Who should be responsible for sedation techniques in digestive endoscopy?
Our point of view

A. Lancho Seco, J. J. Fernández Seara¹ and L. López Rosés

Department of Digestive Diseases. Complexo Hospitalario Xeral Calde. Lugo. ¹Complexo Hospitalario de Ourense. Spain

---

Lancho Seco A, Fernández Seara JJ, López Rosés L. Who should be responsible for sedation techniques in digestive endoscopy? Our point of view. Rev Esp Enferm Dig 2005; 97: 395-404.

---

Recibido: 09-05-05.
Aceptado: 12-05-05.

Correspondencia: Ángel Lancho Seco. Servicio de Aparato Digestivo. Complexo Hospitalario Xeral Calde. C/ Doctor Severo Ochoa, s/n. 27004 Lugo

 

Revista Española de Enfermedades Digestivas publishes in its January 2005 issue an original paper authored by five gastroenterologists on behalf of Sociedad Gallega de Patología Digestiva (1). This paper reports the results of an enquiry to endoscopists carried out by this Society on sedation practices in Endoscopy Units across Galicia. In 85% of these Units, endoscopists administered sedation with varying frequency depending on the type of procedure.

An accompanying editorial asks who should be responsible for sedation techniques in digestive endoscopy. The authors' reply to this question is, literally, "consensus exists (sic) on the fact that specialists in anesthesiology and resuscitation should perform these techniques (sedation)" (2). The authors further claim that the practice of sedation without "a specialist degree (in Anesthesiology and Resuscitation) may not only result in a violation of (the) 'lex artis ad hoc' - and hence in civil liability - but also in criminal liability". And they conclude, "Obviously in this scenario (the practice of sedation without a specialist's degree in Anesthesiology and Resuscitation), healthcare professionals (…) commit a criminal deed of professional intrusion, as typified in Art. 403 under the criminal law in force". These statements seriously question standard practice for many endoscopists not only in Galicia but also in the rest of the country by claiming that this standard practice is indeed punishable by criminal law.

The undersigned include 311 qualified specialist pshysicians from every one of the 52 provinces in the country who perform endoscopy procedures in 110 different hospitals, either private or public, including teaching hospitals from 16 different Regional Health Services within Spain. We consider these statements mistaken, based o no scientific grounds, and of potentially serious consequences. We wish to express our firm disagreement with these statements, both in form and substance.

WE DISAGREE IN FORM

1. We believe that the publication of a paper lacking so much in scientific rigor -as we shall later prove- as an Editorial in Revista Española de Enfermedades Digestivas bestows on it undeserved merit. We are well aware that this writing only represents its two authors' opinions, and that it is solely them who should be held responsible for what it expresses. However, the reputation and wide circulation of Revista Española de Enfermedades Digestivas -Official Journal of Sociedad Española de Patología Digestiva and Sociedad Española de Endoscopia Digestiva, of which many of the undersigned are members- gives a scientifically groundless personal opinion unwarranted influence.

2. Without questioning the editorialists' merits in other fields, we feel there is no lack of adequately qualified professionals in our community to editorialize on sedoanalgesia in endoscopy, be it anesthesiologists working closely with endoscopists or gastroenterologists having published original scientific papers. They might have provided a more realistic view on the use of sedatives and analgesics. Indeed, besides its lack of scientific rigor and inconsistency with previous literature, this Editorial is conspicuous for being out of tune with routine clinical practice. It is otherwise difficult to understand the authors' claim that certain intravenous drugs such as benzodiazepines or meperidine -most commonly used for sedation in endoscopy- should only be given by anesthesiologists. As anyone doing clinical work knows, these drugs are used by hospital physicians of different specialties on a daily basis. And this, of course, includes the non-endoscopic clinical work of gastroenterologists. Is then an anesthetist needed to administer 50 or 100 mg of i.v. meperidine to a patient with acute pancreatitis? Should we request the on-call anesthetist to take care of every agitated patient in need of some sedation?

3. We think it irresponsible, and seriously so, to pillory a great number of Spanish endoscopists by stating -in their own specialty Journal- that they are incurring in criminal liability in their daily practice just by using sedation and analgesia in endoscopic procedures without an attending anesthesiologist.

Such a gratuitous statement may obviously cause serious harm to any endoscopist facing a case in Court, even more so considering where it has been published. Although we are very well aware that this no official position of Sociedad Española de Patología Digestiva, Sociedad Española de Endoscopia Digestiva, or the Journal Editorial Board, in order to prevent wrong interpretations by the lay public, who are less familiar with the nuances of medical publishing, we would appreciate a public statement from the Directing Boards of these two Societies and some comment by the Journal Editorial Board.

WE DISAGREE IN SUBSTANCE

1. The editorialists ask who should be responsible for sedation in endoscopy. They flatly conclude that this pertains only to qualified anesthesiologists.

This statement is not in keeping with the available scientific evidence. A quick look at articles or guidelines on the topic amongst the many already published in well-respected national or international journals suffices to prove it. Some of these articles are referenced by the editorialists, in spite of the fact that sedation and analgesia as performed by the endoscopist is presented as the norm in all of them. This is flagrant inconsistency, and further shows the lack of foundation entailed by the editorialists' claim. Checking up the literature is essential to tell the difference between a legitimate controversial opinion and an assertion which not only contradicts standard practice, but also negates the value of previous literature. This assertion is thus untenable. Since this is the crux of the matter, we will examine in some detail the references provided by the authors. Here are some examples:

a. The first reference provided by the editorialists contains recommendations by the Endoscopy Committee of the British Society of Gastroenterology for standards of sedation and patient monitoring during endoscopy (3). Nowhere in these recommendations is stated that endoscopists cannot or should not perform these procedures. Furthermore, within its major recommendations, number 11 reads as follows: "The endoscopist should ensure the well-being and clinical observation of the patient undergoing endoscopy in conjunction with another individual. This individual should be a qualified nurse trained in endoscopic techniques or another medically qualified practitioner". Major recommendation number 3 states: "Staff of all grades and disciplines should be familiar with resuscitation methods and undergo periodic retraining". The role of nurses in patient monitoring is stated in recommendation number 5: "A qualified nurse, trained in endoscopic techniques and adequately trained in resuscitation techniques, should monitor the patient's condition during procedures".

b. The Editorial's fifth reference is a pilot study on patient-maintained sedation for ERCP with a target-controlled infusion of propofol (4). The authors aim to achieve an adequate level of sedation with this new system, thus preventing the risks of oversedation with benzodiazepines and opioids, and avoiding the need for general anesthesia. The system proved safe, with no episodes of oxygen desaturation or hemodynamic compromise. The authors suggest that a prospective comparison trial with standard bolus sedation is warranted, and conclude by stating: "However, at the present time for safety reasons, the administration of propofol in the endoscopy suite should continue to be supervised by an anesthetist or properly trained nonanesthetist physician".

c. The American Society for Gastrointestinal Endoscopy guidelines for conscious sedation and monitoring during gastrointestinal endoscopy (5) are the 7th reference in the Editorial. These guidelines deal with endoscopist-administered sedation. Anesthetists are only mentioned in the last paragraph, under the entry "Deep Sedation or General Anesthesia", which stresses their role in selected procedures for high-risk patients. It reads as follows: "In this situation, if the practitioner is not trained in the rescue of patients from general anesthesia, then an anesthesiologist should be consulted. The routine assistance of an anesthesiologist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted and is cost-prohibitive".

d. The American Society for Gastrointestinal Endoscopy guidelines for the use of deep sedation and anesthesia for gastrointestinal endoscopy (6) are referenced next in the Editorial. These guidelines apply to "deep sedation" (patient response to painful stimuli), as opposed to "conscious sedation" (response to verbal or tactile stimulation). These guidelines do not state that gastroenterologists cannot or should not administer deep sedation to patients during endoscopy. They only emphasize the need for adequately trained personnel. Table III in these guidelines lists situations in which an anesthesiologist's assistance may be considered, as follows: "Prolonged or therapeutic endoscopic procedure requiring deep sedation, anticipated intolerance to standard sedatives ,increased risk for complication due to severe comorbidity (ASA class III or greater), increased risk for airway obstruction because of anatomic variant".

e. An introductory statement in the guidelines for training in patient monitoring and sedation and analgesia (7), reference number 9 in the Editorial, reads as follows: "The ability to provide sedation and analgesia safely and effectively and to ensure patients clinical stability by appropriate monitoring during gastrointestinal endoscopy are skills that endoscopic trainees must develop".

f. In the study comparing patient-controlled sedation with propofol and alfentanil versus standard sedation with midazolam and meperidine (8), reference number 10 in the Editorial, the authors specifically state in the "Materials and methods" section of the paper: "An anesthetist was not present in the procedure room".

g. Reference number 13 in the Editorial is particularly ill-advised to claim "anesthetist-only sedation", since these are the guidelines for sedation and analgesia by non-anesthesiologists developed by the American Society of Anesthesiologists and endorsed by the American Society for Gastrointestinal Endoscopy (9). This is stated explicitly in its introduction: "These guidelines have been designed to be aplicable to procedures performed in a variety of settings (e.g., hospitals, free-standing clinics, physicians' offices) by practitioners who are not specialists in anesthesiology". This is obviously the kind of cooperation we wish to have with our anesthesiology colleagues, with whom we have excellent personal and professional relationships in our centers. Duly accredited training courses in sedation and analgesia for gastroenterologists, jointly organized with anesthesiologists, stand as a fine example of this interdisciplinary cooperation. Such is the case with the praiseworthy pioneer initiative at Fundación Hospital Alcorcón in Madrid.

h. The British Society of Gastroenterology carried out an audit of upper endoscopies in the North West and East Anglia (10), which is referenced as number 14 in the Editorial. Over a 4-month period, 14,149 gastroscopies were audited in both regions. Intravenous sedation was used in 86% of cases in East Anglia, and in 84% of cases in the North West. No anesthetist was present to administer sedation, which is obvious from the paper.

i. Reference number 15 in the Editorial is eloquent in its own title (11): "Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases". The results of this study are consistent with its title, and their authors conclude: "Propofol can be given safely by appropriately trained nurses under supervision by endoscopists".

In summary, there is little doubt that the literature, even that referenced by the editorialists, answers very clearly the question of who should be responsible for sedation and analgesia regarding patients undergoing endoscopy: a trained professional who can do it properly. In Spain -which we all learned from recently published studies (1,12)- as well as in many other Western countries there are many gastroenterologists who can do it properly, and who are therefore not incurring any malpractice or criminal deed of professional intrusion claims, as bluntly put by the editorialists.

To conclude this section, we would also like to remind that no published study in our country has ever shown increased complication rates from endoscopist-administered sedation versus anesthetist-administered sedation.

2. We are not experts in law, so we can hardly discuss the editorialists assertions regarding criminal deeds as typified under criminal law. However, as they are not legal experts either, we feel that they should have known better than making such gratuitous yet serious statements without due knowledge. Besides, the practice of Medicine is not governed by legal codes, and should rather be judged according to scientific evidence available. As we proved above, the medical literature clearly shows that sedation and analgesia administered and monitored by endoscopists is well within the standard of care (what the editorialists refer to as lex artis ad hoc).

3. We agree with the editorialists, and there is little controversy on this in the literature, that adequate means and training are required to practice sedation and analgesia, so that any potential complications arising from it can be dealt with efficiently. But that does not necessarily mean that a Diploma in Anesthesiology and Resuscitation is required. Again we would like to emphasize that it is anesthesiologists, and therefore colleagues of this Editorial's first author, who develop guidelines and give courses to non-anesthesiologists, and this is in sharp contrast with the bizarre ideas expressed in the Editorial itself.

Considering the above, and in view of the far-reaching consequences this matter has regarding our specialty, we think it necessary that Gastroenterology Societies in our country develop with some urgency clinical guidelines and establish requirements for those willing and able to safely practice sedation and analgesia in patients undergoing endoscopy. Sedation, of course, will never be compulsory practice for those lacking the required skills or not willing to perform it; but no grounds exist on which to forbid it to those meeting the demands to practice it. Sedation techniques should probably receive greater attention during formal endoscopic training in Spain.

Finally, we would like to take issue with the enquiry to patients (as opposed to endoscopists, such as the one reported in the paper the Editorial was meant to comment) on their preferences over who should sedate them for endoscopy. Although the editorialists obviously assume that patients should prefer anesthesiologists, that question can only be scientifically answered by a comparison study. And their conclusions would probably only apply to the anesthetist and gastroenterologist involved in the study, since not everyone holding one same Diploma is equally skilled. For the time being, daily practice and common sense tell us that what patients demand is painless, comfortable and safe procedures. Again, endoscopist-administered sedation fulfils these demands. Many of the undersigned have first-hand experience with physician patients undergoing endoscopy -including those holding Diplomas in Anesthesiology- who are sedated to their full satisfaction by the very same gastroenterologist performing the procedure.

REFERENCES

1. Cubiella Fernández J, Lancho Seco A, Echarri Piudo A, Ulla Rocha JL, Fernández Seara J on behalf of Sociedad Gallega de Patología Digestiva. Sedation at Endoscopic Units in Galicia: results of the "Sociedad Gallega de Patología Digestiva" inquiry. Rev Esp Enferm Dig 2005; 97: 24-37.        [ Links ]

2. López Timoneda F, Ramírez Armengol JA. Who should be responsible for sedation techniques in digestive endoscopy? Rev Esp Enferm Dig 2005; 97: 1-6.        [ Links ]

3. Bell GD, McCloy RF, Charlton JE, Campbell D, Dent NA, Gear MWL, et al. Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. Gut 1991; 32: 823-7.        [ Links ]

4. Gillham MJ, Hutchinson RC, Carter R, Kenny GNC. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc 2001; 54: 14-7.        [ Links ]

5. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 2003; 58: 317-22.        [ Links ]

6. Guidelines for the Use of Deep Sedation and Anesthesia for Gastrointestinal Endoscopy. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 2002; 56: 613-7.        [ Links ]

7. Guidelines for Training in Patient Monitoring and Sedation and Analgesia. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1998; 48: 669-71.        [ Links ]

8. Külling D, Fantin AC, Biro P, Bauerfeind P, Fried M. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Gastointest Endosc 2001; 54: 1-7.        [ Links ]

9. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: A Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 1996; 84: 459-71.        [ Links ]

10. Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB, Hopkins A. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36: 462-7.        [ Links ]

11. Rex DK, Overley C, Kinser K, Coates M, Lee A, Goodwine BW, et al. Safety of propofol admininstered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol 2002; 97: 1159-63.        [ Links ]

12. Campo R, Brullet E, Junquera F, Puig-Diví V, Vergara M, Calvet X, et al. Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña. Gastroenterol Hepatol 2004; 27: 503-7.        [ Links ]

SIGNATURES

Abad Lacruz, A. - H. Viladecans (BARCELONA)
Abreu García, L. - H. Puerta de Hierro (MADRID)
Acero Fernández, D. - H. Josep Trueta (GERONA)
Aguilera Musso, D. - H. Infanta Cristina (BADAJOZ)
Alarcón Fernández, O. - Hospiten (TENERIFE)
Alberca de las Parras, F. - H. Univ. Virgen de la Arrixaca (MURCIA)
Aldeguer Manté, X. - H. Josep Trueta (GERONA)
Alexandre Hurlé, E. - H. de Jove, Gijón (ASTURIAS)
Alfonso Bozzo, M. - C. Hospitalario Xeral-Calde (LUGO)
Aller de la Fuente, R. - H. Clínico Univ. de Valladolid (VALLADOLID)
Alonso Aguirre, P. - H. Juan Canalejo (LA CORUÑA)
Álvarez Cercadillo, R. - H. Nuestra Señora del Prado (TOLEDO)
Álvarez Sánchez, M. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Amorós García, C. - H. de Alzira (VALENCIA)
Andreu Serra, H. - H. Son Llàtzer, Palma de Mallorca (BALEARES)
Angós Musgo, R. - Clínica Univ. de Navarra, Pamplona (NAVARRA)
Aparicio Tormo, J. - H. General Universitario de Alicante (ALICANTE)
Aquise Chávez, M. - H. Santa Bárbara (SORIA)
Arias García, L. - H. Virgen de la Concha (ZAMORA)
Arribas López, R. - H. Santa Bárbara (SORIA)
Atienza Sánchez, R. - H. Medina del Campo (VALLADOLID)
Baeyens Cabrera, E. - C. Hospitalario de Jaén (JAEN)
Ballester Fayos, J. - H. de La Plana, Vila-Real (CASTELLÓN)
Balongo de la Vega, A. - H. Civil de Ceuta (CEUTA)
Barcenilla Laguna, J. - H. Río Carrión (PALENCIA)
Barenys de la Cha, M. - H. Viladecans (BARCELONA)
Barrio Andrés, J. - H. del Río Hortega (VALLADOLID)
Barrio Antoranz, J. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Barrutia Garrido, C. - H. Comarcal de Melilla (MELILLA)
Barturen Barroso, Á. - H. Cruces (VIZCAYA)
Baudet Arteaga, J. - H. Univ. Nuestra Señora Candelaria (TENERIFE)
Benito de Benito, L. - H. Verge del Toro, Menorca (BALEARES)
Bernárdez Martín, E. - H. da Costa, Burela (LUGO)
Betancourt González, A. - H. Virgen de la Concha (ZAMORA)
Betés Ibáñez, M. - Clínica Universitaria de Navarra (NAVARRA)
Blanco González, J. - Hospital Comarcal Monforte (LUGO)
Blanco González, J. - H. Nuestra Señora del Prado (TOLEDO)
Bolado Concejo, F. - H. Fundación de Calahorra (LA RIOJA)
Borda Celaya, F. - H. de Navarra, Pamplona (NAVARRA)
Bordas Alsina, J. - H. Clinic (BARCELONA)
Bosch Esteva, O. - Fundación Jiménez Díaz (MADRID)
Botella Esteban, T. - H. Obispo Polanco (TERUEL)
Briz Romero, R. - H. Virgen del Camino, Pamplona (NAVARRA)
Brotons García, Á. - H. Son Llàtzer, Palma de Mallorca (BALEARES)
Brullet, E. - H. Sabadell (BARCELONA)
Buenestado García, J. - H. Universitario Arnau Vilanova (LERIDA)
Bujanda Fernández de Pierola, L. - H. Donostia (GUIPUZCOA)
Cabrera González, E. - C. Hospitalario de Jaén (JAEN)
Cacho Acosta, G. - H. Fundación Alcorcón (MADRID)
Calleja Panero, J. - H. Puerta de Hierro (MADRID)
Calvo Cenizo, M. - H. Alto Deba (GUIPUZCOA)
Campo Fernández de los Ríos, R. - H. Sabadell (BARCELONA)
Cantero Perona, J. - H. de La Princesa (MADRID)
Carbonero Díaz, P. - C. Hospitalario de Ávila (AVILA)
Cardona Castellá, C. - H. Verge de la Cinta (TARRAGONA)
Carpio López, D. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Carral Martínez, D. - H. de Navarra, Pamplona (NAVARRA)
Casado Caballero, F. - H. Clínico San Cecilio (GRANADA)
Casado Martín, M. - H. Torrecárdenas (ALMERIA)
Cascón Fonseca, L. - H. Civil de Ceuta (CEUTA)
Casellas Valdé, J. - H. General Universitario de Alicante (ALICANTE)
Castañeda Bergamín, C. - H. Nuestra Señora del Prado (TOLEDO)
Castiella Eguzkiza, A. - H. Mendaro (GUIPUZCOA)
Castro Fernández, M. - H. de Valme (SEVILLA)
Clofent Vilaplana, J. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
Colmenero Lechuga, M. - C. Hospitalario de Jaén (JAEN)
Colom Costa, J. - H. General de Castellón (CASTELLÓN)
Corella Malo, C. - H. Guadalajara (GUADALAJARA)
Correa Estañ, J. - H. Vega Baja, Orihuela (ALICANTE)
Cubiella Fernández, J. - C. Hospitalario de Ourense (OURENSE)
De Castro Parga, M. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
De la Calle Valverde, F. - H. Clínico Univ. de Valladolid (VALLADOLID)
De la Coba Ortiz, C. - H. Clínico de Salamanca (SALAMANCA)
De la Iglesia Ramos, M. - Povisa, Vigo (PONTEVEDRA)
De la Morena Madrigal, E. - H. de la Zarzuela (MADRID)
De la Riva Onandía, S. - C. Univ. de Navarra, Pamplona (NAVARRA)
De la Serna Higuera, C. - H. Virgen de la Concha (ZAMORA)
De Sola Earle, C. - H. de Marbella (MÁLAGA)
Del Moral García, Á. - H. Río Carrión (PALENCIA)
Del Pozo García, A. - H. Guadalajara (GUADALAJARA)
del Villar Sordo, V. - H. Santa Bárbara (SORIA)
Delgado Blanco, M. - C. H. Universitario de Santiago (LA CORUÑA)
Díaz Álvarez, G. - H. Central de Asturias, Oviedo (ASTURIAS)
Díaz Blasco, J. - Clínica Virgen de Guadalupe (CÁCERES)
Díez Ordóñez, S. - C. Hospitalario de Ourense (OURENSE)
Díez Redondo, P. - H. Santos Reyes, Aranda de Duero (BURGOS)
Dolz Abadía, C. - H. Son Llàtzer, Palma de Mallorca (BALEARES)
Domínguez Macías, A. - H. Juan Ramón Jiménez (HUELVA)
Domínguez Muñoz, J. - C. H. Universitario de Santiago (LA CORUÑA)
Domínguez Rodríguez, F. - H. do Meixoeiro, Vigo (PONTEVEDRA)
Donoso Flores, M. - H. Infanta Cristina (BADAJOZ)
Ducons García, J. - H. San Jorge (HUESCA)
Enciso Coloma, C. - H. de Txagorritxu, Vitoria (ALAVA)
Espinel Díez, J. - H. de León (LEÓN)
Espinós Pérez, J. - H. Mutua Terrassa (BARCELONA)
Esteve Comas, M. - H. Mutua Terrassa (BARCELONA)
Fernández Bañares, F. - H. Mutua Terrassa (BARCELONA)
Fernández Bermejo, M. - H. San Pedro de Alcántara (CÁCERES)
Fernández Castroagudín, J. - C. H. Univ. de Santiago (LA CORUÑA)
Fernández Forcelledo, J. - H. Sierrallana, Torrelavega (CANTABRIA)
Fernández Gil, P. - H. Sierrallana, Torrelavega (CANTABRIA)
Fernández Orcajo, P. - H. del Río Hortega (VALLADOLID)
Fernández Pérez, R. - H. C. de Poniente, El Ejido (ALMERÍA)
Fernández Rodríguez, C. - H. Fundación Alcorcón (MADRID)
Fernández Salazar, L. - H. Clínico Univ. de Valladolid (VALLADOLID)
Fernández Velázquez, R. - H. Central de Asturias, Oviedo (ASTURIAS)
Fernández-Urién Sainz, I. - C. Univ. de Navarra, Pamplona (NAVARRA)
Ferrer Ríos, M. - H. Juan Ramón Jiménez (HUELVA)
Figa Francesch, M. - H. Josep Trueta (GERONA)
Forné Bardera, M. - H. Mutua Terrassa (BARCELONA)
Fort Martorell, E. - H. Josep Trueta (GERONA)
Fradejas Salazar, P. - H. Clínico de Salamanca (SALAMANCA)
Fuentes Coronel, A. - H. Virgen de la Concha (ZAMORA)
Gallardo Sánchez, F. - H. C. de Poniente, El Ejido (ALMERÍA)
Gallego Rojo, F. - H. C. de Poniente, El Ejido (ALMERÍA)
Gallego Gallegos, M. - H. Juan Ramón Jiménez (HUELVA)
García Campos, F. - H. de Txagorritxu, Vitoria (ALAVA)
García Herreros, V. - H. de La Plana, Vila-Real (CASTELLÓN)
García López, S. - H. Miguel Servet (ZARAGOZA)
García Martín, I. - H. Río Carrión (PALENCIA)
García Pajares, F. - H. del Río Hortega (VALLADOLID)
García Pérez, B. - H. Virgen del Rosell, Cartagena (MURCIA)
García Valriberas, R. - H. General Univ. de Albacete (ALBACETE)
García Vizuete, S. - H. Sur, Alcorcón (MADRID)
Garza Trasobares, E. - H. Obispo Polanco (TERUEL)
Gayoso García, R. - Hospital Comarcal Valdeorras (OURENSE)
Giné Gala, J. - H. Tortosa (TARRAGONA)
Gómez Balado, M. - C. H. Universitario de Santiago (LA CORUÑA)
Gómez Cedenilla, A. - H. Fundación Manacor (BALEARES)
González Abraldes, J. - H. Clinic (BARCELONA)
González Asanza, C. - H. General Univ. Gregorio Marañón (MADRID)
González Calvín, J. - H. Clínico San Cecilio (GRANADA)
González Conde, B. - H. Juan Canalejo (LA CORUÑA)
González de la Ballina González, E. - C. H. de Ourense (OURENSE)
González Hernández, J. - H. Clínico Univ. de Valladolid (VALLADOLID)
González Lama, Y. - H. de la Zarzuela (MADRID)
González Martín, J. - H. Getafe (MADRID)
González Ramírez, J. - C. Hospitalario Xeral-Calde (LUGO)
González Rodríguez, A. - H. Univ. Ntra. Señora Candelaria (TENERIFE)
González-Huix Lladó, F. - H. Josep Trueta (GERONA)
Gonzalo Molina, M. - C. Hospitalario de Ávila (ÁVILA)
Goyeneche Gracia, M. - H. del Río Hortega (VALLADOLID)
Gracia Martín-Salvador, A. - C. Hospitalario de Ávila (ÁVILA)
Guiberteau Sánchez, A. - H. Infanta Cristina (BADAJOZ)
Hermida Rodríguez, C. - Clínica Santa Elena (MADRID)
Hermo Brión, J. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
Hernández Ramírez, V. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
Herráiz Bayod, T. - Clínica Univ. de Navarra, Pamplona (NAVARRA)
Hombrados Verde, M. - H. Josep Trueta (GERONA)
Ibáñez Pinto, A. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Igea Arisqueta, F. - H. Río Carrión (PALENCIA)
Iglesias Picazo, R. - H. Virgen del Camino, Pamplona (NAVARRA)
Iñarrairaegui Bastarrica, M. - H. de Navarra, Pamplona (NAVARRA)
Jiménez Jaén, C. - H. Infanta Cristina (BADAJOZ)
Jiménez Pérez, J. - H. de Navarra, Pamplona (NAVARRA)
Jiménez Vicente, F. - H. Clínico de Salamanca (SALAMANCA)
Juzgado Lucas, D. - Centro Oncológico MD Anderson (MADRID)
Karpman Niremberg, G. - H. del Bierzo, Ponferrada (LEON)
Khorrami Mashhadi, S. - H. Son Llàtzer, P. de Mallorca (BALEARES)
Ledo Barro, L. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Linares Torres, P. - H. del Bierzo, Ponferrada (LEÓN)
Llach Vila, J. - H. Clinic (BARCELONA)
Lledó Navarro, J. - H. Fundación Alcorcón (MADRID)
Llorca Martínez, I. - H. Univ. de Gran Canaria Dr.Negrín (LAS PALMAS)
López Arias, M. - H. Sierrallana, Torrelavega (CANTABRIA)
López Núñez, C. - H. Josep Trueta (GERONA)
López Oliú, C. - H. Santa Caterina (GERONA)
López San Román, A. - H. Ramón y Cajal (MADRID)
López Serrano, P. - H. Fundación Alcorcón (MADRID)
López Vallejos, P. - H. Infanta Cristina (BADAJOZ)
López-Mosquera, E. - Hospital Comarcal Valdeorras (OURENSE)
Lorenzo González, A. - C. H. Universitario de Santiago (LA CORUÑA)
Macenlle García, R. - C. Hospitalario de Ourense (OURENSE)
Macías Rodríguez, M. - H. Universitario Puerta del Mar (CÁDIZ)
Madrigal Domínguez, R. - H. Río Carrión (PALENCIA)
Mahmoud Dajil, S. - H. del Bierzo, Ponferrada (LEÓN)
Maraver García, A. - H. Infanta Elena (HUELVA)
Martín Arribas, M. - H. Virgen de la Concha (ZAMORA)
Martín Eleno, M. - C. Hospitalario de Ourense (OURENSE)
Martín Herrera, L. - H. Universitario Puerta del Mar (CÁDIZ)
Martín Jiménez, J. - H. General de Castellón (CASTELLÓN)
Martín Ramos, L. - H. Sierrallana, Torrelavega (CANTABRIA)
Martínez Cadilla, J. - H. Xeral-Cíes, Vigo (PONTEVEDRA)
Martínez Cara, J. - H. C. de Poniente, El Ejido (ALMERÍA)
Martínez Moreno, J. - H. Virgen de la Concha (ZAMORA)
Martínez Sempere, J. - H. General Universitario de Alicante (ALICANTE)
Martínez Turnes, A. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
Martín-Granizo Barrenechea, I. - H. Xeral-Cíes, Vigo (PONTEVEDRA)
Maté Jiménez, J. - H. de La Princesa (MADRID)
Mateos Rodríguez, J. - H. San Pedro de Alcántara (CÁCERES)
Menchén Fernández-Pacheco, P. - H. G. Univ. G. Marañón (MADRID)
Mereish Tatros, G. - H. General de Igualada (BARCELONA)
Molina Pérez, E. - H. Básico de Defensa en Ferrol (LA CORUÑA)
Monge Romero, M. - H. Infanta Cristina (BADAJOZ)
Montoro, M. - H. San Jorge (HUESCA)
Morales González, S. - H. Univ. Nuestra Señora Candelaria (TENERIFE)
Moreno Almazán, L. - Clínica Montepríncipe (MADRID)
Moreno Gallego, M. - H. Universitario Puerta del Mar (CÁDIZ)
Moreno García, A. - H. Univ. Nuestra Señora Candelaria (TENERIFE)
Moreno Sánchez, I. - H. General de Castellón (CASTELLÓN)
Moretó Canela, M. - H. Cruces (VIZCAYA)
Morillas Ariño, J. - H. Virgen de la Luz (CUENCA)
Mundi Sánchez-Ramade, J. - H. Clínico San Cecilio (GRANADA)
Muñoz Navas, M. - Clínica Univ. de Navarra, Pamplona (NAVARRA)
Naranjo Rodríguez, A. - H. Reina Sofía (CÓRDOBA)
Narváez Rodríguez, I. - H. Infanta Cristina (BADAJOZ)
Navazo Bermejo, L. - H. Univ. Nuestra Señora Candelaria (TENERIFE)
Nerín de la Puerta, J. - H. Clínico Univ. Lozano Blesa (ZARAGOZA)
Obrador Adrover, A. - H. Son Dureta, Palma de Mallorca (BALEARES)
Olivencia Palomar, M. - C. Hospitalario Xeral-Calde (LUGO)
Orive Cura, V. - H. Basurto (VIZCAYA)
Ors Gil, F. - H. General de Castellón (CASTELLÓN)
Ortiz de Diego, R. - H. Sierrallana, Torrelavega (CANTABRIA)
Otazua Mendizábal, P. - H. Alto Deba (GUIPÚZCOA)
Palau Canos, A. - H. General de Castellón (CASTELLÓN)
Palau Romero, A. - H. General de Castellón (CASTELLÓN)
Pallarés Manrique, H. - H. Infanta Elena (HUELVA)
Pamplona Portero, J. - H. Santa Caterina (GERONA)
Papo Berger, M. - H. Joan XXIII (BARCELONA)
Pareja Llorens, G. - H. de La Plana, Vila-Real (CASTELLÓN)
Parra Blanco, A. - H. Universitario de Canarias, La Laguna (TENERIFE)
Pascual Moreno, I. - H. Clínico Universitario de Valencia (VALENCIA)
Pascual Rubín, P. - C. Hospitalario de Ourense (OURENSE)
Pato Rodríguez, M. - C. Hospitalario de Ourense (OURENSE)
Payeras Llodrá, G. - H. General de la Defensa Gómez Ulla (MADRID)
Pedraza Sanz, R. - H. General de Castellón (CASTELLÓN)
Pellisé Urquiza, M. - H. Clinic (BARCELONA)
Penalva Polo, J. - H. Vega Baja, Orihuela (ALICANTE)
Peña Aldea, A. - H. Clínico Universitario de Valencia (VALENCIA)
Pereira Bueno, S. - H. Xeral-Cíes, Vigo (PONTEVEDRA)
Pereira Jorge, J. A. - C. Hospitalario de Ourense (OURENSE)
Pérez Arellano, E. - H. de la Zarzuela (MADRID)
Pérez Carnero, A. - C. Hospitalario Xeral-Calde (LUGO)
Pérez Durán, M. - C. Hospitalario de Jaén (JAÉN)
Pérez García, J. - H. Virgen de la Luz (CUENCA)
Pérez Gisbert, J. - H. de La Princesa (MADRID)
Pérez Gómez, M. - H. Juan Ramón Jiménez (HUELVA)
Pérez Hernández, F. H. Univ. Nuestra Señora Candelaria (TENERIFE)
Pérez Millán, A. - H. Río Carrión (PALENCIA)
Pérez Piqueras, J. - Sanatorio San Francisco de Asis (MADRID)
Pérez Vigara, G. - H. Virgen de la Luz (CUENCA)
Pérez-Cuadrado Martínez, E. - H. Morales Meseguer (MURCIA)
Pérez-Miranda Castillo, M. - H. del Río Hortega (VALLADOLID)
Pineda Mariño, J. - Hospital do Meixoeiro, Vigo (PONTEVEDRA)
Piñol Sánchez, V. - H. Josep Trueta (GERONA)
Pons Renedo, F. - H. del Río Hortega (VALLADOLID)
Prieto Bermejo, A. - H. San Pedro de Alcántara (CÁCERES)
Ramos Lora, M. - H. Juan Ramón Jiménez (HUELVA)
Redondo Cerezo, E. - H. Virgen de la Luz (CUENCA)
Rendón Unceta, P. - H. Universitario Puerta del Mar (CÁDIZ)
Reñé Espinet, J. - H. Universitario Arnau Vilanova (LERIDA)
Ripollés Vilar, V. - H. General de Castellón (CASTELLÓN)
Robledo Andrés, P. - H. San Pedro de Alcántara (CÁCERES)
Rodríguez Gómez, S. - H. Virgen de la Concha (ZAMORA)
Rodríguez Hornillo, M. - H. de Valme (SEVILLA)
Rodríguez Laiz, J. - H. del Mediterráneo (ALMERÍA)
Rodríguez Pérez, A. - H. Clínico de Salamanca (SALAMANCA)
Rodríguez Ramos, C. - H. Universitario Puerta del Mar (CÁDIZ)
Rosiñach Ribera, M. - H. Mutua Terrassa (BARCELONA)
Ruiz Adrados, E. - H. Santiago Apóstol, Miranda de Ebro (BURGOS)
Sacristán López, M. - H. General de Segovia (SEGOVIA)
Sacristán Terroba, B. - H. San Millán (LA RIOJA)
Sáenz Solís, R. - H. Infanta Elena (HUELVA)
Salvatierra Cuenca, C. - H. General de Segovia (SEGOVIA)
Sánchez Antolín, G. - H. del Río Hortega (VALLADOLID)
Sánchez del Río, A. - Hospiten (TENERIFE)
Sánchez Hernández, E. - C. Hospitalario de Ourense (OURENSE)
Sánchez Risco, P. - H. Infanta Cristina (BADAJOZ)
Sanchiz Soler, V. - H. Clínico Universitario de Valencia (VALENCIA)
Santander Vaquero, C. - H. de La Princesa (MADRID)
Santolaria Piedrafita, S. - H. San Jorge (HUESCA)
Santos Blanco, E. - C. Hospitalario Xeral-Calde (LUGO)
Sanz Labrín, E. - H. General Universitario Gregorio Marañón (MADRID)
Saracíbar Serrador, E. - H. del Río Hortega (VALLADOLID)
Sebastián Domingo, J. - H. Miguel Servet (ZARAGOZA)
Sesé Abizanda, E. - H. Universitario Arnau Vilanova (LÉRIDA)
Simón Marco, M. - H. Clínico Universitario Lozano Blesa (ZARAGOZA)
Sobrino Faya, M. - C. H. Universitario de Santiago (LA CORUÑA)
Soria Monje, A. - H. Infanta Cristina (BADAJOZ)
Soriano Salvador, M. - H. Santa Bárbara (SORIA)
Soto Iglesias, S. - C. Hospitalario Xeral-Calde (LUGO)
Subtil Íñigo, J. - Clínica Universitaria de Navarra, Pamplona (NAVARRA)
Talavera Fabuel, A. - H. Infanta Elena (HUELVA)
Tejada Cabrera, M. - Clínica Nuestra Señora de la Salud (CÁDIZ)
Thomson Llisterri, C. - H. Obispo Polanco (TERUEL)
Tojo González, R. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Trapero Martínez, A. - C. Hospitalario de Jaén (JAÉN)
Ulla Rocha, J. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Uribarrena Echebarría, R. - H. Miguel Servet (ZARAGOZA)
Urquiza Calvo, Ó. - H. del Bierzo, Ponferrada (LEON)
Valbuena González, M. - H. Virgen Altagracia, Manzanares (C. REAL)
Vallecillo Sande, M. - H. del Río Hortega (VALLADOLID)
Vázquez Astray, E. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Vázquez López, S. - Povisa, Vigo (PONTEVEDRA)
Vázquez Pérez-Cóleman, L. - C. H. Univ. de Santiago (LA CORUÑA)
Vázquez Santos, M. - C. Hospitalario de Pontevedra (PONTEVEDRA)
Vázquez Sequeiros, E. - H. Ramón y Cajal (MADRID)
Vega García-Luengas, M. - C. Hospitalario de Ourense (OURENSE)
Vela González, M. - H. Univ. Nuestra Señora Candelaria (TENERIFE)
Velayos Jiménez, B. - H. Clínico Univ. de Valladolid (VALLADOLID)
Velicia Llames, M. - H. del Río Hortega (VALLADOLID)
Vilella Martorell, A. - H. Son Llàtzer, Palma de Mallorca (BALEARES)
Villar Fernández, M. - Hospital Comarcal Monforte (LUGO)
Viver Pi-Sunyer, J. - H. Mutua Terrassa (BARCELONA)
Yangüela Terroba, J. - H. San Millán (LA RIOJA)
Yuguero del Moral, L. - H. General Yagüe (BURGOS)
Zaballa Martín, P. - H. Central de Asturias, Oviedo (ASTURIAS)
Zapatero Zamora, L. - H. Sur, Alcorcón (MADRID)