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Evidence review for postoperative recovery in specialist areas
Evidence review M
NICE Guideline, No. 180
National Guideline Centre (UK).
1. Postoperative management and recovery
1.1. Review question: What is the clinical and cost effectiveness of postoperative recovery in specialist areas, including intensive care, for adults?
1.2. Introduction
Decisions about post-operative destinations for patients undergoing surgery usually fall into two categories. Straightforward, clear-cut decisions where the complexity of the patient comorbidities, the magnitude of the surgery, or both, mandate that the patient requires a higher level of post-operative scrutiny and thus requires a specialist area (high dependency or intensive care) rather than a routine ward. Similarly the lack of the same clearly directs the patient to routine care in a ward environment with no requirement for particular or bespoke observation.
The second category however is much more complex. Patients with varying degrees of complexity undergoing routine procedures, or well patients undergoing complex or major surgeries and any combination of the same form a large population group where decisions about post-operative care requirements become opaque and difficult to define. Clinicians have an obligation not only to clarify how best to manage this group of patients from a care point of view but furthermore must make decisions about appropriateness of resource allocation. Particularly when the resource is limited and comes at a significant financial cost. Specialist areas are both.
Although the first category of patients allow fairly easy decision making on specialist area allocation, this second larger group suffers from a lack of a uniform standards and there exists no national guidance to support such decisions. Usually subjective, non-uniform decisions are taken about this group of patients which leads to two sequelae. Over-triage of resources occurs with significant financial implications. Or under-triage takes place where patients later need to be moved to specialist areas whilst having potentially suffered avoidable complications.
It is thus necessary to determine the patient population that will benefit from recovery in specialist areas thereby allowing appropriate triage of patients to correct areas in the hospital and responsible resource allocation during perioperative planning for what is an expensive and limited resource.
1.3. PICO table
For full details see the review protocol in appendix A.
Table 1
PICO characteristics of review question.
1.4. Clinical evidence
1.4.1. Included studies
Four studies were included in the review.1, 3, 16, 17 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).
See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix F.
1.4.2. Excluded studies
See the excluded studies list in appendix I.
1.4.3. Summary of clinical studies included in the evidence review
Table 2
Summary of studies included in the evidence review.
See appendix D for full evidence tables.
1.4.4. Quality assessment of clinical studies included in the evidence review
Table 3
Clinical evidence summary: ICU compared to PACU for adults undergoing surgery – high risk; elective surgery.
Table 4
Clinical evidence summary: ICU compared to surgical ward for adults undergoing surgery – high risk; elective & emergency surgery.
Table 5
Clinical evidence summary: ICU compared to surgical ward for adults undergoing surgery – high risk; elective surgery.
Table 6
Clinical evidence summary: HDU compared to surgical ward for adults undergoing surgery – low/intermediate risk; elective surgery.
See appendix F for full GRADE tables.
Table 7
Evidence not suitable for GRADE analysis: ICU compared to PACU/specialty ward – high risk; elective surgery.
Table 8
Evidence not suitable for GRADE analysis: ICU compared to surgical ward – high risk; elective & emergency surgery.
Table 9
Evidence not suitable for GRADE analysis: ICU compared to surgical ward – high risk; elective surgery.
Table 10
Evidence not suitable for GRADE analysis: HDU compared to surgical ward – low/intermediate risk; elective surgery.
1.5. Economic evidence
1.5.1. Included studies
Two health economic studies were identified with the relevant comparison and have been included in this review.7, 17 These are summarised in the health economic evidence profiles below (Table 11 - Table 12) and the health economic evidence table in appendix H.
1.5.2. Excluded studies
No health economic studies that were relevant to this question were excluded due to assessment of limited applicability or methodological limitations.
See also the health economic study selection flow chart in appendix G.
1.5.3. Summary of studies included in the economic evidence review
Table 11
Health economic evidence profile: Intensive care unit versus general ward.
Table 12
Health economic evidence profile: High dependency unit versus general ward.
1.5.4. Unit costs
Relevant unit costs are provided below to aid consideration of cost effectiveness.
Table 13
UK costs of hospital stay.
1.6. Evidence statements
1.6.1. Clinical evidence statements
No evidence was found for health-related quality of life, hospital readmission, postponed/cancelled surgery, and patient/family/carer experience of care.
ICU compared to PACU for adults undergoing surgery – high risk; elective
Mortality
One study found no clinically important difference of PACU compared to ICU on mortality (1 study, n=244, low quality evidence).
Outcomes not suitable for GRADE analysis
One study found a statistically significant benefit with PACU for length of hospital stay compared to ICU (1 study, n=244, high risk of bias).
One study found no statistically significant difference between PACU and ICU for complications (1 study, n=244, high risk of bias).
ICU compared to surgical ward for adults undergoing surgery – high risk; elective & emergency
Mortality
One study found a clinically important difference in mortality between ICU and surgical ward care. Mortality was significantly higher in people treated in ICU (1 study, n=61, very low quality evidence).
Adverse events
One study found a clinically important difference in post-operative complications between ICU and surgical ward care. Complication rate was significantly higher in people treated in ICU (1 study, n=61, low quality evidence).
Outcomes not suitable for GRADE analysis
One study found length of hospital stay was statistically significantly less with surgical ward care compared to ICU (1 study, n=61, very high risk of bias)
ICU compared to surgical ward for adults undergoing surgery – high risk; elective
Mortality
One study found a clinically important difference in mortality between ICU and surgical ward care. Mortality was significantly higher in people treated in ICU (1 study, n=90, very low quality evidence).
Adverse events
One study found a clinically important difference in post-operative complications between ICU and surgical ward care. Cardiac complication rate was significantly lower in people treated in ICU (1 study, n=90, low quality evidence).
Outcomes not suitable for GRADE analysis
One study found not statistically significant difference in length of hospital stay was between surgical ward care and ICU (1 study, n=90, high risk of bias)
1.6.2. Health economic evidence statements
- One cost-utility analysis found that ICU was cost effective compared to a general ward (ICER: £8794 per QALY gained in planned surgery; ICER: £7,932 per QALY gained in acute surgery). This analysis was assessed as partially applicable with potentially serious limitations.
- One cost-consequence analysis found that HDU was cost-saving compared to a general ward (cost saving: £350) and reduced mortality and emergency laparotomy. This analysis was assessed as partially applicable with potentially serious limitations.
1.7. The committee’s discussion of the evidence
Please see recommendation 1.5.1 in the guideline.
1.7.1. Interpreting the evidence
1.7.1.1. The outcomes that matter most
The committee agreed that appropriate triage of patients to specialist recovery areas can reduce postoperative morbidity. As such, all-cause mortality, health-related quality of life, adverse events and complications, and unplanned intensive care admission/readmission were considered as the critical outcomes for decision making. The following outcomes were identified as important for postoperative recovery in specialist areas: length of hospital stay, hospital readmission, postponed/cancelled surgery, and patient/family/carer experience of care.
No evidence was found for health-related quality of life, hospital readmission, postponed/cancelled surgery, and patient/family/carer experience of care.
1.7.1.2. The quality of the evidence
All of the evidence included in this review was derived from non-randomised studies. As such, there was an inherent increased risk of bias associated with the evidence presented and a subsequent lower quality grade associated. The committee suggested that the observational nature of the included studies may have allowed for the comparison of disparate populations, with people receiving care in specialist recovery areas likely to have been less well than those seen in general wards.
The quality of evidence that was suitable for GRADE analysis ranged from very low to low. The majority of the evidence was graded at low quality. This was mostly due to study design and imprecision of results.
Outcomes which were not suitable for GRADE analysis were considered to be a high and very high risk of bias.
1.7.1.3. Benefits and harms
The committee discussed the evidence from three studies on postoperative recovery in specialist areas for high risk patients undergoing elective surgery.
One study compared recovery in an ICU to recovery in a PACU followed by transfer to a specialty recovery ward. The committee agreed that there was no notable difference in mortality or complications between people treated in ICU or PACU/specialty ward. The committee also noted that the evidence showed that length of stay was statistically longer in patients treated in an ICU, but felt the difference observed was not of clinical significance.
A second study retrospectively compared high risk patients treated in and ICU to those seen in a surgical recovery ward. The evidence from this study suggested that those treated in an ICU experienced a greater risk of mortality, perioperative complications and increased length of stay. The committee noted that patients not admitted to ICU met fewer of the criteria considered to demonstrate a necessity of ICU care. Patients admitted to ICU also had higher ASA and POSSUM scores prior to surgery, indicating a difference in baseline health between the two comparison groups. The committee felt these differences were significant and contributed towards the differences in the outcomes.
The final study compared patients treated in an ICU to those receiving care in a surgical recovery ward after surgery. There was evidence of an increased risk of mortality for patients treated in ICU compared to surgical recovery ward after elective surgery. The study also saw those treated in the ICU were at significantly less risk of experiencing cardiac complications. The committee suggested that this reduced risk of cardiac events echoed their experience of care in specialist areas and could strengthen the support for care in specialty areas for people at increased risk of such complications.
The committee also discussed the evidence from one study on postoperative recovery in specialist areas for low to intermediate risk patients undergoing elective surgery. The evidence from this study showed no significant difference in mortality between patients receiving postoperative care in a HDU or a surgical ward. The study did report that those cared for in the surgical ward were significantly more likely to experience the postoperative complication of anastomotic leak. 16% of those cared for in a surgical ward were subsequently transferred to receive critical care, although the committee highlighted that there was no valid way to compare this result relatively to the HDU group already receiving critical care.
The committee agreed that on the whole, the observational data was too significantly confounded by baseline differences in population health to direct any decision making on the location of post-operative care. The committee discussed the benefits such as improved quality of life and reduced incidence of adverse events with a more focussed care in specialist recovery areas. The committee based a recommendation based on this consensus agreement.
1.7.2. Cost effectiveness and resource use
Two economic evaluations were identified for this question. One study was a cost-utility analysis and one was a cost-consequence analysis.
One economic evaluation from Norway identified compared individuals admitted to intensive care units with individuals hypothetically rejected from ICU and receiving care in a general ward. The study was a cost-utility analysis and the model was run separately for over 30,000 individuals, based on individuals from the Norwegian Intensive Care Registry. Results were presented for both acute and planned surgery. Intensive care unit costs were higher than the general ward costs but also generated more QALYs. The cost per QALY gained was £7,932 and £8,794 for acute and planned surgery, respectively. This study was assessed as partially applicable with potentially serious limitations. This was because it was unclear what valuation method was used to measure quality of life, costs included in the model for ICU and general ward stay were much higher than NHS costs and therefore less applicable and it was unclear if complications were included in the model.
One study conducted a cost-consequence analysis based on a single cohort study in the UK. This study followed people undergoing colorectal surgery with a 1–3% risk of 30 day mortality and admitted them to a general ward or high dependency unit. The study showed that the high dependency unit was cost saving and led to lower mortality and complications. This study was rated as partially applicable with potentially serious limitations. Reasons for this rating included: the measure of effect not being in line with the NICE reference as they did not report QALYs, baseline and treatment effects were based on a single study and a small number of people and the source of unit costs were based on the payment by results tariff which does not capture the actual costs incurred by the NHS.
The committee agreed that the cost-utility analysis presented could not help them make a recommendation with regards to intensive care units as they felt that it demonstrated intensive care was cost-effective for those who needed to be admitted to ICU but did not demonstrate who these patients were. Although the cost-consequence analysis was conducted in the UK, it was based on a small study conducted at a single hospital and did not fully capture costs.
The committee felt that it was appropriate to admit adults to ICU if they are definitely high risk, but that there was less clarity around adults who are medium risk (ASA grade 2 or 3). In some circumstances, elective patients can be admitted to ICU when it is not necessary which can result in a longer recovery time for the patient and a waste of a scarce and expensive resource. It was agreed that these patients are better off recovering on a general ward as these cases would result in a high cost to the NHS at no additional benefit. From an emergency surgical perspective, there are adults who would benefit from being in ICU but because there are no beds available, they end up on a general ward and their recovery is disadvantaged. The committee discussed that there are limited beds available in ICU and that adults can end up staying in postoperative recovery longer than necessary until there is an available bed. This can have a negative knock-on effect for those waiting to have surgery as their surgery can be cancelled.
Since 2011/12 the number of people admitted to critical care (HDU and ICU) in the NHS has increased by 22.5% (Hospital admitted patient care activity, 2016–17), however, this is the overall figure for medical and surgical patients. Those that have undergone a surgical or anaesthetic procedure make up 43.2% of critical care unit admissions. The average cost of a day in intensive care for surgery is very high costing £1,384. For those admitted to a high dependency unit the cost is £707 per day. For those remaining on a general ward the estimated average cost is £407 per day. Therefore, there are considerable differences in the costs of each of these recovery areas, emphasising the need to ensure that the correct adults are being sent to intensive care.
The committee made a recommendation for people who are at a high risk of complications or mortality and agreed that this was current good practice. There may be some hospitals or specialities that are not using specialist recovery areas for these people and therefore this may have a substantial resource impact for the NHS due to the large number of people affected. For people who are undergoing surgery who are not at high risk, the committee agreed that further evidence would be required to guide practice when it is uncertain whether people would benefit from a specialist recovery area and made a research recommendation.
1.7.3. Other factors the committee took into account
The committee recognise that monitoring is continued into the postoperative period.
The committee agreed that it is challenging to determine the effectiveness of postoperative care in specialist areas given that most people requiring care in specialist areas will be very unwell and it would be unethical to deny these people the care they may need in ICU. The committee agreed any further research would likely need to be conducted with an ill-defined population of patients who do not clearly fulfil the criteria for level two or above care.
The committee also noted that the decision as to where a person receives postoperative care can be subjective and dependant on other variables such as bed availability in specialist recovery areas. In addition, the committee noted that National Emergency Laparotomy Audit recommends consideration of admission to critical care for all high risk patients with a predicted mortality ≥5%. The committee therefore made a recommendation that people who are at risk of complications or mortality should receive postoperative care in specialist areas. This is consistent with current practice.
It was felt that there are clear examples of when people are well enough to be treated postoperatively in a general ward and when people are unwell to the extent where postoperative treatment within an ICU is necessary. However, there is a large group of patients where it is not clear whether they will benefit from the input of specialist teams in specialist areas. Given this is an expensive and limited resource it would be helpful if there was evidence to guide decision making for this patient population. Specifically because there is some variation in current practice regarding where people receive care postoperatively. The committee therefore made a research recommendation.
References
- 1.
- Arshad H, Ozer HG, Thatcher A, Old M, Ozer E, Agarwal A et al. Intensive care unit versus non-intensive care unit postoperative management of head and neck free flaps: comparative effectiveness and cost comparisons Head and Neck. 2014; 36(4):536–539 [PubMed: 23780531]
- 2.
- Carter AJ, Deselms J, Ruyle S, Morrissey-Lucas M, Kollar S, Cannon S et al. Postanesthesia care unit visitation decreases family member anxiety. Journal of Perianesthesia Nursing. 2012; 27(1):3–9 [PubMed: 22264615]
- 3.
- Curran JE, Grounds RM. Ward versus intensive care management of high-risk surgical patients. British Journal of Surgery. 1998; 85(7):956–961 [PubMed: 9692572]
- 4.
- Dalziel K. Postoperative management in the recovery room compared to ICU for cardiac surgery patients. Clayton, Victoria. Centre for Clinical Effectiveness, 2001.
- 5.
- de Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The utility of routine intensive care admission for patients undergoing intracranial neurosurgical procedures: A systematic review. Neurocritical Care. 2018; 28(1):35–42 [PubMed: 28808901]
- 6.
- Department of Health. NHS reference costs 2017–18. 2017. Available from: https://improvement
.nhs .uk/resources/reference-costs/#rc1718 Last accessed: 02/08/2019 - 7.
- Lindemark F, Haaland OA, Kvale R, Flaatten H, Norheim OF, Johansson KA. Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis. Critical Care. 2017; 21:220 [PMC free article: PMC5567919] [PubMed: 28830479]
- 8.
- Lone NI, Gillies MA, Haddow C, Dobbie R, Rowan KM, Wild SH et al. Five-year mortality and hospital costs associated with surviving intensive care. American Journal of Respiratory and Critical Care Medicine. 2016; 194(2):198–208 [PMC free article: PMC5003217] [PubMed: 26815887]
- 9.
- National Institute for Health and Care Excellence. Developing NICE guidelines: the manual, updated 2018. London. National Institute for Health and Care Excellence, 2014. Available from: https://www
.nice.org .uk/process/pmg20/chapter /introduction-and-overview [PubMed: 26677490] - 10.
- NCT. Trial comparing perioperative care for breast cancer patients at a patient hotel vs a general surgical ward [NCT02403973]. 2015. Available from: Https:
//clinicaltrials .gov/show/nct02403973 Last accessed: 21/08/2018 - 11.
- NCT. Use of a non-ICU specialty ward for immediate post-operative management of head and neck free flap [NCT03340038]. 2017. Available from: Https:
//clinicaltrials .gov/show/nct03340038 Last accessed: 21/08/18 - 12.
- NHS Digital. Hospital admitted patient care activity, 2016–17. 2017. Available from: https://digital
.nhs.uk /data-and-information /publications/statistical /hospital-admitted-patient-care-activity/2016-17 - 13.
- Organisation for Economic Co-operation and Development (OECD). Purchasing power parities (PPP). Available from: http://www
.oecd.org/sdd/prices-ppp/ Last accessed: 17/06/2019 - 14.
- Pedoto A, Heerdt PM. Postoperative care after pulmonary resection: Postanesthesia care unit versus intensive care unit. Current Opinion in Anaesthesiology. 2009; 22(1):50–55 [PubMed: 19295292]
- 15.
- Shan LQ, Skaggs DL, Lee C, Kissinger C, Myung KS. Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis. Journal of Bone and Joint Surgery American volume. 2013; 95(7):e40 [PubMed: 23553303]
- 16.
- Swart M, Carlisle JB. Case-controlled study of critical care or surgical ward care after elective open colorectal surgery. British Journal of Surgery. 2012; 99(2):295–9 [PubMed: 22101443]
- 17.
- Swart M, Carlisle JB, Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study. British Journal of Anaesthesia. 2017; 118(1):100–104 [PubMed: 28039247]
- 18.
- Turner J. Randomised controlled trial of a high dependency unit in the post-operative care of patients with fractured neck of femur. A cautionary tale. University of York. 2002. Ph.D.
- 19.
- Turner J, Gemmell LW. Are high dependency units effective and efficient? A systemic review of the evidence. Clinical Intensive Care. 2003; 14(3–4):123–133
- 20.
- Vester-Andersen M, Waldau T, Wetterslev J, Moller MH, Rosenberg J, Jorgensen LN et al. Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial). British Journal of Surgery. 2015; 102(6):619–29 [PubMed: 25789827]
- 21.
- White PF. PACU fast-tracking: an alternative to “bypassing” the PACU for facilitating the recovery process after ambulatory surgery. Journal of Perianesthesia Nursing. 2003; 18(4):247–253 [PubMed: 12923752]
Appendices
Appendix A. Review protocols
Table 14. Review protocol: enhanced recovery programmes (PDF, 181K)
Appendix B. Literature search strategies
The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual 2014, updated 2018.9
For more detailed information, please see the Methodology Review.
B.1. Clinical search literature search strategy
Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.
B.2. Health Economics literature search strategy
Health economic evidence was identified by conducting a broad search relating to the perioperative care population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional health economics searches were run on Medline and Embase.
Appendix C. Clinical evidence selection
Appendix D. Clinical evidence tables
Download PDF (157K)
Appendix E. Forest plots
E.1. ICU compared to PACU – high risk; elective surgery
E.2. ICU compared to surgical ward – high risk; elective & emergency
E.3. ICU compared to surgical ward – high risk; elective
E.4. HDU compared to surgical ward – low/intermediate risk; elective
Appendix F. GRADE tables
Appendix G. Health economic evidence selection
Figure 9. Flow chart of HE study selection for the review of specialist recovery areas
Appendix H. Health economic evidence tables
Download PDF (154K)
Appendix I. Excluded studies
I.1. Excluded clinical studies
I.2. Excluded health economic studies
Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2003 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.
Appendix J. Research recommendations
J.1. Specialist recovery areas
Research question: Which patients, other than those known to have a high risk of complications or mortality, would benefit from postoperative care in a specialist recovery area (a high-dependency unit, a post-anaesthesia unit or an intensive care unit)?
Why this is important:
The increasing medical complexity of patients presenting for surgery and the vast array of surgical procedures possible are changing the landscape of perioperative care. The needs of such patients in the post-operative phase (during which most complications and factors relating to poor outcomes occur) can be highly diverse depending on these patient factors and the nature of their surgery. Rationalising the limited resources of specialist areas is additionally a key imperative. Predicting pre operatively which patients will require specialist recovery areas is an inexact science and supported by limited evidence. A better understanding of this would allow more rational, bespoke and cost effective solutions for resource allocation while ensuring appropriate care levels are correctly provided.
Criteria for selecting high-priority research recommendations
Final
Evidence reviews underpinning recommendation 1.5.1 and the research recommendation in the NICE guideline
This evidence review was developed by the National Guideline Centre
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.
Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Critical Care Network in the State of Qatar.[Qatar Med J. 2019]Critical Care Network in the State of Qatar.Hijjeh M, Al Shaikh L, Alinier G, Selwood D, Malmstrom F, Hassan IF. Qatar Med J. 2019; 2019(2):2. Epub 2019 Nov 7.
- The future of Cochrane Neonatal.[Early Hum Dev. 2020]The future of Cochrane Neonatal.Soll RF, Ovelman C, McGuire W. Early Hum Dev. 2020 Nov; 150:105191. Epub 2020 Sep 12.
- Macromolecular crowding: chemistry and physics meet biology (Ascona, Switzerland, 10-14 June 2012).[Phys Biol. 2013]Macromolecular crowding: chemistry and physics meet biology (Ascona, Switzerland, 10-14 June 2012).Foffi G, Pastore A, Piazza F, Temussi PA. Phys Biol. 2013 Aug; 10(4):040301. Epub 2013 Aug 2.
- Review Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions.[Emerg Med Clin North Am. 2002]Review Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions.Burkle FM Jr. Emerg Med Clin North Am. 2002 May; 20(2):409-36.
- Review Pretherapeutic evaluation of patients with upper gastrointestinal tract cancer using endoscopic and laparoscopic ultrasonography.[Dan Med J. 2012]Review Pretherapeutic evaluation of patients with upper gastrointestinal tract cancer using endoscopic and laparoscopic ultrasonography.Mortensen MB. Dan Med J. 2012 Dec; 59(12):B4568.
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