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Be KH, Zorron Cheng Tao Pu L, Pearce B, Lee M, Fletcher L, Cogan R, Peyton P, Vaughan R, Efthymiou M, Chandran S. High-flow oxygen via oxygenating mouthguard in short upper gastrointestinal endoscopy: A randomised controlled trial. World J Gastrointest Endosc 2022; 14:777-788. [PMID: 36567821 PMCID: PMC9782568 DOI: 10.4253/wjge.v14.i12.777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/26/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anaesthetic care during upper gastrointestinal (GI) endoscopy has the unique challenge of maintaining ventilation and oxygenation via a shared upper airway. Supplemental oxygen is recommended by international society guidelines, however, the optimal route or rate of oxygen delivery is not known. Various oxygen delivery devices have been investigated to improve oxygenation during upper GI endoscopy, however, these are limited by commercial availability, costs and in some cases, the expertise required for insertion. Anecdotally at our centre, higher flows of supplemental oxygen can safely be delivered via an oxygenating mouthguard routinely used during upper GI endoscopic procedures.
AIM To assess the incidence of hypoxaemia (SpO2 < 90%) in patients undergoing upper GI endoscopy receiving supplemental oxygen using an oxygenating mouthguard at 20 L/min flow compared to standard nasal cannula (SNC) at 2 L/min flow.
METHODS A single centre, prospective, randomised clinical trial at two sites of an Australian tertiary hospital between October 2020 and September 2021 was conducted. Patients undergoing elective upper gastrointestinal endoscopy under deep sedation were randomised to receive supplemental oxygen via high-flow via oxygenating mouthguard (HFMG) at 20 L/min flow or SNC at 2 L/min flow. The primary outcome was the incidence of hypoxaemia of any duration measured by pulse oximetry. Intraprocedural-related, procedural-related, and sedation-related adverse events and patient-reported outcomes were also recorded.
RESULTS Three hundred patients were randomised. Eight patients were excluded after randomisation. 292 patients were included in the intention-to-treat analysis. The incidence of hypoxaemia was significantly reduced in those allocated HFMG. Six patients (4.4%) allocated to HFMG experienced an episode of hypoxaemia, compared to thirty-four (22.1%) patients allocated to SNC (P value < 0.001). No significant difference was observed in the rates of adverse events or patient-reported outcome measures.
CONCLUSION The use of HFMG offers a novel approach to reducing the incidence of hypoxaemia during short upper gastrointestinal endoscopic procedures in low-risk patients undergoing deep sedation.
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Affiliation(s)
- Kim Hay Be
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Brett Pearce
- Department of Anaesthesia and Pain Medicine, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Matthew Lee
- Department of Anaesthesia and Pain Medicine, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Luke Fletcher
- Department of Anaesthesia and Pain Medicine, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Rebecca Cogan
- Department of Anaesthesia and Pain Medicine, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Philip Peyton
- Department of Anaesthesia and Pain Medicine, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston 3199, Victoria, Australia
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Novel mandibular advancement bite block with supplemental oxygen to both nasal and oral cavity improves oxygenation during esophagogastroduodenoscopy: a bench comparison. J Clin Monit Comput 2018; 33:523-530. [PMID: 29974302 DOI: 10.1007/s10877-018-0173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
Drug-induced respiratory depression is a major cause of serious adverse events. Adequate oxygenation is very important during sedated esophagogastroduodenoscopy (EGD). Nasal breathing often shifts to oral breathing during open mouth EGD. A mandibular advancement bite block was developed for EGD using computer-assisted design and three-dimensional printing techniques. The mandible is advanced when using this bite block to facilitate airway opening. The device is composed of an oxygen inlet with one opening directed towards the nostril and another opening directed towards the oral cavity. The aim of this bench study was to compare the inspired oxygen concentration (FiO2) provided by the different nasal cannulas, masks, and bite blocks commonly used in sedated EGD. A manikin head was connected to one side of a two-compartment lung model by a 7.0 mm endotracheal tube with its opening in the nasopharyngeal position. The other compartment was driven by a ventilator to mimic "patient" inspiratory effort. Using this spontaneously breathing lung model, we evaluated five nasal cannulas, two face masks, and four new oral bite blocks at different oxygen flow rates and different mouth opening sizes. The respiratory rate was set at 12/min with a tidal volume of 500 mL and 8/min with a tidal volume of 300 mL. Several Pneuflo resistors of different sizes were used in the mouth of the manikin head to generate different degrees of mouth opening. FiO2 was evaluated continuously via the endotracheal tube. All parameters were evaluated using a Datex anesthesia monitoring system. The mandibular advancement bite block provided the highest FiO2 under the same supplemental oxygen flow. The FiO2 was higher for devices with oxygen flow provided via an oral bite block than that provided via the nasal route. Under the same supplemental oxygen flow, the tidal volume and respiratory rate also played an important role in the FiO2. A low respiratory rate with a smaller tidal volume has a relative high FiO2. The ratio of nasal to oral breathing played an important role in the FiO2 under hypoventilation but less role under normal ventilation. Bite blocks deliver a higher FiO2 during EGD. The ratio of nasal to oral breathing, supplemental oxygen flow, tidal volume, and respiratory rate influenced the FiO2 in most of the supplemental oxygen devices tested, which are often used for conscious sedation in patients undergoing EGD and colonoscopy.
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Goudra BG, Singh PM, Penugonda LC, Speck RM, Sinha AC. Significantly reduced hypoxemic events in morbidly obese patients undergoing gastrointestinal endoscopy: Predictors and practice effect. J Anaesthesiol Clin Pharmacol 2014; 30:71-7. [PMID: 24574597 PMCID: PMC3927297 DOI: 10.4103/0970-9185.125707] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Providing anesthesia for gastrointestinal (GI) endoscopy procedures in morbidly obese patients is a challenge for a variety of reasons. The negative impact of obesity on the respiratory system combined with a need to share the upper airway and necessity to preserve the spontaneous ventilation, together add to difficulties. Materials and Methods: This retrospective cohort study included patients with a body mass index (BMI) >40 kg/m2 that underwent out-patient GI endoscopy between September 2010 and February 2011. Patient data was analyzed for procedure, airway management technique as well as hypoxemic and cardiovascular events. Results: A total of 119 patients met the inclusion criteria. Our innovative airway management technique resulted in a lower rate of intraoperative hypoxemic events compared with any published data available. Frequency of desaturation episodes showed statistically significant relation to previous history of obstructive sleep apnea (OSA). These desaturation episodes were found to be statistically independent of increasing BMI of patients. Conclusion: Pre-operative history of OSA irrespective of associated BMI values can be potentially used as a predictor of intra-procedural desaturation. With suitable modification of anesthesia technique, it is possible to reduce the incidence of adverse respiratory events in morbidly obese patients undergoing GI endoscopy procedures, thereby avoiding the need for endotracheal intubation.
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Affiliation(s)
- Basavana Gouda Goudra
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Preet Mohinder Singh
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Lakshmi C Penugonda
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecca M Speck
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA ; Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ashish C Sinha
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
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Wang CY, Ling LC, Cardosa MS, Wong AK, Wong NW. Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation. Anaesthesia 2000; 55:654-8. [PMID: 10919420 DOI: 10.1046/j.1365-2044.2000.01520.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (SaO2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (SaO2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (SaO2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre-oxygenation times on arterial oxygen saturation (SaO2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B-D received supplementary oxygen at 4 1 x min(-1) via nasal cannulae. The pre-oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 1 x min(-1) in sedated patients abolishes desaturation and hypoxia. Pre-oxygenation confers no additional benefit.
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Affiliation(s)
- C Y Wang
- Department of Anaesthesiology & Intensive Care, University of Malaya Medical Centre, Lembah Pantai, Kuala Lumpur, Malaysia
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Yen D, Hu SC, Chen LS, Liu K, Kao WF, Tsai J, Chern CH, Lee CH. Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department. Am J Emerg Med 1997; 15:644-7. [PMID: 9375545 DOI: 10.1016/s0735-6757(97)90178-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
A prospective study was conducted to see whether emergent esophagogastroduodenoscopy (EGD) in patients with active upper gastrointestinal (GI) bleeding is associated with more oxygen desaturation than nonemergent EGD. Emergent EGD was performed in the study patients with active upper GI bleeding. Nonemergent EGD was performed in the control patients. Determination of oxygen saturation (Sao2) was measured by pulse oximeter. A decrease in Sao2 of > 4% was more frequent in the study patients (26%, 13 of 50) than in controls (6%, 3 of 50) (P < .01). During EGD, mean oxygen saturation decreased significantly in both groups of patients. After EGD, mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group (P < .01). A linear association was found that oxygen desaturation = 5.46 + 0.15 (status) -0.06 (baseline oxygen saturation). Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD. Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonsedated EGD in the emergency department.
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Affiliation(s)
- D Yen
- Emergency Department, Veterans General Hospital, Taipei, Taiwan, ROC
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Froehlich F, Thorens J, Schwizer W, Preisig M, Köhler M, Hays RD, Fried M, Gonvers JJ. Sedation and analgesia for colonoscopy: patient tolerance, pain, and cardiorespiratory parameters. Gastrointest Endosc 1997; 45:1-9. [PMID: 9013162 DOI: 10.1016/s0016-5107(97)70295-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonoscopy is generally performed with the patient sedated and receiving analgesics. However, the benefit of the most often used combination of intravenous midazolam and pethidine on patient tolerance and pain and its cardiorespiratory risk have not been fully defined. METHODS In this double-blind prospective study, 150 outpatients undergoing routine colonoscopy were randomly assigned to receive either (1) low-dose midazolam (35 micrograms/kg) and pethidine (700 micrograms/kg in 48 patients, 500 micrograms/kg in 102 patients), (2) midazolam and placebo pethidine, or (3) pethidine and placebo midazolam. RESULTS Tolerance (visual analog scale, 0 to 100 points: 0 = excellent; 100 = unbearable) did not improve significantly more in group 1 compared with group 2 (7 points; 95% confidence interval [-2-17]) and group 3 (2 points; 95% confidence interval [-7-12]). Similarly, pain was not significantly improved in group 1 as compared with the other groups. Male gender (p < 0.001) and shorter duration of the procedure (p = 0.004), but not amnesia, were associated with better patient tolerance and less pain. Patient satisfaction was similar in all groups. Oxygen desaturation and hypotension occurred in 33% and 11%, respectively, with a similar frequency in all three groups. CONCLUSIONS In this study, the combination of low-dose midazolam and pethidine does not improve patient tolerance and lessen pain during colonoscopy as compared with either drug given alone. When applying low-dose midazolam, oxygen desaturation and hypotension do not occur more often after combined use of both drugs. For the individual patient, sedation and analgesia should be based on the endoscopist's clinical judgement.
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Affiliation(s)
- F Froehlich
- Department of Gastroenterology, University Hospital, Lausanne, Switzerland
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Froehlich F, Schwizer W, Thorens J, Köhler M, Gonvers JJ, Fried M. Conscious sedation for gastroscopy: patient tolerance and cardiorespiratory parameters. Gastroenterology 1995; 108:697-704. [PMID: 7875472 DOI: 10.1016/0016-5085(95)90441-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND/AIMS Most patients receive conscious sedation for gastroscopy. However, the benefit of the most often used combination of low-dose intravenous midazolam and topical lidocaine on patient tolerance remains poorly defined and has not been shown to outweigh cardiorespiratory risks. To respond to these issues, a randomized, double-blind, placebo-controlled prospective study was performed. METHODS Two hundred outpatients undergoing diagnostic gastroscopy were assigned to receive either (1) midazolam (35 micrograms/kg) and lidocaine spray (100 mg), (2) midazolam and placebo lidocaine, (3) placebo midazolam and lidocaine, or (4) placebo midazolam and placebo lidocaine. RESULTS Tolerance (visual analogue scale, 0-100 points; 0, excellent; 100, unbearable) improved as compared with placebo midazolam and placebo lidocaine by 23 points (95% confidence interval, 15-32) in group 1, 15 points (95% confidence interval, 7-24) in group 2, and 10 points (95% confidence interval, 2-18) in group 3. Increasing age (P < 0.001), low anxiety (P < 0.001), and male sex (P < 0.03), but not amnesia, were associated with better patient tolerance. Oxygen desaturation (< 1 minute) occurred in 8.2% and was not more frequent after midazolam treatment. Hypotension was rare (2.1%), and no adverse outcome occurred. CONCLUSIONS Both low-dose midazolam (35 micrograms/kg) and lidocaine spray have an additive beneficial effect on patients tolerance and rarely induce significant alterations in cardiorespiratory monitoring parameters, thus supporting the widespread use of conscious sedation.
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Affiliation(s)
- F Froehlich
- Department of Gastroenterology, University Hospital Policlinique Médicale Universitaire/Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Iwao T, Toyonaga A, Harada H, Harada K, Ban S, Minetoma T, Sumino M, Ikegami M, Tanikawa K. Arterial oxygen desaturation during non-sedated diagnostic upper gastrointestinal endoscopy in patients with cirrhosis. Gastrointest Endosc 1994; 40:281-4. [PMID: 8056228 DOI: 10.1016/s0016-5107(94)70056-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Oxygen saturation was studied with a pulse oximeter in 80 patients with cirrhosis (44 Pugh-Child's class A, 25 class B, and 11 class C) and 80 controls undergoing diagnostic esophagogastroduodenoscopy (EGD). No narcotic agent was used during the procedure. Baseline SaO2 was significantly lower in cirrhotics than in controls (97.7 +/- 1.0% versus 98.4 +/- 0.9%, p < 0.01). However, nadir SaO2 during EGD was similar for controls and cirrhotics (94.7 +/- 3.0% versus 94.9 +/- 3.3%, NS). Significant hypoxia was found in 29 (36%) control patients: mild hypoxia (95% > nadir SaO2 > or = 90%) in 22 patients and severe hypoxia (nadir SaO2 < 90%) in 7. Similarly, significant hypoxia was noted in 28 (35%) cirrhotic patients: mild hypoxia in 21 and severe hypoxia in 7. The mean duration of significant hypoxia during total EGD time was also similar for controls and cirrhotics (7.4 +/- 6.3% versus 9.2 +/- 10.7%, NS). When the degree of hypoxia during EGD was correlated with the severity of liver disease, analysis of variance (ANOVA) failed to show a significant relationship between Pugh-Child's class and nadir SaO2 or duration of significant hypoxia during total EGD time. These results suggest that oxygen desaturation during EGD occurs both in cirrhotic patients and in controls. We therefore conclude that a population of patients with cirrhosis does not have an increased risk of oxygen desaturation during non-sedated EGD.
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Affiliation(s)
- T Iwao
- Department of Medicine II, Kurume University School of Medicine, Japan
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Iwao T, Toyonaga A, Harada H, Harada K, Ban S, Ikegami M, Tanikawa K. Arterial oxygen desaturation during non-sedated diagnostic upper gastrointestinal endoscopy. Gastrointest Endosc 1994; 40:277-80. [PMID: 8056227 DOI: 10.1016/s0016-5107(94)70055-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We studied oxygen saturation (SaO2) using a pulse oximeter in 120 patients undergoing non-sedated diagnostic upper gastrointestinal endoscopy. The baseline SaO2 was 98.3 +/- 1.0%. During the procedure, absence of oxygen desaturation (SaO2 > or = 95%) was found in 56%, mild oxygen desaturation (95% > SaO2 > or = 90%) in 35%, and severe oxygen desaturation (SaO2 < 90%) in 9%. Age (p = 0.56), gender (p = 0.47), smoking (p = 0.35), hemoglobin level (p = 0.52), body mass index (p = 0.27), or total endoscopy time (p = 0.72) was not related to the degree of oxygen desaturation. These results suggest that oxygen desaturation is frequently observed during non-sedated diagnostic upper gastrointestinal endoscopy although severe oxygen desaturation, which may induce rare but serious cardiopulmonary events, is not common. Furthermore, we cannot predict in which patients desaturation will occur. We therefore recommend continuous monitoring of arterial oxygenation in all patients during the procedure.
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Affiliation(s)
- T Iwao
- Department of Medicine II, Kurume University School of Medicine, Japan
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Block R. Supplemental oxygen therapy during endoscopy and recovery. Gastrointest Endosc 1993; 39:209. [PMID: 8373462 DOI: 10.1016/s0016-5107(93)70076-0] [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: 01/30/2023]
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