Update of minimally invasive management of esophageal diseases: a narrative review

Introduction

Background

The term esophagus derives from a combination of two ancient Greek words meaning “I carry” and “I ate” with the first surgical intervention dating back to 2,500 BC (1,2). Significant surgical advances have only emerged within the last century, primarily due to the esophagus’ challenging anatomical location between the spine and sternum, its proximity to critical structures, and the necessity of anesthesia to perform surgery safely. A wide range of pathologies requiring surgical intervention can affect the esophagus, including reflux, neoplasm, bleeding, strictures, and motility disorders. One of the primary obstacles to surgery was opening the thoracic cavity, which risked lung collapse and potentially fatal cardiopulmonary complications. The invention and implementation of increasingly complex means of mechanical ventilation allowed for surgery to progress (3-8).

Rationale and knowledge gap

With advancements in technology and increased surgeon expertise in minimally invasive techniques, the standard of care for many esophageal diseases has shifted from traditional open surgery to less invasive approaches. These include laparoscopic, thoracoscopic, robotic and endoscopic methods, each offering specific advantages depending on the pathology and patient factors. This review provides a review of minimally invasive approaches to esophageal surgery and their outcomes. This review also provides recent information and comparisons between single port VATS/RATS approaches and multiport and open approaches. Barriers to the implementation of new technologies are discussed and potential solutions to these barriers are provided.

Objective

In this review, we explore the current and future evolution of thoracoscopic management approaches for esophageal diseases with a focus on outlining their indications, techniques, and outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-41/rc).

Methods

Information and data for this review were obtained from Internet searches on PubMed from 1904 to 2025. Keywords used were “uniportal esophageal surgery”, “single port esophagectomy”, “robotic esophageal surgery”, “comparison of esophageal anastomotic leaks and strictures”, “comparison of single port and multiport esophagectomies”. Information about thoracoscopic approaches to esophageal diseases was also collected from Sugarbaker’s Adult Chest Third Edition, Ferguson Thoracic Surgery Atlas Second Edition, Atlas of Robotic Thoracic Surgery, TRSA Review of Cardiothoracic Surgery Third Edition and TRSA Operative Dictation in Cardiothoracic Surgery Second Edition. Further explanation of methods is listed in Table 1.

Esophageal disease and thoracoscopic approaches

Esophageal motility disorders overview and surgical management

Prior to the advent of surgical options of treatment, the spectrum of esophageal motility disorders was managed primarily through pharmaceutical methods. However, the evolution of minimally invasive techniques has significantly shifted treatment paradigms, making surgical intervention a more appealing first-line option. Currently, the majority of esophageal motility disorders can be managed via an abdominal approach. However, a thoracic approach remains a viable alternative when the abdominal route is contraindicated. Such contraindications may include extensive intra-abdominal adhesions, the need for a long myotomy that cannot be completed through the abdomen, or the presence of an esophageal diverticulum that is not amenable to abdominal excision (9).

The first surgical treatment in the form of myotomy for achalasia was performed by Ernest Heller in 1914, using an open thoracic approach (10). In the case of achalasia, the abdominal approach has demonstrated a high success rate of 90–95% (11-13). For a thoracic approach, the patient is positioned in the right lateral decubitus position to allow optimal access to the left chest. The myotomy is initiated approximately 5 cm proximal to the gastroesophageal junction (GEJ) and extended 2–3 cm onto the stomach. If the hiatus is mobilized, a Belsey Mark IV fundoplication is performed to prevent post-operative reflux much like when a fundoplication is performed following a Heller myotomy in a transabdominal approach.

In non-achalasia motility disorders, the success rate is generally lower but follows the same fundamental goal which entails division of the dysfunctional muscle fibers causing the disease. The myotomy may be extended cephalad to the level of the aortic arch, approximately 10–12 cm (14). In rare cases requiring a particularly long myotomy, a right-sided thoracoscopic approach may be employed. When diffuse esophageal spasm (DES) was the predominant cause of the motility disorder, a long myotomy was traditionally performed with symptomatic improvement in only 70–88% of cases (15-17). One single-center study compared the recurrence of primary motility disorders following a myotomy to the aortic arch and a myotomy to the inferior pulmonary vein and no significant difference was found in the recurrence of the motility disorder (18). The study did demonstrate a higher risk of dysphagia, as well as all of the sequela that can occur after entering the chest including longer operative times, increased length of stay and pain and limited exposure due to the anatomical limits of the intercostal space (18). An explanation for increased rates of dysphagia was not directly stated by the study but this may be due to a higher incidence of reported reflux following a thoracoscopic approach (18). This information demonstrated that long myotomy through a thoracic approach may not be worth the morbidity when outcomes from an abdominal approach were comparable.

Data on thoracoscopic treatment outcomes are limited. For those patients who continue to have symptoms related to dysmotility following the previously mentioned procedures, an endoscopic means of treatment or esophagectomy may be considered. The operation would be more challenging since the esophagus has been previously operated, but the overall complication rates are similar to esophagectomies performed for malignancy (14). The functionality and symptom resolution after an esophagectomy vary since the common symptoms following an esophagectomy and those associated with symptomatic motility disorders are similar, such as dysphagia, regurgitation and reflux. In one single-center study, nearly 75% of patients reported improvement in symptoms and 25% had symptom resolution following esophagectomy (19). In another single-center study, 32% of patients reported an “excellent” result with no symptoms (20). However, in patients with reflux or dysphagia prior to esophagectomy, only 35% stated a “fair” result was obtained (20). The need for reoperation following esophagectomy was reported to range from 25–30% in one study and 12% in another study (20,21). Based on this data, a thorough and extensive discussion should be had with the patient prior to an esophagectomy for dysmotility.

Esophageal diverticula classification and surgical management

An esophageal diverticulum is an outpouching of the esophageal wall, categorized as either pulsion or traction diverticula. Pulsion diverticula are more common in the United States and typically result from esophageal dysmotility distal to the site of the diverticulum (22). These are considered false diverticula, as they involve only the mucosa herniating through the muscular layers of the esophageal wall. The most common pulsion diverticulum is a Zenker’s diverticulum, located in the cervical esophagus. The second most common is the epiphrenic diverticulum, found more distally, typically in association with motility disorders such as achalasia (23). Traction diverticula, in contrast, result from fibrosis due to chronic intrathoracic infections, such as tuberculosis or fungal infections, with inflamed lymph nodes adhering to and pulling on the esophageal wall. Traction diverticula are considered true diverticula, involving all layers of the esophageal wall. Radiographically, pulsion diverticula typically present with a wide neck and rounded contour, and they tend to retain contrast material on barium esophagram. Traction diverticula, by contrast, appear with pointed tips and typically empty completely on imaging (14). Symptom severity is usually greater in pulsion diverticula and correlates with the size of the pouch (14).

Epiphrenic diverticula can be addressed via transabdominal or VATS/RATS approaches depending on location. Diverticula near the GEJ can be accessed abdominally, whereas more proximal diverticula require a transthoracic approach. For thoracoscopic resection, a myotomy is performed up to and beyond the diverticulum. Once the diverticulum is divided, the myotomy can then be closed over the staple line. Then a myotomy is performed on the contralateral wall of the esophagus, extending above and below the site of diverticulectomy, sometimes extending onto the gastric fundus. If the diverticulum is located distally, an antireflux procedure may be performed, but this is performed laparoscopically. Small epiphrenic diverticula may not require resection if asymptomatic.

Despite the minimally invasive nature of the procedure, complications may still occur. The most common postoperative complication is an esophageal leak at the staple line occurring in 5–37% of patients with risk factors including using multiple staple cartridges, a wide-necked diverticula, and having a mediastinal location (24). A common post-operative side effect from the procedure is acid reflux occurring in up to 60% of patients, a risk that may be mitigated by incorporating a partial fundoplication (25). Symptom resolution is achieved in approximately 70% of cases, though symptoms remain unchanged in 21% and are worse in 8% of patients (25).

In traction diverticula, no myotomy is needed. After diverticulectomy, the staple line should be buttressed with pleura or intercostal muscle to prevent esophageal leak. The lymph nodes causing the traction are typically not resected due to fibrosis and adherence to surrounding structures. An algorithm for epiphrenic diverticula can be further reviewed in Table 2.

Benign tumors of the esophagus: overview and surgical management

Benign tumors of the esophagus are rare, accounting for less than 1% of all esophageal neoplasms and under 10% of all surgically resected esophageal lesions (26,27). Most benign esophageal tumors are asymptomatic and discovered incidentally during imaging performed for unrelated reasons. When present, symptoms are typically related to tumor location, size, and origin. The most common presenting symptom is dysphagia, especially with intramural tumors. Extramural tumors are more likely to compress adjacent structures, potentially resulting in pulmonary complications. While many benign tumors can be removed endoscopically, some require surgical resection. Performing an esophagectomy is rarely necessary.

The most common benign tumor is a leiomyoma, which accounts for over 50% of all benign esophageal tumors (28,29). Leiomyomas are not associated with malignant degeneration (30). Radiographic findings typically show a rounded, smooth, well-demarcated intraluminal filling defect. Endoscopically, leiomyomas appear mobile with normal overlying mucosa and protrude into the esophageal lumen. On endoscopic ultrasound (EUS), they appear as smooth, hypoechoic, and well-circumscribed lesions without signs of invasion (31). Surgical excision is indicated for patients with symptoms, as well as for asymptomatic patients with lesions that are increasing in size or larger than 4 cm and associated with mucosal ulceration (14). Histologically, they appear as whorls of spindle cells with eosinophilic cytoplasm (32).

The preferred surgical approach is enucleation, typically performed using thoracoscopy for mid-to-upper esophageal lesions, or laparoscopy for distal esophageal tumors (33,34). If the procedure is performed laparoscopically for a lesion of the distal esophagus, a fundoplication is recommended. Right or left thoracoscopic approaches may be used based on the lesion’s location. These tumors often peel off the mucosa. Any mucosal injury should be repaired and the muscle layers reapproximated. A tissue flap (e.g., intercostal muscle or pleura) can be used to buttress the repair, but this is not mandatory. In rare cases of large or circumferential tumors, esophageal resection or thoracotomy may be required due to muscle distortion or high suspicion of leiomyosarcoma.

Enucleation has excellent outcomes, with 89–95% of patients remaining symptom-free at 5-year follow-up (30,34). A single-center study found that when enucleation is performed thoracoscopically, hospital stay was decreased by two days when compared to thoracotomy (35). Robotic approaches have been described and may aid in reducing the risk of mucosal injury due to the three-dimensional view and multiple arcs of rotation (36). Studies continue to show that minimally invasive approaches have fewer complications and shorter hospital stays than traditional open approaches. Other benign esophageal tumors with location and management are discussed in Table 3.

Esophageal malignancy overview and surgical management

Esophageal cancer is the eighth most common cancer worldwide (14). Approximately 98% of esophageal cancers are either adenocarcinomas, typically located in the mid to distal esophagus, or squamous cell carcinomas, found in the proximal to mid esophagus (14). The remaining cases are associated with genetic predispositions, hereditary syndromes, and other rare malignancies. As with all cancers, treatment decisions are guided by stage, histologic subtype, and tumor location. For patients with resectable disease who are surgical candidates, multiple operative approaches exist. This discussion focuses on thoracoscopic esophagectomy, specifically the Ivor Lewis and McKeown techniques, although open and extrathoracic options are also available. The Ivor Lewis esophagectomy is performed for esophageal carcinoma located in the distal to mid-esophagus whereas the McKeown esophagectomy can be performed for esophageal cancer located in the distal-upper esophagus.

The Ivor Lewis and McKeown approaches, performed either open or thoracoscopically, are the most commonly utilized techniques. Minimally invasive esophagectomy when compared to an open approach has been associated with reduced pulmonary complications, postoperative pain, and shorter hospital stays, without compromising R0 resection rates, lymph node yield, or survival outcomes (14). The Ivor Lewis esophagectomy takes place in two phases: the abdominal phase and thoracic phase. The McKeown approach also has an abdominal and thoracic phase similar to the Ivor Lewis approach but also requires a left cervical incision for creation of the anastomosis. Alternative conduits such as the colon or jejunum are available but rare and not discussed in this review.

After creating the conduit in the abdominal phase of the procedure for the Ivor Lewis approach, the thoracic phase is initiated. The patient is typically positioned in the left lateral decubitus position, with the right lung deflated. However, a slightly right-sided or semi-prone position has been described but less commonly performed (33). Two primary anastomotic techniques are used: stapled and sutured. A stapled anastomosis can be performed with a linear stapled anastomosis or a circular stapled anastomosis. A linear stapled anastomosis has a higher risk of gastric tip necrosis and reflux whereas a circular stapled anastomosis has a higher rate of stricture (9). A single-layer or two-layer closure can be performed to close the common channel. Stricture rates occur in at least one-third of cases, with >80% resolving after potentially multiple dilations (14). Table 4 compares the leak and stricture rates of different common Ivor Lewis anastomotic techniques. For more resistant strictures, steroid injection and multiple dilations can be employed (14). Robotic laparoscopic approaches provide another avenue for the surgery. In a single-center study consisting of 20 patients where laparoscopy was performed for abdominal mobilization and the thoracic portion was performed with a robot, there were no 30-day mortalities, no anastomotic leaks, 100% R0 resection rate and a mean number of 23.2 lymph nodes harvested (49).

The McKeown approach begins with the thoracic portion in the left lateral decubitus position. The thoracic dissection for the McKeown esophagectomy is able to proceed more cephalad in the chest, but this dissection increases the risk of injury to the trachea and right recurrent laryngeal nerve as the right subclavian artery is approached (14). The patient is then placed in the supine position for the abdominal and left cervical incisions (9). There is a risk of injury to the left recurrent laryngeal nerve with left cervical incision, but this is less likely since the course of the left recurrent laryngeal nerve is more predictable due to its location within the tracheoesophageal groove (14). A single-center study found injury to the recurrent laryngeal nerve occurs in 10–20% of patients (50). After completion of the abdominal mobilization, conduit creation and left cervical exposure, the conduit is fed into the cervical incision with the use of a bag and Foley catheter on suction. The gastric staple line should be on the right side of the patient’s cervical incision. A stapled linear or hand sewn anastomosis can be performed.

The most dreaded complication following esophagectomy is an anastomotic leak. Leaks that occur 2–3 days postoperatively are more likely related to technical failure, whereas leaks occurring between 4–10 days are typically related to ischemia of the suture line or gastric tip (14). Minor or subclinical leaks can often be managed non-operatively by keeping the patient nil per os (NPO), initiating IV antibiotics, providing enteral tube nutrition, and ensuring continued drainage of the area until the leak resolves. Due to the location of the anastomosis, a leak following a McKeown esophagectomy is much easier to manage and contamination of the mediastinum is very uncommon (14). The cervical incision should be opened if concerned for leak. For larger leaks with an Ivor Lewis esophagectomy, continued drainage of the chest and mediastinum is needed, and a diverting esophagostomy should be considered, with plans for reconstruction in 3–6 months. An esophagogastroduodenoscopy (EGD) should be routinely performed to assess the conduit. A feeding jejunostomy tube becomes essential in patients with confirmed large leaks.

Additional complications include delayed gastric emptying and reflux. Delayed gastric emptying can result from the absence of a pyloric drainage procedure at the index operation, hiatal narrowing, redundancy or twisting of the conduit. Management options include endoscopic balloon dilation or prokinetic agents. If pharmacologic treatment and dilation fail, conduit repositioning or endoscopic pyloromyotomy for pyloric drainage may be necessary. A single-center study demonstrated that reflux is a common complication, with the lowest severity observed in patients whose anastomosis is located above the azygos vein (51). As a result, reflux is seen less in patients who undergo a McKeown esophagectomy compared to Ivor Lewis esophagectomy (14). This can be managed with small, frequent meals in the upright position and acid-reducing medications, both of which have shown good outcomes.

When performed for malignancy, esophagectomy is a safe and reproducible procedure despite the risk of postoperative complications. However, long-term survival is closely linked to disease stage, number of lymph nodes obtained at the time of resection and histologic subtype. It is recommended that 15 or more lymph nodes be obtained during the time of resection since the 5-year disease-specific survival increases when more lymph nodes are obtained (52,53); the 5-year disease-specific survival rate is 55% when fewer than 11 nodes are resected, 66% when 11 to 17 nodes are resected, and 75% when more than 18 nodes are resected (52). However, despite advances in treatment, the 5-year survival rate is on average 20% for all stages: stage 0–I: 45% to 50%, stage II–III: 20% to 30%, and stage IV: <5% (54,55) (Table 5). Squamous cell carcinoma generally has a worse prognosis than adenocarcinoma due to the higher likelihood of presenting at an advanced age and the association with smoking and alcohol consumption (52). This data underscores the critical importance of early diagnosis in improving outcomes for malignant esophageal disease.

Future

Since the first RATS was performed in 2002, its use in the management of thoracic diseases has grown significantly in both popularity and volume (56). Robotic assistance offers numerous advantages, including enhanced three-dimensional visualization, improved ergonomics for surgeons, better hand-eye coordination, and greater freedom of movement (57).

As technology and surgical expertise have evolved, new strategies have enabled procedures to be performed through a single port rather than multiple access points. Since receiving US FDA approval in 2014, the da Vinci Single Port (SP) robotic surgical system (developed by Intuitive Surgical) has represented a major innovation in uniportal surgery (58). Since its introduction, the SP system has gained adoption across multiple surgical specialties. Compared to its predecessor, the da Vinci Xi system, the SP system reduces instrument collisions and minimizes damage to intrathoracic structures associated with multi-port access. It operates via three robotic arms and a flexible endoscope. However, it lacks an integrated stapler, vessel sealer, and suction instrument, which means vessel ligation must be performed using a separate clip applier or cautery often necessitating a bedside assistant. The bedside assist becomes integral in performing some of the tasks performed by the robot in a multiport approach.

Initially, uniportal RATS and VATS were limited to simpler procedures. However, its application has expanded to include highly complex operations including esophagectomies (59-61). In RATS, the uniportal approach is typically performed through either a 4 cm incision between the seventh and ninth ribs or a 3–4 cm incision in the fourth intercostal space in the right axillary region (Figure 1) (62,63). The approach between the seventh and ninth ribs carries a risk of accidental abdominal entry, which can be mitigated with an additional thoracoscopic incision for better visualization (62). Stapling is facilitated by a bedside assistant who introduces the device through the incision, as the SP system lacks an onboard stapler. For uniportal VATS esophagectomy, the standard approach involves an incision in the right sixth intercostal space between the anterior and posterior axillary lines (Figure 1) (64).

Figure 1 Port placement for uniportal/SP esophagectomy. Port placement for uniportal/SP esophagectomy with each incision 3–4 cm in length. SP, single port.

Traditional robotic systems typically require four 8–12 mm ports: one for the centrally positioned camera and the others for robotic instruments, with one or two arms placed on either side of the camera (32). Staplers used in these systems may be either 8 or 12 mm in diameter (32). To minimize instrument collisions, ports are usually spaced 8–10 mm apart. In addition, a 5–12 mm working port is designated for the bedside assistant, who may assist with retraction, suction, or specimen retrieval (32). Carbon dioxide (CO₂) insufflation can be utilized to enhance exposure, with pressures of up to 8 mmHg in the thoracic cavity and up to 15 mmHg in the abdominal cavity (32). Following lung isolation, chest entry can be achieved using a blunt or sharp-tip trocar in patients without a history of prior thoracic surgery, radiation, or infection. Alternative techniques for chest access include the use of a Veress needle, optical port, or direct cutdown.

Although uniportal RATS is increasingly applied to esophageal and complex thoracic procedures, further refinement of operative techniques is needed to fully assess its long-term benefits and clinical outcomes. A single-center study by Weng et al. (63) involving 443 patients (224 single-port and 219 multi-port minimally invasive esophagectomies) found that uniportal robotic procedures were associated with shorter hospital stays, reduced operative time, lower postoperative drainage volume from the chest and drainage duration, reduced pain, and improved cosmetic results. However, there were no significant differences in oncologic outcomes or lymph node yield. In other studies, the hospital length of stay and lymph nodes obtained are similar. In another single-center study by Guo et al., longer operative times were observed, possibly due to differences in case volume and surgeon experience with the newer technology in the absence of standardized techniques (65). However, the study by Weng et al. (63) focused on McKeown esophagectomies, while the study by Guo et al. (65) evaluated Ivor Lewis esophagectomies. Both studies, however, reported similar perioperative benefits.

These findings suggest that the benefits of uniportal RATS may vary slightly depending on the type of esophagectomy performed but still provide good patient outcomes and similar perioperative benefits. Similar favorable outcomes have been reported with uniportal VATS esophagectomy (64). While early data points to promising perioperative results with the uniportal RATS and VATS approach, especially in esophagectomy, further high-quality studies and broader surgeon training are essential to establish its clinical value and long-term oncologic efficacy. Further comparative data are presented in Table 6.

Although the benefits of VATS/RATS approaches to esophageal surgery have become more apparent, there remain barriers to widespread implementation. Some of these barriers include a long learning curve and limited training opportunities. A VATS/RATS esophagectomy is technically demanding with many surgeons abandoning the approach due to initial difficulty and initially long operative times (72). It is difficult to receive training in VATS/RATS since training usually occurs at a limited number of high-volume cancer centers (72,73). One single-center study recommends over 100 cases in order to become proficient at performing a VATS/RATS esophagectomy (73). The hospital where the procedure is performed must have the resources to adequately care for a patient through all phases surrounding the operation, be able to manage the complications and be able to afford the cost of the hospitalization. A recent retrospective cohort study from 2016–2021 conducted in Florida demonstrated an overall median cost of the index VATS/RATS esophagectomy to be $41,795 (74). This was similar to the cost of an open esophagectomy ($40,289) (74). The same study demonstrated a higher median operating room cost for minimally invasive esophagectomy ($13,964 vs. $10,618), which is related to equipment and operative times but lower Intensive Care Unit costs ($2,325 vs. $5,706), which is due to shorter admissions (74). Since the cost of open and VATS/RATS esophagectomies are similar, the largest barriers to widespread adoption to VATS/RATS could be lack of widespread training and initially longer operative times. Potential solutions include training sessions/courses, proctored surgeries either in person or via video, and attendance at presentations at multidisciplinary conferences with experienced VATS/RATS esophageal surgeons.

Limitations

Although the authors of this paper attempted to provide a thorough presentation of the current and future minimally invasive approaches to esophageal surgery, there are inherent limitations of the review. There is a lack of standardization related to the review design which allows for selection bias when it comes to study selection, data exclusion, and inclusion. This results in the potential for published data and information not to be included in the review. Other limitations include reproducibility and transparency, but means to circumvent these limitations are presented in the methods section. The review presents information pertaining to thoracoscopic approaches to esophageal disease, but is by no means inclusive of all treatment modalities and esophageal diseases, since some diseases are treated endoscopically, laparoscopically, open, or via a cervical approach.

Conclusions

Thoracic esophageal surgery has evolved remarkably from its modest origins, tracing back to the earliest recorded history of surgical practice. Over time, driven by continual advancements in medical knowledge, surgical techniques, and technological innovation, the field has grown into a sophisticated and multifaceted discipline. What began as high-risk, rudimentary procedures has transformed into a comprehensive spectrum of surgical interventions, ranging from traditional open thoracotomies to minimally invasive techniques such as VATS, RATS, and advanced endoscopic approaches.

Today, thoracic esophageal surgery stands at the intersection of precision, innovation, and patient-centered care. The increasing adoption and refinement of single-port surgery represents the next frontier, offering the promise of reduced postoperative pain, faster recovery, and better cosmetic outcomes. As surgeons continue to gain expertise and confidence with these evolving modalities, the future of esophageal surgery is poised to become even more dynamic and patient-focused.

It is evident that the treatment of thoracic esophageal disease remains a field of immense potential; one that will continue to adapt and expand in response to the growing demand for less invasive, highly effective surgical solutions. With ongoing research, technological breakthroughs, and surgical innovation, the discipline is well-positioned to shape the future of thoracic care for decades to come.

Acknowledgments

ChatGPT was used on 11/10/2025 to assist with creating the silhouette used in Figure 1.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-41/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-41/coif). J.W. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from June 2024 to June 2026. J.W. is a paid consultant for Intuitive, Medtronic and Boston Scientific. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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