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International Journal of Surgery 9 (2011) 615e625

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A systematic review on the effectiveness of slowly-absorbable versusnon-absorbable sutures for abdominal fascial closure following laparotomy

M.S. Sajid*, U. Parampalli, M.K. Baig, M.R. McFallDepartment of General & Colorectal Surgery, Worthing Hospital, Worthing, West Sussex BN11 2DH, UK

a r t i c l e i n f o

Article history:Received 15 June 2011Received in revised form6 September 2011Accepted 24 September 2011Available online 30 October 2011

Keywords:Laparotomy closureFascial defectsDehiscenceIncisional herniaSuture sinus

* Corresponding author. Washington Suite, North WSussex BN11 2DH, UK. Tel.: þ44 (0) 1903 205 111x4fax: þ44 (0) 1903 285 010.

E-mail address: [email protected] (M.S.

1743-9191/$ e see front matter � 2011 Surgical Assodoi:10.1016/j.ijsu.2011.09.006

a b s t r a c t

Objective: To systematically analyse the effectiveness of delayed-absorbable (Polydioxanone; PDS) versusnon-absorbable (Polypropylene; Prolene, and Nylon) for abdominal fascial closure in patients undergoinglaparotomy.Methods: Randomised trials evaluating PDS versus Prolene/Nylon for abdominal fascial closure wereselected and analysed by using the statistical tool RevMan� where summative data was expressed asodds ratio (OR).Results: Eight randomised trials encompassing 4261 patients undergoing laparotomy closure with eitherPDS or Prolene/Nylon were retrieved. There was no statistically significant heterogeneity among trials. Inthe fixed effect model PDS was comparable to Prolene/Nylon in terms of risk of incisional hernia (OR,1.10; 95% CI, 0.87, 1.37; z ¼ 0.79; p ¼ 0.43), wound dehiscence (OR, 1.04; 95% CI, 0.67, 1.62; z ¼ 0.19;p ¼ 0.85), peri-operative complications (OR, 0.94; 95% CI, 0.66, 1.33; z ¼ 0.37; p ¼ 0.71), suture sinusformation (OR, 0.58; 95% CI, 0.33, 1.04; z ¼ 1.84; p ¼ 0.07) and surgical site infection (OR, 0.98; 95% CI,0.68, 1.39; z ¼ 0.14; p ¼ 0.89). Subgroup analysis separately comparing Prolene and Nylon with PDSsupported same outcome.Conclusion: PDS and Prolene/Nylon are equally effective for the closure of abdominal fascia followinglaparotomy. Given that there are no significant differences between two suture materials, further studiesmay be conducted to evaluate their cost-effectiveness and measurement of health-related quality of lifeinstead of analysing their effectiveness in laparotomy closure.

� 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Incisional hernia is a frequent complication of abdominal surgery,with a reported incidence of 3e13% of patients following lapa-rotomy.1e4 In the United States of America, approximately 4e5million laparotomies are performed annually,4 leading to at least400,000e500,000 incisional hernias, of which approximately200,000 repairs are performed.4,5 In the Netherlands, 100,000 lapa-rotomies and 3900 incisional hernia repairs are performed annually.6

In the United Kingdom, more than 124,000 laparotomies and 7000incisional hernia repairs were performed in 2005e2006 with bothopen and laparoscopic techniques.7 Thus about 4% of patientsundergoing a laparotomy require additional surgery to repair anincisional hernia. Whenmorbidity is added to the vast numbers andthe tremendous costs associated with incisional hernia repair,8e12 it

ing, Worthing Hospital, West030, 07891667608 (Mobile);

Sajid).

ciates Ltd. Published by Elsevier Lt

becomes quite clear that effective preventive strategies may playa vital role to save healthcare resources by reducing the incidence ofincisional hernia. Development of incisional hernia following lapa-rotomy is multifactorial. These factors may be classified into patientrelated, biological factors and surgical technique related.13e16 Patientrelated factors include age, higher body mass index, synchronouspresence of abdominal aortic aneurysm and multiple co-morbid-ities.17e20 Biological factors include the capacity for normal collagensynthesis and organization to affect sound biological repair. Abno-rmal biological healing of fascial sheath results in the development ofincisional hernia.21e24 Therefore, biological factors are less amenableto modifications. Operative and technical factors may be consideredthe weakest link in the development of incisional hernia whichshould form the highest priority in preventive strategies.

Several systematic reviews25e30 have examined the type ofsuture used for abdominal fascial closure but none have success-fully recommended an agreed suture technique and suture type.The objective of this review is to systematically analyse only thoserandomised controlled trials which have evaluated the efficacy ofthe most commonly used suture material (in the United Kingdom)

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M.S. Sajid et al. / International Journal of Surgery 9 (2011) 615e625616

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for abdominal fascial closure, that is monofilamentous slowly-absorbable Polydioxanone (PDS) versus monofilamentous non-absorbable Polypropylene (Prolene) and Nylon.

2. Methods

Relevant prospective randomized controlled trials on the use of PDS versusProlene/Nylon for abdominal fascial closure following laparotomy until April 2011were included in this review. The Cochrane Colorectal Cancer Group (CCCG)Controlled Trial Register, the Cochrane Central Register of Controlled Trials(CENTRAL) in The Cochrane Library, Medline, Embase and Science Citation IndexExpanded were searched until April 2011 using the medical subject headings(MeSH) terms “laparotomy closure”, and “fascial sheath closure”. These headingswere used in combination with “slowly-absorbable suture”, “non-absorbablesuture”, “polydioxanone”, “PDS”,“polypropylene”, and “prolene”. A filter foridentifying relevant studies recommended by The Cochrane Collaboration31 wasused to filter out irrelevant studies in Medline and Embase. The references of theincluded studies were searched to identify further trials. The software packageRevMan 5.0.132 provided by The Cochrane Collaboration was used for analysis. Theodds ratio (OR) with 95 per cent confidence interval (CI) was calculated for binarydata variables. The random effects model33 and the fixed effect model34 were usedto calculate the combined outcome in both binary and continuous variables. Incase of heterogeneity, only the results of the random effects model were reported.Heterogeneity was explored using the c2 test, with significance set at p< 0$05, andquantified35 using I2 with a maximum value of 30% identifying low heteroge-neity.31 The Mantel-Haenszel method was used for the calculation of OR under thefixed effect model, and the DerSimonian/Laired method was used for the calcu-lation of OR under the random effect model.36 In a sensitivity analysis, 0.5 wasadded to each cell frequency for trials in which no event occurred in either the

Potentially relevant trials identified for the electronic databases and screened for retrieval

n = 79

Printed copies of published trials retrieved from the electronic databases were evaluated in detail

n = 51

Reasons: Trialaparotomy cl

Potentially appropriate randomized trials to be included in the review

n = 20

Trials with usable information by outcome,

n = 8 on 4261 patients

Reasons: Dextended abon same tri

Reasons:reviews (

Fig. 1. Quorum diagram showing

treatment or control group, according to the method recommended by Deekset al.37 The estimate of the difference between both techniques was pooleddepending upon the effect weights in results determined by each trial estimatevariance. A forest plot (Figs. 3e17) was used for the graphical display of resultsfrom the meta-analysis. The square around the estimate stands for the accuracy ofthe estimation (sample size) and the horizontal line represents the 95% CI. We alsoperformed subgroup analysis on trials where comparison between PDS versusProlene and PDS versus Nylon was made separately to evaluate the influence ofindividual suture material.

3. Results

Eight studies38e45 encompassing 4261 patients undergoinglaparotomyclosurewith either PDS or Prolene/Nylonwere retrievedfrom the electronic databases (Fig. 1). There were 2195 patients inPDS group and 2066 patients in Prolene/Nylon group. The charac-teristics of these trials are given in Table 1. Variables used to achievea combined outcome are given in Table 2. On subgroup analysis,combined outcome was achieved by a separate meta-analysis of 4trials38,39,42,44 comparing the effectiveness of PDS (863 patients)versus Prolene (865 patients). Furthermore, combined outcomewasalso achieved after a separate meta-analysis of 4 trials40,41,43,45

comparing the effectiveness of PDS (1332 patients) versus Nylon(1201 patients) and difference between outcomes of these twogroups was critically assessed to quantify bias based on these twosuture materials.

Trials excluded n =28 ls on the use of other types of sutures used for osure

Trials excluded n = 31 uplicate publications of same trials (11), stracts of same trials (8) and commentaries

als (5).

Trials excluded = 12 Clinical controlled trials (4), literature 3) and meta-analysis (5)

trial selection methodology.

Table 1Characteristics of included trials.

Trial Typeof trial

Country Surgical procedures Suture comparison Follow-upduration

Reported outcomes

Bloemen 2011 RCT Netherlands Both electiveand emergencylaparotomy

Polydioxanone 1/0 versusPolypropylene 1/0 Mass closure

Polydioxanone:34.5(31.6e37.3)Polypropylene:33.3(30.5e36.0)

Wound infectionPeri-operative complicationsWound dehiscenceSuture sinusIncisional hernia

Cameron 1987 RCT UK Midline laparotomyfor various abdominalprocedures

Polydiaxanone 1 versusPolypropylene 1 Mass closure

14.70 months Wound infectionPer-ioperative complicationsWound dehiscenceSuture sinusIncisional hernia

Docobo-Durantez2006

RCT Spain Laparotomy forHepatobiliopancreatic diseasesand liver transplantation

Polydioxanone 1 versusNylon 1 Mass closure

18 months Wound infectionPeri-operative complicationsWound dehiscenceSuture sinusIncisional hernia

Israelsson 1994 RCT IcelandSweden

Midline laparotomy for variousabdominal procedures



Krukowski 1987 RCT UK Midline laparotomy for variousabdominal procedures

Polydiaxanone 1 versusPolypropylene 1


Leaper 1985 RCT UK Midline and transverse laparotomyfor various abdominal procedures



Mirza 2003 RCT UAE Midline and transverse laparotomyfor various abdominal procedures

Polydiaxanone 1 versusPolypropylene 1 Mass closure


Wissing 1987 RCT Netherlands All midline laparotomies:emergency and elective



Table 2Outcome variables.

Trial Numberof patients

Incisionalhernia

Surgical siteinfection

Suturesinus

Peri-operativecomplications

30-day wounddehiscence

Bloemen 2011Polydiaxanone 267 58/267 18/267 5/267 41/267 18/267Polypropylene 256 45/256 14/256 3/256 26/256 9/256

Cameron 1987Polydiaxanone 143 10/143 12/143 0/143 44/143 1/143Polypropylene 141 11/141 21/141 1/141 47/141 9/141

Docobo-Durantez 2006Polydiaxanone 451 5/65 21/451 Not 25/451 4/451Nylon 319 2/42 20/319 reported 23/319 2/319

Israelsson 1994Polydiaxanone 405 49/325 38/405 1/405 8/405 2/405Nylon 408 50/318 35/408 1/408 11/408 3/408

Krukowski 1987Polydiaxanone 374 22/285 13/374 0/374 16/374 3/343Polypropylene 383 28/295 27/383 1/383 35/383 7/362

Leaper 1985Polydiaxanone 107 1/107 18/106 0/107 19/107 1/106Nylon 97 0/97 9/97 0/97 9/97 0/97

Mirza 2003Polydiaxanone 79 5/79 8/79 2/79 11/79 1/79Polypropylene 85 4/85 10/85 11/85 23/85 2/85

Wissing 1987Polydiaxanone 370 37/281 43/370 11/281 67/281 13/370Nylon 377 31/299 27/377 23/299 58/299 8/377

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3.1. Methodological quality of included studies

The methodological quality of included trials was initiallyassessed by the published guideline of SIGN (Scottish IntercollegiateGuidelinesNetwork) andRangel et al.46,47 All trials scored from11 to15 amaximumof 19moderates to good strengthof each randomizedcontrolled trial. Based on the quality of included randomisedcontrolled trials,38e45 the strength and summary of evidence wasfurther evaluated by GradePro�,48 a statistical tool provided byCochrane Collaboration (Fig. 2). The Mantel-Haenszel fixed effectmodel was used to compute robustness and susceptibility to anoutlier among these trials. The allocation concealment and blinding

Fig. 2. Summary and strength of the eviden

of investigator or assessor were not clearly reported as is often thecase in trial evaluating surgical procedures. Qualitatively the resultsof this review may be considered relatively weaker. There was nostatistically significant heterogeneity (clinical or methodologicaldiversity) amongst trials except in case of peri-operative compli-cations including surgical site infection.

3.2. Incidence of incisional hernia (PDS versus Prolene/Nylon)

There was no heterogeneity [chi2 ¼ 4.31, df ¼ 7, (p ¼ 0.74);I2 ¼ 0%] among trials. Therefore, in the fixed effects model (OR,1.11;95% CI, 0.89, 1.39; z ¼ 0.92; p ¼ 0.36; Fig. 3), there was no statistical

ce from trials analysed on GradePro�.

Fig. 3. Incisional hernia (PDS versus Prolene/Nylon).


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difference in the incidence of incisional hernia following the use ofboth types of sutures for abdominal fascial closure.

3.3. Surgical site infection rate (PDS versus Prolene/Nylon)

There was a significant heterogeneity [Tau2 ¼ 0.14, chi2 ¼ 15.92,df ¼ 7, (p < 0.03); I2 ¼ 56%] among trials. Therefore, in the randomeffects model (OR, 0.97; 95% CI, 0.68, 1.39; z¼ 0.16; p¼ 0.88; Fig. 4),there was no statistical difference in surgical site infection ratefollowing the use of both types of sutures.

3.4. Suture sinus development rate (PDS versus Prolene/Nylon)

There was no heterogeneity [chi2 ¼ 4.70, df ¼ 5, (p ¼ 0.45);I2 ¼ 0%] among trials. Therefore, in the fixed effects model (OR,0.49; 95% CI, 0.29, 0.85; z ¼ 2.54; p ¼ 0.01; Fig. 5), there wasstatistically significant higher risk of suture sinus developmentfollowing the use of Prolene/Nylon compared to PDS.

3.5. Peri-operative complications (PDS versus Prolene/Nylon)

There was a significant heterogeneity [Tau2 ¼ 0.19, chi2 ¼ 21.66,df¼ 7, (p< 0.003); I2 ¼ 68%] among trials. Therefore, in the randomeffects model (OR, 0.89; 95% CI, 0.61, 1.30; z¼ 0.60; p¼ 0.55; Fig. 6),there was no statistical difference in the incidence of peri-operativecomplications following the use of both types of sutures.

Fig. 4. Surgical site infection (P

3.6. Peri-operative wound dehiscence (PDS versus Prolene/Nylon)

There was no heterogeneity [chi2 ¼ 10.70, df ¼ 7,(p ¼ 0.15); I2 ¼ 35%] among trials. Therefore, in the fixedeffects model (OR, 1.05; 95% CI, 0.68, 1.62; z ¼ 0.20; p ¼ 0.84;Fig. 7), there was no statistical difference in the incidence ofperi-operative wound dehiscence following the use of bothtypes of sutures.

3.7. Incidence of incisional hernia (PDS versus Prolene)

There was no heterogeneity [chi2 ¼ 2.05, df ¼ 3, (p ¼ 0.56);I2 ¼ 0%] among trials. Therefore, in the fixed effects model(OR, 1.08; 95% CI, 0.79, 1.48; z ¼ 0.47; p ¼ 0.64; Fig. 8), therewas no statistical difference in the incidence of incisionalhernia the use of both types of sutures for abdominal fascialclosure.

3.8. Surgical site infection rate (PDS versus Prolene)

There was no heterogeneity [chi2 ¼ 4.46, df ¼ 3, (p ¼ 0.22);I2 ¼ 33%] among trials. Therefore, in the fixed effects model (OR,0.69; 95% CI, 0.48, 1.00; z ¼ 1.94; p ¼ 0.05; Fig. 9), there was nostatistical difference in surgical site infection rate following the useof both types of sutures.

DS versus Prolene/Nylon).

Fig. 6. Peri-operative complications (PDS versus Prolene/Nylon).

Fig. 7. Wound dehiscence (PDS versus Prolene/Nylon).

Fig. 5. Suture sinus formation (PDS versus Prolene/Nylon).


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Fig. 9. Surgical site infection (PDS versus Prolene).

Fig. 8. Incisional hernia (PDS versus Prolene).


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3.9. Suture sinus development rate (PDS versus Prolene)

There was no heterogeneity [chi2 ¼ 4.48, df ¼ 3, (p ¼ 0.21);I2 ¼ 33%] among trials. Therefore, in the fixed effects model (OR,0.47; 95% CI, 0.20, 1.10; z ¼ 1.74; p ¼ 0.08; Fig. 10), there was nostatistical difference in the incidence of suture sinus developmentfollowing the use of both types of sutures materials.

3.10. Peri-operative complications (PDS versus Prolene)

There was a significant heterogeneity [Tau2 ¼ 0.29, chi2 ¼ 12.69,df¼ 3, (p< 0.005); I2 ¼ 76%] among trials. Therefore, in the randomeffectsmodel (OR, 0.83; 95% CI, 0.47,1.46; z¼ 0.65; p¼ 0.51; Fig.11),there was no statistical difference in the incidence of peri-operativecomplications following the use of both types of sutures.

Fig. 10. Suture sinus formatio

3.11. Peri-operative wound dehiscence (PDS versus Prolene)

There was a significant heterogeneity [Tau2 ¼ 1.40, chi2 ¼ 9.87,df ¼ 3, (p < 0.02); I2 ¼ 70%] among trials. Therefore, in the randomeffects model (OR, 0.49; 95% CI, 0.12, 2.09; z¼ 0.96; p¼ 0.34; Fig.12),there was no statistical difference in the incidence of peri-operativewound dehiscence following the use of both types of sutures.

3.12. Incidence of incisional hernia (PDS versus nylon)

There was no heterogeneity [chi2 ¼ 1.44, df ¼ 3, (p ¼ 0.70);I2¼ 0%] among trials. Therefore, in the fixed effects model (OR,1.12;95% CI, 0.81,1.54; z¼ 0.68; p¼ 0.49; Fig. 13), there was no statisticaldifference in the incidence of incisional hernia following the use ofboth types of sutures.

n (PDS versus Prolene).

Fig. 12. Wound dehiscence (PDS versus Prolene).

Fig. 11. Peri-operative complications (PDS versus Prolene).


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3.13. Surgical site infection rate (PDS versus nylon)

There was no heterogeneity [chi2 ¼ 5.68, df ¼ 3, (p ¼ 0.13);I2 ¼ 47%] among trials. Therefore, in the fixed effects model (OR,1.25; 95% CI, 0.94, 1.67; z ¼ 1.56; p ¼ 0.12; Fig. 14), there was nostatistical difference in the incidence of developing surgical siteinfection following the use of both types of sutures.

3.14. Suture sinus development rate (PDS versus Nylon)

There was no heterogeneity [chi2 ¼ 0.24, df ¼ 1, (p ¼ 0.62);I2 ¼ 0%] among trials. Therefore, in the fixed effects model (OR,0.51; 95% CI, 0.25, 1.04; z ¼ 1.85; p ¼ 0.06; Fig. 15), there was nostatistical difference in the incidence of suture sinus developmentfollowing the use of both types of sutures for abdominal fascialclosure in laparotomy.

Fig. 13. Incisional hernia

3.15. Peri-operative complications (PDS versus Nylon)

There was no heterogeneity [chi2 ¼ 5.28, df ¼ 3, (p ¼ 0.15);I2 ¼ 43%] among trials. Therefore, in the fixed effects model (OR,1.14; 95% CI, 0.86, 1.52; z ¼ 0.91; p ¼ 0.37; Fig. 16), there was nostatistical difference in the incidence of peri-operative complica-tions following the use of both types of sutures for abdominalfascial closure.

3.16. Peri-operative wound dehiscence (PDS versus Nylon)

There was no heterogeneity [chi2 ¼ 1.73, df ¼ 3, (p ¼ 0.63);I2¼ 0%] among trials. Therefore, in the fixed effects model (OR,1.35;95% CI, 0.68, 2.67; z¼ 0.87; p¼ 0.38; Fig.17), therewas no statisticaldifference in the incidence of peri-operative wound dehiscencefollowing the use of both types of sutures.

(PDS versus Nylon).

Fig. 15. Suture sinus formation (PDS versus Nylon).

Fig. 14. Surgical site infection (PDS versus Nylon).


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3.17. Subgroup analysis

A subgroup analysis was performed on trials with follow-up ofmore than 1 year because a number of incisional hernias developlater than one year after laparotomy. There was no heterogeneity[chi2 ¼ 4, df ¼ 6, (p ¼ 0.68); I2 ¼ 0%] among trials. Therefore, in thefixed effects model (OR, 1.10; 95% CI, 0.88 1.38; z ¼ 0.87; p ¼ 0.38),there was no statistical difference in the incidence of incisionalhernia following the use of both types of sutures for abdominalfascial closure.

3.18. Other relevant variables

Although the authors of this review intended to analyse data ofother relevant and important variables such as cost-effectiveness,health-related quality of life measurement, length of hospital

Fig. 16. Peri-operative complica

stay, operative time, long-term follow-up and re-admission ratedue intra-abdominal adhesions. These calculations were virtuallyimpossible to perform because of insufficient data reporting.

4. Discussion

This meta-analysis has demonstrated that PDS, Prolene andNylon all are equally effective for abdominal fascial closure. Risk ofincisional hernia, wound dehiscence, peri-operative complications,suture sinus formation, and surgical site infection do not differsignificantly for different suture materials. Subgroup analysiscomparing PDS with both Prolene and Nylon also suggest equiva-lence. There is a lack of agreement within the surgical fraternityabout the ideal abdominal fascial closure technique. Several meta-analyses of variable quality25e30 have reported confusing andconflicting recommendations. Studies have compared the use of

tions (PDS versus Nylon).

Fig. 17. Wound dehiscence (PDS versus Nylon).


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absorbable versus non-absorbable, delayed-absorbable versus non-absorbable, monofilament versus multifilament and the use of steelwires for laparotomy closure but without any solid conclusion. Thefindings of our review correlate well with one meta-analysis27

published in 2002 supporting the use of slowly-absorbable suturematerial. This is further supported by Diener et al25 favouring theuse of delayed-absorbable suture material like PDS. In contrast,Hodgson et al28 favour the use of non-absorbable Prolene andNylon. We consider this meta-analysis a valuable guide in currentsurgical practice for the surgical community because the mostcommonly used suture materials were compared and a conclusiveoutcome could be reached to attain valid recommendations. Arecently published high quality randomised controlled38 trialfavours our conclusion considerably but the incidence of incisionalhernia was reported higher between both groups because ofdifference in baseline characteristics referring towards highernumber of recruited patients with chronic obstructive pulmonarydisease.

No further trials are required for the evaluation of suturematerialin abdominal fascial closure according to the results of summativeoutcomes of this review. Future randomised trials may be aimed toevaluate variables like cost-effectiveness, health-related quality oflife measurement, length of hospital stay, operative time, long-termfollow-up and re-admission rate due to intra-abdominal adhesions.Furthermore, research may be directed towards closure strategy inemergency versus elective laparotomy closure, new suture material,and the use of prophylactic biosynthetic meshes in a group of highrisk population like patients with obesity, chronic obstructivepulmonary disease, metabolic syndromes, abdominal aortic aneu-rysm and patients with previous laparotomy.13e25

Conflict of interestNone.

FundingNone.

Ethical approvalNot applicable.

Trial

Not applicable.

Author contribution

Study idea: SajidStudy design: Sajid, Parampalli, McFallData collections: Sajid, Parampalli

Data confirmation: BaigData analysis: Sajid, ParampalliDraft writing: Sajid, McFallCritical review of the article: BaigFinal approval: Sajid, Parampalli, Baig, McFall

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