Abdominal Imaging
ª Springer Science+Business Media, LLC 2007 Published online: 15 May 2007
Abdom Imaging (2007) 32:351–361 DOI: 10.1007/s00261-007-9221-5
Acute necrotizing pancreatitis: role of CT-guided percutaneous catheter drainage Dmitri Segal,1 Koenraad J. Mortele,1 Peter A. Banks,2 Stuart G. Silverman1 1
Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and WomenÕs Hospital, Harvard Medical School, Boston, MA 02115, USA 2 Center for Pancreatic Disease, Division of Gastroenterology, Department of Medicine, Brigham and WomenÕs Hospital, Harvard Medical School, Boston, MA 02115, USA
Abstract Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality. Percutaneous CT-guided catheter drainage is an important treatment option that can be effective whether used alone, or as an adjunct to operation. Existing literature describing the role of percutaneous catheter drainage of necrotizing pancreatitis is limited. This update reviews techniques, indications, outcomes, and complications of CT-guided percutaneous treatment of acute necrotizing pancreatitis.
The International Symposium on Acute Pancreatitis in Atlanta defined acute pancreatitis as inflammation of the pancreas with variable secondary involvement of remote organs [1]. Acute necrotizing pancreatitis is a severe form of the disease associated with significant morbidity and mortality. Percutaneous image-guided catheter drainage is an important treatment modality that can be life-saving whether used alone, or as an adjunct to surgery [2]. Successful treatment outcomes depend on close cooperation and teamwork among gastroenterologists, surgeons, and interventional radiologists [2]. Existing literature describing the role and efficacy of percutaneous catheter drainage of necrotizing pancreatitis is limited and heterogeneous. Most series describe the results of percutaneous catheter drainage in patients with extrapancreatic fluid collections without pancreatic necrosis [3–13]. Only a few series include patients with pancreatic
Correspondence to: Koenraad J. Mortele; email:
[email protected], Dmitri Segal; email:
[email protected]; Peter A. Banks; email:
[email protected]; Stuart G. Silverman; email: sgsilverman@ partners.org
necrosis [4, 14, 15], and to our knowledge, only one series limited their discussion to patients with acute necrotizing pancreatitis [14]. This article reviews techniques, indications, outcomes, and complications of image-guided percutaneous treatment of acute necrotizing pancreatitis.
Acute necrotizing pancreatitis Etiology The three most common etiologies of acute pancreatitis are obstructive biliary tract disease, alcohol use, and idiopathic causes, accounting for about 90% of the cases [16]. Obstructive biliary tract disease is the most common cause of acute pancreatitis responsible for up to 40% of cases [17] (Fig. 1). Alcohol use is the second most common cause of pancreatitis, responsible for up to 35% of cases [17, 18].
Diagnosis The severity of pancreatitis varies from interstitial pancreatitis, where the disease is limited to inflammation and swelling of the pancreatic parenchyma, to pancreatic necrosis with or without organ failure. Pancreatic necrosis occurs early in the course of pancreatitis, usually at the onset of an acute attack [19]. Pancreatic necrosis is defined as a diffuse or focal area of nonviable pancreatic tissue [19]. Necrotizing pancreatitis may be associated with organ failure and/or local complications, such as hemorrhage or infection [1]. Macroscopic focal or diffuse necrosis of the pancreatic parenchyma, areas of fat necrosis, severe injury with occlusion and thrombosis of the pancreatic microcirculation and occasional peripancreatic hemorrhage characterize necrotizing pancreatitis on pathology [2, 19]. Pancreatic necrosis typically involves the periphery of the lobules initially; however, it may progress to involve the
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Fig. 2. A, B Axial contrast-enhanced CT images show necrotizing pancreatitis involving the majority of the gland. The head of the pancreas is spared and enhances (arrow). There is vicarious excretion of contrast in the gallbladder and ascites.
more strongly linked to the presence of organ failure than the presence of infection itself [21]. Diagnosis of necrotizing pancreatitis is based on clinical presentation, laboratory tests, and imaging.
Clinical presentation Fig. 1. A Axial contrast-enhanced CT image shows pancreatic necrosis (arrow) and gallstones within the gallbladder. B, C Axial and coronal reformatted CT images show two gallstones (arrow) within the common bile duct.
majority of the gland [2] (Fig. 2). Infection of the necrotic portion of the pancreas results in infected necrosis. Infected pancreatic necrosis is an ‘‘intermediate’’ complication of acute pancreatitis, usually occurring between the 3rd and 8th week after onset of symptoms [16]. Infected necrosis and sterile necrosis both carry a high mortality rate [2]. Mortality rates of 30%–35% have been reported in patients with infected necrosis, and 10%–15% in patients with sterile necrosis [20]. Although the presence of infection increases the mortality rate in patients with pancreatic necrosis, a more recent review of 1110 cases of acute pancreatitis demonstrated that mortality is
Epigastric pain, nausea, and vomiting are the most common presenting symptoms of acute pancreatitis [16]. Patients with severe acute pancreatitis may also present with discoloration of the flanks (Grey-TurnerÕs sign) and/or the umbilicus (CullenÕs sign), due to extensive retroperitoneal hemorrhage [22] (Fig. 3). These signs are seen in less than 3% of patients, but are associated with a mortality of 35% [22].
Laboratory investigations Serum amylase and lipase levels are used to diagnose acute pancreatitis. The concentration of these enzymes within the pancreas is several orders of magnitude higher than in other tissues [23]. In patients with acute pancreatitis, these enzymes are elevated because of leakage from pancreatic acinar cells into the interstitial space and subsequent absorption into the circulation. Elevation of
D. Segal et al.: Acute necrotizing pancreatitis: role of CT-guided percutaneous catheter drainage
Fig. 3. Grey-TurnerÕs sign (arrow) in a patient with severe acute pancreatitis.
serum amylase and lipase greater than three times normal is considered diagnostic of pancreatitis [23, 24].
Imaging evaluation Pancreatic necrosis is diagnosed radiographically by identifying unenhanced pancreatic parenchyma, which often involves more than 3 cm of tissue or more than 30% of the gland on a contrast-enhanced CT scan [19]. If more than 90% of the pancreatic width is necrotic, the gland is said to have undergone ‘‘central cavitary necrosis’’ [25]. The basis for assessing the severity of acute pancreatitis is due to the difference in treatment. Mild acute pancreatitis is usually self-limited and treated supportively. Severe acute pancreatitis requires close monitoring and frequently percutaneous drainage and/or surgery [16]. Contrast-enhanced CT is the preferred imaging modality used in the evaluation and treatment of patients with acute pancreatitis [2, 16]. CT is accurate in confirming the diagnosis, but its primary role is staging and assessing for possible complications [16]. Three major indications of CT in patients with suspected or known pancreatitis include the following: (a) to establish the diagnosis when clinical and laboratory evaluations are indeterminate and to exclude other significant intraabdominal conditions; (b) to determine the severity of pancreatitis and to detect pancreatic and extrapancreatic complications, such as infected necrosis and abscess formation, using the (modified) CT severity index; (c) to guide percutaneous interventions, such as needle aspiration and catheter drainage of fluid collections [16, 26–28]. Contrast-enhanced MRI of the pancreas can be performed in patients with renal failure or iodinated contrast media allergy in lieu of contrast-enhanced CT. The presence and extent of pancreatic necrosis and peripancreatic fluid collections can be determined using MRI as well as CT [16]. The extent of parenchymal necrosis is well demonstrated on sequential, multi-slice acquisitions obtained during the first 1–2 min after intravenous gadolinium administration [16]. Fluid collections and the
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Fig. 4. MRCP image of a patient with necrotizing pancreatitis shows a large, poorly liquefied, heterogeneous fluid collection (arrow) in the pancreatic bed.
amount of debris within these collections are best demonstrated on T2-weighted sequences [29, 30]. Therefore, MRI can be useful in predicting drainability of necrotic pancreatic collections by demonstrating solid debris within these collections (Fig. 4). The presence of large amounts of solid (T2-dark) material may mean that the collections will require multiple large catheters or surgery to drain them. In addition, MRI in combination with MRCP is important in the evaluation of patients with pancreatitis suspected of being caused by biliary obstruction, owing to the MRCPÕs ability to visualize the biliary system [16]. However, MRI has not yet been established as the superior imaging modality to CT for evaluation of patients with acute pancreatitis [2]. CT maintains several advantages over MRI. CT is more accessible and less expensive than MRI. CT is more sensitive in detecting gas bubbles, which may indicate infection. MRI examination time is longer than CT. Patients with pacemakers and other ferromagnetic devices cannot undergo MRI [2, 16].
CT-guided catheter drainage Although no universally accepted treatment algorithm exists, a general consensus of indications for interventional approach to patients with acute necrotizing pancreatitis has been described [2–6, 19–6, 31]. Some percutaneous drainage procedures are performed to stabilize the seriously ill patient prior to surgical debridement, while others are done with the intent to cure [2, 7–9]. In some cases, percutaneous drainage follows surgical therapy that has been only partially successful [2–6, 8, 9, 31]. Treatment algorithms vary among medical centers and are sometimes based on expertise of both the interventional radiologist and the surgeon. The clinical status of the patient, for instance presence of sepsis, also influences which approach is best in any given clinical situation [2].
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Fig. 5. Axial CT image through the abdomen of a patient with necrotizing pancreatitis shows a catheter (arrow) placed percutaneously via left lateral approach.
Technique Access route Most pancreatic fluid collections are located in the lesser sac, the anterior pararenal space, or other parts of the retroperitoneum [19]. Access routes that avoid traversing colon, small bowel, stomach, liver, spleen and kidney, are selected to minimize the risk of bacterial contamination and hemorrhage. If possible, a retroperitoneal approach through the lateral flank is preferred to an anterior approach through the peritoneum [19] (Fig. 5). Some suggest that anterior routes involve the theoretical disadvantage of antigravity flow of fluid through the catheter [19]; however, we have not encountered this in our practice. Anterior routes through the liver or stomach can be used if no other routes are available [19] (Fig. 6). Transgressing the liver theoretically increases the risk of bleeding, but in practice, is generally safe. Transgressing the stomach is also safe, but the peristalsing stomach may result in catheter dislodgement several days after its placement. If gastric pH is normal, gastric fluid is sterile. However, caution should be taken in patients who are on H1-receptor blockers or any other medications that raise gastric pH. Fluid collections involving the pancreatic tail can be drained through the left anterior pararenal space, avoiding the descending colon posteriorly [19]. Similarly, pancreatic head collections can be drained through the right anterior pararenal space [19]. Typically, the patientsÕ position on the interventional CT table should be adjusted to a slight posterior oblique to optimize access to the region of interest. Catheter selection and placement The fluid contained in collections caused by pancreatic necrosis is often viscous. Therefore, adequate drainage of pancreatic and peripancreatic collections typically requires catheters with multiple side holes and a minimum
Fig. 6. A–C Axial unenhanced CT images of the abdomen in a patient with necrotizing pancreatitis show percutaneous catheter placement through the left hepatic lobe into the pancreatic collection.
diameter of 12–14 Fr. Multiple catheters may be required to drain large or multiloculated necrotic collections (Fig. 7). If the fluid is not viscous, 12–14 Fr drainage catheters may be satisfactory [19]. Either tandem trochar technique or Seldinger technique can be used depending on the operator experience. If the Seldinger technique is used, the catheter tract should be sequentially dilated over a guidewire. If the necrotic material is viscous and the collection is not drained completely, catheters larger than 14 Fr may be exchanged several days after a 14 Fr catheter is placed
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Fig. 7. A Scout radiograph shows four percutaneous drainage catheters. B Axial contrast-enhanced CT image shows four catheters draining necrotic fluid collection.
initially. An attempt should be made to place as much length of the catheter containing side holes as possible transversely into the necrotic pancreatic collection from the lateral flank approach to maximize drainage [19] (Fig. 8). An anterior transperitoneal approach should be avoided if possible as the number of side holes within the collection is likely to be fewer [19].
Sterile pancreatic necrosis Generally, in patients with sterile pancreatic necrosis, CT scans of the abdomen are repeated every 7–10 days to follow the evolution of pancreatic necrosis and to look for complications [16]. Patients who persistently show clinical instability with tachycardia, fever, leukocytosis, or organ failure may require image-guided percutaneous needle sampling to evaluate for infected pancreatic necrosis (Fig. 9). It is important that the access route avoids small and large bowel so as not to contaminate the collection or the aspiration sample [19]. If sampled pancreatic fluid is sterile, the patient is considered to have sterile pancreatic necrosis. Some of these patients recover rapidly without additional intervention while others remain persistently toxic and require continuous support in an intensive care unit [32].
Fig. 8. A–D Axial unenhanced CT images show multiple drainage catheters, including an 18 Fr catheter (arrow), draining the necrotic fluid collection in the pancreatic bed.
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percutaneous needle sampling to assess for infection vs. indwelling catheter drainage of sterile necrosis [32].
Infected pancreatic necrosis
Fig. 9. Axial non-contrast CT image shows needle sampling of pancreatic collection via left lateral approach. The fluid was analyzed and found to be sterile.
Several years ago, patients with persistent toxicity underwent urgent surgical debridement; however, now these patients are managed non-surgically, since early surgical debridement contributes to morbidity and mortality [32–35]. A combination of percutaneous catheter drainage and supportive care offers an alternative to surgery [32]. Some suggest that persistently toxic patients should undergo percutaneous CT-guided needle sampling every 7–10 days to assess for infected necrosis [32]. Majority of patients with sterile pancreatic necrosis improve in 3– 6 weeks [32]. However, some patients with persistent toxicity and sterile aspirates do not improve due to pancreatic duct disruption with extravasation and accumulation of noxious pancreatic juice into peripancreatic spaces. Instead of performing regular needle sampling, the necrotic fluid may be drained percutaneously (Fig. 10). One or more catheters may be placed and irrigated per standard radiologic protocol in order to provide a ‘‘radiologic necrosectomy’’ and reduce systemic toxicity [32]. Percutaneous catheter drainage of sterile necrosis is, however, controversial. The main rationale for not using percutaneous catheter drainage is potentially infecting a sterile pancreatic collection [2]. Although indwelling catheter colonization is common, serious clinical infection is unlikely to occur if all the fluid and material are drained within 2–3 days of the intervention [2, 10–13, 32–13, 36, 37]. This requires vigilant attention to followup CT scans and placement of additional and/or larger catheters to drain the residual fluid. Adequate drainage is achieved when no residual necrotic fluid is present on follow-up CT scans. Percutaneous CT-guided catheter drainage of sterile necrosis may also be useful to stabilize the patient prior to surgical debridement and thus reduce surgical morbidity [8]. No clinical studies are currently available that have compared the results of therapy utilizing weekly
Although contrast-enhanced CT scan is excellent in assessing for pancreatic necrosis, it cannot distinguish between infected and sterile necrosis with certainty [32]. Intrapancreatic, retroperitoneal or lesser sac gas is a rare finding on CT; however, if it is present it may indicate infection [2]. Bacterial infection of necrotic pancreatic tissue is common and associated with high morbidity and mortality. The risk of infection may or may not increase with the amount of pancreatic necrosis [21]. Infected pancreatic necrosis has traditionally been managed with surgical necrosectomy and antibiotics [32, 38]. Percutaneous catheter drainage is often ineffective due to blockage of the catheter by necrotic tissue fragments and viscous fluid [2, 14, 19]. However, when patients are too unstable to undergo surgery, percutaneous catheter drainage may be successful in draining liquefied pus and minimizing the systemic manifestations of sepsis, thereby preparing patients for surgery [2, 7–9, 32] (Fig. 11). Percutaneous catheter drainage may also be successful alone. In a study of 23 patients with 38 infected pancreatic fluid collections who were drained percutaneously, 65% were cured without surgery and 35% required some type of surgical intervention after drainage [15]. Catheter drainage time averaged 29 days for patients with isolated collections and 96 days for patients with pancreatic duct fistulae [15]. Success largely depends on the following factors: (a) all the collections must be drained; (b) if they are persistent after 2–3 days of drainage, additional catheters should be placed and large bore catheters are often required; (c) vigorous bedside catheter irrigation should be done at least three times a day with 20 mL of sterile saline injected, and aspirated with suction two to three times; (d) follow-up CT scans must be obtained frequently to assess for treatment response [4, 15].
Complications Major complications of CT-guided catheter drainage are hemorrhage and injury to adjacent organs, such as bowel. Hemorrhage is quite uncommon and may be due to pancreatitis itself rather than the drainage procedure [19]. In the rare event of acute hemorrhage after the procedure, CT scan of the abdomen should be done to assess for extent of the retroperitoneal hemorrhage, pseudoaneurysm formation or active contrast extravasation (Fig. 12). Arterial pseudoaneurysm or active arterial hemorrhage due to injury of adjacent vessels, such as the splenic artery, requires angiographic embolization. Venous bleeding is usually self-limiting. Fistulization to adjacent bowel is almost always due to the
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Fig. 10. A Axial contrast-enhanced CT image shows large necrotic fluid collection (arrow) replacing the majority of the pancreas. Needle aspiration revealed sterile necrosis. B–D Axial contrast-enhanced CT images show three percutaneous drainage catheters with significant decrease in size of the collection.
pancreatitis itself rather than catheter drainage [19]. Inadvertent insertion of the catheter through the bowel may occur when bowel loops are collapsed or unopacified. In most cases, however, the bowel heals without the need for surgical repair [19].
Catheter care Daily rounds should be done by the interventional radiologist with assessment of the patientÕs vital signs, white blood cell count, and clinical status [19, 39]. Catheter(s) should be irrigated with sterile saline at least three times a day. We use a technique that involves aspirating and discarding all the fluid that can be withdrawn from the catheter, followed by forward flushing into the abscess cavity with 20 mL of sterile saline [2]. The process is repeated until the fluid is clear, typically two to three times. Finally, 10 mL of sterile saline is instilled into the catheter toward the patient, and an additional 10 mL toward the bag to prevent catheter plugging. The stopcock between the catheter and the drainage bag connecting tube should be left in the open position. It is important to document accurate drainage output amounts by subtracting the instilled volume of saline from the total drainage volume. The nurses should be familiar with drainage catheters placed by interventional radiology so that flushes are done promptly. Abdominal CT scans should be obtained periodically, based on the clinical status and amount of drainage, to check for residual and/or undrained fluid collections [2, 19]. This helps determine whether drainage is adequate or additional catheters should be placed. If a catheter is not draining and abdominal CT shows residual collection, the catheter may be blocked or the side holes may
not be contiguous with the collection. In such cases, the catheter should be exchanged over a guide-wire and repositioned appropriately within the collection, or removed and a new catheter placed. Our criteria for catheter removal include no residual collection on a follow-up CT scan and catheter output of no more than 10 mL per day of non-purulent fluid for two consecutive days. It is important not to remove the catheter solely based on imaging results without assessing the amount of drainage [19]. Likewise it is important not to remove catheters solely because they stopped draining. Catheters may become plugged or be pulled out from the collection. As a result a CT scan will show residual fluid (Fig. 13). In some cases, CT scan may show complete resolution of the collection; however if there is communication with pancreatic duct or its branches, the catheter may still be draining significant amounts of fluid daily [19]. Similarly, catheter output may be scant, however a fistula may still be present. Pancreatic duct fistulae usually close over time if the collection is completely drained. Patient communication and catheter education must be established as the catheters may have to remain in place for weeks to months [19]. Once stabilized, patients can be discharged home with the catheter in situ and followed as outpatients. Periodic visits with the interventional radiologist are scheduled to inspect the catheter insertion site. The patients are instructed to contact our interventional radiology service when the catheter output decreases.
Ancillary procedures Patients with acute pancreatitis may need additional supportive procedures performed by the interventional
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Fig. 11. A–F Axial contrast-enhanced CT images and coronal reformats obtained prior to any intervention show necrotizing pancreatitis involving the majority of the gland. Necrotic fluid is in the pancreatic bed, around the liver, and tracking along the paracolic gutters. G–I Axial contrast-enhanced CT images show two drainage catheters placed within the necrotic fluid collection. J, K Axial contrastenhanced CT images obtained during the second follow-up show decrease in the amount of necrotic material, with significant amount still remaining (arrow). L–O Axial contrast enhanced CT images obtained during the third follow-up show persistent necrotic collection in the pancreatic bed (arrow). The patient, therefore, underwent surgical debridement.
radiologist. These include ultrasound-guided thoracentesis and paracentesis, fluoroscopic guided nasojejunal or percutaneous jejunal feeding tube placement, and angiographic embolization of pseudoaneurysms or hemorrhaging vessel [2]. Several studies support the use of enteral nutrition rather than parenteral nutrition in patients with acute pancreatitis [40–42]. Therefore, nas-
ojejunal or percutaneous jejunal feeding tube placement with radiologic or endoscopic guidance should be attempted whenever possible. Some patients with sterile necrotizing pancreatitis remain toxic after 3–6 weeks. This is often due to one or more pancreatic duct disruptions with extravasation of noxious pancreatic juice into peripancreatic spaces [32].
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Fig. 11. Continued
Some reports advocate endoscopic placement of a stent across a disruption [24, 43]. However, there are several reasons not to recommend ERCP and endoscopic pancreatic stent placement across the disruption in the setting of sterile necrosis [32]. First, the duct may be obstructed and disruption may not be visualized. Second, if there is no obstruction, the injected contrast may extravasate and infect the necrotic area. Third, with extensive necrosis of the body of the pancreas the distal portion of the duct cannot be visualized or accessed by a stent. Fourth, even if a stent can be placed across a disruption, it may act as a foreign body and result in superinfection [32]. It is, therefore, prudent to continue
medical management or percutaneous catheter drainage in patients with sterile pancreatic necrosis [32]. If a follow-up CT scan demonstrates complete resolution of the pancreatic collection, but the catheter continues to drain significant amounts of fluid daily, there is communication with the pancreatic duct. Fluoroscopic abscessography is then used to visualize the communication and appearance of pancreatic duct [19, 40]. Frequently, in patients with a well-drained pancreatic necrosis, communication with the pancreatic duct may have some irregularity or areas of narrowing which result in high drainage amounts [19]. This communication usually heals over time if the collection is drained completely.
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Fig. 12. Axial contrast-enhanced CT image shows a 7 mm pseudoaneurysm (arrow) in the anterior aspect of the pancreatic body.
c Fig. 13. A Axial contrast-enhanced CT image shows necrotic collection (arrow) involving pancreatic head. B Axial CT image obtained on the same day shows percutaneous drainage catheter (arrow) placed via anterior approach. C Axial CT image obtained one month later shows two anterior percutaneous drainage catheters and no residual collection. D Axial CT image obtained after removal of the catheters shows no residual collection.
Conclusion Image-guided catheter drainage of fluid collections in and around the pancreas in patients with acute necrotizing pancreatitis is an important therapeutic option either alone or as an adjunct to surgery. Successful percutaneous treatment of necrotic collections of the pancreas depends on several important factors. Typically, multiple, large-bore catheters are required to drain large and/or multiloculated collections. Catheters often need to remain in place for several weeks and sometimes months, hence the need for close follow-up. Daily interventional radiology rounds on inpatients, frequent, vigorous bedside catheter irrigations, and willingness to place additional cathers for undrained collections are the norm in the care of these patients. Successful outcomes are best achieved when there is close cooperation among the interventional radiologist, gastroenterologist, and surgeon. References 1. Bradley III EL (1993) A clinically based classification system for acute pancreatitis. In: Summary of the International symposium on acute Pancreatitis, Atlanta. Arch Surg 128:586–590 2. Shankar S, vanSonnenberg E, Silverman SG, et al. (2004) Imaging and percutaneous management of acute complicated pancreatitis. Cardiovasc Intervent Radiol 27:567–580 3. Lee MJ, Rattner DW, Legemate DA, et al. (1992) Acute complicated pancreatitis: redefining the role of interventional radiology. Radiology 183:171–174
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