Percutaneous Endoscopic Cecostomy Research Articles

S2643 Percutaneous Endoscopic Cecostomy as Definitive Treatment in an Elderly Patient With Recurrent Ogilvie’s Syndrome

S2643 Percutaneous Endoscopic Cecostomy as Definitive Treatment in an Elderly Patient With Recurrent Ogilvie’s Syndrome

S187 Percutaneous Endoscopic Colostomy: A Systematic Review of More Than Two Decades Experience

Introduction: Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intracTable constipation, and neurogenic bowel. Traditional management of these conditions involving surgical colostomy or bowel resection in many cases has been replaced by percutaneous approaches under imaging or endoscopic guidance due to high rates of technical success and low morbidity rates. We conducted a systematic literature review to summarize the use, indications, and complications of PEC in adult patients. Methods: A systematic literature review was conducted using PubMed, Medline, Google Scholar, and Embase to identify patients who had undergone PEC for any indication. The search terms used were “percutaneous endoscopic colostomy”, “percutaneous endoscopic cecostomy”, “percutaneous cecostomy”, and “percutaneous colostomy”. Exclusion criteria were colostomy tubes that were not placed endoscopically. Results: A total of 11 observational studies (3 prospective, 8 retrospective), 18 case reports, and 7 case series between 1998 and 2022 were identified. A total of 318 patients who underwent PEC were identified. The mean age was 66.4 ± 23.5 and 64% were male. The most common indication was sigmoid volvulus (n= 131) followed by pseudo-obstruction (n=43), chronic intrac table constipation (n=83), neurogenic bowel (n=45), and others (n=9). The procedure was technically successful in 311 patients (97.7%). The total complication rate was 37.6%, 83.5% (n=66) of which were minor complications such as pain, bleeding, infection, leakage, and 16.4% (n=13) of which were major complications such as peritonitis, pneumoperitoneum, and sepsis. PEC-related mortality was 1.3% (n=4). The most common locations for tube placement were the left colon (59%) followed by right colon (13%), the rest of the cases the location was not reported. The number of tubes removed was 57, 8 due to symptom resolution, 3 for planned colostomy, and 1 for pain. (Figure) Conclusion: PEC is an underutilized procedure that offers a viable treatment alternative for select patients who are deemed high risk for surgical intervention and in whom conservative therapy is unsuccessful. It can lead to durable relief of symptoms with good technical success and low risk of major complications. Further prospective studies are needed to establish the optimal placement technique, long-term efficacy, and safety.Figure 1.: Percutaneous Endoscopic Colostomy tube indications

Laparoscopic-asisted percutaneus endoscopic cecostomy (LAPEC) in the treatment of severe constipation of adults - single center study.

Effective treatment for chronic constipation is a real clinical challenge, especially in patients with severe symptoms. If conservative measures do not help, usually subtotal colectomy with ileorectal anastomosis has been used as the treatment of choice for refractory slow-transit constipation, but consequences may unfavorably affect quality of life. Percutaneous endoscopic caecostomy (PEC) with antegrade colonic enema (ACE) is a minimally invasive alternative to avoid radical surgery in order to improve bowel movement. Recently, of various catheter placement techniques, a laparoscopic-assisted percutaneous endoscopic cecostomy has been applied in clinical praxis. We performed retrospective analysis of 5 patients with Chait Trapdoor catheter placed for purpose of ACE by LAPEC. Main outcome was to assess clinical success of PEC defined by an improvement of at least 50% of baseline KESS at 6M. Secondary outcomes were: procedural parameters and safety of procedure. Since may 2019 to march 2021, LAPEC was performed in 5 patients. Median follow-up was 14 months (7V12). All PECs were placed successfully in cecum. Treatment success reached 60% (3/5) of patients. Postoperative complication occurred in three patients. LAPEC provides both endoscopic and laparoscopic visualization, thereby, significantly decreasing potential risks by ensuring precise and safe access to the cecum. Antegrade colonic enema through PEC provides improvement of bowel movement in highly selected patient with severe symptoms.

Therapeutic utility of percutaneous cecostomy in adults: an updated systematic review.

Objective:Percutaneous cecostomy is a minimally invasive procedure that provides access to the colon for therapeutic interventions. This review aimed to update and summarize the existing information on the use and application of percutaneous endoscopic cecostomy in the field of therapeutic gastroenterology.Data Sources:A systematic review of the literature was performed without any restrictions on the year of publication from the date of inception in 1986 to January 2021.Methods:The review was performed using the medical subject heading keywords in the following search engines: MEDLINE, EMBASE, Cochrane, and Google Scholar.Results:A total of 29 articles were subjected to final data extraction. The review included a total of 174 patients who underwent percutaneous cecostomy. Most of the included studies were conducted in the United States (n = 14). The most common comorbidity was cancer (n = 10) and the major indication for performing percutaneous cecostomy was colonic pseudo-obstruction or Ogilvie’s syndrome (n = 15). The main technique for performing percutaneous cecostomy was endoscopy (17 studies), followed by fluoroscopy- (five studies), computed-tomography- (three studies), laparoscopy- (two studies), and ultrasound- (one study) guided procedures. The procedure was technically successful in 153 (88%) cases. The total cumulative rates of major and minor complications were 47.5%. These complications included tube malfunction, local wound site infections, and bleeding and rare complications of peritonitis and death.Conclusion:Percutaneous cecostomy is a safe and effective option for managing acute colonic pseudo-obstruction. It leads to durable symptom relief with low to minimal risk.

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

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 %.

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

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 %.

Primary placement of a skin-level Cecostomy Tube for Antegrade Colonic Enema Administration Using a Modification of the Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC)

PurposeChildren failing medical management for severe constipation and/or fecal incontinence may undergo surgical intervention for antegrade enema administration. We present a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure that allows primary placement of a skin-level device. MethodsA single-institution retrospective review was performed from 2009 to 2015. In the modified technique the colonoscope is advanced to the cecum, cecal suspension sutures are placed under laparoscopic visualization, and percutaneous needle puncture of the cecum is performed under direct laparoscopic and endoscopic visualization. A skin-level cecostomy tube is then placed over a guide wire. Patient characteristics and 30-day results were analyzed by Fisher's exact test. ResultsFifty-two patients underwent attempted LAPEC. Successful LAPEC using both laparoscopic and endoscopic guidance was achieved in 46 (88.5%). A MIC-KEY device was placed in 38. Corflo PEG tube placement was necessary in 14 due to high BMI (mean 28.4). Colonoscopy failed to reach the cecum in 6 and laparoscopy alone was utilized to achieve successful tube placement. Cecostomy site infections occurred in 3 (5.8%), only in those undergoing PEG placement using a pull technique (p < 0.05). ConclusionPrimary placement of a skin-level device was successful in the majority of patients undergoing cecostomy tube placement for bowel management utilizing antegrade colonic enemas. This technique avoids a second anesthesia for tube conversion. Visualization via colonoscopy with the use of cecal suspension sutures is recommended. High BMI necessitates initial placement of a PEG tube and complications exclusively occurred in this group. Type of StudyClinical. Level of EvidenceIV Case series study.

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

Total mesorectal excision and preoperative radiotherapy in mid and low rectal cancer allow us to achieve very good oncological results. However, major and refractory low anterior resection syndrome and fecal incontinence alter the quality of life of patients with a long expected life span. We assessed the functional results of patients treated by antegrade enema for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision. This is a prospective monocentric study from 2012 to 2016. Patients who underwent percutaneous endoscopic cecostomy for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision were prospectively analyzed. We assessed the morbidity of the procedure and compared low anterior resection syndrome score, Wexner score, and Gastrointestinal Quality of Life Index before and after the use of antegrade enema. Of 25 patients treated by antegrade enema over the study period, 6 (24%) had a low anterior resection, 18 (72%) had a coloanal anastomosis, and 1 (4%) had a perineal colostomy. Postoperatively, the rate of local abscess was 8%, all treated by antibiotics. Low anterior resection syndrome score (33 vs 4, p < 0.001), Wexner score (16 vs 4, p <0.001), and Gastrointestinal Quality of Life Index (73 vs 104, p < 0.001) were all significantly improved after antegrade enema. The 2 main symptoms reported by patients were sweating (28%) and local pain (36%). At the end of the follow-up, 16% (n = 4) catheters were removed, and the rate of definitive colostomy was 12% (n = 3). The main limitations of this study are the monocentric features and the sample size. Antegrade enema for major and refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision appears to be a promising treatment to avoid definitive colostomy. See Video Abstract at http://links.lww.com/DCR/A608.

Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC) in Children and Young Adults

ObjectiveWe evaluated the safety and efficacy of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure both in children and young adults, along with review of their pre-operative motility profiles, antegrade continence enema (ACE) regimen, and postoperative complications. MethodsThis retrospective review investigated 38 patients (32 children and 6 young adults) that underwent the LAPEC procedure. Primary outcomes evaluated were success versus failure of the procedure and post-operative complications. Success was defined as daily stool evacuation with minimal to no fecal incontinence per week. ResultsMean follow up time was 25.8±22.4 months. Indications for LAPEC included slow transit constipation or colonic neuropathy (n = 22), other types of constipation (n = 5), and a variety of congenital disorders (n = 11). The overall success rate was 95% (36/38 patients) with the two failures in children, both attributed to inability to use the tube due to underlying behavioral disorders or severe anxiety. Five patients above age 18 had leakage compared to 6 in the under age 18 group (83% vs. 19, P = 0.003). There were no other significant complications. ConclusionLAPEC is a safe and effective means of addressing refractory constipation and fecal incontinence in children and young adults who have failed medical management with minimal post-operative complications.

頸髄損傷後の高度排便障害に対して内視鏡的盲腸瘻造設と順行性浣腸が奏功した一例

頸髄損傷後の高度排便障害に対して内視鏡的盲腸瘻造設と順行性浣腸が奏功した一例

Percutaneous Endoscopic Cecostomy (PEC) Tube Placement: A Case Series

Purpose: Percutaneous cecostomy (PEC) placement has been used to treat recurrent colonic pseudobstruction, colonic atony or obstipation in children since it was first described in the 1980s. However, its role in the adult patient population for similar indications or palliation has yet to be defined. There have only been a few published case reports of successful PEC placement in adults. We report our experience with PEC placement in two adult patients at our institution with colonic atony and dilated colons (Figure A). Methods: With the patient in the supine position, a site was identified in the ascending colon with external transillumination and corresponding indentation on endoscopy in the right lower quandrant. The abdominal wall was marked and prepped in a sterile manner. After a local anesthetic (1% lidocaine) was injected a 22 Gauge needle was advanced under endoscopic visualization into the colon lumen followed by advancement of the trocar needle directly adjacent to the 22 Gauge needle. A snare was introduced through the endoscope and opened in the colonic lumen. The guide wire was passed through the trocar and into the open snare (Figure B). The snare was closed around the guide wire. The endoscope and snare were removed, pulling the wire out through the anus. A skin incision was made at the site of needle insertion. The externally removable Kimberly Clark 20 Fr gastrostomy tube was lubricated and tied to the guide wire and subsequently pulled through the anus and into the colon. The trocar needle was removed, and the colostomy tube was pulled out from the colon through the skin. The external bumper was attached to the colostomy tube, and the tube was cut to remove the guide wire. The final position of the cecostomy tube was confirmed endoscopically (Figure C) and subsequently with an abdominal X-ray (Figure D). The tube was capped and sutured into place externally with 2 vicryl 2.0 sutures, and the tube site was cleaned and dressed. Results: In the cases described above, a colonoscopy was performed without difficulty and successful PEC placement was achieved using the modified PEG pull technique with relative ease. Our patients did well post procedure with complete resolution of their symptoms and were discharged with no active issues secondary to PEC placement. This illustrates how PEC tube placement can be used to safely manage adult patients with colonic atony in day to day practice. Conclusion: PEC is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. Further study in a prospective fashion needs to be performed to further outline its clinical indications, therapeutic possibilities, and potential complications.

Cecostomia endoscópica percutânea na incontinência fecal em adolescentes

Fecal incontinence is common in children with ano-rectal malformations and spina bifida being a disturbing cause of life quality and social integration. Medical treatments (laxatives, enemas, daily habits and diet attitudes) are frequently unsuccessful. Many surgical therapies have been proposed to treat this condition but all of them are far away from being the best treatment option. We report a case of a 17 years-old adolescent with spina bifida and fecal incontinence that has been submitted to percutaneous endoscopic cecostomy. Even though it is not the ideal treatment for this condition, it revealed to be a good option: it's easy and safe to perform; provides a successful management of fecal continence and it's associated with high satisfaction from the adolescent and its family.

Advances and Challenges in the Management of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)

Although acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a well-known clinical entity, in many respects it remains poorly understood and continues to challenge physicians and surgeons alike. Our understanding of ACPO continues to evolve and its epidemiology has changed as new conditions have been identified predisposing to ACPO with critical illness providing the common thread among them. A physician must keep ACPO high in the list of differential diagnoses when dealing with the patient experiencing abdominal distention, and one must be prepared to employ and interpret imaging studies to exclude mechanical obstruction. Rapid diagnosis is the key, and institution of conservative measures often will lead to resolution. Fortunately, when this fails pharmacologic intervention with neostigmine often proves effective. However, it is not a panacea: consensus on dosing does not exist, administration techniques vary and may impact efficacy, contraindications limit its use, and persistence and or recurrence of ACPO mandate continued search for additional medical therapies. When medical therapy fails or is contraindicated, endoscopy offers effective intervention with advanced techniques such as decompression tubes or percutaneous endoscopic cecostomy providing effective results. Operative intervention remains the treatment of last resort; surgical outcomes are associated with significant morbidity and mortality. Therefore, a surgeon should be aware of all options for decompression-conservative, pharmacologic, and endoscopic-and use them in best combination to the advantage of patients who often suffer from significant concurrent illnesses making them poor operative candidates.

Laparoscopic-assisted percutaneous endoscopic cecostomy in children with defecation disorders (with video)

The antegrade continence enema (ACE) procedure has been widely used in the management of children with defecation disorders. The ACE procedure has undergone many technical modifications. We developed a safe and minimally invasive technique, the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC). To compare LAPEC to laparoscopic cecostomy in terms of operative time, hospital length of stay, and procedure-related morbidity. Retrospective review of children undergoing the ACE procedure. Two tertiary-care centers. This study involved children with defecation disorders. The ACE procedure. Procedure complications, length of stay, and operative time. Fifty patients underwent LAPEC, and 15 underwent laparoscopic cecostomy. Of the LAPEC patients, 70% were male, with mean age 12 ± 4.2 years, mean operative time 100.1 ± 16.6 minutes, and mean length of stay 3.4 ± 1.4 days. Of the laparoscopic cecostomy patients, 56% were male, with mean age 10.5 ± 4 years, mean operative time 100.8 ± 19.1 minutes, and mean length of stay 3.8 ± 1.6 days. There was no statistical difference between the 2 groups. The single intraoperative complication during LAPEC was a cecal hematoma. Postoperative complications after LAPEC included 6 patients with low-grade fever, 3 patients with tube dislodgement (2 treated by repeat LAPEC and the other by open surgery), and 2 patients with skin breakdown. Of the 50 LAPEC patients and their families, 48 were satisfied with the outcome. Retrospective study. LAPEC is a safe, minimally invasive procedure for cecostomy placement in children with refractory constipation or fecal incontinence.

Buried bumper syndrome arising from a percutaneous endoscopic cecostomy tube

Buried bumper syndrome (BBS) is a well-recognized complication of PEG placement caused by excessive outward traction on the tube. It can develop 1 to 50 months after tube insertion and is manifested by difficulty in feeding; peristomal leakage, bulging, and pain; and skin breakdown.1,2 Treatment involves manual or endoscopic removal of the tube with replacement, if needed.1,3 To our knowledge, this is the first case of BBS arising in a patient with a percutaneous endoscopic cecostomy (PEC) tube.

A case of hepatic encephalopathy successfully treated by antegrade glycerin enema through percutaneous endoscopic cecostomy

A case of hepatic encephalopathy successfully treated by antegrade glycerin enema through percutaneous endoscopic cecostomy

Palliative Use of Percutaneous Endoscopic Gastrostomy and Percutaneous Endoscopic Cecostomy Tubes

Percutaneous endoscopic gastrostomy (PEG) tubes are most commonly placed for feeding purposes with the intention of maintenance or improvement in nutritional status; however, they may also be used in a palliative role in patients who have terminal illnesses for feeding or decompression. Percutaneous endoscopic cecostomy (PEC) tubes can be used to decompress malignant and functional bowel disorders with accepted morbidity and mortality. This article reviews the use of PEG and PEC tubes for palliative use.

Fecal incontinence treated with percutaneous endoscopic cecostomy

Fecal incontinence is a socially devastating disorder in adults [1] [2]. We report here a case in which percutaneous endoscopic cecostomy (PEC) was carried out for antegrade colon irrigation in a patient with fecal incontinence.

Percutaneous endoscopic cecostomy in adults: a case series

Percutaneous cecostomy is used to treat recurrent colonic pseudoobstruction or obstipation in children and adults with multiple medical comorbidities. Percutaneous endoscopic cecostomy is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. A few reports describe percutaneous endoscopic cecostomy for management of these problems in children, whereas there are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, complications, and outcomes. Report our experience with percutaneous endoscopic cecostomy in adults. Case series. Single tertiary referral center in the United States. Five patients with recurrent colonic pseudoobstruction and 2 with chronic refractory constipation. Percutaneous endoscopic cecostomy. Eight cases of percutaneous endoscopic cecostomy were performed from May 2001 through October 2005: 6 for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. One patient required surgical removal of the percutaneous endoscopic cecostomy tube at 4 days for fecal spillage resulting in peritonitis despite successful tube placement for chronic constipation. Removal of the cecostomy tube occurred in 3 of 6 cases of pseudoobstruction (the other 3 remain in place). In the other patient with chronic constipation, clinical improvement occurred, but the patient died of underlying illness 21 days after placement. No other serious complications occurred. Retrospective, single-center study. Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in a select group of patients with recurrent colonic pseudoobstruction or chronic intractable constipation.

Percutaneous Endoscopic Cecostomy in Adults: A Case Series

Background: Percutaneous cecostomy has been reported for treatment of recurrent colonic pseudoobstruction or obstipation. Percutaneous endoscopic cecostomy (PEC) is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. Two reports describe percutaneous endoscopic cecostomy for management of these problems in children. There are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, outcomes and complications. Observations: We performed a retrospective review of eight cases of PEC performed from May 2001 through October 2005 at the University of Utah Health Sciences Center.