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Dell’Anna G, Fasulo E, Fanizza J, Barà R, Vespa E, Barchi A, Cecinato P, Fuccio L, Annese V, Malesci A, Azzolini F, Danese S, Mandarino FV. The Endoscopic Management of Zenker's Diverticulum: A Comprehensive Review. Diagnostics (Basel) 2024; 14:2155. [PMID: 39410559 PMCID: PMC11475965 DOI: 10.3390/diagnostics14192155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/15/2024] [Accepted: 09/24/2024] [Indexed: 10/20/2024] Open
Abstract
Zenker's Diverticulum (ZD) is the most common hypopharyngeal diverticulum; however, it is often underdiagnosed. It results from the herniation of the mucosa and submucosa through Killian's Triangle. Dysphagia is the primary symptom, occurring in 80-90% of cases. The primary goal of treatment is to transect the cricopharyngeal muscle (CM) and connect the ZD cavity to the esophageal lumen. Traditional treatments include surgical open transcervical diverticulectomy and CM septomyotomy, using rigid or flexible endoscopes. However, surgery is burdened by technical difficulties and not negligible rates of adverse events (AEs). For this reason, endoscopic techniques for ZD treatment have gained traction in recent years. Flexible endoscopic septum division (FESD), introduced nearly 20 years ago, involves a full-thickness incision of the diverticular septum. The advent of third-space endoscopy has led to the application of these techniques to ZD treatment as well. Zenker-POEM (Z-POEM) and, subsequently, Per Oral Endoscopic Septomyotomy (POES) have been developed. Hybrid techniques, such as Peroral Endoscopic Diverticulotomy (POED) and tunneling-free methods, represent additional ZD treatment options. This review outlines the armamentarium of ZD endoscopic management, summarizing the characteristics of these techniques, their benefits and limitations, and highlighting future research directions.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Paolo Cecinato
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (P.C.); (L.F.)
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (P.C.); (L.F.)
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
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Cassidy DJ, Coe TM, Jogerst KM, McKinley SK, Sell NM, Sampson M, Park YS, Petrusa E, Goldstone RN, Hashimoto DA, Gee DW. Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training. Surg Endosc 2022; 36:6767-6776. [PMID: 35146554 PMCID: PMC8831003 DOI: 10.1007/s00464-021-08958-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.
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Affiliation(s)
- Douglas J Cassidy
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA.
| | - Taylor M Coe
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Kristen M Jogerst
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
- Department of Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Sophia K McKinley
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Naomi M Sell
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Michael Sampson
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Yoon Soo Park
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emil Petrusa
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Robert N Goldstone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA
| | - Denise W Gee
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St. GRB-425, Boston, MA, 02114, USA.
- Department of Surgery, Massachusetts General Hospital, 15 Parkman St. WAC-460, Boston, MA, 02114, USA.
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Devices and techniques for flexible endoscopic management of Zenker's diverticulum (with videos). Gastrointest Endosc 2021; 94:3-13. [PMID: 33926711 DOI: 10.1016/j.gie.2021.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Zenker's diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed. METHODS This document reviews current endoscopic techniques and devices used to treat ZD. RESULTS The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations. CONCLUSIONS Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives.
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Billig S, Zayat R, Ebeling A, Steffen H, Nix C, Hatam N, Schnöring H, Derwall M. Transesophageal echocardiography in swine: evaluation of left and right ventricular structure, function and myocardial work. Int J Cardiovasc Imaging 2021; 37:835-846. [PMID: 33048268 PMCID: PMC7969559 DOI: 10.1007/s10554-020-02053-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
This study aimed to determine standard left (LV) and right ventricular (RV) transesophageal echocardiographic (TEE) measurements in swine. Additionally, global myocardial work index (GWI) was estimated using pressure-strain loops (PSL). A comprehensive TEE examination was conducted in ten anesthetized, intubated and mechanically ventilated healthy female German landrace swine, weighing 44 to 57 kg. For GWI calculation, we performed LV and RV segmental strain analysis and used invasively measured LV and RV pressure to obtain PSL. The GWI and further myocardial work indices were calculated from the area of the PSL using commercially available software. Furthermore, hemodynamic measurements were obtained using indwelling catheters. We obtained complete standardized baseline values for left and right ventricular dimensions and function. Biplane LV ejection fraction was 63 ± 7 % and the LV end-diastolic volume was 70.5 ± 5.9 ml. Tissue Doppler estimated peak tricuspid annular systolic velocity was 13.1 ± 1.8 cm/s. The Doppler estimated LV and RV stroke volume index were 75.6 ± 7.2 ml/m2 and 76.7 ± 7.8 ml/m2 respectively. Pulsed wave Doppler derived cardiac output correlated well with cardiac output estimated using the thermodilution method (7.0 ± 1.2 l/min vs. 7.0 ± 1.1 l/min, r = 0.812, p = 0.004). The LV global longitudinal strain was -21.3 ± 3.9 % and the RV global longitudinal strain was -15.4 ± 2.5 %. LV GWI was 1885(1281-2121) mmHg*% and 297 ± 62 mmHg*% for the RV. LV global myocardial work efficiency was 82.6 ± 4 % and 83(72-88) % for the RV. TEE offers sufficient morphological, functional and hemodynamic assessment of the heart in swine. Myocardial contractility and mechanics can be reliably evaluated with the non-invasive GWI derived from echocardiography without additional invasive measures.
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Affiliation(s)
- Sebastian Billig
- University Hospital RWTH Aachen, Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Rashad Zayat
- University Hospital RWTH Aachen, Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Andreas Ebeling
- University Hospital RWTH Aachen, Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Henning Steffen
- University Hospital RWTH Aachen, Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Christoph Nix
- University Hospital RWTH Aachen, Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
- Abiomed Europe GmbH, Neuenhofer Weg 3, Aachen, 52074, Germany
| | - Nima Hatam
- University Hospital RWTH Aachen, Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Heike Schnöring
- University Hospital RWTH Aachen, Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Matthias Derwall
- University Hospital RWTH Aachen, Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany.
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Hoffman MR, Kletzien H, Dailey SH, McMurray JS. Simulation of KTP Laser-Based Zenker Diverticulotomy with a Porcine Model and Laryngeal Dissection Station. OTO Open 2018; 1. [PMID: 29350715 PMCID: PMC5751941 DOI: 10.1177/2473974x17736288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Zenker’s diverticulum is a rare cause of progressive dysphagia that is treated
surgically. Potassium titanyl phosphate (KTP) laser–based diverticulotomy is one
effective treatment. Developing a simulation model is helpful for rare
conditions. Pigs have a natural hypopharyngeal pouch similar to a diverticulum.
We present a model for performing rigid endoscopic KTP laser diverticulotomy in
a porcine model with a laryngeal dissection station. Eleven pigs were examined
to confirm presence of the hypopharyngeal pouch. A specimen was mounted on the
modified laryngeal dissection station, and a KTP laser–based diverticulotomy was
performed. Novel aspects include use of the laryngeal dissection station and
application of the model for simulating rigid endoscopic KTP laser
diverticulotomy. This model allows trainees to practice equipment setup,
positioning of the laryngoscope to isolate the cricopharyngeal bar, tissue
handling, laser safety techniques, and use of the KTP laser through the
laryngoscope under microscopic visualization.
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Affiliation(s)
- Matthew R Hoffman
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heidi Kletzien
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Seth H Dailey
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J Scott McMurray
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Zenker's Diverticulum. Clin Gastroenterol Hepatol 2014; 12:1773-82; quiz e111-2. [PMID: 24055983 DOI: 10.1016/j.cgh.2013.09.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 09/10/2013] [Accepted: 09/10/2013] [Indexed: 02/06/2023]
Abstract
Zenker's diverticulum (ZD) is an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle. ZD is a relatively uncommon disorder occurring in the elderly. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Videofluoroscopy confirms the diagnosis. Therapy of symptomatic ZD has evolved from an open surgical approach to less invasive transoral endoscopic techniques. Transoral endoscopic therapy using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by surgical endoscopists and gastroenterologists. The common goal of all modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. Although flexible endoscopic therapy was described nearly 20 years ago, it has experienced a recent resurgence paralleling the advancements of therapeutic endoscopy in other areas, such as endoscopic submucosal dissection. Direct head-to-head comparisons of rigid and flexible endoscopic therapy are lacking, and each approach has variations in techniques as well as advantages and disadvantages. In this article, we review the pathophysiology and management of patients with ZD with an emphasis on flexible endoscopic therapy.
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Tang SJ. Flexible endoscopic Zenker’s diverticulotomy: approach that involves thinking outside the box (with videos). Surg Endosc 2014; 28:1355-9. [DOI: 10.1007/s00464-013-3335-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/04/2013] [Indexed: 10/25/2022]
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Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection. Surg Endosc 2011; 25:3273-8. [DOI: 10.1007/s00464-011-1704-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 03/26/2011] [Indexed: 01/02/2023]
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Abstract
OBJECTIVE To describe the outcome of patients undergoing flexible endoscopic therapy for symptomatic Zenker diverticulum. PATIENTS AND METHODS We retrospectively evaluated the outcome of 22 consecutive patients who underwent flexible endoscopic cricopharyngeal myotomy using needle-knife electrocautery performed by a single endoscopist from March 2006 through January 2010. RESULTS Of the 22 patients with symptomatic Zenker diverticulum, 13 were men and 9 were women (median age, 84.5 years). Moderate sedation was used in all but 3 (14%) of the patients. Postprocedural free air occurred in 6 patients (27%) and resolved uneventfully in all. Another patient developed a neck abscess 1 week after endoscopic treatment, which was surgically drained. All procedures were performed on an outpatient basis, although 8 patients (36%) required subsequent hospitalization. The mean (SD) length of stay in the hospital was 2.9 (1.64) days. All patients had initial symptomatic improvement, and 18 (82%) maintained improvement at a mean (SD) follow-up of 12.7 (9.2) months. CONCLUSION Flexible endoscopic cricopharyngeal myotomy is an effective treatment of symptomatic Zenker diverticulum, with low recurrence rates and with the benefit of no general anesthesia and hospitalization in most cases. Esophageal perforation is the most common procedural complication.
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Affiliation(s)
- David J Case
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Bibliography. Current world literature. Laryngology and bronchoesophagology. Curr Opin Otolaryngol Head Neck Surg 2007; 15:417-24. [PMID: 17986882 DOI: 10.1097/moo.0b013e3282f3532f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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