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Mandavdhare HS, Samanta J, Jafra A, Singh H, Gupta P, Dutta U. OUTCOME OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) IN SIGMOID ACHALASIA AT A MEDIAN FOLLOW UP OF 17 MONTHS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:478-482. [PMID: 36515342 DOI: 10.1590/s0004-2803.202204000-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging. METHODS Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted. RESULTS Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence. CONCLUSION Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.
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Affiliation(s)
- Harshal S Mandavdhare
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Jayanta Samanta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Anudeep Jafra
- Post Graduate Institute of Medical Education and Research, Department of Anesthesiology, Chandigarh, India
| | - Harjeet Singh
- Post Graduate Institute of Medical Education and Research, Department of Surgery, Chandigarh, India
| | - Pankaj Gupta
- Post Graduate Institute of Medical Education and Research, Department of Radiodiagnosis, Chandigarh, India
| | - Usha Dutta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
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Savarino E, Bhatia S, Roman S, Sifrim D, Tack J, Thompson SK, Gyawali CP. Achalasia. Nat Rev Dis Primers 2022; 8:28. [PMID: 35513420 DOI: 10.1038/s41572-022-00356-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.
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Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy. .,Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua, Padua, Italy.
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Sabine Roman
- Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Inserm U1032, LabTAU, Lyon, France
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Jan Tack
- Division of Gastroenterology, University Hospital of Leuven, Leuven, Belgium
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Bard V, Solomon D, Raveh G, Menasherov N, Kashtan H. Long‐term Outcomes After Esophagectomy for
End‐Stage
Achalasia: a Bridge to a Better Quality of Life? SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Vyacheslav Bard
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Daniel Solomon
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Guy Raveh
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Nikolai Menasherov
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Hanoch Kashtan
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
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Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, Longaroni M, Mattioli S. Quality of Life After Operation for End-Stage Achalasia: Pull-Down Heller-Dor Versus Esophagectomy. Ann Thorac Surg 2021; 113:271-278. [PMID: 33515542 DOI: 10.1016/j.athoracsur.2020.12.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. METHODS The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P = .806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. RESULTS The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P = .598). No statistically significant differences were observed for dysphagia (P = .948), reflux symptoms (P = .186), or esophagitis (P = .253). No statistically significant differences were observed in the domains physical functioning (P = .092), bodily pain (P = .075) or general health (P = .453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P = .043), role emotional (100 vs 0, P = .002), vitality (90 vs 55, P< .001), mental health (92 vs 68, P = .002), and social functioning (100 v s75, P = .011). CONCLUSIONS The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy.
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Affiliation(s)
- Valentina Tassi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Vladimiro Pilotti
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Luca Ferruzzi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | | | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy.
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Liu D, Liu YY, Chen JX, Song L, Zhou YY, Ullah S, Zhao LX, Hai B, Zheng QF, Li DY, He DZ, Liu BR. Influence of esophageal morphology on the clinical efficacy of peroral endoscopic myotomy in treating advanced achalasia cardia. Exp Ther Med 2021; 21:196. [PMID: 33488805 PMCID: PMC7812585 DOI: 10.3892/etm.2021.9629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is the first-line treatment of achalasia cardia (AC). However, the efficacy of POEM in treating patients with advanced AC remains to be determined. The aim of the present study was to evaluate the feasibility and clinical outcome of POEM in treating patients with advanced AC involving different esophageal morphologies. The study was a single-center, retrospective analysis of patients suffering from advanced AC. The primary endpoint was the Eckardt score at the follow-up examination. Secondary endpoints were procedural-related details, including the operation time and length of myotomy, adverse events (AEs) and hospital stay, as well as post-procedural gastroesophageal reflux disease. The technical success rate was 100%. All 50 patients enrolled underwent successful endoscopic myotomy (conventional POEM, n=20; modified POEM, n=30). AEs were observed in 10 patients. During a 6- to 50-month follow-up period, 41 patients achieved clinical success as evidenced by a decrease in the Eckardt score. Only 3 of 6 patients with a sigmoid-shaped megaesophagus obtained symptomatic relief. Symptomatic reflux occurred in 13 of 46 patients who completed their follow-up. In conclusion, POEM is safe, feasible and effective in treating advanced AC. Patients with a sigmoid-shaped megaesophagus are less likely to report palliation of symptoms.
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Affiliation(s)
- Dan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Yue-Yuan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jia-Xin Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lei Song
- Department of Gastroenterology, The Hospital of Hei Long Jiang Province, Harbin, Heilongjiang 150036, P.R. China
| | - Yang-Yang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Li-Xia Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China.,Department of Digestive Endoscopy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Bin Hai
- Department of Digestive Endoscopy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Qing-Fen Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Dong-Ying Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - De-Zhi He
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Bing-Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China.,State Key Laboratory of Esophageal Cancer Prevention and Treatment, Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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Gracia-Ramos AE, Hernández-Utrera JE, Adalid-Arellano D, Solis-López RÁ. Transhiatal Visceral Herniation. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci 2020; 65:38-65. [PMID: 31451984 DOI: 10.1007/s10620-019-05784-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023]
Abstract
AIM To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy. METHODS Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria. RESULTS Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM. CONCLUSION This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY, 11501, USA
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Tan Y, Li C, Yan J, Long L, Huo J, Liu D. Difficult peroral endoscopic myotomy: definition and management strategies. Expert Rev Gastroenterol Hepatol 2019; 13:933-942. [PMID: 31566998 DOI: 10.1080/17474124.2019.1674648] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Peroral endoscopic myotomy (POEM) has been established as an alternative endoscopic method for the treatment of achalasia, and several studies have confirmed its relatively long-term efficacy. Although most of the POEM procedures can be smoothly completed, technical difficulties do arise during the treatment of some patients, which may lead to prolonged procedure duration, increased procedure-related complications, or even aborted POEM.Area covered: In the present review, we provide a comprehensive review of difficult POEM, focusing on its definition, risk factors, and intraoperative management strategies. The present review is expected to provide tips for not so experienced operators who perform POEM.Expert commentary: Submucosal fibrosis and sigmoid-type esophagus are associated with difficult POEM. Sometimes, the following may also be associated with difficult POEM: previous endoscopic or surgical treatments, spastic esophageal disorders (type III achalasia, distal esophageal spasm, and hypercontractile esophagus), achalasia with diverticulum or situs inversus. For operators who begin to perform POEM, I suggest an exclusion of patients with severe submucosal fibrosis or sigmoid-type esophagus, and begin to perform POEM for these patients when they have completed at least 50 cases of 'easy POEM' and the proposed management strategies may be helpful.
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Affiliation(s)
- Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chen Li
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jin Yan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Limin Long
- Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jirong Huo
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Crema E, Terra Júnior JA, Borges MC, Queiroz CAS, Soares LA, Silva AAD. Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy. Acta Cir Bras 2018; 33:834-841. [PMID: 30328916 DOI: 10.1590/s0102-865020180090000012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. METHODS Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. RESULTS Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. CONCLUSION The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.
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Affiliation(s)
- Eduardo Crema
- PhD, Full Professor, Division of Digestive Surgery, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
| | - Júverson Alves Terra Júnior
- PhD, Assistant Professor, Division of Surgical Technique and Experimental Surgery, UFTM, Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
| | - Marisa Carvalho Borges
- Postdoctoral Fellow, Postgraduate Program in Health Sciences, UFTM, Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
| | - Carlos Alfredo Salci Queiroz
- Assistant Professor, Division of Surgical Technique and Experimental Surgery, UFTM, Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
| | - Luciana Arantes Soares
- Postdoctoral Fellow, Postgraduate Program in Health Sciences, UFTM, Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
| | - Alex Augusto da Silva
- PhD, Associate Professor, Division of Digestive Surgery, UFTM, Uberaba-MG, Brazil. Conception of the study, analysis and interpretation of data, manuscript writing, critical revision
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