Skip to main content
SpringerLink
Log in

Management of Gastrointestinal EMR and ESD Perforation: From Lab to Practice

  • Chapter
Endoscopic Submucosal Dissection

Abstract

Endoscopic submucosal dissection and endoscopic mucosal resection allow complete resection of flat lesions of the GI tract, as they utilize submucosal fluid injection for lifting that makes lesions accessible for complete resection. However, perforation is a serious risk as these procedures involve cutting the mucosa and submucosa while sparing the deep submucosa and muscularis propria of the rather thin gut wall. Advances in clinical practice as well as investigative work in the animal laboratory have helped us to develop techniques for successful endoluminal closure of such perforations.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 69.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 119.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Pohl H, Srivastava A, Bensen SP, et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144:74–80 e1.

    Article  PubMed  Google Scholar 

  2. Tanabe S, Koizumi W, Mitomi H, et al. Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer. Gastrointest Endosc. 2002;56:708–13.

    Article  PubMed  Google Scholar 

  3. Saito Y, Fukuzawa M, Matsuda T, et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc. 2010;24:343–52.

    Article  PubMed  Google Scholar 

  4. Yokoi C, Gotoda T, Hamanaka H, Oda I. Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc. 2006;64(2):212–8.

    Article  PubMed  Google Scholar 

  5. Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy. 2009;41:751–7.

    Article  CAS  PubMed  Google Scholar 

  6. ASGE Technology Committee, Kantsevoy SV, Adler DG, et al. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc. 2008;68:11–8.

    Article  Google Scholar 

  7. Toyonaga T, Man-i M, East JE, et al. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc. 2013;27:1000–8.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Lee DW, Jeon SW. Management of complications during gastric endoscopic submucosal dissection. Diagn Ther Endosc. 2012;2012:624835.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Jeon SW, Jung MK, Kim SK, et al. Clinical outcomes for perforations during endoscopic submucosal dissection in patients with gastric lesions. Surg Endosc. 2010;24:911–6.

    Article  PubMed  Google Scholar 

  10. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc. 1993;39:172–4.

    Article  CAS  PubMed  Google Scholar 

  11. Raju GS, Gajula L. Endoclips for GI endoscopy. Gastrointest Endosc. 2004;59:267–79.

    Article  PubMed  Google Scholar 

  12. Jayaraman V, Hammerle C, Lo SK, et al. Clinical application and outcomes of over the scope clip device: initial US experience in humans. Diagn Ther Endosc. 2013;2013:381873.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Committee AT, Banerjee S, Barth BA, et al. Endoscopic closure devices. Gastrointest Endosc. 2012;76:244–51.

    Article  Google Scholar 

  14. Kirschniak A, Kratt T, Stuker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc. 2007;66:162–7.

    Article  PubMed  Google Scholar 

  15. Pohl J, Borgulya M, Lorenz D, et al. Endoscopic closure of postoperative esophageal leaks with a novel over-the-scope clip system. Endoscopy. 2010;42:757–9.

    Article  CAS  PubMed  Google Scholar 

  16. Seebach L, Bauerfeind P, Gubler C. “Sparing the surgeon”: clinical experience with over-the-scope clips for gastrointestinal perforation. Endoscopy. 2010;42:1108–11.

    Article  CAS  PubMed  Google Scholar 

  17. Baron TH, Song LM, Ross A, et al. Use of an over-the-scope clipping device: multicenter retrospective results of the first U.S. experience (with videos). Gastrointest Endosc. 2012;76:202–8.

    Article  PubMed  Google Scholar 

  18. Weiland T, Fehlker M, Gottwald T, et al. Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review. Surg Endosc. 2013;27:2258–74.

    Article  PubMed  Google Scholar 

  19. Reavis KM, Melvin WS. Advanced endoscopic technologies. Surg Endosc. 2008;22:1533–46.

    Article  PubMed  Google Scholar 

  20. Fritscher-Ravens A, Hampe J, Grange P, et al. Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model (with videos). Gastrointest Endosc. 2010;72:1020–6.

    Article  PubMed  Google Scholar 

  21. Fritscher-Ravens A, Patel K, Ghanbari A, et al. Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures. Endoscopy. 2007;39:870–5.

    Article  CAS  PubMed  Google Scholar 

  22. Fritscher-Ravens A, Cuming T, Jacobsen B, et al. Feasibility and safety of endoscopic full-thickness esophageal wall resection and defect closure: a prospective long-term survival animal study. Gastrointest Endosc. 2009;69:1314–20.

    Article  PubMed  Google Scholar 

  23. Gomez-Esquivel R, Raju GS. Endoscopic closure of acute esophageal perforations. Curr Gastroenterol Rep. 2013;15:321.

    Article  PubMed  Google Scholar 

  24. Qadeer MA, Dumot JA, Vargo JJ, et al. Endoscopic clips for closing esophageal perforations: case report and pooled analysis. Gastrointest Endosc. 2007;66:605–11.

    Article  PubMed  Google Scholar 

  25. Voermans RP, Le Moine O, von Renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10:603–8.

    Article  PubMed  Google Scholar 

  26. Nishiyama N, Mori H, Kobara H, et al. Efficacy and safety of over-the-scope clip: including complications after endoscopic submucosal dissection. World J Gastroenterol. 2013;19:2752–60.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Fujishiro M, Yahagi N, Kakushima N, et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms. Clin Gastroenterol Hepatol. 2006;4:688–94.

    Article  PubMed  Google Scholar 

  28. Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc. 2012;4:162–6.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Oyama T, Tomori A, Hotta K, et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol. 2005;3:S67–70.

    Article  PubMed  Google Scholar 

  30. Repici A, Hassan C, Carlino A, et al. Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series. Gastrointest Endosc. 2010;71:715–21.

    Article  PubMed  Google Scholar 

  31. Ishihara R, Iishi H, Uedo N, et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest Endosc. 2008;68:1066–72.

    Article  PubMed  Google Scholar 

  32. Yamashina T, Ishihara R, Uedo N, et al. Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter. Dig Endosc. 2012;24:220–5.

    Article  PubMed  Google Scholar 

  33. Sato H, Inoue H, Ikeda H, et al. Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection. Dis Esophagus. 2013;27:617–22.

    Article  PubMed  Google Scholar 

  34. Hirasawa K, Kokawa A, Oka H, et al. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection. Gastrointest Endosc. 2010;72:960–6.

    Article  PubMed  Google Scholar 

  35. Kakushima N, Fujishiro M. Endoscopic submucosal dissection for gastrointestinal neoplasms. World J Gastroenterol. 2008;14:2962–7.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Yoshinaga S, Gotoda T, Kusano C, et al. Clinical impact of endoscopic submucosal dissection for superficial adenocarcinoma located at the esophagogastric junction. Gastrointest Endosc. 2008;67:202–9.

    Article  PubMed  Google Scholar 

  37. von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy. 2009;41:1056–61.

    Article  Google Scholar 

  38. Voermans RP, van Berge Henegouwen MI, Bemelman WA, et al. Novel over-the-scope-clip system for gastrotomy closure in natural orifice transluminal endoscopic surgery (NOTES): an ex vivo comparison study. Endoscopy. 2009;41:1052–5.

    Article  CAS  PubMed  Google Scholar 

  39. Matthes K, Jung Y, Kato M, et al. Efficacy of full-thickness GI perforation closure with a novel over-the-scope clip application device: an animal study. Gastrointest Endosc. 2011;74:1369–75.

    Article  PubMed  Google Scholar 

  40. Zhang XL, Qu JH, Sun G, et al. Feasibility study of secure closure of gastric fundus perforation using over-the-scope clips in a dog model. J Gastroenterol Hepatol. 2012;27:1200–4.

    Article  PubMed  Google Scholar 

  41. Rajan E, Gostout CJ, Aimore Bonin E, et al. Endoscopic full-thickness biopsy of the gastric wall with defect closure by using an endoscopic suturing device: survival porcine study. Gastrointest Endosc. 2012;76:1014–9.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Park PO, Bergstrom M, Rothstein R, et al. Endoscopic sutured closure of a gastric natural orifice transluminal endoscopic surgery access gastrotomy compared with open surgical closure in a porcine model. A randomized, multicenter controlled trial. Endoscopy. 2010;42:311–7.

    Article  CAS  PubMed  Google Scholar 

  43. Dray X, Krishnamurty DM, Donatelli G, et al. Gastric wall healing after NOTES procedures: closure with endoscopic clips provides superior histological outcome compared with threaded tags closure. Gastrointest Endosc. 2010;72:343–50.

    Article  PubMed  Google Scholar 

  44. Sumiyama K, Gostout CJ, Rajan E, et al. Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors. Gastrointest Endosc. 2007;65:134–9.

    Article  PubMed  Google Scholar 

  45. Magno P, Giday SA, Dray X, et al. A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial. Endoscopy. 2007;39:876–80.

    Article  CAS  PubMed  Google Scholar 

  46. Meireles OR, Kantsevoy SV, Assumpcao LR, et al. Reliable gastric closure after natural orifice translumenal endoscopic surgery (NOTES) using a novel automated flexible stapling device. Surg Endosc. 2008;22:1609–13.

    Article  CAS  PubMed  Google Scholar 

  47. Ersoy OF, Ozkan N, Celik A, et al. Effect of cyanoacrylate on closure of gastric perforation: a comparative study in a rat model. Minim Invasive Ther Allied Technol. 2009;18:225–31.

    Article  PubMed  Google Scholar 

  48. Cios TJ, Reavis KM, Renton DR, et al. Gastrotomy closure using bioabsorbable plugs in a canine model. Surg Endosc. 2008;22:961–6.

    Article  PubMed  Google Scholar 

  49. Hashiba K, Carvalho AM, Diniz Jr G, et al. Experimental endoscopic repair of gastric perforations with an omental patch and clips. Gastrointest Endosc. 2001;54:500–4.

    Article  CAS  PubMed  Google Scholar 

  50. Dray X, Giday SA, Buscaglia JM, et al. Omentoplasty for gastrotomy closure after natural orifice transluminal endoscopic surgery procedures (with video). Gastrointest Endosc. 2009;70:131–40.

    Article  PubMed  Google Scholar 

  51. Toyokawa T, Inaba T, Omote S, et al. Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: analysis of 1123 lesions. J Gastroenterol Hepatol. 2012;27:907–12.

    Article  PubMed  Google Scholar 

  52. Ohta T, Ishihara R, Uedo N, et al. Factors predicting perforation during endoscopic submucosal dissection for gastric cancer. Gastrointest Endosc. 2012;75:1159–65.

    Article  PubMed  Google Scholar 

  53. Kim M, Jeon SW, Cho KB, et al. Predictive risk factors of perforation in gastric endoscopic submucosal dissection for early gastric cancer: a large, multicenter study. Surg Endosc. 2013;27:1372–8.

    Article  PubMed  Google Scholar 

  54. Watari J, Tomita T, Toyoshima F, et al. Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: a prospective pilot study. World J Gastrointest Endosc. 2013;5:281–7.

    Article  PubMed Central  PubMed  Google Scholar 

  55. Yoo JH, Shin SJ, Lee KM, et al. Risk factors for perforations associated with endoscopic submucosal dissection in gastric lesions: emphasis on perforation type. Surg Endosc. 2012;26:2456–64.

    Article  PubMed  Google Scholar 

  56. Li L, Wang F, Wu B, et al. Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria. Exp Ther Med. 2013;6:391–5.

    PubMed Central  PubMed  Google Scholar 

  57. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc. 2006;63:596–601.

    Article  PubMed  Google Scholar 

  58. Matsumoto S, Miyatani H, Yoshida Y. Endoscopic submucosal dissection for duodenal tumors: a single-center experience. Endoscopy. 2013;45:136–7.

    Article  CAS  PubMed  Google Scholar 

  59. Honda T, Yamamoto H, Osawa H, et al. Endoscopic submucosal dissection for superficial duodenal neoplasms. Dig Endosc. 2009;21:270–4.

    Article  PubMed  Google Scholar 

  60. Min YW, Min BH, Kim ER, et al. Efficacy and safety of endoscopic treatment for nonampullary sporadic duodenal adenomas. Dig Dis Sci. 2013;58:2926–32.

    Article  PubMed  Google Scholar 

  61. Hatogai K, Oono Y, Fu KI, et al. Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor. World J Gastroenterol. 2013;19:4267–70.

    Article  PubMed Central  PubMed  Google Scholar 

  62. Matsumoto S, Miyatani H, Yoshida Y, et al. Duodenal carcinoid tumors: 5 cases treated by endoscopic submucosal dissection. Gastrointest Endosc. 2011;74:1152–6.

    Article  PubMed  Google Scholar 

  63. Kim GH, Kim JI, Jeon SW, et al. Endoscopic resection for duodenal carcinoid tumors: a multicenter, retrospective study. J Gastroenterol Hepatol. 2014;29:318–24.

    Article  PubMed  Google Scholar 

  64. Raju GS, Pham B, Xiao SY, et al. A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model. Gastrointest Endosc. 2005;62:791–5.

    Article  PubMed  Google Scholar 

  65. Raju GS, Ahmed I, Brining D, et al. Endoluminal closure of large perforations of colon with clips in a porcine model (with video). Gastrointest Endosc. 2006;64:640–6.

    Article  PubMed  Google Scholar 

  66. Raju GS, Ahmed I, Shibukawa G, et al. Endoluminal clip closure of a circular full-thickness colon resection in a porcine model (with videos). Gastrointest Endosc. 2007;65:503–9.

    Article  PubMed  Google Scholar 

  67. Raju GS, Ahmed I, Xiao SY, et al. Controlled trial of immediate endoluminal closure of colon perforations in a porcine model by use of a novel clip device (with videos). Gastrointest Endosc. 2006;64:989–97.

    Article  PubMed  Google Scholar 

  68. Raju GS, Shibukawa G, Ahmed I, et al. Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos). Gastrointest Endosc. 2007;65:906–11.

    Article  PubMed  Google Scholar 

  69. Raju GS, Malhotra A, Ahmed I. Colonoscopic full-thickness resection of the colon in a porcine model as a prelude to endoscopic surgery of difficult colon polyps: a novel technique (with videos). Gastrointest Endosc. 2009;70:159–65.

    Article  PubMed  Google Scholar 

  70. Schurr MO, Hartmann C, Ho CN, et al. An over-the-scope clip (OTSC) system for closure of iatrogenic colon perforations: results of an experimental survival study in pigs. Endoscopy. 2008;40:584–8.

    Article  CAS  PubMed  Google Scholar 

  71. von Renteln D, Schmidt A, Vassiliou MC, et al. Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study. Endoscopy. 2009;41:481–6.

    Article  Google Scholar 

  72. Voermans RP, Vergouwe F, Breedveld P, et al. Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model. Endoscopy. 2011;43:217–22.

    Article  CAS  PubMed  Google Scholar 

  73. Pham BV, Raju GS, Ahmed I, et al. Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video). Gastrointest Endosc. 2006;64:113–9.

    Article  PubMed  Google Scholar 

  74. Liu K, Yu H, Zhang M, et al. Sutureless primary repair of colonic perforation with a degradable stent in a porcine model of fecal peritonitis. Int J Colorectal Dis. 2012;27:1607–17.

    Article  PubMed  Google Scholar 

  75. Nocca D, Aggarwal R, Deneve E, et al. Use of collagen wrap from bovine origin for the management of colic perforation. Preliminary study in a pig model. J Laparoendosc Adv Surg Tech A. 2009;19:79–83.

    Article  PubMed  Google Scholar 

  76. Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc. 1997;46:464–6.

    Article  CAS  PubMed  Google Scholar 

  77. Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc. 2001;54:258–9.

    Article  CAS  PubMed  Google Scholar 

  78. Carvalho R, Areia M, Brito D, et al. Endoscopic mucosal resection of large colorectal polyps: prospective evaluation of recurrence and complications. Acta Gastroenterol Belg. 2013;76:225–30.

    PubMed  Google Scholar 

  79. Masci E, Viale E, Notaristefano C, et al. Endoscopic mucosal resection in high- and low-volume centers: a prospective multicentric study. Surg Endosc. 2013;27:3799–805.

    Article  CAS  PubMed  Google Scholar 

  80. Kim ES, Cho KB, Park KS, et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy. 2011;43:573–8.

    Article  CAS  PubMed  Google Scholar 

  81. Lee EJ, Lee JB, Choi YS, et al. Clinical risk factors for perforation during endoscopic submucosal dissection (ESD) for large-sized, nonpedunculated colorectal tumors. Surg Endosc. 2012;26:1587–94.

    Article  PubMed  Google Scholar 

  82. Coda S, Trentino P, Antonellis F, et al. A Western single-center experience with endoscopic submucosal dissection for early gastrointestinal cancers. Gastric Cancer. 2010;13:258–63.

    Article  PubMed  Google Scholar 

  83. Yoon JY, Kim JH, Lee JY, et al. Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum. Surg Endosc. 2013;27:487–93.

    Article  PubMed  Google Scholar 

  84. Ohata K, Nonaka K, Minato Y, et al. Endoscopic submucosal dissection for large colorectal tumor in a Japanese General Hospital. J Oncol. 2013;2013:218670.

    Article  PubMed Central  PubMed  Google Scholar 

  85. Thorlacius H, Uedo N, Toth E. Implementation of endoscopic submucosal dissection for early colorectal neoplasms in Sweden. Gastroenterol Res Pract. 2013;2013:758202.

    Article  PubMed Central  PubMed  Google Scholar 

  86. Maeda Y, Hirasawa D, Fujita N, et al. A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation. Endoscopy. 2012;44:565–71.

    Article  CAS  PubMed  Google Scholar 

  87. Cho SB, Lee WS, Joo YE, et al. Therapeutic options for iatrogenic colon perforation: feasibility of endoscopic clip closure and predictors of the need for early surgery. Surg Endosc. 2012;26:473–9.

    Article  PubMed  Google Scholar 

  88. Kim JS, Kim BW, Kim JI, et al. Endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients. Surg Endosc. 2013;27:501–4.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street—Unit 1466, Houston, TX, 77030, USA

    Selvi Thirumurthi M.D., M.S. & Gottumukkala S. Raju M.D., F.A.S.G.E.

Authors
  1. Selvi Thirumurthi M.D., M.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gottumukkala S. Raju M.D., F.A.S.G.E.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gottumukkala S. Raju M.D., F.A.S.G.E. .

Editor information

Editors and Affiliations

  1. Division of Gastroenterology & Hepatology, University of Colorado, Denver, Aurora, Colorado, USA

    Norio Fukami

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer Science+Business Media New York

About this chapter

Cite this chapter

Thirumurthi, S., Raju, G.S. (2015). Management of Gastrointestinal EMR and ESD Perforation: From Lab to Practice. In: Fukami, N. (eds) Endoscopic Submucosal Dissection. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2041-9_17

Download citation

  • DOI: https://doi.org/10.1007/978-1-4939-2041-9_17

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-2040-2

  • Online ISBN: 978-1-4939-2041-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation