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Ann Thorac Surg 1998;66:1886-1892
© 1998 The Society of Thoracic Surgeons

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Original Articles

Success of laparoscopic fundoplication for gastroesophageal reflux disease¹

^a Allegheny University Hospitals, Allegheny General, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA
^b St. Louis University Medical Center, St. Louis, Missouri, USA
^c University of Southern Illinois Medical Center, Springfield, Illinois, USA

Address reprint requests to Dr Landreneau, Division of Thoracic Surgery, Allegheny University of the Health Sciences, Suite 0242, 02 Level, South Tower, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212-4772

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 
Background. We explored the efficacy of laparoscopic fundoplication (LF) in patients with uncomplicated, medically recalcitrant pathologic gastroesophageal reflux disease (GERD) for whom we previously would have recommended open surgical repair.

Methods. From January 1994 to January 1998, we performed LF on 150 patients (80 men and 70 women) with GERD recalcitrant to maximal medical therapy. No patient suffered from esophageal stricture or epithelial dysplasia; however 16% (24 of 150) had benign Barrett’s mucosa. Preoperative esophageal manometry and 24-hour pH testing were obtained in 93% (139 of 150) and 89% (134 of 150) of patients, respectively. Nissen LF (n = 123), Toupet LF (n = 26), or Dor LF (n = 1) were accomplished over a large (54 F) intraesophageal bougie. Preoperative (1 month) and postoperative (>6 month) symptom scoring were assessed on a 0 to 10 scale. Thirty-eight patients with a greater than 6-month postoperative period had manometry and pH studies performed.

Results. The laparoscopic approach was successful in 99% (148 of 150) of patients, and there has been no mortality. Operative time was 160 ± 59 minutes. Open conversion was required for 2 patients: because of difficulty with dissection owing to adhesions in 1 case and due to perforation in another. Reoperation was required for 5 patients (1 paraesophageal, 2 dysphagia, 2 recurrent reflux). Major postoperative complications involved stroke and pancreatitis in 1 patient each. Mean hospital stay was 2.6 ± 1.2 days, full activity resumed by 7 days. Postoperative esophageal pH testing among 38 patients tested more than 6 months after operation demonstrated normal esophageal acid exposure in all but 2. GERD symptoms were relieved at 1 month, 6 months, and after 1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients, respectively.

Conclusions. Intermediate-term results with LF suggest this to be a reasonable approach to surgical management of medically recalcitrant uncomplicated GERD. Thoracic surgeons interested in GERD should become familiar with minimally invasive surgical approaches.

	Introduction

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 
It is estimated that nearly 50% of Americans experience heartburn at least once a month and 1 of every 10 Americans experiences heartburn even more frequently [1,2]. Roughly 4 of every 1,000 persons have unremitting symptoms or complications related to chronic bathing of the esophagus by refluxed gastric contents and may be considered as having significant gastroesophageal reflux disease, or GERD [3]. It is also appreciated that GERD is a chronic disease that waxes and wanes at intervals of variable duration depending on the patient’s emotional state, dietary indiscretion, and change in body habitus [4,5]. As this is perceived as a chronic disease state, many family physicians, internists, and gastroenterologists accept the concept of providing life-long acid antisecretory and prokinetic therapy as the desired management of uncomplicated GERD; however, chronic suppression of normal gastric acid secretion coupled with unchecked bile acid effects on the gastric and esophageal mucosa may be primary contributors to the rising incidence of adenocarcinoma of the distal esophagus and gastric cardia seen today [6–8]. The long-term expense and the alteration in lifestyle necessary for such a chronic medical approach to GERD further increases our interest in recommending antireflux operation for good risk patients with significant symptoms or recurrent esophagitis when they are taken off aggressive antisecretory medical therapy. This sentiment is further strengthened as a result of the reported outcomes with minimally invasive surgical approaches to antireflux surgery for uncomplicated recalcitrant GERD [9–14].

For the most part, thoracic surgeons interested in the surgical management of benign esophageal diseases have maintained allegiance to the "open" operative approaches that they have championed or otherwise had experience. The rush of enthusiasm with less invasive surgical approaches among patients, primary care physicians, and referring gastroenterologists has resulted in a swing in surgical management of GERD from the hands of experienced esophageal surgeons toward laparoscopic surgeons of highly variable esophageal surgical experience. In some respects, this has eroded the influence of the enormous GERD knowledge base provided to us by surgeons experienced with open reparative techniques, and this has also accounted for a "reinventing of the wheel" of many aspects of tried and true surgical management of GERD by inexperienced laparoscopists becoming involved with this esophageal problem. Thoracic surgeons can take the smug approach of waiting and watching for this laparoscopic "hype" to fade away and remain available in the wings anticipating future years of "I told you so" redo open operative antireflux operations resulting from laparoscopic surgical failures. But such an attitude is faulty.

Our group has explored the utility of the laparoscopic approach to surgical correction of clinically significant uncomplicated GERD, and we report our intermediate-term experience with these minimally invasive surgical approaches.

	Materials and methods

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 
Patient profile
From 1994 to 1998, we performed laparoscopic fundoplication on 150 patients with uncomplicated GERD recalcitrant to maximal medical therapy. The ratio of women to men was 80 to 70 and the mean age was 48 ± 14 years. No patient suffered from esophageal stricture or epithelial dysplasia; however, 16% (24 of 150) had benign Barrett’s mucosa documented by endoscopic biopsy. Three of these patients had previously undergone antireflux surgery, and 29 had a history of abdominal surgery for unrelated causes. The primary complaints of these GERD patients were heartburn and regurgitation. A minority of patients presented for antireflux surgery to assist in the management of what was believed to be reflux-induced respiratory symptoms or atypical chest pain, or both.

Preoperative objective evaluation of GERD
All patients referred to us for antireflux surgery had medically recalcitrant symptoms with objective documentation of pathologic GERD. Barium esophagrams and upper gastrointestinal contrast series were routinely performed. A sliding hiatal hernia was present in 48% (72 of 150) of patients, with 2% (3 of 150) of all patients having "large" hiatal hernias. None of these hernias would be characterized as paraesophageal in nature, which has been the subject of a recent report by our group [15]. Endoscopic examination with mucosal biopsy by referring gastroenterologists before our encounter with the GERD patient was the rule. Preoperative esophageal manometry and 24-hour pH testing documenting impairment in lower esophageal sphincter function, assessing peristaltic integrity, and determining the degree of pathologic esophageal acid exposure were obtained in 93% (139 of 150) and 89% (134 of 150) of patients, respectively. The mean preoperative values for lower esophageal sphincter pressure was 17.5 mm Hg. Preoperative 24-hour pH testing was 13.2%. The minority of patients who for a variety of reasons would not or could not tolerate manometric or prolonged esophageal pH testing had their esophagogastric motility estimated with nuclear scintigraphic assessment of solid phase emptying. Manometric evaluation demonstrated impaired peristaltic amplitude of esophageal body contraction (less than 30 mm Hg) or disordered esophageal motility in 26 patients. The partial Toupet fundoplication was chosen for 27 of these patients and the Dor fundoplication in the remaining patients to manage their GERD [16,17].

Preoperative endoscopic evaluation
After general anesthesia had been successfully established, all patients underwent fiber optic esophagogastroduodenoscopy by the operative surgeon to evaluate the esophageal anatomy and the degree of reflux-induced esophagitis. Specific attention was placed on visual inspection of the esophageal, gastric, and duodenal mucosa; the presence of any luminal narrowing; and the integrity of the proximal stomach cardiac "flop valve" on retroflexed inspection. Endoscopic inspection of the esophageal mucosa demonstrated that only minimal esophageal inflammation was present at the time of surgical treatment in 85% of patients. Many of these patients had previous evidence of more extensive esophageal inflammation that had responded to aggressive antisecretory therapy with proton pump inhibitors. The recurrence of classic symptoms on deescalation of medical management led to the referral for laparoscopic antireflux surgery. Fifteen percent of patients demonstrated persistent significant esophageal inflammation (grade II to III) on preoperative evaluation. Sixteen percent of all patients demonstrated evidence of Barrett’s mucosa without dysplasia.

Laparoscopic approach to hiatal dissection, crural approximation, and fundic mobilization
We have previously detailed our surgical approach to laparoscopic management of GERD [18]. Five sites of trochar access are routinely employed. The trochar access is basically arranged in two horizontal lines across the abdomen. A "Veres needle puncture" approach is usually used to gain access to the abdominal cavity for carbon dioxide insufflation. We see no particular safety advantage with the minilaparotomy access used with the Hassan trochar access technique. This is particularly true since the development of trochar instrumentation that allows for direct visualization as the trochar is introduced through the abdominal wall (Ethicon Endosurgical, Cincinnati, OH). An umbilical site for the Veres needle entry is chosen unless previous abdominal surgery increases the possibility of adhesions in this location. Alternate sites of upper abdominal access are used at a proposed trochar site when the umbilical location has potential jeopardy. After abdominal insufflation is achieved, the lower row of trochar access is centered about the site of access for the endoscopic camera. This is located in a left paramedian position approximately 3 to 5 cm above the umbilicus in patients of normal habitus. For patients with a significant abdominal declension, this paramedian access should not be based on the location of the umbilicus but instead on a horizontal line at a level approximately 3 cm below the costal margin in the anterior axillary line. Two other sites along this lower tier of trochar access are placed in the right and left upper quadrant along the anterior axillary line. We routinely elevate the abdominal wall with two towel clips positioned lateral to the trochar access incision so as to provide upward traction on the abdominal wall during the introduction of the trocar through the abdominal wall. It is obviously important to ensure that hepatomegaly or splenomegaly is absent by physical examination to avoid injury to these abdominal viscera during trochar access or instrument manipulation. Direct visualization of the sites of entry of the lateral trochar access is accomplished with the laparoscope positioned at the left paramedian trochar position. A 5-mm trochar is used for the right lateral access to introduce instrumentation for liver retraction (Snowden Pencer, Inc, Gasden, GA). The hiatal exposure is facilitated by leaving the triangular ligamentous attachments of the liver intact. The left lower lateral trochar access is usually 11 mm in diameter so as to accommodate the coaxial hand instrumentation that greatly facilitates manipulation and dissection about the hiatus ("mashers," Starr Medical, New York, NY). These atraumatic grasping forceps, scissors, and needle holders allow for trochar access without departing from the orientation of standard open surgical tools. Their use also avoids the awkwardness of the "pistol grip" design of most endosurgical hand instrumentation. This left lower trochar access is primarily used for retraction of the gastric fundus during the hiatal dissection.

A fourth trochar access site is established in the left upper quadrant for the right-handed endoscopic instrument access used to accomplish the hiatal dissection. A final trochar access is achieved in a near midline subxiphoid position to introduce the left-handed endoscopic dissecting instrumentation.

Our approach to the hiatal dissection is nearly the same as that performed through an open laparotomy. We begin the dissection by grasping the fat pad at the gastroesophageal junction to reduce any degree of hiatal herniation that may be present and to establish tension on the phrenoesophageal ligament. Sharp dissection begins on the right side of the phrenoesophageal membrane and is extended on the lesser omentum along the lesser curvature of the stomach to the level of the hepatic branch of the vagus nerve. This maneuver provides excellent visualization of the margin of the right crus of the diaphragm. We then make a deliberate effort to incise the peritoneum over the hiatal aspect of the right crus so as to expose the distal esophagus and the posterior vagal trunk. This incision is carried to the level of the arcuate ligament to facilitate the creation of an adequate posterior tunnel for future gastric mobilization during creation of the fundoplication. Once this incision on the right crural margin has been established, we insinuate the "curved tear-shaped masher" dissecting forceps into the posterior mediastinal space that is being developed and apply lateral traction toward the left upper quadrant on the gastroesophageal junction. This maneuver facilitates the exposure of the left crus and the path to be developed for creation of the posterior gastric tunnel. We have found this maneuver to be particularly valuable in preventing inadvertent injury to the retroperitoneal gastric fundus. Difficulty with posterior transposition of the fundus is also reduced with this extended dissection about the right crura. The "curved masher" is then repositioned to grasp the gastric fat pad to once again establish tension on the phrenoesophageal ligament. We then extend the dissection in a clockwise fashion and incise toward the left aspect of the anterior crural arc. Gastrophrenic attachments are divided during the course of this dissection. Once visualization of the posterior and left lateral aspects of the phrenoesophageal dissection near the hilum of the spleen become difficult, we change our attention to division of the upper four short gastric vessels. We prefer to use the Harmonic scalpel (Ultracision, Inc, Smithfield, RI) to accomplish short gastric vascular division. The separation of the fundus from its the short gastric leach allows for visualization of the posterior and left lateral attachment that were difficult to visualize earlier. This short gastric division is also important in preparing the fundus for creation of a "floppy" loose fundoplication. As the upper aspect of the left-sided dissection progresses, we take particular care to avoid uncontrolled division of the posterior gastric vessels coming directly off the splenic artery before reaching the spleen.

Care is taken to identify and avoid injury to the vagal nerve trunks during all phases of this dissection. Next, the distal esophagus and posterior fundus are separated further from their posterior retroperitoneal attachments. This results in development of a posterior gastric tunnel of generous size through which the fundus will be subsequently delivered to create the fundoplication.

A large intraesophageal bougie (54F) is introduced transorally by the anesthesiologist into the stomach. Proper positioning of this catheter is confirmed under direct laparoscopic vision. Posterior approximation of the right and left crura is performed with the catheter in place. Endoscopic suturing is used with the coaxially oriented masher endoscopic needle holders or an endoscopic stitching device (United States Surgical Corporation, Norwalk, CT). Knots are tied using an extracorporeal knot tying technique. The curved tear-shaped masher forceps are then used to grasp the upper fundus and advance it around the back of the esophagus to accomplish the subsequent fundoplication. The esophageal catheter is left in place during the suturing of the fundus about the distal esophagus as the fundoplication is created.

Nissen "complete" fundoplication
Before creation of the fundoplication, the gastroesophageal junction fat pad is resected so as to accurately visualize the true gastroesophageal junction. With the intraesophageal bougie in place, a "floppy" 2-cm long total fundoplication is then created by suturing the left margin of the upper fundus to the distal esophagus and to the mobilized fundus that is to the right of the distal esophagus. A total of three stitches are used to create this total fundoplication, beginning with the lowest stitch of the proposed fundoplication at the level of the gastroesophageal junction. The next two stitches of similar character are placed cephalad to this first stitch during creation of the fundoplication.

After completion of the fundoplication, pexing sutures are placed between the upper aspect of the fundic "collar" and each margin of the diaphragmatic crura to prevent slippage of the repair. A third stitch between the lower aspect of the fundoplication and the arcuate ligament is also performed to establish a secure three-point pexation of the fundoplication. The procedure is completed after meticulous hemostasis is ensured. The skin incisions are closed with subcuticular dissolving sutures and covered with sterile bandages.

Toupet "partial" fundoplication
The Toupet partial fundoplication requires a number of steps to create the antireflux barrier. The mobilized fundus is first positioned and sutured along the approximated diaphragmatic crura at three points from the arcuate ligament to the highest aspect of this posterior crural approximation that has just been completed. We then grasp the upper aspect of the fundus mobilized to the right of the distal esophagus and begin the partial plication with an upper "triangulation stitch" between the fundus, the anterolateral aspect of the distal esophagus approximately 4 cm above the gastroesophageal junction, and the right crura. A similar triangulation stitch is performed between the left anterolateral aspect of the distal esophagus, the left crura, and the upper fundus of the stomach. Three to four subsequent sutures are then placed distally along each anterolateral border of the distal esophagus to just beyond to gastroesophageal junction. Particular attention is made to avoid injury to the anterior vagal trunk. An anterior median furrow of 1 to 2 cm along the anterior esophagus separates the right and left margins of the plicated fundus once the partial fundoplication is completed. This establishes a partial fundoplication of approximately 240 to 270 degrees about the posterior and lateral aspects of the distal esophagus. The procedure is terminated after hemostasis is ensured in a fashion similar to the laparoscopic Nissen procedure.

Assessment of response to surgical therapy
Symptomatic evaluation was performed using a visual analogue scale ranging from 0 to 10, with no symptoms related as a 0 score and 10 being worst symptoms imaginable (Table 1). Patients were also asked to grade their symptoms of heartburn, regurgitation, dysphagia or chest pain, gas bloat, and diarrhea according to this visual analogue scale. Preoperative symptoms were compared with those present at 1 month, 6 months, and beyond 1 year of the surgical intervention. A hiatal hernia symptom score modeled after that described by Jamieson and Duranceau [19] was also used to characterize the patients’ lifestyle and sense of well-being before and after their antireflux operation. Using this scoring system, the frequency of symptoms is added to the duration of symptoms and the sum is multiplied by the severity of symptoms. A minimum score of 0 and a maximum score of 32 is possible with this format. The percent change from preoperative values assessed by visual analogue system and the Jamieson index for the various symptoms in question were then calculated.

Statistical analyses
Data were collected and entered into a computerized information management system and subjected to analysis with the SPSS (Chicago, IL) (version 6.0) statistical program. A probability of chance being responsible for a given difference less than or equal to 0.05 was accepted as statistically significant. The primary study endpoint was the absolute change in the postoperative symptom scores from the preoperative baseline values. Differences in percentage of change and the mean symptom scores were assessed by visual analogue scales and the Jamieson symptom index preoperatively and at 1, 6, and greater than 6 months postoperatively using the analysis of variance. Significant differences were determined by the Tukey test.

Postoperative management
Patients are instructed to maintain a frequent small-feeding soft diet during the first 6 to 8 weeks following surgery, as dysphagia related to edema about the fundoplication often persists over this time period. We also instruct patients to regularly rely on simethicone preparations to reduce abdominal gaseousness as many of these patients’ have a tendency toward aerophagia, which can be problematic with a now competent lower esophageal sphincter mechanism. There are no other specific recommendations for these patients other than to avoid excessive weight lifting after their surgery.

	Results

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 
We were able to accomplish the laparoscopic approach to antireflux surgery in 99% (148 of 150) of patients who underwent operations. Conversion to an open surgical approach was required for 1 patient because of difficulty with dissection due to adhesions related to previous abdominal surgery. Another patient required conversion to an open procedure to adequately manage an iatrogenic perforation at the gastroesophageal junction occurring during the dissection to create the posterior tunnel about the crura. A second patient who sustained an iatrogenic perforation underwent successful endoscopic suture closure of the gastric injury and laparoscopic fundoplication. There were no postoperative deaths, and major postoperative complications were limited to the development of a cerebrovascular accident and pancreatitis in 1 patient each. Mean hospital stay was 2.6 ± 1.2 days; however, postoperative hospital stay among our last 40 patient averaged less than 24 hours. Similarly, the operative time that was found to be 160 ± 59 minutes fell to 70 minutes among the last 40 patients. Resumption of full activity has been routinely noted in less than 7 days.

Delayed reoperation has been performed for 5 patients. This was required to repair an acute paraesophageal hernia recognized shortly after surgery resulting from disruption of the crural repair in one patient. One patient complained of significant postoperative dysphagia and underwent laparoscopic conversion of a Nissen fundoplication to a partial Toupet fundoplication with good postoperative results. Another patient complained of troublesome left shoulder pain and left upper quadrant discomfort after meals related to gas and bloating. Again laparoscopic conversion from a total fundoplication to a partial fundoplication greatly improved these symptoms. Two patients complained of troublesome postoperative GERD, which was also addressed with repeat fundoplication. One of these patients was successfully treated with redo laparoscopic fundoplication to correct the inadequate antireflux mechanism. The second patient underwent open transabdominal redo Nissen fundoplication. Both of these patients developed recurrent symptoms less than 6 months from their original laparoscopic operation.

Postoperative prolonged esophageal pH testing was performed among 40 of 73 patients at 1 year after their antireflux operation. The mean postoperative lower esophageal sphincter pressure was 21.4 mm Hg, and the postoperative mean 24-hour pH exposure was 2.0%. Normal esophageal acid exposure was noted in all but two patients at this time. These two individuals demonstrated mild elevation in acid exposure and were generally content with their control of GERD symptoms without antisecretory therapy. Overall, GERD symptoms were relieved at 1 month, 6 months, and greater than 1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients, respectively.

Table 2 relates the changes in typical GERD symptoms after the laparoscopic fundoplication. The values expressed are a percentage of the patient’s preoperative symptoms assessed on a 0 to 10 visual analogue scale at 1 month, 6 months, and more than 6 months after operation. Notable improvement in heartburn, regurgitation, and dysphagia symptoms were identified; however, gaseousness and bloating were more prominent symptoms after surgery. Among patients beyond a year after surgery, only 8% of patients were receiving antisecretory gastric acid inhibition, whereas nearly all of these patients were being treated with these agents at the time of their preoperative assessment.

	Comment

Top Footnotes Abstract Introduction Materials and methods Results Comment References

The next generation of thoracic surgeons are unlikely to be primarily involved in the management of esophageal disease unless practicing thoracic surgeons become involved in minimally invasive esophageal surgical approaches. Most residents in thoracic surgery have considerable surgical laparoscopic experience from their general surgical training. This experience can facilitate their education with these laparoscopic approaches to GERD. The use of laparoscopic instrumentation can be relatively easily mastered, and, once this experience is established, most surgeons actually prefer the view of the left upper quadrant anatomy afforded through the laparoscopic approach. This visibility can often be far superior to that available through open surgical procedures. This may be a consequence of positive pressure carbon dioxide insufflation of the abdomen or the lack of crowding of the operative field by the surgeon’s hands obscuring the view of the anatomy. Visualization of the operative field optimized by the endoscopic camera also allows the entire operative team to become engaged in the surgical intervention.

Taking on these minimally invasive techniques does demand a positive attitude toward learning something new by the thoracic surgeon and surgical nurses engaged in traditional cardiothoracic surgery. Unfortunately, this requirement for change is commonly met with skeptism and a reluctant attitude. This opposition to get involved can be overcome by assertive direction from the thoracic surgeon interested in minimally invasive thoracic surgical approaches.

With few exceptions, thoracic surgeons who have moved surgery of the esophagus forward over the last three decades have chosen to downplay the validity of laparoscopic surgical interventions. Some of these leaders with a spirit for change have actually developed new kinships with general surgeons interested in minimally invasive surgery as the "rules of engagement" in the operative management of GERD have changed.

The spirit of lassitude toward laparoscopic techniques by the general thoracic surgical leadership risks the loss of further referral of any esophageal pathology to our junior faculty and residents in training as general surgeons engaged in these techniques gain the upper hand of referral relationships with gastroenterologists and primary care physicians. We have seen this phenomenon develop not only with regard to these benign esophageal problems commonly managed by thoracic surgeons, but also in the management of esophageal carcinoma [22,23]. Accordingly, it is now a common circumstance in many clinical settings to have esophagectomy for carcinoma performed through the transhiatal approach by general surgeons with limited experience in managing intrathoracic problems that may be encountered during or following esophagectomy. In this setting, the thoracic surgeon’s role is confined to management of intrathoracic complications after these surgical interventions.

Thoracic surgeons of North America can be assured that this denigration of their role in the clinical management of esophageal disease is not unprecedented. Most of our thoracic surgical colleagues in Europe and Asia have succumbed to accept this subordinate role in the management of pathologic conditions of the esophagus requiring surgical intervention.

In response to this trend, we are compelled to urge thoracic surgeons to become engaged in the practice and education of present-day minimally invasive surgical approaches to GERD and other esophageal disease processes. This should include adequate endoscopic evaluation of the esophagus, stomach, and duodenum. It should also include exposure to the laparoscopic approaches to esophageal pathology described here.

The results of this prospective experience demonstrate the utility of laparoscopic approaches to uncomplicated GERD. These results are comparable to intermediate-term accounts of surgical management of GERD accomplished through laparotomy or thoracotomy. Longer term follow-up is obviously necessary; however, we strongly suggest that thoracic surgeons and their trainees develop laparoscopic experience and embrace minimally invasive esophageal surgery.

	Footnotes

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 
¹ This article has been selected for the open discussion forum on the STS Website: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Materials and methods Results Comment References

 

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