Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders.


Journal

Current gastroenterology reports
ISSN: 1534-312X
Titre abrégé: Curr Gastroenterol Rep
Pays: United States
ID NLM: 100888896

Informations de publication

Date de publication:
Sep 2022
Historique:
accepted: 12 07 2022
pubmed: 11 8 2022
medline: 30 9 2022
entrez: 10 8 2022
Statut: ppublish

Résumé

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum. POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

Identifiants

pubmed: 35947337
doi: 10.1007/s11894-022-00845-6
pii: 10.1007/s11894-022-00845-6
doi:

Types de publication

Journal Article Review

Langues

eng

Sous-ensembles de citation

IM

Pagination

105-114

Informations de copyright

© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Références

Fox MR, Sweis R, Yadlapati R, Pandolfino J, Hani A, Defilippi C, et al. Chicago classification version 4.0(©) technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility. Neurogastroenterol Motil. 2021;33(4):e14120. doi: https://doi.org/10.1111/nmo.14120 .
doi: 10.1111/nmo.14120 pubmed: 33729668 pmcid: 8268048
Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet. 2014;383(9911):83–93. doi: https://doi.org/10.1016/s0140-6736(13)60651-0 .
doi: 10.1016/s0140-6736(13)60651-0 pubmed: 23871090
Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ. Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls. Am J Gastroenterol. 2008;103(1):27–37. doi: https://doi.org/10.1111/j.1572-0241.2007.01532.x .
doi: 10.1111/j.1572-0241.2007.01532.x pubmed: 17900331
Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39(9):761–4. doi: https://doi.org/10.1055/s-2007-966764 .
doi: 10.1055/s-2007-966764 pubmed: 17703382
Kahrilas PJ, Katzka D, Richter JE. Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute. Gastroenterology. 2017;153(5):1205–11. doi: https://doi.org/10.1053/j.gastro.2017.10.001 .
doi: 10.1053/j.gastro.2017.10.001 pubmed: 28989059
Werner YB, Hakanson B, Martinek J, Repici A, von Rahden BHA, Bredenoord AJ, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019;381(23):2219–29. doi: https://doi.org/10.1056/NEJMoa1905380 .
doi: 10.1056/NEJMoa1905380 pubmed: 31800987
Andolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg. 2019;106(4):332–41. doi: https://doi.org/10.1002/bjs.11049 .
doi: 10.1002/bjs.11049 pubmed: 30690706
Schlottmann F, Luckett DJ, Fine J, Shaheen NJ, Patti MG. Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Ann Surg. 2018;267(3):451–60. doi: https://doi.org/10.1097/SLA.0000000000002311 .
doi: 10.1097/SLA.0000000000002311 pubmed: 28549006
Jayan N, Jacob JS, Mathew M, Mukkada RJ. Anesthesia for peroral endoscopic myotomy: A retrospective case series. J Anaesthesiol Clin Pharmacol. 2016;32(3):379–81. doi: https://doi.org/10.4103/0970-9185.188829 .
doi: 10.4103/0970-9185.188829 pubmed: 27625490 pmcid: 5009848
Khashab MA, Kumbhari V, Kalloo AN, Saxena P. Peroral endoscopic myotomy: a 4-step approach to a challenging procedure. Gastrointest Endosc. 2014;79(6):997–8. doi: https://doi.org/10.1016/j.gie.2013.12.004 .
doi: 10.1016/j.gie.2013.12.004 pubmed: 24462165
Inoue H, Tianle KM, Ikeda H, Hosoya T, Onimaru M, Yoshida A, et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 2011;21(4):519–25. doi: https://doi.org/10.1016/j.thorsurg.2011.08.005 .
doi: 10.1016/j.thorsurg.2011.08.005 pubmed: 22040634
Weusten B, Barret M, Bredenoord AJ, Familiari P, Gonzalez JM, van Hooft JE, et al. Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52(6):498–515. doi: https://doi.org/10.1055/a-1160-5549 .
doi: 10.1055/a-1160-5549 pubmed: 32375192
Tan Y, Lv L, Wang X, Zhu H, Chu Y, Luo M, et al. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc. 2018;88(1):46–54. doi: https://doi.org/10.1016/j.gie.2018.03.009 .
doi: 10.1016/j.gie.2018.03.009 pubmed: 29571969
Rodríguez de Santiago E, Mohammed N, Manolakis A, Shimamura Y, Onimaru M, Inoue H. Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials. J Gastrointestin Liver Dis. 2019;28(1):107–15. doi: https://doi.org/10.15403/jgld.2014.1121.281.pom .
doi: 10.15403/jgld.2014.1121.281.pom pubmed: 30851179
Khashab MA, Sanaei O, Rivory J, Eleftheriadis N, Chiu PWY, Shiwaku H, et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc. 2020;91(2):288 – 97.e7. doi: https://doi.org/10.1016/j.gie.2019.07.034 .
doi: 10.1016/j.gie.2019.07.034 pubmed: 31408652
Nabi Z, Ramchandani M, Sayyed M, Chavan R, Darisetty S, Goud R, et al. Comparison of Short Versus Long Esophageal Myotomy in Cases With Idiopathic Achalasia: A Randomized Controlled Trial. J Neurogastroenterol Motil. 2021;27(1):63–70. doi: https://doi.org/10.5056/jnm20022 .
doi: 10.5056/jnm20022 pubmed: 32675389 pmcid: 7786097
Edelman DS, Arroyo PJ, Unger SW. Laparoscopic gastrostomy versus percutaneous endoscopic gastrostomy. Surg Endosc. 1994;8(1):47–9. doi: https://doi.org/10.1007/BF02909493 .
doi: 10.1007/BF02909493 pubmed: 8153865
Teitelbaum EN, Sternbach JM, El Khoury R, Soper NJ, Pandolfino JE, Kahrilas PJ, et al. The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia. Surg Endosc. 2016;30(2):745–50. doi: https://doi.org/10.1007/s00464-015-4269-8 .
doi: 10.1007/s00464-015-4269-8 pubmed: 26092005
Ramirez M, Zubieta C, Ciotola F, Amenabar A, Badaloni A, Nachman F, et al. Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter? Surg Endosc. 2018;32(1):282–8. doi: https://doi.org/10.1007/s00464-017-5675-x .
doi: 10.1007/s00464-017-5675-x pubmed: 28660419
Ghazaleh S, Beran A, Khader Y, Nehme C, Chuang J, Sharma S, et al. Short versus standard peroral endoscopic myotomy for esophageal achalasia: a systematic review and meta-analysis. Ann Gastroenterol. 2021;34(5):634–42. doi: https://doi.org/10.20524/aog.2021.0644 .
doi: 10.20524/aog.2021.0644 pubmed: 34475733 pmcid: 8375650
Familiari P, Gigante G, Marchese M, Boskoski I, Bove V, Tringali A, et al. EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy. United Eur Gastroenterol J. 2014;2(2):77–83. doi: https://doi.org/10.1177/2050640614521193 .
doi: 10.1177/2050640614521193
Jain AS, Carlson DA, Triggs J, Tye M, Kou W, Campagna R, et al. Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia-Anatomy Matters! Am J Gastroenterol. 2019;114(9):1455–63. doi: https://doi.org/10.14309/ajg.0000000000000137 .
doi: 10.14309/ajg.0000000000000137 pubmed: 30741739 pmcid: 6682473
Campagna RAJ, Carlson DA, Hungness ES, Holmstrom AL, Pandolfino JE, Soper NJ, et al. Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia. Surg Endosc. 2020;34(6):2593–600. doi: https://doi.org/10.1007/s00464-019-07028-x .
doi: 10.1007/s00464-019-07028-x pubmed: 31376012
Holmstrom AL, Campagna RAJ, Cirera A, Carlson DA, Pandolfino JE, Teitelbaum EN, et al. Intraoperative use of FLIP is associated with clinical success following POEM for achalasia. Surg Endosc. 2021;35(6):3090–6. doi: https://doi.org/10.1007/s00464-020-07739-6 .
doi: 10.1007/s00464-020-07739-6 pubmed: 32632483
Cai MY, Zhou PH, Yao LQ, Zhu BQ, Liang L, Li QL. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc. 2014;80(6):1046–55. doi: https://doi.org/10.1016/j.gie.2014.05.004 .
doi: 10.1016/j.gie.2014.05.004 pubmed: 24998467
Benias PC, Korrapati P, Raphael KL, D’Souza LS, Inamdar S, Trindade AJ, et al. Safety and feasibility of performing peroral endoscopic myotomy as an outpatient procedure with same-day discharge. Gastrointest Endosc. 2019;90(4):570–8. doi: https://doi.org/10.1016/j.gie.2019.04.247 .
doi: 10.1016/j.gie.2019.04.247 pubmed: 31078571
Cloutier Z, Mann A, Doumouras AG, Hong D. Same-day discharge is safe and feasible following POEM surgery for esophageal motility disorders. Surg Endosc. 2021;35(7):3398–404. doi: https://doi.org/10.1007/s00464-020-07781-4 .
doi: 10.1007/s00464-020-07781-4 pubmed: 32648037
Attaar M, Su B, Wong HJ, Kuchta K, Denham W, Haggerty SP, et al. Factors associated with admission after implementation of a same-day discharge pathway in patients undergoing peroral endoscopic myotomy (POEM). Surg Endosc. 2021;35(7):3971–80. doi: https://doi.org/10.1007/s00464-020-07866-0 .
doi: 10.1007/s00464-020-07866-0 pubmed: 32780244
Haito-Chavez Y, Inoue H, Beard KW, Draganov PV, Ujiki M, Rahden BHA, et al. Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study. Am J Gastroenterol. 2017;112(8):1267–76. doi: https://doi.org/10.1038/ajg.2017.139 .
doi: 10.1038/ajg.2017.139 pubmed: 28534521
Zhang XC, Li QL, Xu MD, Chen SY, Zhong YS, Zhang YQ, et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy. 2016;48(11):967–78. doi: https://doi.org/10.1055/s-0042-110397 .
doi: 10.1055/s-0042-110397 pubmed: 27448052
Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G, Inoue H, et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc. 2014;80(1):1–15. doi: https://doi.org/10.1016/j.gie.2014.04.014 .
doi: 10.1016/j.gie.2014.04.014 pubmed: 24950639
Triggs JR, Krause AJ, Carlson DA, Donnan EN, Campagna RAJ, Jain AS, et al. Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia. Gastrointest Endosc. 2021;93(4):861-8.e1. doi: https://doi.org/10.1016/j.gie.2020.07.041 .
doi: 10.1016/j.gie.2020.07.041
Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, et al. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc. 2018;87(4):934 – 43.e18. doi: https://doi.org/10.1016/j.gie.2017.10.022 .
doi: 10.1016/j.gie.2017.10.022 pubmed: 29102729
Inoue H, Shiwaku H, Kobayashi Y, Chiu PWY, Hawes RH, Neuhaus H, et al. Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience. Esophagus. 2020;17(1):3–10. doi: https://doi.org/10.1007/s10388-019-00689-6 .
doi: 10.1007/s10388-019-00689-6 pubmed: 31559513
Tyberg A, Choi A, Gaidhane M, Kahaleh M. Transoral incisional fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open. 2018;6(5):E549-e52. doi: https://doi.org/10.1055/a-0584-6802 .
doi: 10.1055/a-0584-6802
Brewer Gutierrez OI, Chang KJ, Benias PC, Sedarat A, Dbouk M, Lee D, et al. Mo1229 TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) TO THE RESCUE: IS TIF THE ANSWER TO POST-POEM GERD? Gastrointest Endosc. 2019;89(6):AB475-AB. doi: https://doi.org/10.1016/j.gie.2019.03.767 .
doi: 10.1016/j.gie.2019.03.767
Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut. 2016;65(6):899–906. doi: https://doi.org/10.1136/gutjnl-2014-308649 .
doi: 10.1136/gutjnl-2014-308649 pubmed: 25934759
Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265–71. doi: https://doi.org/10.1055/s-0029-1244080 .
doi: 10.1055/s-0029-1244080 pubmed: 20354937
Ponds FA, Fockens P, Lei A, Neuhaus H, Beyna T, Kandler J, et al. Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. JAMA: the journal of the American Medical Association. 2019;322(2):134–44. doi: https://doi.org/10.1001/jama.2019.8859 .
doi: 10.1001/jama.2019.8859 pubmed: 31287522
Meng F, Li P, Wang Y, Ji M, Wu Y, Yu L, et al. Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc. 2017;31(11):4665–72. doi: https://doi.org/10.1007/s00464-017-5530-0 .
doi: 10.1007/s00464-017-5530-0 pubmed: 28411346
Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Official journal of the American College of Gastroenterology | ACG. 2020;115(9).
Zhou PH, Li QL, Yao LQ, Xu MD, Chen WF, Cai MY, et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy. 2013;45(3):161–6. doi: https://doi.org/10.1055/s-0032-1326203 .
doi: 10.1055/s-0032-1326203 pubmed: 23389963
Ngamruengphong S, Inoue H, Ujiki MB, Patel LY, Bapaye A, Desai PN, et al. Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy. Clin Gastroenterol Hepatol. 2017;15(10):1531–7.e3. doi: https://doi.org/10.1016/j.cgh.2017.01.031 .
doi: 10.1016/j.cgh.2017.01.031 pubmed: 28189695
Tyberg A, Seewald S, Sharaiha RZ, Martinez G, Desai AP, Kumta NA, et al. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM. Gastrointest Endosc. 2017;85(6):1208–11. doi: https://doi.org/10.1016/j.gie.2016.10.015 .
doi: 10.1016/j.gie.2016.10.015 pubmed: 27756611
Kandulski A, Fuchs KH, Weigt J, Malfertheiner P. Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM). Dis Esophagus. 2016;29(6):695–6. doi: https://doi.org/10.1111/dote.12182 .
doi: 10.1111/dote.12182 pubmed: 24460870
Louis H, Covas A, Coppens E, Devière J. Distal esophageal spasm treated by peroral endoscopic myotomy. Am J Gastroenterol. 2012;107(12):1926–7. doi: https://doi.org/10.1038/ajg.2012.317 .
doi: 10.1038/ajg.2012.317 pubmed: 23211862
Minami H, Isomoto H, Yamaguchi N, Ohnita K, Takeshima F, Inoue H, et al. Peroral endoscopic myotomy (POEM) for diffuse esophageal spasm. Endoscopy. 2014;46(Suppl 1 UCTN):E79–81. doi: https://doi.org/10.1055/s-0032-1309922 .
doi: 10.1055/s-0032-1309922 pubmed: 24676826
Khashab MA, Messallam AA, Onimaru M, Teitelbaum EN, Ujiki MB, Gitelis ME, et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc. 2015;81(5):1170–7. doi: https://doi.org/10.1016/j.gie.2014.10.011 .
doi: 10.1016/j.gie.2014.10.011 pubmed: 25634487
Patti MG, Pellegrini CA, Arcerito M, Tong J, Mulvihill SJ, Way LW. Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders. Arch Surg. 1995;130(6):609–15. doi: https://doi.org/10.1001/archsurg.1995.01430060047009 . discussion 15 – 6.
doi: 10.1001/archsurg.1995.01430060047009 pubmed: 7763169
Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN, Ujiki MB, et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open. 2015;3(3):E195–201. doi: https://doi.org/10.1055/s-0034-1391668 .
doi: 10.1055/s-0034-1391668 pubmed: 26171430 pmcid: 4486039
Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker’s diverticulum). Postgrad Med J. 2001;77(910):506–11. doi: https://doi.org/10.1136/pmj.77.910.506 .
doi: 10.1136/pmj.77.910.506 pubmed: 11470929 pmcid: 1742115
Anagiotos A, Preuss SF, Koebke J. Morphometric and anthropometric analysis of Killian’s triangle. Laryngoscope. 2010;120(6):1082–8. doi: https://doi.org/10.1002/lary.20886 .
doi: 10.1002/lary.20886 pubmed: 20513021
Siddiq MA, Sood S. Current management in pharyngeal pouch surgery by UK otorhinolaryngologists. Ann R Coll Surg Engl. 2004;86(4):247–52. doi: https://doi.org/10.1308/147870804524 .
doi: 10.1308/147870804524 pubmed: 15239864 pmcid: 1964216
Kensing KP, White JG, Korompai F, Dyck WP. Massive bleeding from a Zenker’s diverticulum: case report and review of the literature. South Med J. 1994;87(10):1003–4.
doi: 10.1097/00007611-199410000-00008
Sharma R, DeCross AJ. Zenker’s diverticulitis secondary to alendronate ingestion: a rare cause of recurrent dysphagia. Gastrointest Endosc. 2011;73(2):368–70. doi: https://doi.org/10.1016/j.gie.2010.10.043 .
doi: 10.1016/j.gie.2010.10.043 pubmed: 21295647
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel JJ, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus. 2021;18(3):693–9. doi: https://doi.org/10.1007/s10388-020-00809-7 .
doi: 10.1007/s10388-020-00809-7 pubmed: 33387150
Yang J, Novak S, Ujiki M, Hernández Ó, Desai P, Benias P, et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum. Gastrointest Endosc. 2020;91(1):163–8. doi: https://doi.org/10.1016/j.gie.2019.04.249 .
doi: 10.1016/j.gie.2019.04.249 pubmed: 31082393
Al Ghamdi SS, Farha J, Moran RA, Pioche M, Moll F, Yang DJ, et al. Zenker’s peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker’s diverticulum: a multicenter retrospective comparison. Endoscopy. 2021. doi: https://doi.org/10.1055/a-1518-7223 .
doi: 10.1055/a-1518-7223 pubmed: 34710910

Auteurs

Dylan Olson (D)

Department of Medicine, Feinberg School of Medicine, Northwestern University, 251 E Huron St, 60611, Chicago, IL, USA.

Kevin C Liu (KC)

Division of Gastroenterology and Hepatology, Banner University Medical Center, University of Arizona, Tucson, AZ, USA.

Aziz Aadam (A)

Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 1400, 60611, Chicago, IL, USA. abdul.aadam@northwestern.edu.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female
Humans United States Aged Cross-Sectional Studies Medicare Part C
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH