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Takahara N, Nakai Y, Ishida K, Endo G, Kurihara K, Tange S, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Suzuki T, Sato T, Hakuta R, Ishigaki K, Saito T, Hamada T, Fujishiro M. Second Covered and Uncovered Self-Expandable Metal Stents for Recurrent Gastric Outlet Obstruction: A Retrospective Comparative Study. J Clin Med 2023; 12:5241. [PMID: 37629282 PMCID: PMC10455318 DOI: 10.3390/jcm12165241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Background: Endoscopic self-expandable metal stent (SEMS) placement is a current mainstay for malignant gastric outlet obstruction (GOO), but symptomatic recurrence due to initial SEMS dysfunction commonly occurs. We aimed to compare the safety and effectiveness of second SEMS for recurrent GOO (RGOO). Methods: Between April 2006 and December 2022, a total of 95 cases with malignant RGOO undergoing second endoscopic SEMS placement were enrolled. Technical and clinical success rates, RGOO, time to RGOO (TRGOO), stent patency rate, adverse events (AE), and overall survival (OS) were retrospectively compared between covered and uncovered SEMS (cSEMS/uSEMS) groups. Risk factors for TRGOO were also explored. Results: Baseline characteristics were well balanced between cSEMS (n = 48) and uSEMS (n = 47) groups, except for the causes of the initial SEMS dysfunction. High technical and clinical success rates with a similar incidence of AE (15% vs. 17%, p = 0.78) and OS (median of 101 vs. 102 days, p = 0.68) were achieved in both groups. There were no statistical differences in cumulative incidence of RGOO (19% vs. 13%, p = 0.58), TRGOO (median, not reached in both groups, p = 0.57), and stent patency rates at 1, 2, and 3 months between the groups (60%, 47% and 26%, respectively vs. 70%, 55% and 38%, respectively). However, TRGOO tended to be longer in cSEMS in cases with RGOO due to tumor ingrowth (median, not reached vs. 111 days, p = 0.19). A Cox regression analysis demonstrated that chemotherapy after second SEMS placement was significantly associated with an improved TRGOO (the hazard ratio of 0.27 [95% confidence interval, 0.08-0.93], p = 0.03). Conclusions: Regardless of the type of SEMS, second SEMS placement was similarly safe and effective for RGOO. The type of second SEMS might be considered based on the cause of initial SEMS dysfunction.
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Affiliation(s)
- Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kota Ishida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Go Endo
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Kohei Kurihara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Shuichi Tange
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Shinya Takaoka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yurie Tokito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Chemotherapy, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
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Okamoto T, Sasaki T, Yoshio T, Mori C, Mie T, Furukawa T, Yamada Y, Takeda T, Kasuga A, Matsuyama M, Ozaka M, Fujisaki J, Sasahira N. Outcomes after partially covered self-expandable metal stent placement for recurrent duodenal obstruction. Surg Endosc 2023; 37:319-328. [PMID: 35941307 DOI: 10.1007/s00464-022-09519-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Outcomes of partially covered self-expandable metal stents (SEMS) as an additional stent after recurrent duodenal obstruction (RDO) have not been elucidated. In this study, we compared outcomes of partially covered and uncovered SEMS placement after RDO in patients with malignant duodenal obstruction and explored factors affecting re-recurrent obstruction and overall survival in this population. METHODS We conducted a retrospective study of patients undergoing SEMS placement for RDO at a cancer institute in Japan from July 2014 to June 2021. Clinical variables and outcomes of patients undergoing partially covered and uncovered SEMS placement were compared. RESULTS Sixty-one patients underwent SEMS placement after RDO, for which the COMVI stent was used in 38 cases and uncovered stents were used in 23 cases. Stent ingrowth was the most common cause of RDO (51.4%). Stent migration only occurred after partially covered stent placement (20% vs. 0%, p = 0.018). Choice of SEMS had no impact on time to re-RDO (median 2.8 vs. 4.1 months, p = 0.776) or overall survival (median 2.6 vs. 2.4 months, p = 0.703). Median overall survival was longer in patients receiving chemotherapy after second stenting (4.6 vs. 1.8 months, p < 0.001) and shorter in those with early RDO, regardless of the SEMS used. Use of the partially covered stent had no impact on survival or time to RDO. CONCLUSIONS While outcomes after partially covered SEMS placement for RDO were not significantly different from uncovered SEMS, migration remains a concern when they are used as a second stent. Chemotherapy after second stenting was associated with longer overall survival but not with longer time to re-RDO.
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Affiliation(s)
- Takeshi Okamoto
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Toshiyuki Yoshio
- Upper Gastrointestinal Division, Department of Gastroenterological Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Chinatsu Mori
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yuto Yamada
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Junko Fujisaki
- Upper Gastrointestinal Division, Department of Gastroenterological Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Krishnamoorthi R, Bomman S, Benias P, Kozarek RA, Peetermans JA, McMullen E, Gjata O, Irani SS. Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis. Endosc Int Open 2022; 10:E874-E897. [PMID: 35692924 PMCID: PMC9187371 DOI: 10.1055/a-1794-0635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background and study aims Malignant disease accounts for up to 80 % of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4 %) or surgical GJ (99.9%) ( P = 0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9 % vs. 89.0 % vs. 92.3 % respectively, P = 0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P = 0.0036), while duodenal SEMS had a higher rate of reintervention ( P = 0.041). Overall procedural complications were similar (duodenal SEMS 18.7 % vs. EUS-GE 21.9 % vs. surgical GJ 23.8 %, P = 0.32), but estimated bleeding rate was lowest ( P = 0.0048) and stent occlusion rate was highest ( P = 0.0002) for duodenal SEMS. Conclusions Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.
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Affiliation(s)
- Rajesh Krishnamoorthi
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shivanand Bomman
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Petros Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, United States
| | - Richard A. Kozarek
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Shayan S. Irani
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
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Palliation in Gallbladder Cancer: The Role of Gastrointestinal Endoscopy. Cancers (Basel) 2022; 14:cancers14071686. [PMID: 35406458 PMCID: PMC8997124 DOI: 10.3390/cancers14071686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
Gallbladder cancer is a rare malignancy burdened by poor prognosis with an estimated 5-year survival of 5% to 13% due to late presentation, early infiltration of surrounding tissues, and lack of successful treatments. The only curative approach is surgery; however, more than 50% of cases are unresectable at the time of diagnosis. Endoscopy represents, together with surgery and chemotherapy, an available palliative option in advanced gallbladder cancers not eligible for curative treatments. Cholangitis, jaundice, gastric outlet obstruction, and pain are common complications of advanced gallbladder cancer that may need endoscopic management in order to improve the overall survival and the patients’ quality of life. Endoscopic biliary drainage is frequently performed to manage cholangitis and jaundice. ERCP is generally the preferred technique allowing the placement of a plastic stent or a self-expandable metal stent depending on the singular clinical case. EUS-guided biliary drainage is an available alternative for patients not amenable to ERCP drainage (e.g., altered anatomy). Gastric outlet obstruction is another rare complication of gallbladder malignancy growing in contact with the duodenal wall and causing its compression. Endoscopy is a less invasive alternative to surgery, offering different options such as an intraluminal self-expandable metal stent or EUS-guided gastroenteroanastomosis. Abdominal pain associated with cancer progression is generally managed with medical treatments; however, for incoercible pain, EUS-guided celiac plexus neurolysis has been described as an effective and safe treatment. Locoregional treatments, such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and intraluminal brachytherapy (IBT), have been described in the control of disease progression; however, their role in daily clinical practice has not been established yet. The aim of this study is to perform a review of the literature in order to assess the role of endoscopy and the available techniques in the palliative therapy of advanced gallbladder malignancy.
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Abstract
Malignant gastric outlet obstruction (MGOO) is a late complication of advanced malignancies, mostly occurring due to gastrointestinal cancers or external compression outside the lumen. It causes nausea, vomiting, poor appetite, weight loss, and decreased quality of life. In the past, surgical bypass was the gold standard for the management of MGOO. However, the introduction of self-expandable metallic stent (SEMS) provides several advantages over surgical bypass, including earlier oral intake, rapid symptom relief, less invasiveness, and shorter hospital stays; therefore, it has replaced surgical bypass as the mainstream management approach in most situations. Although SEMS placement is a safe and effective way for palliation of MGOO, stent dysfunction with obstruction or migration limits the utilization and increases repeated intervention. Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent has emerged as an alternative way to bypass the obstruction site and restore the oral intake of patients. Although a lower stent dysfunction rate was reported, further prospective studies are warranted to validate its effectiveness and safety.
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Affiliation(s)
- Bing-Wei Ye
- Division of Gastroenterology, Department of Medicine, Taiwan Adventist Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
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Baldaque-Silva F. Stent-in-Stent for Malign Obstruction: Should We Go Back to a Place Where We Were Happy? GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:375-377. [PMID: 33251285 PMCID: PMC7670327 DOI: 10.1159/000510739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Francisco Baldaque-Silva
- Endoscopy Unit, Department of Upper Abdominal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
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