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Halland M, Prichard DO, Kahn A, Lavey CJ, Katzka DA, Alexander JA. Esophageal Self-Dilation in Benign Refractory Esophageal Strictures: Outcomes from a Randomized Controlled Trial and a Prospective Observational Study. Dig Dis Sci 2024; 69:2883-2889. [PMID: 38811502 PMCID: PMC11341595 DOI: 10.1007/s10620-024-08402-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/20/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Patients with benign esophageal strictures may not maintain a response to endoscopic dilation, stenting, incisional or injectional therapies. For patients with these refractory esophageal strictures, esophageal self-dilation therapy (ESDT), performed to maintain luminal patency, may provide persistent symptomatic benefit while reducing patients' reliance on healthcare services and the risk associated with repeated endoscopic procedures. AIMS The aim of this study was to evaluate the efficacy and safety of EDST in a randomized controlled trial and prospective observational study. METHODS Twenty-five patients with refractory benign esophageal strictures were recruited at two esophageal clinics between November 2018 and June 2021. Twelve patients participated in the randomized trial and 13 in the prospective observational study. The number of endoscopic dilations, impact of therapy on dysphagia, adverse events, and complications were recorded. RESULTS In the randomized study, 50% of patients performing ESDT and 100% of controls required endoscopic dilation during follow-up (P = 0.02). In the observational study, the median (IQR) number of endoscopic dilations fell from 7 [7-10] in the 6 months prior to commencing ESDT to 1 [0-2] in the 6 months after (P < 0.0001). Most patients (22/25) were able to learn self-dilation. Few serious adverse events were noted. Dysphagia severity remained unchanged or improved. CONCLUSIONS ESDT appears to be a safe effective therapy for benign esophageal strictures refractory to endoscopic treatment. CLINICAL TRIAL NUMBER NCT03738566.
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Affiliation(s)
- Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
- School of Medicine, University of Newcastle, Newcastle, NSW, 2300, Australia.
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- St James' Hospital, University of Dublin, Dublin, Ireland
- Trinity College, Dublin, Ireland
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Crystal J Lavey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Li L, Xu N, Wang P, Liu L, Gong W, Bi Y, Ru N, Su S, Wang N, Xiang J, Han K, Chai N, Linghu E. A novel self-inflatable balloon for treating refractory benign esophageal strictures: a prospective, single-arm, multicenter study. Int J Surg 2024; 110:2055-2064. [PMID: 38668658 PMCID: PMC11020001 DOI: 10.1097/js9.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/09/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND AND AIM Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety. METHODS A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months. RESULTS The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture. CONCLUSIONS The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.
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Affiliation(s)
- Longsong Li
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Ning Xu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Pengju Wang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Li Liu
- The Second Hospital of Hebei Medical University, Shijiazhuang
| | - Wei Gong
- Shenzhen Hospital of Southern Medical University, Shenzhen, People’s Republic of China
| | - Yawei Bi
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Nan Ru
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Song Su
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Nanjun Wang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Jingyuan Xiang
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Ke Han
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Ningli Chai
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing
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Lian J, Chu Y, Chen T, Li F, Xu A, Zhang H, Xu M. Outcome of a novel self-control stricture-preventing water balloon for complete circular esophageal endoscopic submucosal dissection. Surg Endosc 2023; 37:290-297. [PMID: 35930071 DOI: 10.1007/s00464-022-09456-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 07/08/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Post-ESD esophageal stricture especially after wholly circumferential ESD remains an unresolved issue without ideal strategies. Our initiative novel self-control stricture-preventing water balloon may be an alternative. METHODS Patients with esophageal neoplastic lesions expected to result in a whole circular mucosa defect after esophageal ESD from February 2018 to August 2020 were included in the study. We used a novel self-control stricture-preventing water balloon combined with oral prednisolone as preventive strategy for the enrolled patients. RESULTS Thirty-seven patients (9 females and 28 males, patients aged 52 to 82 years) finished the 12-week treatment including steroid treatment and balloon placement. The median size of longitudinal diameter was 7 cm (range from 4 to 14 cm). All the lesions achieved curative resection and the median procedure time was 110 min (range 50 to 180 min). Balloons were found migration in 4 patients. As a result, there were 3 patients (8.1%) experienced stricture. Generally, patients could tolerate to balloons, only with mild uncomfortableness, such as occasional sore throat, cough, and retrosternal pain. In addition, during the follow-up period, no significant adverse events associated to oral steroid administration were observed and no recurrence was found. CONCLUSIONS Our novel self-control stricture-preventing water balloon based on the oral steroid therapy is effective and safe. This strategy well prevents esophageal stricture after complete circumferential ESD.
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Affiliation(s)
- Jingjing Lian
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China
| | - Yuan Chu
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China
| | - Tao Chen
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China
| | - Fang Li
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China
| | - Aiping Xu
- Department of Gastroenterology and Hepatology, Jing'an District Central Hospital, Fudan University, Shanghai, China
| | - Haibin Zhang
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China
| | - Meidong Xu
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, 150 Jimo Road, Shanghai, 200120, China.
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4
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Self-Dilation of Refractory Benign Esophageal Strictures. Am J Gastroenterol 2022; 117:364-366. [PMID: 34913874 DOI: 10.14309/ajg.0000000000001589] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
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Spaander MCW, van der Bogt RD, Baron TH, Albers D, Blero D, de Ceglie A, Conio M, Czakó L, Everett S, Garcia-Pagán JC, Ginès A, Jovani M, Repici A, Rodrigues-Pinto E, Siersema PD, Fuccio L, van Hooft JE. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:751-762. [PMID: 33930932 DOI: 10.1055/a-1475-0063] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
MALIGNANT DISEASE 1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. BENIGN DISEASE 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.
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Affiliation(s)
- Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Antonella de Ceglie
- Department of Gastroenterology, Ospedale Civile di Sanremo, Sanremo (IM), Italy
| | - Massimo Conio
- Department of Gastroenterology, Ospedale Santa Corona, Pietra Ligure (SV), Italy
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Juan-Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit - Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver) - Hospital Clinic, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Angels Ginès
- Gastroenterology Department, Hospital Clinic of Barcelona, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Alwan M, Giddings CE. Self-dilatation of benign oesophageal strictures: a literature review. ANZ J Surg 2021; 91:1385-1389. [PMID: 33956382 DOI: 10.1111/ans.16775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures. METHODS This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures. RESULTS This study identified 13 articles with 274 participants. CONCLUSION Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.
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Affiliation(s)
- Mostafa Alwan
- Department of Otolaryngology Head & Neck Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Charles E Giddings
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Schimberg AS, Wellenstein DJ, Schutte HW, Honings J, Marres HAM, Takes RP, van den Broek GB. Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma. Dysphagia 2021; 37:93-98. [PMID: 33689024 PMCID: PMC8844154 DOI: 10.1007/s00455-021-10253-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2–4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints – 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia – 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.
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Affiliation(s)
- Anouk S Schimberg
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.
| | - David J Wellenstein
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henrieke W Schutte
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - J Honings
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henri A M Marres
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Guido B van den Broek
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
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Boregowda U, Goyal H, Mann R, Gajendran M, Patel S, Echavarria J, Sayana H, Saligram S. Endoscopic management of benign recalcitrant esophageal strictures. Ann Gastroenterol 2021; 34:287-299. [PMID: 33948052 PMCID: PMC8079876 DOI: 10.20524/aog.2021.0585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022] Open
Abstract
Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.
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Affiliation(s)
- Umesha Boregowda
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY (Umesha Boregowda)
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduation Medical Center, Scranton, PA (Hemant Goyal)
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA (Rupinder Mann)
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX (Mahesh Gajendran)
| | - Sandeep Patel
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Juan Echavarria
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Hari Sayana
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Shreyas Saligram
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
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Heading RC. Editorial: self-dilation for refractory oesophageal strictures is worth considering. Aliment Pharmacol Ther 2018; 48:230-231. [PMID: 29939418 DOI: 10.1111/apt.14838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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10
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Halland M. Editorial: self-dilation for refractory oesophageal strictures is worth considering-author's reply. Aliment Pharmacol Ther 2018; 48:231. [PMID: 29939415 DOI: 10.1111/apt.14839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- M Halland
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
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