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ORIGINAL ARTICLE Table of Contents  
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Analysis of hysterectomy trends in the last 5 years at a tertiary center


 Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital Izmir, Turkey

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Date of Submission08-Apr-2022
Date of Decision18-Apr-2022
Date of Acceptance05-May-2022
 

  Abstract 


Objectives: This study aimed to assess trends by evaluating the types and complications of hysterectomies performed for benign gynecological reasons at our clinic, which is one of the largest hospitals in Turkey.
Materials and Methods: Hysterectomies performed for benign reasons at our gynecology and obstetrics clinic between January 1, 2015 and December 31, 2020 were retrospectively reviewed and included in the analysis. Of the 4288 patients who had undergone hysterectomy, 888 patients were excluded some reasons. The data of the remaining 3400 patients were analyzed
Results: For the 3400 patients, the hysterectomy methods performed were as follows: Total Abdominal Hysterectomy (TAH (60%, n = 2055), Total Laparoscopic Hysterectomy (TLH), (27%, n = 948), Vaginal Hysterectomy (VH), (8.9%, n = 302), Conversion from laparoscopy to laparotomy (L / S > LT). (1.4%, n = 49), Robotic hysterectomy (RH), (1%, n = 33), and Subtotal hysterectomy (SH), (0.4%, n = 13). The length of hospital stay was statistically significantly lower in the TLH group than in the TAH group (P < 0.05). A statistically significant and moderate correlation was noted between the length of hospital stay and the duration of operation (r: 0.68 P = 0.00).
Conclusion: The ratio of TLH group among hysterectomy modalities has increased over the years. There are many factors that affect the surgeon's decision in determining the hysterectomy method.TLH is the first option in patients who are not suitable for vaginal hysterectomy.

Keywords: Laparoscopic hysterectomy, minimally invasive surgery, major complications


How to cite this URL:
Kantarci S, İnan AH, Töz E, Bolukbasi M, Kanmaz AG. Analysis of hysterectomy trends in the last 5 years at a tertiary center. Gynecol Minim Invasive Ther [Epub ahead of print] [cited 2022 Oct 3]. Available from: https://www.e-gmit.com/preprintarticle.asp?id=356424





  Introduction Top


Hysterectomy involves the surgical removal of the uterus for various causes, such as chronic pelvic pain, symptomatic fibroids, abnormal uterine bleeding, adenomyosis, endometriosis, and gynecological malignancies. It is the most frequently performed gynecological operation globally.[1] In developed or developing countries, 20%–40% of women undergo hysterectomy by the age of 60 years, and approximately 500,000 hysterectomies are performed annually in the United States.[2],[3] The first known hysterectomy procedure conducted was vaginal hysterectomy (VH), which was performed by Soranus of Ephesus in 120 AD. However, several studies have shown that patients who undergo VH, primarily for uterine prolapse, rarely survive.[4],[5] Abdominal hysterectomy was performed by Charles Clay in 1843; this procedure has become a safe and life-enhancing operation since the implementation of medical practices and asepsis–antisepsis rules in the mid-20th century.[4] Owing to the development of medical applications along with technological advancements, the first laparoscopic hysterectomy was performed in 1989 by Harry Reich.[6]

Although VH is the standard recommended method in the literature, it is currently the least preferred method.[7] Laparoscopic hysterectomy is associated with faster recovery than abdominal hysterectomy; however, as fewer postoperative fever and infection rates are observed with abdominal hysterectomy, it is the most common method used for hysterectomy.[8],[9]

The mobility of the uterus, body mass index (BMI), preoperative medical and surgical history, anatomical variations, experience of the surgeon and surgical team, and patient preference play a crucial role in selecting the hysterectomy method. In the past decade, hysterectomy rates have steadily decreased annually in the United States and Canada; however, the frequency of laparoscopy in hysterectomy is gradually increasing, owing to alternative treatment options, such as hysteroscopic surgery, endometrial ablation systems, progesterone-releasing intrauterine devices, and hormonal suppressive options.[8]

The study aimed to describe and compare hysterectomy trends in the past 5 years at our hospital, which is the largest gynecology and obstetrics center in Western Turkey, serving as a tertiary referral center.


  Materials and Methods Top


Hysterectomies performed for benign diseases at our gynecology and obstetrics clinic between January 1, 2015, and December 31, 2020, were retrospectively reviewed and included in the analysis. The study was initiated after obtaining approval from the ethics committee (decision no. 2020/14–33). Simultaneously, preoperative consent was routinely obtained from patients at our clinic, in addition to a document requesting consent for the academic use of pathology results and clinical information. Patients who underwent hysterectomy for benign indications between 2015 and 2020, whose pathology results reported benign masses, and whose results could be completely accessed via the hospital information system were included in the analysis. In contrast, patients who had undergone hysterectomy for malignant signs or emergency obstetric conditions were excluded from the analysis. Of the 4288 patients who had undergone hysterectomy, 888 patients were excluded: 526 were excluded due to malignant pathology results, 55 due to hysterectomy performed for emergency obstetric indications, and 307 due to inaccessible medical records in the patient registry system. The data of the remaining 3400 patients were analyzed.

At our clinic, the time from the first skin incision to the last skin suture was routinely recorded by an anesthesia technician during the surgery, and routine complete blood count was performed on the day before the surgery and at 6 h postoperatively for all patients. The patients were examined by categorizing them into six groups: total laparoscopic hysterectomy (TLH), robotic hysterectomy (RH), total abdominal hysterectomy (TAH), subtotal hysterectomy (SH), VH, and cases with conversion from laparoscopy to laparotomy (L/S > LT).

Demographic information, such as age, parity, BMI, comorbid systemic diseases, menopausal status, indications for surgery, and previous surgeries, were obtained from patient files. Data on preoperative and postoperative hemoglobin levels, perioperative or postoperative blood transfusions, preoperative and postoperative endometrial pathology reports, smear findings, operation time, perioperative complications and management, and peritoneal drainage catheter insertion were recorded. The size and location of fibroids and the presence of adnexal masses were noted by examining the preoperative imaging reports and were compared with the results of the postoperative pathology report.

The bladder, ureteral, large vessel, and bowel injuries that occurred during the operation and were recorded as operation notes were defined as major complications. Complications requiring hospitalization after surgery, such as vaginal cuff dehiscence, surgical wound infection, and subcutaneous hematoma, were defined as minor complications.

All statistical analyses were performed using the Statistical Package for the Social Sciences(SPSS) v.23.0 for Windows (SPSS, Inc., Chicago, IL, USA). Categorical variables were presented as numbers and percentages, and continuous variables as mean, deviation, and minimum–maximum. Pearson's Chi-square test was used to compare categorical variables. For comparing continuous variables between the groups, independent Student's t-test was used for binary variables by controlling the distributions. The differences observed between the groups were summarized using a boxplot. The statistical significance level was set at P = 0.05 for all the tests.


  Results Top


In the 3400 patients, the following hysterectomy methods were performed: TAH (60%, n = 2055), TLH (27%, n = 948), VH (8.9%, n = 302), L/S > LT (1.4%, n = 49), RH (1%, n = 33), and SH (0.4%, n = 13). Among the indications for surgery, the most common indication was myoma uteri (42.3%, n = 1439), followed by menorrhagia resistant to medical treatment (14.8%, n = 504), uterine prolapse (12.6%, n = 430), endometrial hyperplasia (11.8%, n = 403), pelvic mass (11.1%, n = 376), postmenopausal bleeding (1.76%, n = 60), persistent cervical dysplasia (1.50%, n = 51), chronic pelvic pain (1.70%, n = 58), endometrioma (0.94%, n = 32), BRCA gene mutation (0.85%, n = 29), and tubo-ovarian abscess (0.53%, n = 18 patients). The most common indication in vaginal hysterectomies was uterine prolapse (%94, n = 284). While the most common indication was myoma uteri in the TAH (52.3%, n = 1074), TLH (34.3%, n = 325), SH (84.6%, n = 11), and RH (33.3%, n = 11) groups and pelvic mass (n = 20, 40%) was noted in the L/S > LT group [Table 1]. A statistically significant difference detected between hysterectomy modalities for indications (P < 0.05).
Table 1: Distribution of indications by type of hysterectomy

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Although the TAH group had the shortest mean operative time (98 ± 39 min), it had the highest mean uterine weight (295 ± 449 g). The VH group had the shortest hospital stay (2.72 ± 1.3 days), whereas the L/S > LT group had the longest stay (4.31 ± 1.7 days). BMI (40.16 kg/m2) with the highest mean and the longest duration of hospitalization (4.31 ± 1.77 days) was observed as the L/S > LT group. Statistically significant difference was observed between hysterectomy modalities in terms of the operation time, decrease in hemoglobin, BMI, uterine weight, and length of hospital stay parameters (P < 0,05) The length of hospital stay was found statistically significantly lower in the TLH group than in the TAH group (P < 0.05) [Table 2]. A statistically significant and moderate correlation was noted between the length of hospital stay and the duration of operation (r: 0.68 P = 0.00).
Table 2: Operative and postoperative findings

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During the study period, no fatal complication was observed among the 3400 hysterectomies performed for benign reasons. Bladder injury (1.5%, n = 51), bowel injury (0.6%, n = 23), ureteral injury (0.8%, n = 29), and major vessel injury (0.1%, n = 4) was observed. Overall, 142 patients with minor complications had to extend their hospital stay. This was because of wound infection (3.2%, n = 110), vaginal cuff dehiscence (0.79%, n = 27), and subcutaneous hematoma (0.1%, n = 4). Wound infection (5%, n = 105) and vaginal cuff dehiscence (0.8%, n = 18) were the most common in the TAH group. Bladder (22, 4%, n = 11) and ureter (16%, n = 8) injury was the most common in the L/S > LT group. Urinary system damage (bladder and ureteral injury) was observed in the TAH (1%, n = 24) and TLH (3%, n = 30) groups, respectively. Furthermore, intestinal injury was most common in the SH group (%15, 3, n = 2). Statistically significant difference was observed between hysterectomy modalities and major, minor complications as well (P < 0.05) [Table 3].
Table 3: Major and minor complications by hysterectomy types

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The highest number of hysterectomies was performed in 2017 (23.8%, n = 810), whereas the lowest number of hysterectomies was performed in 2020 (4%, n = 165). TLH rates in hysterectomies by year detected, respectively: 2015 (11.3%, n = 102), 2016 (18.8%, n = 109), 2017 (32.9% n = 266), 2018 (30.4%, n = 190), 2019 (61.2%, n = 194), and 2020 (52.7%. n = 87) [Figure 1].
Figure 1: Percentage distribution of hysterectomy modalities by years

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  Discussion Top


This study aimed to assess trends in hysterectomy by evaluating the types and complications of hysterectomies performed for benign gynecological diseases at our clinic, which is one of the largest hospitals in Turkey.

The rate of major complications in 3400 hysterectomy cases included in this study was 3% (n = 107). This rate was comparable with the reported rate of major complications following hysterectomies in the literature (0.44%–7%).[10],[11] Moreover, a previous study has reported that major complications are more common with laparoscopic hysterectomy compared to other modalities.[12] Consistent with this study, all laparoscopic hysterectomies (TLH + L/S > LT) in the past 5 years revealed 29 (2.9%) bladder and 20 (2%) ureteral injuries in 997 cases; however, the rate of lower urinary tract injury was totally 1.1% (n = 24) in the TAH group. On the other hand, the assessment of cases in the past 3 years as a separate group revealed that the rate of lower urinary tract injury in the TLH + L/S > LT group was 2.8% (n = 14) in 488 cases, whereas that in the TAH group was 2.8% (n = 13) in 457 cases. Laparoscopy is gradually being preferred over other hysterectomy modalities. In addition, it is observed that the rate of major complications and conversion rates have decreased over the years.

The rate of bladder and bowel damage in the SH group (30.6%, n = 4) was significantly higher than in other modalities. The rate was found to be high because SH is preferred in cases that may predispose to complications such as severe bowel, bladder adhesions and frozen pelvis instead of one of the routine hysterectomy modalities.

The distribution of complications in TLH cases varied according to the years. L/S > LT was observed in 23 (18%) of 125 cases that underwent laparoscopic hysterectomy in 2015, whereas it was observed in 7 (2.5%) of 272 cases that underwent laparoscopic hysterectomy in 2017, which was the highest number of laparoscopic cases. In 2020, three cases (3%) of conversion to laparotomy were noted in 90 patients who underwent TLH. This significant decrease in the conversion rate is one of the important indicators of the increase in our experience with laparoscopic surgery over the years.

In a meta-analysis of 27 randomized controlled studies, Johnson et al. reported that patients who underwent laparoscopic hysterectomy returned to normal life within 14 days (95% confidence interval: 11.8–15.4), which was shorter than the time required for those who underwent abdominal hysterectomy.[13] In our study, the shortest length of hospital stay, which can be an indicator of rapid recovery, was noted in the VH group, followed by that in the laparoscopic hysterectomy group.

In accordance with the literature, the operation time in our study was statistically significantly longer in the TLH group than in the TAH group (TLH = 128 min, TAH = 98 min). However, the laparoscopic hysterectomy rates increased over the years, and the operation time decreased, although not significantly. The average time required for TLH between 2015 and 2017 was 130 min, whereas that required for TLH between 2017 and 2020 was 122 min. It has been reported that the operation time is longer for laparoscopic hysterectomy than for abdominal hysterectomy.[14] We believe that the longer operation time of TLH in our study is related to residency education and the increased rate of complex surgeries, such as huge myoma and endometriosis, performed by specialists.

The rate of vaginal cuff dehiscence after hysterectomy ranges from 0.3% to 3% and is more common after laparoscopic hysterectomy than after abdominal and vaginal hysterectomies.[15],[16] The rate of vaginal cuff dehiscence was 0.5% in the TLH as well as TAH groups, which is inconsistent with the results reported in the literature. However, the rate of vaginal cuff dehiscence in our study was 0.8% which is similar to the literature. In this study, vaginal cuff dehiscence was observed in TAH (0.8%, n = 18) and TLH (0.5%, n = 5) groups.

Andries Twijnstra et al. reported that 1,534 laparoscopic hysterectomies that performed in 1 year and the rate of L/S > LT was found to be 4.6%,[17] which was similar to the rate of 4% which observed in our study. According to the literature, the most common causes of conversion were the patient's inability to tolerate obesity-related anesthesia, urinary system damage, and uncontrollable bleeding. BMI is reportedly associated with operation time and conversion rates.[18]

Among the minor complications requiring postoperative hospitalization wound infection was the most common complication in the TAH group (n = 127, 6.1%). When the TAH and TLH groups were compared, wound infection was detected significantly less common in the TLH group (P < 0.05), whereas vaginal cuff dehiscence and subcutaneous hematoma were less common in the TLH group, although they were not statistically significant.

In the group that underwent L/S > LT, uterus weight was significantly higher, the operation time was longer, and the hospital stay was longer than those in the TAH and TLH groups (P < 0.05). Moreover, the BMI value in the L/S > LT group was higher than that in the TAH or TLH groups (P < 0.05).

The significant decrease in the number of cases in 2020 has dramatically demonstrated the impact of the COVID-19 pandemic on the number of benign hysterectomies for all modalities. The most important reason for this is that our hospital completely postponed elective surgeries, especially in the early days of the pandemic, and served only as a pandemic hospital except one part where laparoscopic surgeries are performed frequently. Therefore, unlike the whole world, our laparoscopic hysterectomy rates have increased gradually in 2019 and 2020. A previous study suggests that VH should be preferred due to various reasons, such as reduced viral transmission during the pandemic, shorter recovery time, and less contact time with suitable patients.[19] The rate of VH was 8% among the hysterectomies performed in our hospital up to 2020; however, this rate increased to 10% during the pandemic in 2020.

There has been a shift toward minimally invasive methods in hysterectomy modalities globally. Although approximately 25%–30% of the recent hysterectomies in our country are performed using minimally invasive methods, open surgical technique is still an important treatment method. This rate is similar to the general rates observed in our clinic. Thus, we aimed to assess the change in the rates of hysterectomies performed in our clinic over the years. The most important limitation of our study, in addition to being retrospective in nature, is the inability to determine the effect of surgical experience, which has a significant influence on each parameter. All operations were performed by a surgical team comprising a specialist and assistants. Assistant training is provided in our hospital, and it should be considered that the constant change of assistants and the lack of standardization among them may affect the results.

Laparoscopic hysterectomy can be safely performed by experienced specialists and is the most appropriate technique for the majority of patients. In our study, minor and major complications did not increase in the TLH group compared with those in the TAH group. In addition, lower rates of wound infection and subcutaneous hematoma were observed. However, if we group them separately, urinary system damage was found to be statistically significantly higher in the TLH group and wound infection in the TAH group. The length of hospital stay, which is the most important indicator of recovery, was significantly less in the TLH group (P < 0.05).

TLH rates increased over the years: 2015 (11.8%), 2016 (18.8%), 2017 (32.8%), 2018 (30.4%), 2019 (61.2%), and 2020 (52.7%). Despite the decreasing number of cases due to the pandemic, a proportional increase in laparoscopy compared with other modalities was observed in developed countries. The experience of TLH at our center has increased over the years, major complications have decreased, and the conversion rates to laparotomy have decreased. This trend has several advantages, such as shorter length of hospital stay, lower wound infection rate, and lower vaginal cuff dehiscence in the TLH group than those in the TAH group.

The decision regarding the hysterectomy route depends on the surgeon's experience, indication for surgery, and patient's personal preference. Some inconsistencies have been observed between physician preferences and physician practices in the literature.[20] Although gynecologists prefer minimally invasive surgery, the rates of abdominal hysterectomy are high and the rates of laparoscopic hysterectomy have increased over the years in practice. Surgeons experienced in minimally invasive methods can more easily perform laparoscopic hysterectomy in patients. Given the desire of gynecologists to change their route of surgical access, the minimally invasive surgical approach to hysterectomy should be further emphasized during training.


  Conclusion Top


Although the number of hysterectomies has decreased due to technological developments, intrauterine hormonal devices, and the COVID-19 pandemic, the number of laparoscopic hysterectomies has been increasing proportionally over the years compared with that of other modalities. The laparoscopic approach has been gaining popularity over the years owing to its advantages over other hysterectomy modalities in several respects, particularly in terms of less intraoperative blood loss, lower need for analgesics, shorter recovery time, and shorter length of hospital stay. TLH performed by experienced specialists should be one of the preferred techniques in patients who are not suitable for VH, considering the surgeon's experience and patient request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schollmeyer T, Elessawy M, Chastamouratidhs B, Alkatout I, Meinhold-Heerlein I, Mettler L, et al. Hysterectomy trends over a 9-year period in an endoscopic teaching center. Int J Gynaecol Obstet. 2014;126:45-9.  Back to cited text no. 1
    
2.
Wilson LF, Pandeya N, Mishra GD. Hysterectomy trends in Australia, 2000-2001 to 2013-2014: Joinpoint regression analysis. Acta Obstet Gynecol Scand 2017;96:1170-9.  Back to cited text no. 2
    
3.
Huang CC, Lo TS, Huang YT, Long CY, Law KS, Wu MP. Surgical trends and time frame comparison of surgical types of hysterectomy: A nationwide, population-based 15-year study. J Minim Invasive Gynecol 2020;27:65-73.e1.  Back to cited text no. 3
    
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Sutton C. Hysterectomy : A historical perspective. Baillieres Clin Obstet Gynaecol 1997;11:1-22.  Back to cited text no. 4
    
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Bachmann GA. Hysterectomy. A critical review. J Reprod Med 1990;35:839-62.  Back to cited text no. 5
    
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7.
Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;2015(8):CD003677.  Back to cited text no. 7
    
8.
Chen I, Choudhry AJ, Tulandi T. Hysterectomy trends: A Canadian perspective on the past, present, and future. J Obstet Gynaecol Can 2019;41 Suppl 2:S340-2.  Back to cited text no. 8
    
9.
Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;(3):CD003677.  Back to cited text no. 9
    
10.
Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: Evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116:492-500.  Back to cited text no. 10
    
11.
Ghosh D, Wipplinger P, Byrne DL. Can total laparoscopic hysterectomy replace total abdominal hysterectomy? A 5-year prospective cohort study of a single surgeon's experience in an unselected population. Gynecol Surg 2013;10:109-15.  Back to cited text no. 11
    
12.
Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The eVALuate study: Two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328:129.  Back to cited text no. 12
    
13.
Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: Systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330:1478.  Back to cited text no. 13
    
14.
Lepka P, Jedryka M, Misiek M, Matkowski R. Hysterectomy in Poland between 2011 and 2016. Changing trends in the surgical approach to hysterectomy. Ginekol Pol 2018;89:529-35.  Back to cited text no. 14
    
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Hur HC, Donnellan N, Mansuria S, Barber RE, Guido R, Lee T. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol 2011;118:794-801.  Back to cited text no. 15
    
16.
Blikkendaal MD, Twijnstra AR, Pacquee SC, Rhemrev JP, Smeets MJ, de Kroon CD, et al. Vaginal cuff dehiscence in laparoscopic hysterectomy: Influence of various suturing methods of the vaginal vault. Gynecol Surg 2012;9:393-400.  Back to cited text no. 16
    
17.
Twijnstra AR, Blikkendaal MD, van Zwet EW, Jansen FW. Clinical relevance of conversion rate and its evaluation in laparoscopic hysterectomy. J Minim Invasive Gynecol 2013;20:64-72.  Back to cited text no. 17
    
18.
Martinek IE, Haldar K, Tozzi R. Laparoscopic surgery for gynaecological cancers in obese women. Maturitas 2010;65:320-4.  Back to cited text no. 18
    
19.
Chene G, Cerruto E, Nohuz E. The comeback of vaginal surgery during and after the COVID-19 pandemic: A new paradigm. Int Urogynecol J 2020;31:2185-6.  Back to cited text no. 19
    
20.
Einarsson JI, Matteson KA, Schulkin J, Chavan NR, Sangi-Haghpeykar H. Minimally invasive hysterectomies – A survey on attitudes and barriers among practicing gynecologists. J Minim Invasive Gynecol 2010;17:167-75.  Back to cited text no. 20
    

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Correspondence Address:
Sercan Kantarci,
Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital Izmir 35170
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/gmit.gmit_30_22



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