Thoracolumbar spondylodiscitis surgery

Thoracolumbar spondylodiscitis surgery

see Spondylodiscitis surgery indications.

The aim of a study was to investigate the suitability of percutaneous posterior pedicle screw fixation for surgical treatment in patients with thoracolumbar spondylodiscitis.

Janssen et al. conducted a retrospective review of a consecutive cohort of patients undergoing surgical treatment for thoracolumbar spondylodiscitis between January 2017 and December 2019. They assessed intraoperative and clinical data, comparing the classic open and the percutaneous approach. In total, they analyzed 125 cases (39 female, 86 male). The mean age was 69.49 years ± 12.63 years.

Forty-seven (37.6%) patients were operated on by a percutaneous approach for pedicle screw fixation, and 78 (62.4%) received open surgery. There was no significant difference in the mean age of patients between both groups (p= 0.57). The time of surgery for percutaneous fixation was statistically significantly shorter (p= 0.03). Furthermore, the estimated intraoperative blood loss was significantly lower in the minimally invasive group (p < 0.001). No significant difference could be observed regarding the recurrence rate of spondylodiscitis and the occurrence of surgical site infections (p= 0.2 and 0.5, respectively).

Percutaneous posterior pedicle screw fixation appears to be a feasible option for the surgical treatment of a selected patient group with spondylodiscitis of the thoracic spine and lumbar spine 1).

Although minimally invasive spine stabilization (MISt) with percutaneous pedicle screws is less invasive, percutaneous sacropelvic fixation techniques are not common practice.

Surgical intervention is indicated if neurological deficit, progressive deformity, failure to respond to conservative treatment, or the need to obtain specimens to identify causative pathogens is present. However, traditional anterior debridement and reconstruction with or without posterior instrumentation are associated with high rates of morbidity and mortality, especially in elderly immunocompromised patients and patients with multiple comorbidities. Percutaneous endoscopic discectomy, debridement, and drainage provide a minimally invasive surgical choice for the treatment of infectious spondylodiscitis 2) 3) 4).

High rates of fusion and infection clearance have been reported with anterior lumbar interbody fusion (ALIF), but this approach requires a morbid exposure, associated with non-trivial rates of vascular and peritoneal complications. XLIF is an increasingly popular interbody fusion technique that utilizes a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride and place a large, lordotic cage. The outcome measures for this study included lumbar lordosis, sagittal balance, subsidence, fusion, pain, neurological deficit, and microbiology/laboratory evidence of infection. The mean follow-up time was 9.3months. All patients had improvements in pain and neurological symptoms. The mean lordosis change was 11.0°, from 23.1° preoperatively to 34.0° postoperatively. Fusion was confirmed with CT scans in five of six patients. At the last follow-up, all patients had normalization of inflammatory markers, no symptoms of infection, and none required repeat surgical treatment for spondylodiscitis. XLIF with percutaneous posterior instrumentation is a minimally invasive technique with reduced morbidity for lumbar spine fusion which affords adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue.

XLIF may be a safe and effective alternative to ALIF for the treatment of spondylodiscitis 5).


High rates of fusion and infection clearance have been reported with anterior lumbar interbody fusion (ALIF), but this approach requires a morbid exposure, associated with non-trivial rates of vascular and peritoneal complications. XLIF is an increasingly popular interbody fusion technique which utilizes a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride and place a large, lordotic cage. The outcome measures for this study included lumbar lordosis, sagittal balance, subsidence, fusion, pain, neurological deficit, and microbiology/laboratory evidence of infection. The mean follow-up time was 9.3months. All patients had improvements in pain and neurological symptoms. The mean lordosis change was 11.0°, from 23.1° preoperatively to 34.0° postoperatively. Fusion was confirmed with CT scans in five of six patients. At the last follow-up, all patients had normalization of inflammatory markers, no symptoms of infection, and none required repeat surgical treatment for spondylodiscitis. XLIF with percutaneous posterior instrumentation is a minimally invasive technique with reduced morbidity for lumbar spine fusion which affords adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue.

XLIF may be a safe and effective alternative to ALIF for the treatment of spondylodiscitis 6).


Mini-open anterior debridement and lumbar interbody fusion in combination with posterior percutaneous fixation via a modified ALIF approach results in little surgical trauma and intraoperative blood loss, acceptable postoperative complications, and is effective and safe for the treatment of single-level lumbar pyogenic spondylodiscitis. This approach could be an alternative to the conventional open surgery 7).


Funao et al., describe two cases in which spondylodiscitis in the lumbosacral spine was treated with a percutaneous stabilization using S2 alar-iliac (S2AI) screw technique.

Case 1: a 77-year-old male presented with low back pain and high fever. He was diagnosed with spondylodiscitis at L4-5. He had a history of lung cancer, which was complicated by the recurrence. Because non-surgical treatment failed, MISt with percutaneous S2AI screws was performed. The patient’s low back pain subsided markedly one week after surgery, and there was no screw/rod breakage or recurrence of infection during follow-up period.

Case 2: a 71-year-old male presented with hemiparesis due to a stroke. He also developed high fever and was diagnosed with spondylodiscitis at L5-S. Because non-surgical treatment failed, the patient was treated by MISt with percutaneous S2AI screws while being maintained on anticoagulants for stroke. Although his clinical symptoms had markedly improved, a postoperative lumbar computed tomography demonstrated a bone defect at L5-S. An anterior spinal fusion with an iliac bone graft at L5-S was performed when a temporary cessation of anticoagulants was permitted. Both patients tolerated the procedures well, and had no major perioperative complications.

MISt with percutaneous S2AI screws was less invasive and efficacious for lumbosacral spondylodiscitis in providing rigid percutaneous sacropelvic fixation 8).


1)

Janssen IK, Jörger AK, Barz M, Sarkar C, Wostrack M, Meyer B. Minimally invasive posterior pedicle screw fixation versus open instrumentation in patients with thoracolumbar spondylodiscitis. Acta Neurochir (Wien). 2021 Mar 3. doi: 10.1007/s00701-021-04744-z. Epub ahead of print. PMID: 33655377.
2)

Fu T.-S., Chen L.-H., Chen W.-J. Minimally invasive percutaneous endoscopic discectomy and drainage for infectious spondylodiscitis. Biomedical Journal. 2013;36(4):168–174. doi: 10.4103/2319-4170.112742.
3)

Ito M., Abumi K., Kotani Y., Kadoya K., Minami A. Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis: results of 15 patients with serious comorbid conditions. Spine. 2007;32(2):200–206. doi: 10.1097/01.brs.0000251645.58076.96.
4)

Yang S.-C., Fu T.-S., Chen H.-S., Kao Y.-H., Yu S.-W., Tu Y.-K. Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center. BMC Musculoskeletal Disorders. 2014;15(1, article 105) doi: 10.1186/1471-2474-15-105.
5) , 6)

Blizzard DJ, Hills CP, Isaacs RE, Brown CR. Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci. 2015 Jun 29. pii: S0967-5868(15)00282-9. doi: 10.1016/j.jocn.2015.05.021. [Epub ahead of print] PubMed PMID: 26138052.
7)

Lin Y, Li F, Chen W, Zeng H, Chen A, Xiong W. Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach. J Neurosurg Spine. 2015 Sep 4:1-7. [Epub ahead of print] PubMed PMID: 26340382.
8)

Funao H, Kebaish KM, Isogai N, Koyanagi T, Matsumoto M, Ishii K. Utilization of a technique of percutaneous S2-alar-iliac fixation in immunocompromised patients with spondylodiscitis: Two case reports. World Neurosurg. 2016 Oct 15. pii: S1878-8750(16)31006-3. doi: 10.1016/j.wneu.2016.10.018. PubMed PMID: 27756675.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

see Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic


During the Covid-19 pandemic, every hospital has had to change its internal organization. The nature of the transsphenoidal corridor exposes the pituitary surgery team to an increased risk of virus exposure 1).

It was reported that the aerosolization and mucosal involvement increase the risk of viral transmission during operation. Therefore, transcranial is a safer surgical approach during the COVID-19 pandemic.

Nine cases of pituitary adenomas have presented with urgent manifestations. The endoscopic endonasal approach was performed in eight patients, while a craniotomy was selected for a recurrent pituitary adenoma. Pre- and postoperative thorough clinical evaluations with chest CT scans were performed. Other strict infection control measures have been applied.

In 8 weeks duration starting from the past days of February 2020, we have operated on four females and five males of pituitary adenomas. Visual deterioration was the main presenting symptom. The driving factor for surgery was saving vision in eight patients. Fortunately, the postoperative course was uneventful for all patients. No suspected COVID-19 infection has been reported in any patient or health-care team except one patient. In our city, PCR test was routinely not available 2).


A retrospective cohort study was conducted of all patients who underwent high-priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.

Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.

This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions 3).

A 21-year old male, who required urgent surgery because of progressive visual disturbance due to giant pituitary adenoma. On brain MRI with contrast, it was revealed an extra-axial tumor extending anteriorly over planum sphenoidal with the greatest diameter was 5.34 cm. A transcranial approach was chosen to resect the tumor. Near-total removal of the tumor was achieved without damaging the vital neurovascular structure. The visual acuity was improved and no significant postoperative complication. Pathology examination revealed pituitary adenoma.

Transcranial surgery for pituitary adenoma is still an armamentarium in neurosurgical practice, especially in the COVID-19 pandemic to provide a safer surgical approach 4).


The goal of a paper of Penner et al. is to illustrate the feasibility of pituitary region surgery during the SARS-CoV-2 pandemic.

After two negative COVID tests were obtained, three patients with macro GH-secreting tumors, and two patients with micro ACTH-secreting tumors resistant to medical treatment underwent surgery during the pandemic. During the surgery, every patient was treated as if they were positive.

Neither operator nor patient has developed COVID symptoms. The two neurosurgeons performing the operations underwent two COVID swabs, which resulted in negative.

Pituitary surgery is high-risk non-urgent surgery. However, the method described has so far been effective and is safe for both patients and healthcare providers 5).


The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017 6).


A 47-year-old male COVID-19 positive patient presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention 7).


A 72-year-old woman who required urgent endonasal transsphenoidal surgery (eTSS) because of progressive visual field disturbance due to pituitary adenoma, in whom we conducted reverse-transcriptase-polymerase-chain-reaction (RT-PCR) for COVID-19 and chest CT before eTSS. We took care of her by following the rule for suspected infection patient and safely completed her treatment without medical staff infection. Under COVID-19 pandemic state, essentially careful management including RT-PCR test and chest CT should be taken for the high infection risk surgeries to avoid the outbreak through the hospital. And the cost of the RT-PCR test for the patients should be covered by the government budget 8).


1)

Quillin JW, Oyesiku NM. Status of Pituitary Surgery During the COVID-19 Pandemic. Neurol India. 2020 May-Jun;68(Supplement):S134-S136. doi: 10.4103/0028-3886.287685. PMID: 32611904.
2)

Arnaout MM, Bessar AA, Elnashar I, Abaza H, Makia M. Pituitary adenoma surgeries in COVID-19 era: Early local experience from Egypt. Surg Neurol Int. 2020 Oct 29;11:363. doi: 10.25259/SNI_472_2020. PMID: 33194296; PMCID: PMC7655998.
3)

Naik PP, Tsermoulas G, Paluzzi A, McClelland L, Ahmed SK. Endonasal surgery in the coronavirus era – Birmingham experience. J Laryngol Otol. 2020 Nov 4:1-4. doi: 10.1017/S0022215120002364. Epub ahead of print. PMID: 33143753; PMCID: PMC7729149.
4)

Golden N, Niryana W, Awyono S, Eka Mardhika P, Bhuwana Putra M, Stefanus Biondi M. Transcranial approach as surgical treatment for giant pituitary adenoma during COVID 19 pandemic – What can we learn?: A case report. Interdiscip Neurosurg. 2021 Feb 25:101153. doi: 10.1016/j.inat.2021.101153. Epub ahead of print. PMID: 33654658; PMCID: PMC7906516.
5)

Penner F, Grottoli S, Lanotte MMR, Garbossa D, Zenga F. Pituitary surgery during Covid-19: a first-hand experience and evaluation [published online ahead of print, 2020 Jul 10]. J Endocrinol Invest. 2020;10.1007/s40618-020-01354-x. doi:10.1007/s40618-020-01354-x
6)

Mitchell RA, King JA, Goldschlager T, Wang YY. The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017.
7)

Santos CDSE, Filho LMDCL, Santos CAT, Neill JS, Vale HF, Kurnutala LN. Pituitary tumor resection in a patient with SARS-CoV-2 (COVID-19) infection. A case report and suggested airway management guidelines. Braz J Anesthesiol. 2020 Mar-Apr;70(2):165-170. doi: 10.1016/j.bjane.2020.05.003. Epub 2020 Jun 10. PMID: 32834194; PMCID: PMC7283047.
8)

Akai T, Maruyama K, Takakura H, Yamamoto Y, Morinaga Y, Kuroda S. Safety management in urgent endonasal trans-sphenoidal surgery for pituitary adenoma during the COVID-19 pandemic in Japan – A case report. Interdiscip Neurosurg. 2020 Dec;22:100820. doi: 10.1016/j.inat.2020.100820. Epub 2020 Jul 10. PMID: 32835016; PMCID: PMC7347482.

Lactotroph Adenoma Surgery

Lactotroph Adenoma Surgery

Lactotroph Adenoma Surgery is safe and efficient. It is particularly suitable for enclosed prolactinomas. The patient should be well informed of the pros and cons of the treatment options, which include dopamine agonist (DA) and transsphenoidal microsurgery, and the patient’s preference should be taken into account during decision-making 1).

In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonist2).

Prolactin level < 500 ng/ml in prolactinomas that are not extensively invasive: PRL may be normalized with surgery.


PRL > 500 ng/ml: the chances of normalizing PRL surgically are very low 3).

If no acute progression, an initial attempt of medical therapy should be made as the chances of normalizing PRL surgically with preop levels > 500 ng/ml are very low 4) (these tumors may shrink dramatically with bromocriptine).

If tumor not controlled medically (≈ 18 % will not respond to bromocriptine: surgery followed by restitution of medical therapy may normalize PRL).


Barrow et al. reviewed the results of transsphenoidal microsurgical management in 69 patients with prolactin-secreting pituitary adenomas who had preoperative serum prolactin levels over 200 ng/ml. The patients were divided into three groups based on their preoperative serum prolactin levels: over 200 to 500 ng/ml (Group A); over 500 to 1000 ng/ml (Group B); and over 1000 ng/ml (Group C). The percentage of successful treatment (“control rate”) was 68%, 30%, and 14%, respectively, in these three groups of patients. Based on these results, the authors offer guidelines for the management of patients with prolactin-secreting pituitary adenomas associated with exceptionally high serum prolactin levels. The surgical control rate of 68% in Group A seems to justify surgery for these patients, while primary medical care with bromocriptine is recommended for most patients with serum prolactin levels over 500 ng/ml 5).


Dopamine agonist therapy is the first line of treatment for prolactinomas because of its effectiveness in normalizing serum prolactin levels and shrinking tumor size. Though withdrawal of dopamine agonist treatment is safe and may be implemented following certain recommendations, recurrence of disease after cessation of the drug occurs in a substantial proportion of patients. Concerns regarding the safety of dopamine agonists have been raised, but its safety profile remains high, allowing its use during pregnancy. Surgery is typically indicated for patients who are resistant to medical therapy or intolerant of its adverse side effects, or are experiencing progressive tumor growth. Surgical resection can also be considered as a primary treatment for those with smaller focal tumors where a biochemical cure can be expected as an alternative to lifelong dopamine agonist treatment. Stereotactic radiosurgery also serves as an option for those refractory to medical and surgical therapy 6).


Many guidelines and reports that caution against surgical treatment are based on data over a decade or more old using different techniques such as microsurgical transsphenoidal surgery or from the nascent era of endoscopic transphenoidal surgery 7).

Endoscopic techniques have continued to evolve and provide for excellent visualization, low CSF leak rates, and high rates of gross total resection. In a study of DA-resistant prolactinomas, Vroonen et al. showed that surgical debulking led to a significant de- crease in prolactin levels at a significantly lower DA dose 8).

Kreutzer et al. report a remission rate of 91 % in patients who had elective surgery of microprolactinomas, and Babey et al. also had a high long-term remission rate, without morbidity or mortality for patients with microprolactinomas 9) 10).

Cost considerations are also a concern, especially in countries such as the USA, which is undergoing rapid changes in its healthcare system. A study by Jethwa and Patel et al. found surgical resection of microprolactinomas to be more cost effective long term than medical therapy 11).


Tumor size and invasion of extrasellar and/or cavernous sinuses have typically been seen as limitations of surgery, and some patients with refractory very large or giant tumors may necessitate multistage surgical procedures with a combi- nation of endonasal and transcranial approaches.

see Lactotroph adenoma radiosurgery.


Expanded endoscopic endonasal techniques have been developed that allow for safe treatment of larger adenomas that have extra-/parasellar extension as long as the extension is in the cranio-caudal direction and not lateral to the carotids. However, the issue of partial resection and the risk of apoplexy in the residual irritated tumor is of some concern. As in many other areas of neuro-oncology, a combination approach may be optimal. Surgical resection may allow for definitive removal of the tumor and relief of the mass effect and provide tissue for precisely targeted therapies to prevent recurrence. Sophisticated immunohistochemistry and genetic testing are rapidly being applied to many other tumors and may in the future allow for superior targeted adjuvant therapies in prolactinomas and help reduce recurrences. Finally, surgery might be an answer to the long-term cost of medical therapy specifically in younger patients. However, this issue should be carefully assessed on an individual basis to not jeopardize the standard of care in prolactinoma management by unnecessary surgical treatment. Medical treatment remains the first and the treatment of choice in the general population with recently diagnosed prolactinoma in the absence of rapidly progressive neurological symptoms 12).

Few studies address the cost of treating prolactinomas.

The Department of Neurological Surgery, University of California at San Francisco, performed a cost-utility analysis of surgical versus medical treatment for prolactinomas. Materials and Methods We determined total hospital costs for surgically and medically treated prolactinoma patients. Decision-tree analysis was performed to determine which treatment produced the highest quality-adjusted life years (QALYs). Outcome data were derived from published studies. Results Average total costs for surgical patients were $19,224 ( ± 18,920). Average cost for the first year of bromocriptine or cabergoline treatment was $3,935 and $6,042, with $2,622 and $4,729 for each additional treatment year. For a patient diagnosed with prolactinoma at 40 years of age, surgery has the lowest lifetime cost ($40,473), followed by bromocriptine ($41,601) and cabergoline ($70,696). Surgery also appears to generate high health state utility and thus more QALYs. In sensitivity analyses, surgery appears to be a cost-effective treatment option for prolactinomas across a range of ages, medical/surgical costs, and medical/surgical response rates, except when surgical cure rates are ≤ 30%. Conclusion Our single institution analysis suggests that surgery may be a more cost-effective treatment for prolactinomas than medical management for a range of patient ages, costs, and response rates. Direct empirical comparison of QALYs for different treatment strategies is needed to confirm these findings 13).


1)

Giese S, Nasi-Kordhishti I, Honegger J. Outcomes of Transsphenoidal Microsurgery for Prolactinomas – A Contemporary Series of 162 Cases. Exp Clin Endocrinol Diabetes. 2021 Jan 18. doi: 10.1055/a-1247-4908. Epub ahead of print. PMID: 33461233.
2)

Zamanipoor Najafabadi AH, Zandbergen IM, de Vries F, et al. Surgery as a Viable Alternative First-Line Treatment for Prolactinoma Patients. A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2020;105(3):e32‐e41. doi:10.1210/clinem/dgz144
3) , 4) , 5)

Barrow DL, Mizuno J, Tindall GT. Management of prolactinomas associated with very high serum prolactin levels. J Neurosurg. 1988 Apr;68(4):554-8. PubMed PMID: 3351583.
6)

Wong A, Eloy JA, Couldwell WT, Liu JK. Update on prolactinomas. Part 2: Treatment and management strategies. J Clin Neurosci. 2015 Oct;22(10):1568-74. doi: 10.1016/j.jocn.2015.03.059. Epub 2015 Aug 1. Review. PubMed PMID: 26243714.
7)

Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD, Brue T, Cappabianca P, Colao A, Fahlbusch R, Fideleff H, Hadani M, Kelly P, Kleinberg D, Laws E, Marek J, Scanlon M, Sobrinho LG, Wass JA, Giustina A (2006) Guidelines of the pituitary society for the diagnosis and management of prolactinomas. Clin Endocrinol 65:265–273
8)

Vroonen L, Jaffrain-Rea ML, Petrossians P, Tamagno G, Chanson P, Vilar L, Borson-Chazot F, Naves LA, Brue T, Gatta B, Delemer B, Ciccarelli E, Beck-Peccoz P, Caron P, Daly AF, Beckers A (2012) Prolactinomas resistant to standard doses of cabergoline: a multicen- ter study of 92 patients. Eur J Endocrinol 167:651–662
9)

Babey M, Sahli R, Vajtai I, Andres RH, Seiler RW (2011) Pituitary surgery for small prolactinomas as an alternative to treatment with dopamine agonists. Pituitary 14:222–230
10)

Kreutzer J, Buslei R, Wallaschofski H, Hofmann B, Nimsky C, Fahlbusch R, Buchfelder M (2008) Operative treatment of prolactinomas: indications and results in a current consecutive series of 212 patients. Eur J Endocrinol 158:11–18
11)

Jethwa PR, Patel TD, Hajart AF, Eloy JA, Couldwell WT, Liu JK (2015) Cost-effectiveness analysis of microscopic and endoscopic transsphenoidal surgery versus medical therapy in the management of microprolactinoma in the United States. World Neurosurg 5:2015
12)

Chakraborty S, Dehdashti AR. Does the medical treatment for prolactinoma remain the standard of care? Acta Neurochir (Wien). 2016 May;158(5):943-4. doi: 10.1007/s00701-016-2763-y. Epub 2016 Mar 11. PubMed PMID: 26965287.
13)

Zygourakis CC, Imber BS, Chen R, Han SJ, Blevins L, Molinaro A, Kahn JG, Aghi MK. Cost-Effectiveness Analysis of Surgical versus Medical Treatment of Prolactinomas. J Neurol Surg B Skull Base. 2017 Apr;78(2):125-131. doi: 10.1055/s-0036-1592193. Epub 2016 Sep 27. PubMed PMID: 28321375; PubMed Central PMCID: PMC5357228.
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