Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Bas L. A. M. Weusten; Maximilien Barret; Albert J. Bredenoord; Pietro Familiari; Jean-Michel Gonzalez; Jeanin E. van Hooft; Vicente Lorenzo-Zúñiga; Hubert Louis; Jan Martinek; Suzanne van Meer; Helmut Neumann; Daniel Pohl; Frederic Prat; Daniel von Renteln; Edoardo Savarino; Rami Sweis; Jan Tack; Radu Tutuian; Sauid Ishaq

doi:10.1055/a-1171-3174

Endoscopy, Table of Contents

Endoscopy 2020; 52(07): 600-614
DOI: 10.1055/a-1171-3174

Guideline

Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Bas L. A. M. Weusten

¹Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, The Netherlands

²Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands

,

Maximilien Barret

³Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique-Hopitaux de Paris and University of Paris, France

,

Albert J. Bredenoord

⁴Department of Gastroenterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands

,

Pietro Familiari

⁵Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy

,

Jean-Michel Gonzalez

⁶Department of Gastroenterology, Hôpital Nord, Marseille, France

,

Jeanin E. van Hooft

⁴Department of Gastroenterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands

,

Vicente Lorenzo-Zúñiga

⁷Endoscopy Unit, University Hospital La Fe, Valencia, Spain

,

Hubert Louis

⁸Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium

,

Jan Martinek

⁹Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic

,

Suzanne van Meer

¹Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, The Netherlands

²Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands

,

Helmut Neumann

¹⁰Department of Medicine I, University Medical Center Mainz, Mainz, Germany

,

Daniel Pohl

¹¹Department of Gastroenterology, University Hospital Zurich, Zurich, Switzerland

,

Frederic Prat

³Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique-Hopitaux de Paris and University of Paris, France

,

Daniel von Renteln

¹²Division of Gastroenterology, Montréal University Hospital (CHUM), Montréal, Canada

,

Edoardo Savarino

¹³Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova, Padova, Italy

,

Rami Sweis

¹⁴Department of Gastroenterology, University College London Hospital, London, UK

,

Jan Tack

¹⁵Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium

,

Radu Tutuian

¹⁶Department of Gastroenterology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland

,

Sauid Ishaq

¹⁷Department of Gastroenterology, Dudley Group NHS Foundation Trust and Birmingham City University, Birmingham, UK

› Author Affiliations

Abstract

Main Recommendations

ESGE suggests flexible endoscopic treatment over open surgical treatment as first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size.

Weak recommendation, low quality of evidence, level of agreement 100 %.

ESGE recommends that emerging treatments for Zenker’s diverticulum, such as Zenker’s peroral endoscopic myotomy (Z-POEM) and tunneling, be considered as experimental; these treatments should be offered in a research setting only.

Strong recommendation, low quality of evidence, level of agreement 100 %.

ESGE recommends against the widespread clinical use of transoral incisionless fundoplication (TIF) as an alternative to proton pump inhibitor (PPI) therapy or antireflux surgery in the treatment of gastroesophageal reflux disease (GERD), because of the lack of data on the long-term outcomes, the inferiority of TIF to fundoplication, and its modest efficacy in only highly selected patients. TIF may have a role for patients with mild GERD who are not willing to take PPIs or undergo antireflux surgery.

Strong recommendation, moderate quality of evidence, level of agreement 92.8 %.

ESGE recommends against the use of the Medigus ultrasonic surgical endostapler (MUSE) in clinical practice because of insufficient data showing its effectiveness and safety in patients with GERD. MUSE should be used in clinical trials only.

Strong recommendation, low quality evidence, level of agreement 100 %.

ESGE recommends against the use of antireflux mucosectomy (ARMS) in routine clinical practice in the treatment of GERD because of the lack of data and its potential complications.

Strong recommendation, low quality evidence, level of agreement 100 %.

ESGE recommends endoscopic cecostomy only after conservative management with medical therapies or retrograde lavage has failed.

Strong recommendation, low quality evidence, level of agreement 93.3 %.

ESGE recommends fixing the cecum to the abdominal wall at three points (using T-anchors, a double-needle suturing device, or laparoscopic fixation) to prevent leaks and infectious adverse events, whatever percutaneous endoscopic cecostomy method is used.

Strong recommendation, very low quality evidence, level of agreement 86.7 %.

ESGE recommends considering endoscopic decompression of the colon in patients with Ogilvie’s syndrome that is not improving with conservative treatment.

Strong recommendation, low quality evidence, level of agreement 93.8 %.

ESGE recommends prompt endoscopic decompression if the cecal diameter is > 12 cm and if the Ogilvie’s syndrome exists for a duration of longer than 4 – 6 days.

Strong recommendation, low quality evidence, level of agreement 87.5 %.

Full Text

References

References
1 Atkins D, Best D, Briss P. et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490
2 Dumonceau JM, Hassan C, Riphaus A. et al. European Society of Gastrointestinal Endoscopy (ESGE) guideline development policy. Endoscopy 2012; 44: 626-629
3 Linstone HA, Turoff M. The Delphi Method: Techniques and Applications. 2002 Available from: https://web.njit.edu/~turoff/pubs/delphibook/index.html
4 Watemberg S, Landau O, Avrahami R. Zenker’s diverticulum: reappraisal. Am J Gastroenterol 1996; 91: 1494-1498
5 Wheeler WI. Pharyngocele and dilatation of pharynx, with existing diverticulum at lower poertion of pharynx lying posterior to the oesophagus, cured by pharyngotomy, being the first case of the kind recorded. Dublin J Med Sci 1886; 82: 349-357
6 Negus V. Pharyngeal diverticula: observations on their evolution and treatment. Br J Surg 1950; 38: 129-146
7 Fulp S, Castell D. Manometric aspects of Zenker’s diverticulum. Hepatogastroenterology 1992; 39: 123-126
8 Cook I, Gabb M, Panagopoulos V. et al. Pharyngeal (Zenker’s) diverticulum is a disorder of the upper esophageal sphincter opening. Gastroenterology 1992; 103: 1229-1235
9 Mantsopoulos K, Psychogios G, Künzel J. et al. Evaluation of the different transcervical approaches for Zenker diverticulum. Otolaryngol Head Neck Surg 2012; 146: 725-729
10 Yuan Y, Zhao Y, Hu Y. et al. Surgical treatment of Zenker’s diverticulum. Dig Surg 2013; 30: 207-218
11 Leong S, Wilkie M, Webb C. Endoscopic stapling of Zenker’s diverticulum: Establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol 2012; 269: 1877-1884
12 Luna R, Collard J. Transoral stapled diverticulotomy. Rev Col Bras Cir 2009; 36: 268-270
13 Mulder CJ, den Hartog G, Robijn RJ. et al. Flexible endoscopic treatment of Zenker’s diverticulum: a new approach. Endoscopy 1995; 27: 438-442
14 Huberty V, El Bacha S, Blero D. et al. Endoscopic treatment for Zenker’s diverticulum: Long-term results (with video). Gastrointest Endosc 2013; 77: 701-707
15 Antonello A, Ishaq S, Zanatta L. et al. The role of flexible endotherapy for the treatment of recurrent Zenker’s diverticula after surgery and endoscopic stapling. Surg Endosc 2016; 30: 2351-2357
16 Shahawy S, Janisiewicz AM, Annino D. et al. A comparative study of outcomes for endoscopic diverticulotomy versus external diverticulectomy. Otolaryngol Head Neck Surg 2014; 151: 646-651
17 Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol 2015; 272: 3095-3107
18 Albers D, Kondo A, Bernardo W. et al. Endoscopic versus surgical approach in the treatment of Zenker’s diverticulum: systematic review and meta-analysis. Endosc Int Open 2016; 04: E678-E686
19 Ishaq S, Hassan C, Antonello A. et al. Flexible endoscopic treatment for Zenker’s diverticulum: A systematic review and meta-analysis. Gastrointest Endosc 2016; 83: 1076-1089.e5
20 Costamagna G, Iacopini F, Bizzotto A. et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc 2016; 83: 765-773
21 Oestreicher-Kedem Y, Wasserzug O, Sagi B. et al. Revision endoscopic stapler Zenker’s diverticulotomy. Surg Endosc 2016; 30: 2022-2025
22 Buchanan MA, Riffat F, Mahrous AK. et al. Endoscopic or external approach revision surgery for pharyngeal pouch following primary endoscopic stapling: Which is the favoured approach?. Eur Arch Otorhinolaryngol 2013; 270: 1707-1710
23 Costamagna G, Iacopini F, Tringali A. et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007; 39: 146-152
24 Yang J, Novak S, Ujiki M. et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum. Gastrointest Endosc 2020; 91: 163-168
25 Ishioka S, Sakai P, Maluf Filho F. et al. Endoscopic incision of Zenker’s diverticula. Endoscopy 1995; 27: 433-437
26 Repici A, Pagano F, Danese S. et al. Endoscopic flexible treatment of Zenker’s diverticulum: a modification of the needle-knife technique. Endoscopy 2010; 42: 532-535
27 Rouquette O, Abergel A, Mulliez A. et al. Usefulness of the Hook knife in flexible endoscopic myotomy for Zenker’s diverticulum. World J Gastrointest Endosc 2017; 9: 411-416
28 Battaglia G, Antonello A, Realdon S. et al. Flexible endoscopic treatment for Zenker’s diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc 2015; 27: 728-733
29 Gölder SK, Brueckner J, Ebigbo A. et al. Double incision and snare resection in symptomatic Zenker’s diverticulum: A modification of the stag beetle knife technique. Endoscopy 2018; 50: 137-141
30 El-Serag HB, Sweet S, Winchester CC. et al. Update on the epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut 2014; 63: 871-880
31 Cohen LB, Johnson DA, Ganz RA. et al. Enteryx implantation for GERD: Expanded multicenter trial results and interim postapproval follow-up to 24 months. Gastrointest Endosc 2005; 61: 650-658
32 Wong RF, Davis TV, Peterson KA. Complications involving the mediastinum after injection of Enteryx for GERD. Gastrointest Endosc 2005; 61: 753-756
33 Fockens P, Bruno MJ, Gabbrielli A. et al. Endoscopic augmentation of the lower esophageal sphincter for the treatment of gastroesophageal reflux disease: multicenter study of the Gatekeeper Reflux Repair System. Endoscopy 2004; 36: 682-689
34 Fockens P, Cohen L, Edmundowicz SA. et al. Prospective randomized controlled trial of an injectable esophageal prosthesis versus a sham procedure for endoscopic treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24: 1387-1397
35 Mahmood Z, McMahon BP, Arfin Q. et al. Endocinch therapy for gastro-oesophageal reflux disease: A one year prospective follow up. Gut 2003; 52: 34-39
36 Schiefke I, Zabel-Langhennig A, Neumann S. et al. Long term failure of endoscopic gastroplication (EndoCinch). Gut 2005; 54: 752-758
37 Siersema PD. Endoscopic therapeutic esophageal interventions: what is new? What needs further study? What can we forget?. Curr Opin Gastroenterol 2005; 21: 490-497
38 Rinsma NF, Farré R, Bouvy ND. et al. The effect of endoscopic fundoplication and proton pump inhibitors on baseline impedance and heartburn severity in GERD patients. Neurogastroenterol Motil 2015; 27: 220-228
39 Witteman BPL, Conchillo JM, Rinsma NF. et al. Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease. Am J Gastroenterol 2015; 110: 531-542
40 Trad KS, Barnes WE, Simoni G. et al. Transoral incisionless fundoplication effective in eliminating GERD symptoms in partial responders to proton pump inhibitor therapy at 6 months: The TEMPO randomized clinical trial. Surg Innov 2015; 22: 26-40
41 Hunter JG, Kahrilas PJ, Bell RCW. et al. Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial. Gastroenterology 2015; 148: 324-333
42 Håkansson B, Montgomery M, Cadiere GB. et al. Randomised clinical trial: Transoral incisionless fundoplication vs. sham intervention to control chronic GERD. Aliment Pharmacol Ther 2015; 42: 1261-1270
43 Huang X, Chen S, Zhao H. et al. Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Surg Endosc 2017; 31: 1032-1044
44 Frazzoni M, Conigliaro R, Manta R. et al. Reflux parameters as modified by EsophyX or laparoscopic fundoplication in refractory GERD. Aliment Pharmacol Ther 2011; 34: 67-75
45 Zacherl J, Roy-Shapira A, Bonavina L. et al. Endoscopic anterior fundoplication with the Medigus Ultrasonic Surgical Endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial. Surg Endosc 2015; 29: 220-229
46 Kim HJ, Kwon CIl, Kessler WR. et al. Long-term follow-up results of endoscopic treatment of gastroesophageal reflux disease with the MUSE™ endoscopic stapling device. Surg Endosc 2016; 30: 3402-3408
47 Danalioglu A, Cipe G, Toydemir T. et al. Endoscopic stapling in comparison to laparoscopic fundoplication for the treatment of gastroesophageal reflux disease. Dig Endosc 2014; 26: 37-42
48 Arts J, Bisschops R, Blondeau K. et al. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol 2012; 107: 222-230
49 Corley DA, Katz P, Wo JM. et al. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: A randomized, sham-controlled trial. Gastroenterology 2003; 125: 668-676
50 Abdel Aziz AM, El-Khayat HR, Sadek A. et al. A prospective randomized trial of sham, single-dose Stretta, and double-dose Stretta for the treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24: 818-825
51 Coron E, Sebille V, Cadiot G. et al. Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients. Aliment Pharmacol Ther 2008; 28: 1147-1158
52 Fass R, Cahn F, Scotti DJ. et al. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc 2017; 31: 4865-4882
53 Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015; 13: 1058-1067
54 Richards WO, Houston HL, Torquati A. et al. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg 2003; 237: 638-649
55 Liang W-T, Yan C, Wang Z-G. et al. Early and midterm outcome after laparoscopic fundoplication and a minimally invasive endoscopic procedure in patients with gastroesophageal reflux disease: a prospective observational study. J Laparoendosc Adv Surg Tech 2015; 25: 657-661
56 Noar M, Squires P, Khan S. Radiofrequency energy delivery to the lower esophageal sphincter improves gastroesophageal reflux patient-reported outcomes in failed laparoscopic Nissen fundoplication cohort. Surg Endosc 2017; 31: 2854-2862
57 Inoue H, Ito H, Ikeda H. et al. Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: A pilot study. Ann Gastroenterol 2014; 27: 346-351
58 Benias P, D’Souza L, Lan G. et al. Initial experience with a novel resection and plication (RAP) method for acid reflux: a pilot study. Endosc Int Open 2018; 06: E443-E449
59 Hedberg HM, Kuchta K, Ujiki MB. First experience with banded anti-reflux mucosectomy (ARMS) for GERD: feasibility, safety, and technique (with video). J Gastrointest Surg 2019; 23: 1274-1278
60 Holm AN, Baron TH. Palliative use of percutaneous endoscopic gastrostomy and percutaneous endoscopic cecostomy tubes. Gastrointest Endosc Clin N Am 2007; 17: 795-803
61 Duchalais E, Meurette G, Mantoo SK. et al. Percutaneous endoscopic caecostomy for severe constipation in adults: feasibility, durability, functional and quality of life results at 1 year follow-up. Surg Endosc 2015; 29: 620-626
62 Küllmer A, Schmidt A, Caca K. Percutaneous endoscopic cecostomy (introducer method) in chronic intestinal pseudo-obstruction: Report of two cases and literature review. Dig Endosc 2016; 28: 210-215
63 Lynch CR, Jones RG, Hilden K. et al. Percutaneous endoscopic cecostomy in adults: a case series. Gastrointest Endosc 2006; 64: 279-282
64 Ricard J, Quénéhervé L, Lefevre C. et al. Anterograde colonic irrigations by percutaneous endoscopic caecostomy in refractory colorectal functional disorders. Int J Colorectal Dis 2019; 34: 169-175
65 Didailler R, Denost Q, Loughlin P. et al. Antegrade enema after total mesorectal excision for rectal cancer: the last chance to avoid definitive colostomy for refractory low anterior resection syndrome and fecal incontinence. Dis Colon Rectum 2018; 61: 667-672
66 Uno Y. Introducer method of percutaneous endoscopic cecostomy and antegrade continence enema by use of the Chait Trapdoor cecostomy catheter in patients with adult neurogenic bowel. Gastrointest Endosc 2006; 63: 666-673
67 Koyfman S, Swartz K, Goldstein AM. et al. Laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) in children and young adults. J Gastrointest Surg 2017; 21: 676-683
68 Rodriguez L, Flores A, Gilchrist BF. et al. Laparoscopic-assisted percutaneous endoscopic cecostomy in children with defecation disorders (with video). Gastrointest Endosc 2011; 73: 98-102
69 Baraza W, Brown S, McAlindon M. et al. Prospective analysis of percutaneous endoscopic colostomy at a tertiary referral centre. Br J Surg 2007; 94: 1415-1420
70 Rivera MT, Kugathasan S, Berger W. et al. Percutaneous colonoscopic cecostomy for management of chronic constipation in children. Gastrointest Endosc 2001; 53: 225-228
71 Ramage JI, Baron TH. Percutaneous endoscopic cecostomy: a case series. Gastrointest Endosc 2003; 57: 752-755 3
72 Cascio S, Flett ME, De La Hunt M. et al. MACE or caecostomy button for idiopathic constipation in children: A comparison of complications and outcomes. Pediatr Surg Int 2004; 20: 484-487
73 Biyani D, Barrow E, Hodson P. et al. Endoscopically placed caecostomy buttons: A trial ACE procedure. Colorectal Dis 2007; 9: 373-376
74 Cowlam S, Watson C, Elltringham M. et al. Percutaneous endoscopic colostomy of the left side of the colon. Gastrointest Endosc 2007; 65: 1007-1014
75 Graham CD, Rodriguez L, Flores A. et al. Primary placement of a skin-level cecostomy tube for antegrade colonic enema administration using a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC). J Pediatr Surg 2019; 54: 486-490
76 Rawat DJ, Haddad M, Geoghegan N. et al. Percutaneous endoscopic colostomy of the left colon: A new technique for management of intractable constipation in children. Gastrointest Endosc 2004; 60: 39-43
77 Rao AS, Loftus CG, Baron TH. Buried bumper syndrome arising from a percutaneous endoscopic cecostomy tube. Gastrointest Endosc 2011; 73: 168-169
78 Ogilvie H. Large-intestine colic due to sympathetic deprivation; a new clinical syndrome. Br Med J 1948; 2: 671-673
79 Saunders MD. Acute colonic pseudo-obstruction. Best Pract Res Clin Gastroenterol 2007; 21: 671-687
80 Peker KD, Cikot M, Bozkurt MA. et al. Colonoscopic decompression should be used before neostigmine in the treatment of Ogilvie’s syndrome. Eur J Trauma Emerg Surg 2017; 43: 557-566
81 Tsirline VB, Zemlyak AY, Avery MJ. et al. Colonoscopy is superior to neostigmine in the treatment of Ogilvie’s syndrome. Am J Surg 2012; 204: 849-855
82 Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. NEJM 1999; 341: 137-141
83 Elsner JL, Smith JM, Ensor CR. Intravenous neostigmine for postoperative acute colonic pseudo-obstruction. Ann Pharmacother 2012; 46: 430-435
84 Valle RGL, Godoy FL. Neostigmine for acute colonic pseudo-obstruction: A meta-analysis. Ann Med Surg 2014; 3: 60-64
85 Ross SW, Oommen B, Wormer BA. et al. Acute colonic pseudo-obstruction: Defining the epidemiology, treatment, and adverse outcomes of Ogilvie’s syndrome. Am Surg 2016; 82: 102-111
86 Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvieʼs syndrome). Dis Colon Rectum 1986; 29: 203-210
87 Johnson CD, Rice RP, Kelvin FM. et al. The radiologic evaluation of gross cecal distension: Emphasis of cecal ileus. Am J Roentgenol 1985; 145: 1211-1217
88 Geller A, Petersen BT, Gostout CJ. Endoscopic decompression for acute colonic pseudo-obstruction. Gastrointest Endosc 1996; 44: 144-150
89 Jetmore AB, Timmcke AE, Gathright JB. et al. Ogilvie’s syndrome: Colonoscopic decompression and analysis of predisposing factors. Dis Colon Rectum 1992; 35: 1135-1142
90 Harig JM, Fumo DE, Loo FD. et al. Treatment of acute nontoxic megacolon during colonoscopy: tube placement versus simple decompression. Gastrointest Endosc 1988; 34: 23-27
91 Lavignolle A, Jutel P, Bonhomme J. et al. Ogilvie’s syndrome: results of endoscopic exsufflation in a series of 29 cases. Gastroenterol Clin Biol 1986; 10: 147-151
92 Pham TN, Cosman BC, Chu P. et al. Radiographic changes after colonoscopic decompression for acute pseudo-obstruction. Dis Colon Rectum 1999; 42: 1586-1591
93 Sgouros SN, Vlachogiannakos J, Vassiliadis K. et al. Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: A prospective, randomised, placebo controlled trial. Gut 2006; 55: 638-642
94 Ponsky JL, Aszodi A, Perse D. Percutaneous endoscopic cecostomy: a new approach to nonobstructive colonic dilation. Gastrointest Endosc 1986; 32: 108-111
95 Salm R, Rückauer K, Waldmann D. et al. Endoscopic percutaneous cecostomy (EPC). Surg Endosc 1988; 2: 92-95

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