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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Elkafrawy AA, Ahmed M, Alomari M, Elkaryoni A, Kennedy KF, Clarkston WK, Campbell DR. Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding. World J Clin Cases 2021; 9:1048-1057. [PMID: 33644168 PMCID: PMC7896652 DOI: 10.12998/wjcc.v9.i5.1048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a major concern in patients hospitalized with acute coronary syndrome (ACS) due to the common use of both antiplatelet medications and anticoagulants. Studies evaluating the safety of gastrointestinal endoscopy (GIE) in ACS patients with GIB are limited by their relatively small size, and the focus has generally been on upper GIB and esophago-gastroduod-enoscopy (EGD) only.
AIM To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States.
METHODS The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014. The International Classification of Diseases Code, 9th Revision Clinical Modification was utilized for patient identification. Patients were further classified into two groups based on undergoing endoscopic procedures (EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy). Both groups were compared regarding demographic information, outcomes, and comorbi-dities. Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay. Chi-square test was used to compare categorical variables, while Student’s t-test was used to compare continuous variables. All analyses were performed using SAS 9.4 (Cary, NC, United States).
RESULTS A total of 35612318 patients with ACS were identified between January 2005 and December 2014. 269483 (0.75%) of the patients diagnosed with ACS developed concomitant GIB during the same admission. At least one endoscopic procedure was performed in 68% of the patients admitted with both ACS and GIB. Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality (3.8%) compared to the group not undergoing endoscopy (8.6 %, P < 0.001). A shorter length of stay (LOS) was observed in patients who underwent GIE (mean 6.59 ± 7.81 d) compared to the group not undergoing endoscopy (mean 7.84 ± 9.73 d, P < 0.001). Multivariate analysis showed that performing GIE was associated with lower mortality (odds ratio: 0.58, P < 0.001) and shorter LOS (-0.36 factor, P < 0.001).
CONCLUSION Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS. Approximately two-thirds of patients with both ACS and GIB undergo GIE during the same hospitalization.
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Affiliation(s)
- Ahmed A Elkafrawy
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, United States
| | - Mohamed Ahmed
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, United States
| | - Mohammad Alomari
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL 33331, United States
| | - Ahmed Elkaryoni
- Division of Cardiovascular Medicine, Loyola University Medical Center and Stritch School of Medicine, Maywood, IL 60153, United States
| | - Kevin F Kennedy
- Mid America Heart Institute, Saint Luke's Health System, Kansas City, MO 64111, United States
| | - Wendell K Clarkston
- Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States
| | - Donald R Campbell
- Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States
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Salmanroghani H, Mirvakili M, Mirjalili M, Baghbanian M, Salmanroghani R. The Efficacy and Safety of Low Dose versus Usual Dose of Hyoscine During Endoscopic Retrograde Cholangiopancreatography: A Randomized Clinical Trial. Clin Pharmacol 2020; 12:123-130. [PMID: 32903953 PMCID: PMC7445520 DOI: 10.2147/cpaa.s263531] [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] [Received: 05/28/2020] [Accepted: 08/04/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate the efficacy and safety of low dose versus usual dose of Hyoscine during endoscopic retrograde cholangiopancreatography (ERCP). Patients and Methods This randomized, open-label clinical trial included 282 patients undergoing ERCP who had duodenal peristalsis interfering with cannulation. Patients were randomly divided into two groups: Group one and two received low (5 mg) and usual (10 mg) dose of Hyoscine, respectively. Cardiovascular service consultation was performed for all patients before entering the study and performing ERCP. Hyoscine was injected intravenously, and the spasmolytic effect of the drug was assessed while the papilla was in a completely enface view. The time interval between cessation of peristalsis and its further onset was recorded by the chronometer. Also, patient’s heart rate and blood pressure were monitored during ERCP by digital monitoring. Results The results showed no statistically significant differences in the mean duration of peristalsis, the duration of the antispasmodic activity and the time required to increase the heart rate between two groups (P=0.38, P=0.48, P=0.32, respectively). No significant differences were observed regarding the average of heart rate and mean arterial blood pressure (MAP) before drug administration between the two groups (P=0.182 and P=0.29, respectively), but after the drug administration, tachycardia and hypotension were significantly higher in the second group (P=0.007 and P=0.001, respectively). There was no statistically significant difference in the frequency of arrhythmia between two groups (P=0.08). The results also showed that tachycardia and hypotension occurred more frequently in men and elderly patients (P <0.05). Conclusion A low dose of Hyoscine is as effective as the usual dose and its side effects such as alteration in blood pressure and heart rate are much fewer, especially in men and elderly patients.
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Affiliation(s)
- Hassan Salmanroghani
- Department of Internal Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Massoud Mirvakili
- Department of Internal Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmud Baghbanian
- Department of Internal Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Roham Salmanroghani
- Medical Student Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Bazoukis G, Tsimos K, Korantzopoulos P. Episodic Left Bundle Branch Block-A Comprehensive Review of the Literature. Ann Noninvasive Electrocardiol 2016; 21:117-25. [PMID: 27296905 DOI: 10.1111/anec.12361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/10/2016] [Accepted: 01/19/2016] [Indexed: 01/09/2023] Open
Abstract
Episodic (transient/ intermittent) left bundle branch block (LBBB) has been associated with different conditions such as bradycardia, tachycardia, anesthesia, acute pulmonary embolism, changes in intrathoracic pressure, chest trauma, cardiac interventional procedures, mad honey poisoning, and in other clinical settings. Of note, exclusion of an acute coronary syndrome in the setting of episodic LBBB is of great importance. Moreover, episodic LBBB is sometimes symptomatic and may be associated with left ventricular systolic and/or diastolic dysfunction or conduction disturbances leading to syncope. This review article provides a comprehensive overview of the conditions associated with episodic LBBB and discusses the clinical impact of this phenomenon.
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Affiliation(s)
- George Bazoukis
- Department of Internal Medicine, General Hospital of Athens "Elpis,", Athens, Greece
| | - Konstantinos Tsimos
- First Department of Cardiology, University of Ioannina, Medical School, Ioannina, Greece
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Chawla S, Willingham FF. Cardiopulmonary complications of endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lee YN, Moon JH, Choi HJ, Kim DC, Chung JH, Lee TH, Cha SW, Cho YD, Park SH, Kim SJ. Direct biliary drainage using transnasal endoscopy for patients with severe-to-moderate acute cholangitis. J Gastroenterol Hepatol 2013; 28:739-43. [PMID: 23278442 DOI: 10.1111/jgh.12105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIM Endoscopic biliary drainage (BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy (TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy (ES) previously. METHODS Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5-Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated. RESULTS A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred. CONCLUSION Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously.
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Affiliation(s)
- Yun Nah Lee
- Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Seoul, Korea
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Lee CT, Lee TL, Liao WC, Chang CY, Tai CM, Chiang TH, Tu CH, Tseng WK, Lin JT. Myocardial ischemia during endoscopic retrograde cholangiopancreatography: an overlooked issue with significant clinical impact. J Gastroenterol Hepatol 2010; 25:1518-24. [PMID: 20796149 DOI: 10.1111/j.1440-1746.2010.06274.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM The occurrence of peri-procedural myocardial ischemia with endoscopic retrograde cholangiopancreatography (ERCP) has been documented, but its significance remains controversial. This study aimed to investigate the incidence and risk factors of myocardial ischemia during ERCP procedures and to analyze the potential association between myocardial ischemia and post-ERCP complications. METHODS Ambulatory 24-h ST-segment monitoring from 30 min prior to 24 h after ERCP was obtained on 71 patients from September 2006 to August 2007. Changes in vital signs during ERCP, post-ERCP complications, and their outcomes were recorded and analyzed. RESULTS Cardiac ischemia occurred in 13 patients (18.3%) during ERCP and one patient developed myocardial infarction. More patients in the ischemic group (38.5%) than in the non-ischemic group (5.2%) had ST-T changes in pre-ERCP resting electrocardiography (P < 0.01). Hypotension during ERCP was found only in the ischemic group (15.4% vs 0%; P = 0.03). Patients with cardiac ischemia during ERCP had a significantly higher rate of elevated serum amylase and lipase levels (53.8% vs 15.5%; P < 0.01) and post-ERCP pancreatitis (30.8% vs 6.9%; P = 0.03). Multivariable logistic regression analysis revealed that cardiac ischemia during ERCP (OR: 5.21, P = 0.050) and pancreatic duct cannulation (OR: 5.7, P = 0.036) were independent predictors for post-ERCP pancreatitis. CONCLUSIONS ST-T changes on resting electrocardiography and intra-procedural hypotension are risk factors of myocardial ischemia during ERCP. Post-ERCP hyperamylasemia, hyperlipasemia, and pancreatitis were associated with myocardial ischemia during ERCP.
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Affiliation(s)
- Ching-Tai Lee
- Division of Gastroenterology, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohisung, Taiwan
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Tseng PH, Liou JM, Lee YC, Lin LY, Yan-Zhen Liu A, Chang DC, Chiu HM, Wu MS, Lin JT, Wang HP. Emergency endoscopy for upper gastrointestinal bleeding in patients with coronary artery disease. Am J Emerg Med 2009; 27:802-9. [PMID: 19683108 DOI: 10.1016/j.ajem.2008.06.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 06/22/2008] [Accepted: 06/24/2008] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopy is useful for diagnosis and treatment of upper gastrointestinal bleeding (UGIB). However, both endoscopy and UGIB may compromise the cardiovascular function. The present study is to investigate the cardiovascular responses of emergency endoscopy for patients with UGIB and stable coronary artery disease (CAD). METHODS Consecutive 50 patients with known CAD and 50 patients without CAD history (non-CAD group) in whom emergency endoscopy was requested for UGIB were prospectively enrolled. All patients received ambulatory electrocardiographic monitoring before, during, and after endoscopies. Cardiac indices including supraventricular and ventricular arrhythmia, ST ischemic change, and autonomic nervous function evaluated by heart rate variability were compared. RESULTS All patients in both groups had successful primary hemostasis, and peptic ulcer bleeding was the main etiology (82%). Compared with the non-CAD group, patients with CAD had a significantly higher incidence (42% vs 16%, P = .004) and frequency (1.19 vs 0.12 events per minute, P = .003) of ventricular arrhythmias during endoscopy. Nine patients with CAD and 1 patient without CAD had ischemic ST changes (P = .016). Comorbidity with congestive heart failure was not only associated with a higher frequency (P = .02) but also a more severe fluctuation (P = .002) of ventricular arrhythmia. None in both groups had angina or MI before, during, or after endoscopy. Heart rate variability did not show a difference. CONCLUSIONS Ventricular arrhythmias and myocardial ischemia, although mostly subclinical, were common in patients with stable CAD undergoing emergent endoscopy for UGIB, especially in those with concomitant congestive heart failure.
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Affiliation(s)
- Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin County 640, Taiwan
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Fisher L, Fisher A, Thomson A. Cardiopulmonary complications of ERCP in older patients. Gastrointest Endosc 2006; 63:948-55. [PMID: 16733108 DOI: 10.1016/j.gie.2005.09.020] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2005] [Accepted: 09/01/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biochemical markers of ERCP-related myocardial injury have not previously been investigated. OBJECTIVE To evaluate ERCP-related cardiac troponin I (cTnI) release, myocardial ischemia, hemodynamic changes, and arterial hypoxemia in a series of consecutive patients according to age and to determine their relationship to preexisting cardiovascular risk factors (RF) and the development of post-ERCP pancreatitis. DESIGN Prospective cohort study. SETTING Tertiary teaching hospital, Canberra, Australia. PATIENTS Data were collected on 130 consecutive ERCPs performed on 100 unselected patients (aged 18-93 years) by one endoscopist. Patients were divided into two groups: 65 years of age and older (group 1, n = 53; 27 women) and less than 65 years of age (group 2, n = 47; 33 women). INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Cardiovascular RFs were identified, and electrocardiogram (ECG), cTnI, creatine kinase (CK), amylase, and lipase were measured before and 24 hours after ERCP. Oxygen saturation (SpO(2)), heart rate (HR), blood pressure (BP), and ECG were monitored continuously during each procedure. RESULTS New ECG changes (ischemia, arrhythmias) occurred in 24% of procedures in group 1 and in 9.3% in group 2 (p = 0.168), and episodic arterial hypoxemia (SpO(2) < 90%) in 16.2% (group 1) and 21.4% (group 2) (p = 0.596). A post-ERCP rise in cTnI levels was documented in 6 patients in the older group. Two of these patients died: one from acute myocardial infarction and one from undiagnosed ascending aortic aneurysm. A cTnI rise was not related to any comorbid conditions, total number of RFs, hemodynamic or ECG changes, or arterial desaturation. In patients with a new cTnI rise, the duration of ERCP was significantly longer (59.5 vs. 26.4 minutes, p = 0.026), being 30 minutes or longer in 5 of 6 patients. Post-ERCP pancreatitis was associated with desaturation (relative risk [RR] = 5.9; 95% confidence interval [CI] [1.2, 32.0], p = 0.027) and myocardial ischemia/injury (RR = 4.4; 95% CI [1.4, 7.8]; p = 0.009). CONCLUSIONS Although the majority of older patients tolerated ERCP well, in 8% of procedures, most of which were prolonged (>30 minutes), myocardial injury, as defined by the release of cTnI, occurred. Desaturation and myocardial ischemia/injury were associated with post-ERCP pancreatitis.
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Affiliation(s)
- Leon Fisher
- Department of Gastroenterology, The Canberra Hospital, Woden, Canberra, ACT 2606, Australia
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Rastogi A, Campbell DR. ERCP in the elderly: how safe is it? (marathons, marathon ERCPs, and marathon ERCPs in the elderly). Gastrointest Endosc 2006; 63:956-8. [PMID: 16733109 DOI: 10.1016/j.gie.2005.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 11/09/2005] [Indexed: 01/11/2023]
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