The concept of damage control: Extending the paradigm to emergency general surgery

Injury, Int. J. Care Injured (2008) 39, 93—101

www.elsevier.com/locate/injury

The concept of damage control: Extending the paradigm to emergency general surgery S. Peter Stawicki a,*, Adam Brooks b, Tracy Bilski a, David Scaff a, Rajan Gupta c, C. William Schwab a, Vicente H. Gracias a a

Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, 3340 Market Street, Philadelphia, PA 19104, USA b University Hospital, Queens Medical Centre, Nottingham, UK c Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Accepted 18 June 2007

KEYWORDS Open abdomen; Acute care surgery; POSSUM score; Surgical complications; Damage control

Summary Objective: A damage control (DC) approach was developed to improve survival in severely injured trauma patients. The role of DC in acute surgery (AS) patients who are critically ill, as a result of sepsis or overwhelming haemorrhage continues to evolve. The goal of this study was to assess morbidity and mortality of AS patients who underwent DC, and to compare observed and predicted morbidity and mortality as calculated from APACHE II and physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scores. Methods: Consecutive acute surgery patients who underwent DC from 2002 to 2004 were included. Retrospectively collected data included patient demographics, physiological parameters, surgical indications and procedures, mortality, morbidity, as well as volumes of crystalloid and colloid (plasma and red blood cell) resuscitation. Observed mortality and complications were compared to those calculated from APACHE II and POSSUM scores. Data were analysed using the Mann—Whitney test for median values, chi-square and Fisher’s exact tests for proportions. Results: Sixteen patients (mean age 53 years, seven men, nine women) underwent DC. The most common indications for DC included abdominal sepsis (6/15), intraoperative bleeding (5/15), and bowel ischaemia (3/15). The mean intraoperative blood loss during the index procedure was 2060 mL. There were 2.4 average procedures per patient. At the end of DC II (36.5 h), mean infusion of crystalloid was 17 L, packed red blood cells was 3.6 L, and plasma was 3 L. Eight of 16 patients required vasopressor administration during resuscitation. At 28 days, there were five unexpected survivors as predicted by POSSUM and three by APACHE II (observed mortality seven, predicted

* Corresponding author. Tel.: +215 588 5153. E-mail address: [email protected] (S.P. Stawicki). 0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.06.011

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S.P. Stawicki et al. mortality by the two methods: 12 (P = 0.074), and 10 (P = 0.24), respectively). Five patients died prior to definitive abdominal closure. Split thickness skin grafting (4/16) and primary fascial closure (4/16) constituted the most common methods of abdominal closure. Surgical morbidity predicted by POSSUM (98%) and actual morbidity (100%) were similar. Conclusion: Although the morbidity and mortality of AS patients undergoing DC is high, the application of DC principles in this group may reduce mortality compared to that predicted by POSSUM or APACHE II. In order to adequately demonstrate this contention, large, multi-institutional studies of DC in AS patients need to be performed. The POSSUM score appears to accurately estimate the high morbidity in general surgery DC patients, and supports the importance of team management of these complex patients by acute care surgery specialists. # 2007 Elsevier Ltd. All rights reserved.

Introduction The concept of damage control (DC) surgery has evolved significantly since its inception2,5,25. It now spans an entire spectrum of traumatic and nontraumatic indications8,13,15,31. The acute care surgery (AS) model, wherein the trauma/surgical critical care specialist evaluates, performs surgery, and manages critically ill nontrauma emergency general surgery patients is gaining popularity around the world1,3,7,11,17,18,22. This extension in scope of trauma/critical care surgeons seems logical because despite different initial aetiologies, the magnitude of physiological injury and its sequelae are similar in critically ill trauma and nontrauma patients22,23,28—30. In fact, both the American Association for the Surgery of Trauma (AAST) and the European Association for Trauma and Emergency Surgery (EATES) emp-hasise the important role of acute care surgery in the overall scheme of the evolving specialty of trauma, surgical critical care, and emergency surgery1,11. The purpose of this study is to examine the use and results of DC surgery for nontraumatic indications at an academic level I trauma centre. We hypothesise that use of DC in AS patients may contribute to improved outcomes. Specifically, our goal was to assess morbidity and mortality of AS patients who underwent DC, and to compare observed morbidity and mortality to those estimated by APACHE II and physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scores.

Methods After obtaining Institutional Review Board approval, a retrospective evaluation of acute care general surgical patients was performed. Over a 2-year period (2002—2004), acute care surgery general surgical

patients underwent damage control for one or more of the following indications: abdominal sepsis, massive intraoperative bleeding, ischaemic bowel and necrotising pancreatitis. Patients in this study constitute a consecutive sample of acute surgery patients who were identified from a prospectively accrued database that included all patients who underwent surgery for trauma or emergency general surgical indications at our institution. The DC approach for nontraumatic indications was used infrequently at our institution prior to this study. All patients met the standard criteria for damage control, including hypothermia, coagulopathy, and acidosis25. The relatively small number of DC patients over a 2-year study period supports the notion that little, if any, overuse of the DC approach took place. All patients in this study underwent DC in a standardised approach, with a team of trauma and emergency surgery specialists applying DC principles in a uniform fashion. Initially, all patients had a vacuum assisted abdominal coverage (VAAC) applied. Two VAAC techniques employed (based on surgeon preference) included: (a) polyethylene covered surgical towel with suction drains layered above the towel and covered with an impervious adhesive drape or (b) a commercially prepared sponge device (V.A.C., KCI International, San Antonio, Texas). All patients underwent re-exploration within 6—48 h depending on clinical stability and indications for initial laparotomy. When possible, a tension-free primary fascial closure was performed at that time. Abdominal closure performed within 48 h of the initial surgery was termed early delayed primary closure (DPC). If patients continued to manifest clinical characteristics that obviated abdominal closure (e.g. continued bleeding, bowel or retroperitoneal oedema, gross contamination) then VAAC was continued. Primary fascial closure using VAAC more than 48 h after the initial laparotomy was termed DPC with VAAC. Patients with prolonged VAAC (greater than seven days) were re-evaluated after definitive operative

Points

1

2

Possum data sheet physiologic score (calculated at the time of surgery) Patient age <60 61—70 Cardiac signs + chest roentgenogram No cardiac failure Use of diuretic, digoxin, antianginal or antihypertensive agents Respiratory history + chest roentgenogram No dyspnoea Presence of dyspnoea present on exertion

Systolic blood pressure (mm/Hg) Heart rate (beats/min) Glasgow coma scale Haemoglobin (g/100 mL) White blood cell count (thousands/L) Serum urea (mmol/L) Sodium (mmol/L) Potassium (mmol/L) Electrocardiogram

110—130 50—80 15 13—16 4—10 <7.5 >136 3.5—5.0 Normal

131—170 or 100—109 81—100 or 40—49 12—14 11.5—12.9 or 16.1—17.0 10.1—20.0 or 3.1—4.0 7.6—10.0 131—135 3.2—3.4 or 5.1—5.3

Minor 1 <100 None

Moderate

Presence of malignancy

None

Primary tumour only

Mode of surgery

Elective

Possum data sheet operative severity score Operative severity score Multiple procedures Total blood loss (mL) Contamination

101—500 Minor (serous fluid)

4 >71 Peripheral oedema, warfarin use, borderline cardiomegaly Presence of limiting dyspnoea (one flight of stairs), moderate coronary artery disease >171 or 90—99 101—120 9—11 10.0—11.4 or 17.1—18.0 > 20.1 or <3.0 10.1—15.0 126—130 2.9—3.1 or 5.4—5.9 Atrial fibrillation (rate 60—90/min)

Major 2 501—999 Localised purulence

Presence of nodal metastatic disease Emergency resuscitation >2 h, Possible operation <24 h after admission

8

Observation of raised JVP, cardiomegaly Presence of dyspnoea at rest, respirations >30 breaths/min, pulmonary fibrosis or consolidation <90 >121 or <40 <8 <9.9 or >18.1 >15.1 <125 <2.8 or >6.0 Any abnormal rhythm, ectopy >5/min, Q waves ST/T wave changes

DAMAGE CONTROL IN EMERGENCY GENERAL SURGERY

Table 1 The POSSUM scoring system components

Major + >2 >999 Presence of free bowel perforation, purulence or blood Presence of distant metastatic disease Emergency (immediate surgery within 2 h required)

The system is divided into two groups of parameters: physiologic severity (left sided column) and operative severity (right sided column). Each of the parameters is graded according to preassigned score. In addition, detailed list of complications is included and meticulously recorded.

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and physiological restoration was complete. When possible, DPC with VAAC was performed. If the patient had lost abdominal domain, one of two management options was considered. Patients with gross contamination at any time during the resuscitation were managed as planned ventral hernias. These patients had a split thickness skin graft (STSG) placed over the OA wound when a healthy, clean granulation bed formed. An abdominal wall reconstructive procedure would be performed on these patients at a later time. Other patients underwent skin-level closure only, with repair of the fascial defect performed at a later time. Variables examined in this study include patient demographics, physiological parameters at the time of initial presentation (activated partial thromboplastin time, prothrombin time, serum lactate, haemoglobin level, POSSUM and APACHE II scores), estimated blood loss at the time of the initial damage control operation, fluid resuscitation (quantitative assessment of crystalloid and colloid solutions used), vasopressor requirement, number and types of procedures, as well as a detailed analysis of all associated complications (pneumonia, abdominal fistula, abdominal abscess, urinary tract infection, coagulopathy, acute respiratory distress syndrome (ARDS), acute renal failure (ARF), gastrointestinal bleeding, bacteraemia, deep venous thrombosis (DVT), wound infection, ventilator dependent respiratory failure, adrenal insufficiency, thrombocytopaenia, atrial fibrillation). Physiological and operative severity score for the enumeration of mortality and morbidity is a composite scoring system that incorporates preoperative morbidity, operative data, and physiological parameters in order to calculate morbidity and mortality scores. It has been validated in acute surgery patients and has demonstrated improved outcome prediction as compared to APACHE II scores in acute surgical patients4,16. There are two separate scores, the physiological score and the operative severity score. See Table 1 for details of the POSSUM scoring system9. Published formulae allow for calculation of

predicted surgical morbidity and mortality once the score is established (Table 2)9. Observed mortality was compared to that calculated from APACHE II and POSSUM scores. Observed morbidity was compared to that calculated from POSSUM score. The Mann—Whitney test was used for comparisons of median values, Student’s t-test for comparisons involving normally distributed continuous variables and Fishers exact test for categorical variables. Statistical significance was set at alpha = 0.05.

Results Sixteen consecutive emergency general surgery patients (mean age 53; nine women; seven men) underwent damage control surgery at our institution from 2002 to 2004. Initial physiological parameters (including APACHE II and POSSUM scores), blood loss associated with the initial DC procedure, fluid resuscitation data, and the mean number of procedures per patient are listed in Table 3. Mean resuscitation to accomplish complete physiological restoration required 36 h, 17 L of crystalloid fluid administration, 3.6 L of red blood cells, and 3 L of fresh frozen plasma infusion. The mean estimated blood loss during the initial damage control operation was approximately 2 L (Table 3). Eight of 16 patients (50%) required vasopressor administration at some point during their resuscitations. The most common aetiology leading to use of the DC approach was abdominal sepsis (6/16), followed by massive intraoperative bleeding (5/16), ischaemic bowel (3/16), and necrotising pancreatitis (2/ 16) (Fig. 1). On average, there were 2.44 procedures per patient, with a range of 1—4 procedures until definitive abdominal closure. There was a tendency to leave patients with contaminated wounds with an open abdomen (VAAC) and to allow granulation as opposed to at least a skin-level closure on patients who presented with haemorrhage.

Table 2 Formulae used to calculate morbidity and mortality from POSSUM score Morbidity calculation x = (0.16  physiologic score) + (0.19  operative score) 5.91 Predicted morbidity = 1/(1 + e( x)) Mortality calculation y = (0.13  physiologic score) + (0.16  operative score) 7.04 Predicted mortality = 1/(1 + e( y)) Figure 1

Aetiology of acute surgery patient in this study.

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Table 3 Physiological, resuscitation, and procedural parameters associated with damage control/open abdominal approach in this study Parameter

Mean  S.D.

Physiological parameters on initial presentation aPTT PT Serum lactate Haemoglobin POSSUM Physiological Operative APACHE II Blood loss and fluid resuscitation data Time to physiological restoration (h) Initial crystalloids (mL) Initial PRBC (mL) a Initial FFP (mL) b Initial procedure EBL (mL) a Initial procedure crystalloids (mL) Initial procedure PRBC (mL) b Initial procedure FFP (mL) c Subsequent crystalloids (mL) d Subsequent PRBC (mL)b, d Subsequent FFP (mL)c, d

32.7 15.1 3.90 8.50

23.0—150 12.6—23.2 1.70—5.90 3.00—12.4

38.1  10.5 26.8  4.11 24.4  11.7

39.0 27.0 27.5

19.0—57.0 19.0—35.0 9.00—48.0

36.50  19.76 4768  6418 932.9  1389 616.2  1315 2060  2742 4363  2977 1414  1642 779.9  820.3 7801  4109 1276  2768 1655  2279

35.00 2000 575.0 450.0 500.0 4000 750.0 662.5 7011 532.5 800.0

11.00—88.00 1000—19,500 0—4120 0—4700 100.0—10,000 325.0—12,000 0—5250 0—2750 1900—18,900 0—11,500 0—9259

Number of procedures per patient b c d

Range

50.2  40.1 15.9  2.97 3.54  1.67 8.41  2.59

Parameter a

Median

Mean  S.D.

Range

2.44  0.81

1—4

EBL = estimated blood loss. PRBC = packed red blood cells. FFP = fresh frozen plasma. Fluids given prior to definitive closure of the abdomen.

A detailed description of procedures listed according to the stage of damage control, can be found in Table 4. Of note, one patient did not survive to phase II damage control, and a total of five patients died prior to the definitive abdominal closure (stage III damage control). When actual and predicted 28-day mortality rates were compared, the observed mortality was lower than that predicted by physiologic scores. The comparison between POSSUM-predicted mortality and observed mortality demonstrated five unexpected survivors (observed mortality seven patients (43.8%); POSSUM-predicted mortality 12, P = 0.074). A comparison of observed and predicted mortality based on the APACHE II score, revealed three unexpected survivors (observed mortality seven patients (43.8%); APACHE II-predicted mortality 10/16, P = 0.24) (Fig. 2). Analysis of morbidity demonstrated that pneumonia (7/16), abdominal fistula (7/16), and abdominal abscess (6/16) occurred most frequently. The POSSUM score-predicted morbidity (98%) and the observed morbidity (100%) were similar. See Table 5 for a detailed description of patient morbidity in this study.

Discussion The recognition of the lethal triad of acidosis, hypothermia, and coagulopathy has led to the evolution of the damage control approach, which was found to ameliorate the physiological effects of this triad25. Initially used in trauma patients, the DC approach has since been increasingly applied in

Figure 2 Comparison of POSSUM and APACHE-II predicted mortalities and actual mortality in this study.

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Table 4 Surgical procedures and techniques Type of procedure

Patients (%)

Category

Initial procedures — stage I damage control Appendicetomy and abdominal washout for perforated appendicitis Drainage of abdominal abscess Pancreatic debridement for necrotising pancreatitis Intraoperative pancreatic haemorrhage Right hemicolectomy with peripancreatic bleeding Sigmoid resection for perforated diverticulitis Small bowel and colonic resection Small bowel resection for ischaemic bowel Small bowel resection for perforated small bowel Small bowel resection with extensive lysis of adhesions Subtotal gastrectomy, splenectomy, transverse colectomy for carcinoma Subtotal gastrectomy, small bowel resection, oesophagojejunostomy for cancer Whipple procedure and subtotal colectomy for carcinoma

1 1 2 1 1 1 2 1 2 1 1 1 1

ABS a ABS a NEPb IOB c IOB c ABS a ISB d ISB d ABS a ABS a IOB c IOB c IOB c

(6.25) (6.25) (12.5) (6.25) (6.25) (6.25) (12.5) (6.25) (12.5) (6.25) (6.25) (6.25) (6.25)

Type of procedure

Patients (%)

Secondary procedures — stage II damage control Died prior to stage II damage control Abdominal washout and damage control only Abdominal washout and IVC filter placement e Abdominal washout and resection of distal colonic (Hartman’s) remnant Abdominal washout, vicryl mesh placement, skin closure with retentions Abdominal washout, vicryl mesh placement only AllodermTM-assisted fascial reconstruction and closure f Control of retroperitoneal bleeding, colostomy maturation, damage control Extended right hemicolectomy and primary fascial closure Ileostomy and cholecystectomy Ileostomy and mucus fistula, small bowel resection, washout, skin closure Ileo-colonic anastomosis following colon resection Ileo-ileostomy anastomosis following bowel resection Left hemicolectomy and abdominal washout Right hemicolectomy, abdominal washout, and end-ileostomy

1 1 1 1 1 2 1 1 1 1 1 1 1 1 1

(6.25) (6.25) (6.25) (6.25) (6.25) (12.5) (6.25) (6.25) (6.25) (6.25) (6.25) (6.25) (6.25) (6.25) (6.25)

Abdominal closure techniques — stage III damage control Died prior to definitive abdominal coverage Split thickness skin grafting Primary fascial closure possible Component separation procedure Skin closed over open fascia AllodermTM fascial closure f

5 4 4 1 1 1

(31.3) (25.0) (25.0) (6.25) (6.25) (6.25)

Please note that some overlap exists between the stages of damage control. For example, some patients underwent definitive closure at the time of stage II DC. a ABS = abdominal sepsis. b NEP = necrotising pancreatitis. c IOB = intraoperative bleeding. d ISB = ischaemic bowel. e IVC = inferior vena cava. f AllodermTM = human acellular dermis-based bioprosthetic material.

critically ill nontrauma surgical patients8. This logical extension of DC is based on the premise that physiological derangements seen in severely injured trauma patients are also present in surgical patients with severe abdominal sepsis, intra-abdominal haemorrhage, and severe pancreatitis, among other conditions8,13.

Damage control consists of three-phases, beginning with an abbreviated laparotomy to control haemorrhage and contamination (phase I), followed by resuscitation in an intensive care setting (phase II), and then a further laparotomy or series of laparotomies to provide definitive repair of injuries or physiological deficits (phase III)8,31. A definitive

DAMAGE CONTROL IN EMERGENCY GENERAL SURGERY Table 5 Complications observed in the study cohort. Complication

Number of patients

Percentage of patients (%)

Pneumonia Abdominal fistula Abdominal abscess Urinary tract infection Coagulopathy ARDS a Acute renal failure Gastrointestinal bleed Bacteraemia DVTb Wound infection VDRFc Adrenal insufficiency Thromocytopaenia Atrial fibrillation Patients with >1 complication

7 7 6 5 5 5 5 4 4 4 4 4 3 3 3 16

43.8 43.8 37.5 31.3 31.3 31.3 31.3 25.0 25.0 25.0 25.0 25.0 18.8 18.8 18.8 100

a b c

ARDS = acute respiratory distress syndrome. DVT = deep venous thrombosis. VDRF = ventilator dependent respiratory failure.

abdominal closure then follows either in an early or a delayed fashion8. The decision to use DC is often made on a physiological basis, considering the presence of coagulopathy, hypothermia, acidosis, response to fluid therapy, requirement for vasopressors, evidence of end-organ dysfunction, and magnitude of blood loss8,15. Patients in this study demonstrated coagulopathy, lactic acidosis, and mean initial haemoglobin of approximately 8 mg/dL. Moreover, the mean APACHE II score was 24.4 and the mean physiological POSSUM score was 38.1, both indicating a severe degree of physiological derangement at the time of initial presentation and phase I of damage control. This study also well demonstrates large volumes of both crystalloid and biologically active colloid resuscitation needed in order to accomplish physiological normalisation in the setting of damage control. On average, nearly 17 L of crystalloids, over 3.6 L of packed red blood cells and nearly 3 L of fresh frozen plasma were given in order to achieve physiological restoration during a mean continuous resuscitation period of over 36 h. Moreover, 50% of patients required vasopressor support at some point during their resuscitations. One of the physiological insults associated with severe trauma or sepsis in the Surgical Intensive Care Unit is persistent tissue hypoperfusion, secondary to gradual increase in intra-abdominal pressure (intra-abdominal hypertension), leading to abdominal compartment syndrome and subsequently patient death8,25,26. Damage control largely

99 avoids this phenomenon by leaving the abdomen open, alleviating the intra-abdominal hypertension, preventing the abdominal compartment syndrome and end-organ damage, and resulting in improvement of haemodynamic, cardiorespiratory, and renal function8,10,14. The importance of the abdominal compartment syndrome as a clinical entity is underscored by the fact that it can affect a wide variety of patients in both trauma and nontrauma settings, and has been identified as an independent risk factor for development of multiple organ failure6,12,19—21,23,24,27. As shown in this study, emergency general surgery patients with gastrointestinal sepsis, intra-abdominal haemorrhage, or necrotising pancreatitis may benefit from DC in a fashion similar to that of DC trauma patients. Tsuei et al. investigated the management and outcome of the damage control approach in patients with gastrointestinal sepsis, pancreatitis, and trauma31. Similar to our study, they found that DC management could be effectively applied to nontrauma general surgery patients, with acceptable mortality31. In fact, mortality in the current series was lower than predicted by either APACHE II (three unexpected survivors) or POSSUM (five unexpected survivors) scores. Although this finding was not statistically significant, most likely due to small study size, it certainly deserves a closer re-examination in multicentre studies designed to compare both predicted and observed morbidity and mortality in a larger sample of AS patients. Finlay et al. sought to determine if treatment of critically ill nontrauma patients using the DC approach resulted in lower mortality rates13. In that study, 57% of patients underwent laparotomy for peritonitis, 36% for intra-abdominal haemorrhage, and 7% for severe pancreatitis13. Finlay as well as other investigators noted an impressive reduction in observed patient mortality as compared to physiological score-predicted mortality rates, with actual mortality rates being approximately half of those in the predicted range between 49 and 73%8,13. The trend toward reduced patient mortality in our study, as compared to the predicted mortality, may be due to several factors, with use of DC approach being only one of these factors. Another factor probably responsible for the improved outcomes is the uniform approach to critically ill nontrauma patients by a dedicated team of trauma and surgical critical care specialists. Thirdly, aggressive resuscitative and end organ supportive measures may play a role as well. The relative effects of these factors require further study, preferably in a multicentre setting. The high predicted and observed morbidity in this series is worthy of comment. Similar to other

100 studies, the most common abdominal complications were abdominal fistula and abscess, with respective frequencies of 44 and 38%. However, complication rates in this series appear to be much higher than those reported by others (fistula incidence between 11 and 17%, abscess incidence of 7%)8,31. This may be explained by the more advanced age of patients who underwent DC in this study, as well as the already highly stressed physiological status of these critically ill general surgical patients. In terms of intensive care complications, this study clearly demonstrates the many potential problems that may be encountered while caring for DC general surgical patients in the ICU. These complications include urinary tract infections, acute respiratory distress, bacteraemia, deep venous thrombosis, gastrointestinal bleeding, among many others (Table 5). This series provides a very detailed assessment of complications in this population of patients, with many of the listed complications not well characterised in the open abdominal or damage control setting. Deficiencies of this study include its small sample size, lack of control group, and lack of patient randomisation to a specific treatment group. Its strengths include very accurate record of both surgical and critical care-related complications, as well as the use of two different scoring systems for morbidity and mortality comparison purposes.

Conclusion Although the morbidity and mortality of AS patients undergoing DC remains high, the application of DC principles in this patient group may reduce mortality compared to that predicted by physiologic scoring systems. In order to adequately demonstrate this contention, large, multi-institutional studies of DC in AS patients need to be performed. This study accurately demonstrates complications associated with DC approach in acute surgical patients and underscores the importance of the management of these complex patients by a team of acute surgery specialists.

Conflict of interest statement The authors of this manuscript report no conflicts of interest related to this work. None of the authors have any financial and/or personal relationships with other people or organisations that could inappropriately influence or bias their work.

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