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Dr. Rob Bechara

Medical Grand Rounds: An Introduction to Third Space Endoscopy Featuring Dr. Rob Bechara

Cassie Brand, MSc Candidate (Translational Medicine)

At last week’s Medical Grand Rounds, we had the pleasure of hearing from Dr. Rob Bechara on the emerging field of third space endoscopy. Third space endoscopy refers to a group of endoscopic proceedures that take advantage of accessing the submucosal space of the body for therapeutic intervention1. The development of these relatively new proceedures offers a less invasive and less painful alternative to traditional surgical techniques for the treatment of gastrointestinal neoplasms and motility disorders2.
 

Dr. Bechara started off his presentation with an introduction to endoscopic submucosal dissection (ESD), a technique that bridges the gap between traditional endoscopic mucosal resections (EMR) and surgery. Here it was highlighted that while ESD does not replace traditional proceedures, it allows for otherwise challenging en blocresections and offers the highest chance of avoiding unnecessary surgery3. This technique has laid the foundation for the development of a new chain of endoscopic therapeutics2.
 

In 2008, the first peroral endoscopy myotomy (POEM) proceedure was performed4. POEM is commonly used to treat achalasia and has more recently been expanded to other spastic esophageal and foregut conditions5. In addition to being less invasive, POEM can be performed after previous therapeutic interventions such as Laparoscopic Heller Myotomies, botulinum injections and previous POEM6. The POEM proceedure relies on five core steps: 1) submucosal injection to expand the third space 2) mucosal incision 3) creation of a submucosal tunnel 4) myotomy 5) closure of the incisions with clips5. Meta analyses have shown POEM to have a technical success rate of 97% and a clinical efficacy of 93%, highlighting the value of this proceedure7. Furthermore, POEM is a safe proceedure with a low rate of adverse events, most of which are non-severe and can easily be managed without affecting the overall post operative state of the patient. As a result, POEM has become the standard therapy for achalasia4.
 

Dr. Bechara proceeded to introduce peroral endoscopy tumor resection (POET), which came into practice shortly after the development of POEM. POET is a technique used to resect benign submucosal gastrointestinal tumors with low lymph node metastatic potential8. However, POET is limited to tumors less than 4 cm in size to allow for oral resection. Similar to POEM, a submucosal injection is made above the lesion allowing for an incision to be made. The tumor is then dissected and removed orally8. This offers a less painful and shorter alternative to traditional resection techniques whilst being effective (92%) and safe (adverse events are rare and easily treated)9. POEM and POET have similar contraindications including conditions preventing the use of anesthetics, pathologies precluding submucosal tunnel formation, cirrhosis with portal hypertension and severe coagulopathies.
 

The principles of POEM have recently been expanded to address new therapeutic avenues for the treatment of other gastrointestinal pathologies. Gastric peroral endoscopy myotomy (G-POEM) is a variation of POEM that targets the pyloric sphincter to treat gastroparesis10. While this technique is still somewhat experimental, there is evidence of an 81.3% long term clinical improvement G-POEM11. In addition to the traditional contraindications of POEM, the use of G-POEM is further limited by unmanaged psychiatric conditions and uncontrolled diabetes. Zenker’s peroral endoscopy myotomy (Z-POEM) is another variation in which submucosal tunnels are created improving septal visualization and allowing for a complete cricopharyngeal myotomy to be performed12. Although closure for this technique is generally quite challenging, preliminary results have indicated a high clinical success rate (95.8% ). While both proceedures have evidence supporting their efficacy, better physiological studies and larger prospective trials are required to refine these proceedures and identify the population of patients best suited to benefit from them. 
 

Following Grand Rounds, the Translational Medicine (TMED) students were fortunate to continue the discussion of third space endoscopy with Dr. Bechara. A common theme of the discussion revolved around challenges associated with the implementation of these new techniques to benefit patients. Dr. Bechara highlighted that while these are highly effective treatments that avoid unnecessary surgeries, implementation in Canada is limited by funding and justification. Even with appropriate funding, Dr. Bechara predicts that these proceedures would only be available at tertiary hospitals due to the expertise required. We ended off the discussion by talking about Dr. Bechara’s challenging but rewarding international medical training in Japan and were very excited to hear about the introduction of a new third space endoscopy fellowship program starting up at Queen’s University this fall.
 

On behalf of the TMED students, I would like to thank Dr. Bechara for his time and contributions to increasing the practice of endoscopic procedures in Canada. 
 

References:

  1. Nabi Z, Reddy DN, Ramchandani M. Recent advances in third-space endoscopy. Gastroenterology & Hepatology. 2018;14(4):224.

  2. Shanbhag AB, Thota PN, Sanaka MR. Recent advances in third space or intramural endoscopy. World Journal of Gastrointestinal Endoscopy. 2020;12(12):521.

  3. Asano M. Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer. World journal of gastrointestinal endoscopy. 2012;4(10):438.

  4. Ahmed Y, Othman MO. Peroral endoscopic myotomy (POEM) for achalasia. Journal of Thoracic Disease. 2019;11(Suppl 12):S1618.

  5. Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World journal of gastrointestinal endoscopy. 2015;7(5):496.

  6. Kolb JM, Jonas D, Funari MP, Hammad H, Menard-Katcher P, Wagh MS. Efficacy and safety of peroral endoscopic myotomy after prior sleeve gastrectomy and gastric bypass surgery. World Journal of Gastrointestinal Endoscopy. 2020;12(12):532.

  7. Barbieri LA, Hassan C, Rosati R, Romario UF, Correale L, Repici A. Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European gastroenterology journal. 2015;3(4):325-34.

  8. Chiu PWY, Yip HC, Teoh AYB, Wong VWY, Chan SM, Wong SKH, et al. Per oral endoscopic tumor (POET) resection for treatment of upper gastrointestinal subepithelial tumors. Surgical Endoscopy. 2019;33(4):1326-33.

  9. Onimaru M, Inoue H, Bechara R, Tanabe M, Abad MRA, Ueno A, et al. Clinical outcomes of per‐oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia. Digestive Endoscopy. 2020;32(3):328-36.

  10. Mohan BP, Chandan S, Jha LK, Khan SR, Kotagiri R, Kassab LL, et al. Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surgical endoscopy. 2020;34(8):3352-67.

Comments

Name
Kyla

Wed, 03/23/2022 - 08:28

Hello, Cassie,

First off, great blog post. You did an incredible job summarizing Dr. Bechara’s talk, and the fundament take away of Third Space endoscopy. I think you captured the common theme of our discussion well regarding the challenges associated with implementing new techniques at the surgical level. One of the things I was thinking about during this talk is the implications of the pandemic for new interventions going forward. I wonder if people would be more or less likely to accept a new intervention as we have all learned to adapt to changes quickly. However, one of the things Dr. Bechara discussed, was that these procedures are not novel. Rather, they have been around and practiced for years, improving the strategy is where they are evolving. Do you think, in your personal opinion, evolving techniques will have push back even though they have been around for years?

Thank you again Cassie for a wonderful discussion and post.

Kyla

Name
Kyla

Hi Kyla,

Thank you for your comment. I think this is a really interesting point that you bring up as we have seen how different groups of individuals respond to rapidly changing health care guidelines, treatments and vaccines. In terms of evolving surgical techniques, while there may some initial push back, I personally believe that these new developments will generally be well received. Part of my reasoning is that since these techniques are evolving, there is already evidence of the efficacy of their framework and predecessors, allowing for individuals to compare techniques and recognize how a newer technique may be able to address a gap that an older one cannot. Like you mentioned, framing these new techniques as improvements, also makes me believe that this will reduce hesitancy for similar reasons. Additionally, particularly with third space endoscopy, it has been used more widely internationally and for longer in places such as in Japan where POEM originated. Seeing real world evidence of the success of these procedures over several years may also help in patient decisions.

Bringing the conversation back to the pandemic, I am actually wondering if it has made people more adaptable to accept the care that that is presented to them. With all of the unfortunate surgical backlogs and delays in care, I am wondering if this factor may actually push patients to trust the advice of their health care team and go with the first and soonest option available. I am curious to hear what others think of this as well as my peer's opinions on push backs surrounding evolving techniques.

Best,
Cassie

Name
Cassie

Hi Cassie and Kyla,

Thank you for your summary of the MGR! I came across a news article about ESD being offered as a new surgical intervention in Alberta, including quotes from patients and physicians. (1) As third space endoscopy procedures are less invasive, patients can recover much more quickly. I think this would cause patients to be more interested in this newer procedure. For example, one patient who was interviewed, mentioned that he was home the next day and was even able to play pool! (1) I would guess that the benefits of new interventions, such as much faster recovery time, factor into patient’s decisions about whether they’re likely to accept the intervention. I would be very interested to see in the next few years whether there are changes to the public’s acceptance of new interventions in medicine. I look forward to hearing your thoughts!

Samantha

References
1. Minimally invasive techniques at PLC reduce recovery time for GI cancer patients. 2021. CBC. https://calgary.ctvnews.ca/minimally-invasive-techniques-at-plc-reduce-…

Name
Samantha

Name
James King

Wed, 03/23/2022 - 12:11

Hi Cassie,
Thank you for a fantastic summary of last week's MGR and facilitated discussion. In conducting background reading prior to class last week, I came across an interesting study on the subject of the challenges posed by POEM for anesthesiologists (1). The study found that mean arterial partial pressure of carbon dioxide (PaCO2) was higher during the procedure than prior or following the procedure, and peak airway pressure was higher as well. The group also identified several complications of the procedure, with subcutaneous emphysema and pneumoperitoneum requiring decompression being fairly common (21.8 and 30%, respectively). Much rarer, were pneumothorax and aspiration pneumonia (both 0.5% of cases) and bronchospasm (2.2%). Another concerning aspect was that more than 1/4 of patients required analgesia following POEM. This study highlights, that POEM has certain complications that should be accounted for and made aware to patients in terms of their anesthesia. Although POEM is safe and efficacious, with any new and evolving technology, I believe it is important to continue to study and improve it! I am curious if others have come across informations regarding the challenges or limitations of POEM.
Best,
James
1. Yurtlu, D. A., Aslan, F. (2021). Challenges in anesthesia management for peroral endoscopic myotomy: a retrospective analysis. Surg Laparosc Endosc Percutan Tech. 31(6): 729-733.

Name
James King

Hi James,
Thank you for your comment and for starting a conversation on the potential downside of POEM. It was very interesting to read your comment regarding anesthetic related complications of POEM, which was something I had not realized prior to your comment. I think this also in part speaks to why patients who have had previous issues with anesthesia is a contraindication for POEM surgery.
I agree that it important for patients to be aware of all risks and to continually try and improve surgical processes. From my own research, I found it quite surprising to learn that that the incidence of acid-reflux in post-operative POEM patients is quite high (1). While in Dr. Bechara's presentation we learned that the incidence of acid-reflux as an adverse event is approximately 13%, this only refers to symptomatic patients (1). Acid-reflux can be measured by the pH of the esophagus. In a study by Dr. Sanaka, it was found that 48% of post-op POEM patients have elevated esophageal pH compared to 14% in patients who undergo the traditional Laparoscopic Heller's Myotomy (2). This indicates that most patients with this adverse event are asymptomatic which raises concern as it indicates an underlying mucosal injury (1, 3). In response to the high prevalence, some papers have suggested a need for closer monitoring post-op.

Best,
Cassie

(1) Arevalo, G., Sippey, M., Martin-del-Campo, L. A., He, J., Ali, A., & Marks, J. (2020). Post-POEM reflux: who’s at risk?. Surgical Endoscopy, 34(7), 3163-3168.
(2) (2018). Risk of reflux after achalasia treatment: Poem vs. Heller myotomy: A comparison of esophageal pH findings. Cleaveland Clinic . Retrieved March 23, 2022, from https://consultqd.clevelandclinic.org/risk-reflux-achalasia-treatment-p….
(3) Lu, C. L. (2012). Silent gastroesophageal reflux disease. J Neurogastroenterol Motil, 18(3), 236-238.

Name
Cassie Brand

Name
Kiera Liblik

Wed, 03/23/2022 - 12:49

Hello Cassie,
Thank you for your wonderful summary of Dr. Bechara's MGR. I thought that the discussion last week around developing training programs for new procedures was very interesting. In regards to POEM, the literature suggests that the learning curve varies widely across programs (1,2). Some of the key barriers to standardizing teaching are limited staff available for training, differences in learner background, and a lack of well-established parameters for measuring competency in POEM (2).
I am wondering if, in your opinion, there is enough promise for the future use of third space endoscopy that there should be standardized early exposure to this training?
Warm regards,
Kiera

1) Liu, Z., Zhang, X., Zhang, W., Zhang, Y., Chen, W., Qin, W., Hu, J., Cai, M., Zhou, P., & Li, Q. (2018). Comprehensive Evaluation of the Learning Curve for Peroral Endoscopic Myotomy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 16(9), 1420–1426.e2. https://doi.org/10.1016/j.cgh.2017.11.048
2) Jawaid, S., Draganov, P. V., Aihara, H., Khashab, M. A., & Yang, D. (2021). Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship. Endoscopy international open, 9(12), E1890–E1899. https://doi.org/10.1055/a-1610-8962

Name
Kiera Liblik

Name
Cassie Brand

Wed, 03/23/2022 - 20:41

In reply to by Anonymous (not verified)

Hi Kiera,
Thank you for your comment and for bringing up the complex process of training! Like you mentioned, third space endoscopy require lots of training and I can definitely see the value of early standardized exposure to these techniques. However, I am personally unsure if we are ready for widespread exposure due to issues with frequency and accessibility of these procedures. Like Dr. Bechara mentioned in our discussion, these procedures are very specialized and require specific facilities and equipment, making widespread access challenging and not completely feasible. Further, Dr. Bechara mentioned that due to the nature of these techniques, they require frequent practice to maintain the surgeons skills . Since these techniques are still being refined, I am skeptical that in Canada we have the volume of patients to meet these requirements.

While I do not think we are ready for standardized exposure, I do think that there should be more exposure to these methods than there currently is. For example, introducing the principles of the procedures during medical school could help increase awareness. Further education could then be expanded to GI residents. Additionally, I think it would be important to incorporate a similar framework into nursing and anesthesiologist programs.
I would love to hear if any others have any thoughts on third space endoscopy education!

Best,
Cassie

Name
Cassie Brand

Hi Cassie and Kiera,

Cassie, great post, thank you for summarizing the presentation and discussion so well! I agree with both of you about the barriers to training these procedures. While increasing professional competency in this area would benefit any hospital, I think that facilities in low- and middle-income countries would be most impacted. Five billion people globally do not have accessible, affordable, safe surgical care, including 90% of people in lower-income countries (1). Since laparoscopic procedures like those discussed are associated with less time in hospital and lower post-procedure pain, they would be preferable to open procedures, especially in these regions. The same barriers that Kiera mentioned are highlighted again in a review focused on these countries, including funding, equipment challenges, and lack of a structured curriculum (2). Unique to more remote areas of lower-income countries, the equipment shortages are exacerbated by poor maintenance and insufficient transport infrastructure. Since a challenge everywhere is the need to consistently perform procedures to maintain skills, I wonder if there is potential for surgeons trained in higher-income countries to travel to regions-in-need to supplement their own skills. Of course, this is still limited by equipment and funding barriers, but there is clearly an unmet need that should be addressed. Do you have any other ideas for increasing laparoscopic procedure access in low GDP areas?
Thanks,
Georgia

References
1. Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., … Yip, W. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet (London, England), 386(9993), 569–624. https://doi.org/10.1016/S0140-6736(15)60160-X
Wilkinson, E., Aruparayil, N., Gnanaraj, J., Brown, J., & Jayne, D. (2021). Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review. Tropical doctor, 51(3), 408–414. https://doi.org/10.1177/0049475521998186

Name
Georgia Kersche

Hi Georgia,
Thank you for your comment. Besides the challenges of equipment and funding that you pointed out, I think the idea of "traveling surgeons" was a very clever idea. Accessibility has been a common theme amongst other post-MGR discussions we have had. While I am unsure of the feasibility of transporting equipment to areas with less access to health care due to the size and cost of the endoscopy machine, maybe the we could consider implementing a program to compensate residents of these areas for their travel fees and lost days of work. This could be combined with increased training and awareness of POEM techniques so that local health care providers could over post-op monitoring and follow up appointments. I would love to hear if anyone else has any innovative ideas to increase access to endoscopic surgery!

Best,
Cassie

Name
Cassie Brand

Name
Lubnaa Hossenbaccus

Wed, 03/23/2022 - 16:44

Hi Cassie!

Well done facilitating last week's discussion and on this wonderful summary!

I wanted to get your thoughts on the use of artificial intelligence (AI) with these endoscopic techniques. I came across a recently-published piece that reported that a computer vision technique was able to identify phases of the POEM procedure from surgery videos, with ~88% accuracy (1). The authors suggested that this could offer real-time updates on the procedure’s progress, in efforts to optimize workflow.

In what ways do you foresee AI impacting the field?

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/32720177/

Name
Lubnaa Hossenbaccus

Hi Lubnaa and Cassie!

Cassie, you did an excellent job facilitating last week! Especially considering the hybrid format with students both in-person and on Zoom, you led the discussion with such ease!

Lubnaa, thank you for bringing up the topic of AI! The article you’ve highlighted is fascinating. During our discussion period, Dr. Bechara mentioned that AI-assisted endoscopy is commercially available in Japan, with usages including the detection of gastric neoplasms and characterization of cancer. A 2021 news article announced that Medtronic Canada, a medical technology company, has received a Health Canada license for an AI system that assists in identifying precancerous lesions in the colon that may otherwise go unnoticed (1). I’m wondering if anyone has thoughts on whether there might be any barriers to the implementation of AI-assisted endoscopy technology in Canada? I would imagine there will be limitations, at least initially, in implementing such technology outside of major academic health centers.

Looking forward to hearing your thoughts!

Best,

Trinity

1. https://www.newswire.ca/news-releases/medtronic-receives-health-canada-…

Name
Trinity Vey

Hi Trinity,
Thank you for contributing to the discussion of AI. Like you mentioned, I think while AI hold lots of promise for early and more precise detection of lesions and other pathologies, there will inevitably be limitations with its implementation in Canada. I found an article posted by Canadian Agency for Drugs and Technologies in Health (CADTH) that did a great job of discussion some troubles with implementing clinical AI in Canada (https://www.cadth.ca/overview-clinical-applications-artificial-intellig…). Briefly, this article highlights the need for patience acceptance, ethical and security issues, training requirements and of course cost.

Best,
Cassie

Name
Cassie Brand

Hi Lubnaa,
Thank you for your comment - the emerging field of AI is certainly interesting! While my knowledge is limited on the topic of AI, I very much enjoyed what I learned from the research I did to address your question. First of all, I think the high level of accuracy of the computer vision technique offers lots of promise for POEM and its derivatives. With machine learning from numerous and diverse sources accustomed to the traditional steps of POEM procedure, this may allow for unexpected or missed steps to be recognized (1). This could be applied to predicting adverse events and complications that may be triggered during the procedure, which may translate into better management and prevention due to earlier detection. I also personally think that AI could be used to increase the precision of tumor resection and incision formation.

Additionally, I am curious to see if AI assisted POEM surgery will evolve in the future. It has been demonstrated that robotic assisted colonoscopies have improved patient tolerance, decreased pain and reduced the risk of adverse events (2). While this does vary from a POEM procedure, it does emphasize the benefit that robotic and AI could bring to the field. This is further highlighted by the development and increased use of robotic Heller Myotomies over Laparoscopic Heller Myotomies to treat achalasia (3). I do think AI and robotic learning will bring multiple benefits to the world of third space endoscopy, however, I think It will be a while before the precise machines are developed and implemented clinically.

(1) Hashimoto, D. A., Rosman, G., Rus, D., & Meireles, O. R. (2018). Artificial intelligence in surgery: promises and perils. Annals of surgery, 268(1), 70.
(2) Visconti, T. A. D. C., Otoch, J. P., & Artifon, E. L. D. A. (2020). Robotic endoscopy. A review of the literature 1. Acta Cirúrgica Brasileira, 35.
(3) Fisichella, P. M., & Patti, M. G. (2014). From Heller to POEM (1914–2014): a 100-year history of surgery for achalasia. Journal of Gastrointestinal Surgery, 18(10), 1870-1875.

Name
Cassie Brand

Name
Alyssa Burrows

Fri, 03/25/2022 - 17:44

Hi Cassie,

Great job facilitating the discussion last week and succinctly summarising this surgical topic. For both peroral endoscopy myotomy (POEM) and peroral endoscopy tumour resection (POET) you have highlighted that they are safe and clinical efficacious when compared to other resectional techniques. A question that I was pondering is if they are cost-effective. Also discussed in your post is that these procedures would only be available at tertiary hospitals due to the expertise required. One study compared POEM to laparoscopic Heller myotomy (LHM) and found that POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006) (1). Another study elucidated that effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 per quality-adjusted life year ) however the cost-effective value for POEM was found when looking at postprocedural gastroesophageal reflux disease (2). I could not identify any studies evaluating the cost effectiveness of POET. Limited evidence points to that POEM is cost effective however more research is needed and this could potentially convince federal payers that this surgical approach is worthwhile to pay for in the Canadian health care system. What do you think?

I look forward to hearing your thoughts.

-Alyssa

Attaar M, Su B, Wong HJ, Kuchta K, Denham W, Linn JG, Ujiki MB. Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy. Am J Surg. 2021 Jul;222(1):208-213. doi: 10.1016/j.amjsurg.2020.10.037. Epub 2020 Nov 4. PMID: 33162014.
Shah ED, Chang AC, Law R. Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia. Gastrointest Endosc. 2019 Feb;89(2):264-273.e3. doi: 10.1016/j.gie.2018.04.2341. Epub 2018 Apr 21. PMID: 29684386.

Name
Alyssa Burrows

Name
Bethany Wilken

Sun, 04/03/2022 - 15:42

Hi Cassie,

Thank you for facilitating an excellent discussion with Dr. Bechara. Your summary was well done and you effectively emphasized important aspects of third space endoscopy.

At the end of your summary, you mentioned our discussion with Dr. Bechara about his time in Japan. His international training was fascinating, and he touched on barriers when communicating in a different language. He also explained the healthcare system structure in Japan. Japan has a two-tiered healthcare system. So, with third space endoscopy in Japan, the government would partially pay for the procedure as well as the individual. This is in contrast to the United States where the price for third space endoscopy is excessive for an individual and compared to Canada, where it is performed at no cost. Interestingly, Dr. Bechara suggested that due to our growing population it may be time to adapt a two-tiered healthcare system in Canada. I found an interesting Global News article that says more Canadians are open to private healthcare options than they were before the pandemic (1). One professional stated it may have been due to thousands of surgeries being postponed as well as frustrating wait times. Either way, Canadians want to increase their healthcare options and improve their access to care. Perhaps if some people access private care, wait times in the public system will improve. But is it ethical for people who can afford surgeries and diagnostics it do be put ahead of those who cannot pay? I think this is a big topic of debate that could ultimately reform our healthcare system! Does anyone else have thoughts on a two-tiered system?

Best,
Bethany

1. https://globalnews.ca/news/8428767/canada-health-care-reform-private-pa…

Name
Bethany Wilken

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