Research

10 pages, 919 KiB

Open AccessArticle

Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video)

by Laurent Monino and Tom G. Moreels

Diagnostics 2024, 14(2), 142; https://doi.org/10.3390/diagnostics14020142 - 08 Jan 2024

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Abstract

Background: Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. Methods: 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics [...] Read more.

Background: Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. Methods: 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected. Results: Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple’s duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m²) compared to C-ERCP (1600 ± 117 µGy*m², p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose). Conclusions: Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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12 pages, 4331 KiB

Open AccessArticle

The Use of a New Dedicated Electrocautery Lumen-Apposing Metal Stent for Gallbladder Drainage in Patients with Acute Cholecystitis

by Luca Brandaleone, Gianluca Franchellucci, Antonio Facciorusso, Jayanta Samanta, Jong Ho Moon, Jorge Vargas-Madrigal, Carlos Robles Medranda, Carmelo Barbera, Francesco Di Matteo, Milutin Bulajic, Francesco Auriemma, Danilo Paduano, Federica Calabrese, Carmine Gentile, Marco Massidda, Marco Bianchi, Luca De Luca, Davide Polverini, Benedetta Masoni, Valeria Poletti, Giacomo Marcozzi, Cesare Hassan, Alessandro Repici and Benedetto Mangiavillano Show full author list Hide full author list

Diagnostics 2023, 13(21), 3341; https://doi.org/10.3390/diagnostics13213341 - 30 Oct 2023

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Abstract

Aims: Lumen-apposing metal stents (LAMSs) in ultrasonography-guided gallbladder drainage (EUS-GBD) have become increasingly important for high-risk surgical patients. Our study aims to evaluate the technical and clinical success, safety, and feasibility of endoscopic ultrasonography-guided gallbladder drainage using a new dedicated LAMS. Methods: This [...] Read more.

Aims: Lumen-apposing metal stents (LAMSs) in ultrasonography-guided gallbladder drainage (EUS-GBD) have become increasingly important for high-risk surgical patients. Our study aims to evaluate the technical and clinical success, safety, and feasibility of endoscopic ultrasonography-guided gallbladder drainage using a new dedicated LAMS. Methods: This is a retrospective multicenter study that included all consecutive patients not suitable for surgery who were referred to a tertiary center for EUS-GBD using a new dedicated electrocautery LAMS for acute cholecystitis at eight different centers. Results: Our study included 54 patients with a mean age of 76.48 years (standard deviation: 12.6 years). Out of the 54 endoscopic gallbladder drainages performed, 24 (44.4%) were cholecysto-gastrostomy, and 30 (55.4%) were cholecysto-duodenostomy. The technical success of LAMS placement was 100%, and clinical success was achieved in 23 out of 30 patients (76.67%). Adverse events were observed in two patients (5.6%). Patients were discharged after a median of 5 days post-stenting. Conclusions: EUS-GBD represents a valuable option for high-surgical-risk patients with acute cholecystitis. This new dedicated LAMS has demonstrated a high rate of technical and clinical success, along with a high level of safety. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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10 pages, 1746 KiB

Open AccessArticle

Endoscopic Submucosal Dissection of Superficial Colorectal Neoplasms at “Challenging Sites” Using a Double-Balloon Endoluminal Interventional Platform: A Single-Center Study

by Gianluca Andrisani and Francesco Maria Di Matteo

Diagnostics 2023, 13(19), 3154; https://doi.org/10.3390/diagnostics13193154 - 09 Oct 2023

Viewed by 686

Abstract

Background: Colonic endoscopic submucosal dissection (ESD) at “challenging sites” such as the cecum, ascending colon, and colonic flexures could be difficult even for expert endoscopists due to poor endoscope stability/maneuverability, steep angles, and thinner wall thickness. A double-balloon endoluminal intervention platform (EIP) has [...] Read more.

Background: Colonic endoscopic submucosal dissection (ESD) at “challenging sites” such as the cecum, ascending colon, and colonic flexures could be difficult even for expert endoscopists due to poor endoscope stability/maneuverability, steep angles, and thinner wall thickness. A double-balloon endoluminal intervention platform (EIP) has been introduced in the market to fasten and facilitate ESD, particularly when located at difficult sites. Here, we report our initial experience with an EIP comparing the outcomes of an EIP versus standard ESD (S-ESD) at “challenging sites”. Materials and methods: We retrospectively collected data on consecutive patients with colonic lesions located in the right colon and at flexures who underwent ESD in our tertiary referral center between March 2019 and May 2023. Endoscopic and clinical outcomes (technical success, en bloc resection rate, R0 resection rate, procedure time, time to reach the lesion, and adverse events) and 6-month follow-up outcomes were analyzed. Results: Overall, 139 consecutive patients with lesions located at these challenging sites were enrolled (EIP: 31 and S-ESD: 108). Demographic characteristics did not differ between groups. En bloc resection was achieved in 92.3% and 93.5% of patients, respectively, in the EIP and S-ESD groups. Both groups showed a comparable R0 resection rate (EIP vs. S-ESD: 92.3% vs. 97.2%). In patients undergoing EIP-assisted ESD, the total procedure time was shorter (96.1 [30.6] vs. 113.6 [42.3] minutes, p = 0.01), and the mean size of the resected lesions was smaller (46.2 ± 12.7 vs. 55.7 ± 17.6 mm, p = 0.003). The time to reach the lesion was significantly shorter in the EIP group (1.9 ± 0.3 vs. 8.2 ± 2.7 min, p ≤ 0.01). Procedure speed was comparable between groups (14.9 vs. 16.6 mm²/min, p = 0.29). Lower adverse events were observed in the EIP patients (3.8 vs. 10.2%, p = 0.31). Conclusions: EIP allows results that do not differ from S-ESD in the resection of colorectal superficial neoplasms localized in “challenging sites” in terms of efficacy and safety. EIP reduces the time to reach the lesions and may more safely facilitate endoscopic resection. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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15 pages, 1818 KiB

Open AccessArticle

Outcomes of Endoscopic Intervention Using Over-the-Scope Clips for Anastomotic Leakage Involving Secondary Fistula after Gastrointestinal Surgery: A Japanese Multicenter Case Series

by Naoya Tada, Hideki Kobara, Tomoaki Tashima, Hayato Fukui, Satoshi Asai, Takumi Ichinona, Koji Kojima, Kunihisa Uchita, Noriko Nishiyama, Joji Tani, Asahiro Morishita, Akihiro Kondo, Keiichi Okano, Hajime Isomoto, Kazuki Sumiyama, Tsutomu Masaki and Osamu Dohi

Diagnostics 2023, 13(18), 2997; https://doi.org/10.3390/diagnostics13182997 - 19 Sep 2023

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Abstract

Background: The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of [...] Read more.

Background: The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions. Methods: We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020. Results: The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates. Conclusion: OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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Review

Jump to: Research, Other

18 pages, 4001 KiB

Open AccessReview

Indications, Techniques and Future Perspectives of Walled-off Necrosis Management

by Edoardo Troncone, Rosa Amendola, Fabio Gadaleta, Elena De Cristofaro, Benedetto Neri, Pasquale De Vico, Omero Alessandro Paoluzi, Giovanni Monteleone, Andrea Anderloni and Giovanna Del Vecchio Blanco

Diagnostics 2024, 14(4), 381; https://doi.org/10.3390/diagnostics14040381 - 09 Feb 2024

Viewed by 691

Abstract

Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage [...] Read more.

Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage and debridement procedures. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the diffusion of such techniques. Several studies have reported excellent outcomes of endoscopic interventions, in terms of technical success, clinical efficacy and safety compared to surgical interventions, and thus endoscopic drainage of walled-off necrosis (WON) has become a fundamental tool for the management of such conditions. Despite these advancements, some critical unresolved issues remain. Endoscopic therapeutic approaches to WON are still heterogeneous among different centers and experts. A standardized protocol on indication, timing and technique of endoscopic necrosectomy is still lacking, and experts often adopt a strategy based on personal experience more than robust data from well-conducted studies. In this review, we will summarize the available evidence on endoscopic management of WON and will discuss some unanswered questions in this rapidly evolving field. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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15 pages, 774 KiB

Open AccessReview

Advancements in Endoscopic Resection for Colitis-Associated Colorectal Neoplasia in Inflammatory Bowel Disease: Turning Visible into Resectable

by Roberta Maselli, Roberto de Sire, Davide Massimi, Gianluca Franchellucci, Anita Busacca, Fabiana Castiglione, Antonio Rispo, Cesare Hassan, Alessandro Armuzzi and Alessandro Repici

Diagnostics 2024, 14(1), 9; https://doi.org/10.3390/diagnostics14010009 - 20 Dec 2023

Viewed by 966

Abstract

Patients suffering from inflammatory bowel disease (IBD) face a two to three-fold higher risk of developing colorectal cancer (CRC) compared to the general population. In recent years, significant progress has been made in comprehending the natural history of IBD-associated CRC (IBD-CRC) and refining [...] Read more.

Patients suffering from inflammatory bowel disease (IBD) face a two to three-fold higher risk of developing colorectal cancer (CRC) compared to the general population. In recent years, significant progress has been made in comprehending the natural history of IBD-associated CRC (IBD-CRC) and refining its treatment strategies. The decreased incidence of IBD-CRC can be attributed to improved therapeutic management of inflammation, advancements in endoscopy, and early detection of precancerous lesions via surveillance programs. Advanced imaging technologies have made previously undetectable dysplasia visible in most cases, allowing for a much more precise and detailed examination of the mucosa. Additionally, new tools have facilitated the endoscopic resection (ER) of visible lesions in IBD. Particularly, the key to effectively manage colitis-associated colorectal neoplasia (CAN) is to first identify it and subsequently guarantee a complete ER in order to avoid surgery and opt for continuing surveillance. Advanced ER techniques for CAN include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and hybrid ESD-EMR (h-ESD). This narrative review aims to consolidate the current literature on IBD-CRC, providing an overview of advanced techniques for ER of CAN in IBD, with a particular emphasis on the impact of ESD on the long-term outcomes of IBD patients. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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13 pages, 4774 KiB

Open AccessReview

The Role of Luminal Apposing Metal Stents on the Treatment of Malignant and Benign Gastric Outlet Obstruction

by Mihai Rimbaș, Kar Wai Lau, Giulia Tripodi, Gianenrico Rizzatti and Alberto Larghi

Diagnostics 2023, 13(21), 3308; https://doi.org/10.3390/diagnostics13213308 - 25 Oct 2023

Viewed by 708

Abstract

Gastric outlet obstruction (GOO) is a clinical syndrome traditionally managed by surgical gastrojejunostomy or enteral stenting. The surgical approach is burdened with a high rate of adverse events (AEs), while enteral stenting has a limited long-term clinical effectiveness, with the need for repeat [...] Read more.

Gastric outlet obstruction (GOO) is a clinical syndrome traditionally managed by surgical gastrojejunostomy or enteral stenting. The surgical approach is burdened with a high rate of adverse events (AEs), while enteral stenting has a limited long-term clinical effectiveness, with the need for repeat procedures. The availability of lumen-apposing metal stents (LAMSs) has resulted a shift in the treatment paradigm of GOO. Indeed, endoscopists are now able to create a stable anastomosis between the stomach and small bowel under endosonographic guidance. EUS-guided gastro-enteroanastomosis (EUS-GE) has the theoretical advantage of a durable luminal patency resulting from stent placement away from the site of obstruction, free from surgical-related AEs. This approach could be especially valuable in terminally ill patients with a limited life expectancy. The present paper reviews procedural techniques and clinical outcomes of EUS-GE in the context of both malignant and benign GOOs. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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20 pages, 2310 KiB

Open AccessReview

The Role of Cholangioscopy in Biliary Diseases

by Aurelio Mauro, Stefano Mazza, Davide Scalvini, Francesca Lusetti, Marco Bardone, Pietro Quaretti, Lorenzo Cobianchi and Andrea Anderloni

Diagnostics 2023, 13(18), 2933; https://doi.org/10.3390/diagnostics13182933 - 13 Sep 2023

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Abstract

Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image [...] Read more.

Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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11 pages, 883 KiB

Open AccessReview

Endoscopy Ultrasound-Guided Biliary Drainage Using Lumen Apposing Metal Stent in Malignant Biliary Obstruction

by Alessandro Fugazza, Marta Andreozzi, Alessandro De Marco, Leonardo Da Rio, Matteo Colombo, Marco Spadaccini, Silvia Carrara, Marco Giacchetto, Mrigya Sharma, Vincenzo Craviotto, Anita Busacca, Chiara Ferrari and Alessandro Repici

Diagnostics 2023, 13(17), 2788; https://doi.org/10.3390/diagnostics13172788 - 29 Aug 2023

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Abstract

This narrative review provides an overview of the application of endoscopic ultrasound-guided biliary drainage (EUS-BD), including EUS-guided gallbladder drainage (EUS-GBD), for the treatment of malignant biliary obstruction. EUS-BD has demonstrated excellent technical and clinical success rates, with lower rates of adverse events when [...] Read more.

This narrative review provides an overview of the application of endoscopic ultrasound-guided biliary drainage (EUS-BD), including EUS-guided gallbladder drainage (EUS-GBD), for the treatment of malignant biliary obstruction. EUS-BD has demonstrated excellent technical and clinical success rates, with lower rates of adverse events when compared with percutaneous trans-hepatic biliary drainage (PTBD). EUS-BD is currently the preferred alternative technique for biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Particularly, this review will focus on EUS-BD performed with the use of lumen apposing metal stent (LAMS). The introduction of these innovative devices, followed by the advent of electrocautery-enhanced LAMS (EC-LAMS), gave the procedure a great technical implementation and a widespread application. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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Other

Jump to: Research, Review

11 pages, 26044 KiB

Open AccessCase Report

Peroral Endoscopic Myotomy for Achalasia after Bariatric Surgery: A Case Report and Review of the Literature

by Roberta Maselli, Matteo Fiacca, Gaia Pellegatta, Roberto de Sire, Federico De Blasio, Antonio Capogreco, Piera Alessia Galtieri, Davide Massimi, Manuela Trotta, Cesare Hassan and Alessandro Repici

Diagnostics 2023, 13(21), 3311; https://doi.org/10.3390/diagnostics13213311 - 26 Oct 2023

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Abstract

Introduction: Achalasia following bariatric surgery is a rare phenomenon with diverse potential physiopathological origins. Aims: This article aims to explore the hypothetical physiopathological connection between bariatric surgery and the subsequent onset of achalasia. Material and Methods: A review was conducted to identify studies [...] Read more.

Introduction: Achalasia following bariatric surgery is a rare phenomenon with diverse potential physiopathological origins. Aims: This article aims to explore the hypothetical physiopathological connection between bariatric surgery and the subsequent onset of achalasia. Material and Methods: A review was conducted to identify studies reporting cases of peroral endoscopic myotomy (POEM) after bariatric procedures and detailing the outcomes in terms of the technical and clinical success. Additionally, a case of a successful POEM performed on a patient two years after undergoing laparoscopic sleeve gastrectomy (LSG) is presented. Results: The selection criteria yielded eight studies encompassing 40 patients treated with POEM for achalasia after bariatric surgery: 34 after Roux-en-Y gastric bypass (RYGB) and 6 after LSG. The studies reported an overall technical success rate of 97.5%, with clinical success achieved in 85% of cases. Adverse events were minimal, with only one case of esophageal leak treated endoscopically. However, a postprocedural symptomatic evaluation was notably lacking in most of the included studies. Conclusions: Achalasia poses a considerable challenge within the bariatric surgery population. POEM has emerged as a technically viable and safe intervention for this patient demographic, providing an effective treatment option where surgical alternatives for achalasia are limited. Our findings highlight the promising outcomes of POEM in these patients, but the existing data remain limited. Hence, prospective studies are needed to elucidate the optimal pre-surgical assessment and timing of endoscopic procedures for optimizing outcomes. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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8 pages, 2795 KiB

Open AccessCase Report

Direct Endoscopic Necrosectomy of a Recurrent Walled-Off Pancreatic Necrosis at High Risk for Severe Bleeding: A Hybrid Technique Using a Dedicated Device

by Cecilia Binda, Chiara Coluccio, Antonio Vizzuso, Alessandro Sartini, Monica Sbrancia, Alessandro Cucchetti, Emanuela Giampalma, Stefano Fabbri, Giorgio Ercolani and Carlo Fabbri

Diagnostics 2023, 13(14), 2321; https://doi.org/10.3390/diagnostics13142321 - 10 Jul 2023

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Abstract

Direct endoscopic necrosectomy (DEN) is a challenging procedure for the debridement of walled-off pancreatic necrosis (WOPN), which may be complicated by several adverse events, primarily bleeding which may require radiological embolization or even surgery. The lack of dedicated devices for this purpose largely [...] Read more.

Direct endoscopic necrosectomy (DEN) is a challenging procedure for the debridement of walled-off pancreatic necrosis (WOPN), which may be complicated by several adverse events, primarily bleeding which may require radiological embolization or even surgery. The lack of dedicated devices for this purpose largely affects the possibility of safely performing DEN which increases the risk of complications. We present the case of a 63 years-old man who underwent an endoscopic ultrasound (EUS)-guided drainage of a WOPN, and who was readmitted one month after stent removal with clinical, endoscopic, and radiological signs of infected necrosis involving the splenic artery. A second EUS-guided drainage was performed, with clear visualization of the arterial vessel in the midst of a large amount of solid necrosis. Due to the high risk of major bleeding during DEN, a hybrid procedure in the angiographic room was performed, in order to identify and avoid, under fluoroscopic control, the splenic artery during the entire procedure guide, which was successfully performed using the EndoRotor system. We hereby review the current literature regarding DEN using the EndoRotor system. The case reported, with a literature overview, may help the management of these patients affected by benign but life-threatening conditions which involve a multidisciplinary setting. Full article

(This article belongs to the Special Issue Endoscopic Techniques for Diagnosis and Interventions in Digestive Diseases)

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