defects closed using EHS-Clips were reviewed. EHS-Clips refers to a strategy where defects are sutured as much as possible by EHS first, with clips being used to close the remaining parts of defects that cannot be completely sutured. The primary endpoints included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for the sustained closure. RESULTS All 49 (100%) defects (42 ESD defects and 7 ESD-ME defects) were completely closed through the strategy of EHS-Clips, with 35 (71.4%) through EHS alone and 14 (28.6%) through EHS and additional clips. No patients experienced DB. Thirty-six (73.5%) defects remained sustained closure on postoperative days 3 to 5 (73.8% for ESD defects vs 71.4% for ESD-ME defects). The multivariate analyses identified a stitch margin of ≥5 mm (hazard ratio, 0.313; 95% confidence interval, 0.023-0.781; P = .009) as the only independent advantage factor for the sustained closure. CONCLUSIONS EHS-Clips can be used to effectively close the rectal defects after ESD or ESD-ME and prevent DB. Complete suture with a stitch margin of ≥5 mm may achieve more reliable sustained closure.
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Affiliation(s)
- Shibo Song
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lizhou Dou
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueming Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Fang Z, Xu Y, Huang X. Impact of prophylactic wound closure in colorectal ESD on postoperative wound complications: A meta-analysis. Int Wound J 2024; 21:e14783. [PMID: 38472107 PMCID: PMC10932785 DOI: 10.1111/iwj.14783] [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: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 03/14/2024] Open
Abstract
Endoscopic submucosa dissection (ESD) has been applied extensively in the treatment of large intestine tumours due to its high total excision ratio. Nevertheless, there is a high incidence of adverse reactions in colon ESD, and the efficacy of prophylactic ESD following ESD in prevention of postoperative haemorrhage is still disputed. The purpose of this meta-analysis is to evaluate the effectiveness of prophylaxis of wound closure in large intestine ESD after operation. For eligibility, we looked through three databases: PubMed, Embase and Cochrane Library. Heterogenity was measured by means of a chi-square method of Q-statistic and an I2 test. Fixed or random effects models were used for data processing. Based on the retrieval policy, we found a total of 1286 papers, and then we collected nine papers to extract the data. Regarding postoperative haemorrhage, there was a significant reduction in the risk of wound haemorrhage in the wound closure group than in the control group (OR, 0.29; 95% CI, 0.19-0.44 p < 0.0001). No statistical significance was found in the incidence of perforation in the wound closure and the control group (OR, 0.45; 95% CI, 0.19-1.03 p = 0.06). There was a significant reduction in the incidence of postoperation fever among those in the wound closure group than in the control group (OR, 0.37; 95% CI, 0.15-0.93 p = 0.04). Preventive endoscopic closure decreased the rate of ESD in colon disease, but did not significantly decrease the rate of postoperation perforation and postoperative fever. Future research will be required to clarify the risk factors and classify high-risk individuals in order to formulate a cost-effective prevention strategy.
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Affiliation(s)
- Zhengdong Fang
- Department of Critical Care MedicineSir Run Run Shaw Hospital, School of Medicine, Zhejiang UniversityHangzhouChina
| | - Yan Xu
- Department of Endoscopic CenterWenzhou Hospital of Intergrated Traditional Chinese Western MedicineWenzhouChina
| | - Xiaolin Huang
- Department of Endoscopic CenterWenzhou Hospital of Intergrated Traditional Chinese Western MedicineWenzhouChina
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Ogiyama H, Kato M, Yamaguchi S, Kanesaka T, Yamada T, Yamamoto M, Komori M, Nagaike K, Nakahara M, Tsutsui S, Tsujii Y, Saita R, Iijima H, Hayashi Y, Takehara T. Efficacy of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection in patients on anticoagulant therapy: Multicenter prospective study. Dig Endosc 2024. [PMID: 38375544 DOI: 10.1111/den.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The high rate of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) in patients undergoing anticoagulant therapy remains a problem. Whether prophylactic clip closure reduces the rate of delayed bleeding in these patients is unclear. This study aimed to evaluate the efficacy of prophylactic clip closure in patients receiving anticoagulants. METHODS This multicenter prospective interventional trial was conducted at nine referral centers in Japan. Patients regularly taking anticoagulants, including warfarin potassium or direct oral anticoagulants, and undergoing ESD for colorectal neoplasms were enrolled. The discontinuation of anticoagulants was minimized according to recent guidelines. After the ESD, post-ESD ulcers were prophylactically closed using endoclips. The primary end-point was the incidence of delayed bleeding. The sample size was 45 lesions, and prophylactic clip closure was considered effective when the upper limit of the 90% confidence interval (CI) for delayed bleeding did not exceed 20%. RESULTS Forty-five lesions were used, and three were excluded. Complete closure was achieved in 41/42 lesions (97.6%). The overall delayed bleeding rate was low, at 4.9% (2/41; 90% [CI] 0.8-14.5), which was significantly lower than that at the prespecified threshold of 20% (P = 0.007). The median closure procedure time was 17 min, and the median number of clips was nine. No massive delayed bleeding requiring transfusion, interventional radiology, or surgery was observed, and no thromboembolic events were observed. CONCLUSION Prophylactic clip closure may reduce the risk of delayed bleeding following colorectal ESD in patients receiving anticoagulants. TRIAL REGISTRATION UMIN Clinical Trial Registry (UMIN000036734).
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Affiliation(s)
- Hideharu Ogiyama
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Minoru Kato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Osaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Masato Komori
- Department of Gastroenterology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Masanori Nakahara
- Departments of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Osaka, Japan
| | - Shusaku Tsutsui
- Departments of Gastroenterology and Hepatology, Itami City Hospital, Hyogo, Japan
| | - Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryotaro Saita
- Department of Medical Innovation, Osaka University Hospital, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
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Dong L, Zhu W, Zhang X, Xie X. Does Prophylactic Closure Improve Outcomes After Colorectal Endoscopic Submucosal Dissection? A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2024; 34:94-100. [PMID: 38011072 DOI: 10.1097/sle.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Several studies have described prophylactic closure after endoscopic submucosal dissection (ESD) of colorectal lesions for improving postoperative outcomes. We reviewed the evidence on the impact of prophylactic closure after ESD. METHODS A literature search was conducted on PubMed, Embase, CENTRAL, and Web of Science by 2 reviewers independently for studies published up to July 9, 2023. All types of comparative studies were eligible. RESULTS Ten studies compared 939 patients undergoing prophylactic closure with 1074 controls. Three were randomized controlled trials (RCTs) while the rest were observational. Pooled data from all included studies showed that prophylactic closure resulted in reduced incidence of delayed bleeding after ESD [odds ratio (OR): 0.30; 95% CI: 0.15, 0.72; I2 =0%]. These results were significant only for observational studies but not for RCTs. Meta-analysis showed no significant difference in the risk of delayed perforation (OR: 0.55; 95% CI: 0.18, 1.70; I2 =0%) or post-ESD coagulation syndrome (PECS) (OR: 1.15; 95% CI: 0.41, 3.19; I2 =63%) between closure and nonclosure groups. CONCLUSIONS Observational data suggest that prophylactic closure of colorectal mucosal defects after ESD may reduce the risk of delayed bleeding. However, the results are not concurred by RCTs. Furthermore, there seems to be no impact of prophylactic closure on the risk of delayed perforation and PECS.
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Affiliation(s)
- Liang Dong
- Department of Gastroenterology, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
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Blasberg T, Hochberger J, Meiborg M, Jung C, Weber M, Brunk T, Leifeld L, Seif Amir Hosseini A, Wedi E. Prophylactic clipping using the over-the-scope clip (OTSC) system after complex ESD and EMR of large colon polyps. Surg Endosc 2023; 37:7520-7529. [PMID: 37418148 DOI: 10.1007/s00464-023-10235-2] [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: 04/03/2023] [Accepted: 06/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps. METHODS This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding. RESULTS A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%. CONCLUSIONS The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.
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Affiliation(s)
- T Blasberg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - J Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - M Meiborg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - C Jung
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - M Weber
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - T Brunk
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - L Leifeld
- Department of Internal Medicine III, St. Bernward Hospital, Hildesheim, Germany
| | - A Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - E Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany.
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany.
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Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023; 35:216-231. [PMID: 35778927 DOI: 10.1111/den.14397] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.
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Affiliation(s)
- Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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