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Langenbeck's Archives of Surgery

Published in:

01-08-2017 | REVIEW ARTICLE

Portal vein embolization in extended liver resection

Authors: Nisha Narula, Thomas A. Aloia

Published in: Langenbeck's Archives of Surgery | Issue 5/2017

Abstract

Background

Liver resection of benign, primary, and metastatic tumors is challenging and places patients at risk of postoperative liver insufficiency. This risk is largely dependent on the volume and function of the future liver remnant (FLR). It is, therefore, critical that hepatobiliary surgeons are well versed in the measurement of liver volume and function, as well as various techniques for preoperative liver volume augmentation.

Purpose

This comprehensive review of portal vein embolization (PVE) begins with an overview of FLR measurement and progresses to patient factors to consider when choosing PVE and assessment of hypertrophy. PVE techniques and complications are subsequently discussed.

Conclusions

The absolute volume of FLR required to avoid postoperative liver insufficiency is dependent on the patient, disease, and anatomic factors. Rapid expansion of the FLR can be achieved with PVE of contralateral liver segments. Although multiple metrics have been used to correlate hypertrophy with postoperative outcomes after PVE, the kinetic growth rate (KGR) is the most reliable predictor of freedom from postoperative liver insufficiency. PVE is now considered a safe and effective procedure when performed at high-volume hepatobiliary centers. It is an effective tool that, by lowering the risk of liver failure, increases the number of patients who can undergo potential curative hepatectomy.

Abdalla EK, Denys A, Chevalier P, Nemr RA, Vauthey JN (2004) Total and segmental liver volume variations: implications for liver surgery. Surgery 135(4):404–410. doi:10.1016/j.surg.2003.08.024 CrossRefPubMed

Shoup M, Gonen M, D’Angelica M, Jarnagin WR, DeMatteo RP, Schwartz LH, Tuorto S, Blumgart LH, Fong Y (2003) Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg 7(3):325–330CrossRefPubMed

Shirabe K, Shimada M, Gion T, Hasegawa H, Takenaka K, Utsunomiya T, Sugimachi K (1999) Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. J Am Coll Surg 188(3):304–309CrossRefPubMed

Abdalla EK, Barnett CC, Doherty D, Curley SA, Vauthey JN (2002) Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg 137(6):675–680 discussion 680-671CrossRefPubMed

Kishi Y, Abdalla EK, Chun YS, Zorzi D, Madoff DC, Wallace MJ, Curley SA, Vauthey JN (2009) Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry. Ann Surg 250(4):540–548. doi:10.1097/SLA.0b013e3181b674df PubMed

Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, Denys A, Sauvanet A (2003) Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 237(2):208–217. doi:10.1097/01.SLA.0000048447.16651.7B PubMedPubMedCentral

Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P (2004) A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg 240(6):1037–1049 discussion 1049-1051CrossRefPubMedPubMedCentral

Huang SY, Aloia TA, Shindoh J, Ensor J, Shaw CM, Loyer EM, Vauthey JN, Wallace MJ (2014) Efficacy and safety of portal vein embolization for two-stage hepatectomy in patients with colorectal liver metastasis. J Vasc Interv Radiol 25(4):608–617. doi:10.1016/j.jvir.2013.10.028 CrossRefPubMed

Hoekstra LT, de Graaf W, Nibourg GA, Heger M, Bennink RJ, Stieger B, van Gulik TM (2013) Physiological and biochemical basis of clinical liver function tests: a review. Ann Surg 257(1):27–36. doi:10.1097/SLA.0b013e31825d5d47 CrossRefPubMed

10.

Mpabanzi L, van Mierlo KM, Malago M, Dejong CH, Lytras D, Olde Damink SW (2013) Surrogate endpoints in liver surgery related trials: a systematic review of the literature. HPB (Oxford) 15(5):327–336. doi:10.1111/j.1477-2574.2012.00590.x CrossRef

11.

Heymsfield SB, Fulenwider T, Nordlinger B, Barlow R, Sones P, Kutner M (1979) Accurate measurement of liver, kidney, and spleen volume and mass by computerized axial tomography. Ann Intern Med 90(2):185–187CrossRefPubMed

12.

Gotra A, Chartrand G, Vu KN, Vandenbroucke-Menu F, Massicotte-Tisluck K, de Guise JA, Tang A (2017) Comparison of MRI- and CT-based semiautomated liver segmentation: a validation study. Abdom Radiol (NY) 42(2):478–489. doi:10.1007/s00261-016-0912-7 CrossRef

13.

Karlo C, Reiner CS, Stolzmann P, Breitenstein S, Marincek B, Weishaupt D, Frauenfelder T (2010) CT- and MRI-based volumetry of resected liver specimen: comparison to intraoperative volume and weight measurements and calculation of conversion factors. Eur J Radiol 75(1):e107–e111. doi:10.1016/j.ejrad.2009.09.005 CrossRefPubMed

14.

Couinaud C (1999) Liver anatomy: portal (and suprahepatic) or biliary segmentation. Dig Surg 16(6):459–467CrossRefPubMed

15.

Nakayama Y, Li Q, Katsuragawa S, Ikeda R, Hiai Y, Awai K, Kusunoki S, Yamashita Y, Okajima H, Inomata Y, Doi K (2006) Automated hepatic volumetry for living related liver transplantation at multisection CT. Radiology 240(3):743–748. doi:10.1148/radiol.2403050850 CrossRefPubMed

16.

Suzuki K, Epstein ML, Kohlbrenner R, Garg S, Hori M, Oto A, Baron RL (2011) Quantitative radiology: automated CT liver volumetry compared with interactive volumetry and manual volumetry. AJR Am J Roentgenol 197(4):W706–W712. doi:10.2214/AJR.10.5958 CrossRefPubMedPubMedCentral

17.

Kubota K, Makuuchi M, Kusaka K, Kobayashi T, Miki K, Hasegawa K, Harihara Y, Takayama T (1997) Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 26(5):1176–1181. doi:10.1053/jhep.1997.v26.pm0009362359 PubMed

18.

Sato Y, Matsushima S, Inaba Y, Sano T, Yamaura H, Kato M, Shimizu Y, Senda Y, Ishiguchi T (2015) Preoperative estimation of future remnant liver function following portal vein embolization using relative enhancement on gadoxetic acid disodium-enhanced magnetic resonance imaging. Korean J Radiol 16(3):523–530. doi:10.3348/kjr.2015.16.3.523 CrossRefPubMedPubMedCentral

19.

Matsumata T, Kanematsu T, Yoshida Y, Furuta T, Yanaga K, Sugimachi K (1987) The indocyanine green test enables prediction of postoperative complications after hepatic resection. World J Surg 11(5):678–681CrossRefPubMed

20.

Imamura H, Sano K, Sugawara Y, Kokudo N, Makuuchi M (2005) Assessment of hepatic reserve for indication of hepatic resection: decision tree incorporating indocyanine green test. J Hepato-Biliary-Pancreat Surg 12(1):16–22. doi:10.1007/s00534-004-0965-9 CrossRef

21.

Okochi O, Kaneko T, Sugimoto H, Inoue S, Takeda S, Nakao A (2002) ICG pulse spectrophotometry for perioperative liver function in hepatectomy. J Surg Res 103(1):109–113. doi:10.1006/jsre.2001.6328 CrossRefPubMed

22.

Kinoshita K, Ukikusa M, Iwaisako K, Arimoto A, Fujisawa N, Ozaki T, Tanaka H, Seo S, Naitoh M, Nomura A, Inomoto T, Kitai T, Ino K, Higashiyama H, Hanafusa T, Nakajima Y (2003) Preoperative assessment of hepatic function: utility of a new convenient two-compartment model analysis using galactosyl human serum albumin scintigraphy. J Gastroenterol Hepatol 18(1):99–104CrossRefPubMed

23.

Vauthey JN, Abdalla EK, Doherty DA, Gertsch P, Fenstermacher MJ, Loyer EM, Lerut J, Materne R, Wang X, Encarnacion A, Herron D, Mathey C, Ferrari G, Charnsangavej C, Do KA, Denys A (2002) Body surface area and body weight predict total liver volume in Western adults. Liver Transpl 8(3):233–240. doi:10.1053/jlts.2002.31654 CrossRefPubMed

24.

Ribero D, Abdalla EK, Madoff DC, Donadon M, Loyer EM, Vauthey JN (2007) Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. The British Journal of Surgery 94(11):1386–1394. doi:10.1002/bjs.5836 CrossRefPubMed

25.

Abdalla EK, Adam R, Bilchik AJ, Jaeck D, Vauthey JN, Mahvi D (2006) Improving resectability of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol 13(10):1271–1280. doi:10.1245/s10434-006-9045-5 CrossRefPubMed

26.

Azoulay D, Castaing D, Smail A, Adam R, Cailliez V, Laurent A, Lemoine A, Bismuth H (2000) Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Ann Surg 231(4):480–486CrossRefPubMedPubMedCentral

27.

Teh SH, Christein J, Donohue J, Que F, Kendrick M, Farnell M, Cha S, Kamath P, Kim R, Nagorney DM (2005) Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: Model of End-Stage Liver Disease (MELD) score predicts perioperative mortality. J Gastrointest Surg 9(9):1207–1215; discussion 1215. doi:10.1016/j.gassur.2005.09.008 CrossRefPubMed

28.

Hwang S, Ko GY, Kim MH, Lee SK, Gwon DI, Ha TY, Song GW, Jung DH, Park DH, Lee SS (2016) Preoperative left portal vein embolization for left liver resection in high-risk hepatobiliary malignancy patients. World J Surg 40(11):2758–2765. doi:10.1007/s00268-016-3618-7 CrossRefPubMed

29.

Ogata S, Belghiti J, Farges O, Varma D, Sibert A, Vilgrain V (2006) Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma. The British journal of surgery 93(9):1091–1098. doi:10.1002/bjs.5341 CrossRefPubMed

30.

Choi JH, Hwang S, Lee YJ, Kim KH, Ko GY, Gwon DI, Ahn CS, Moon DB, Ha TY, Song GW, Jung DH, Lee SG (2015) Prognostic effect of preoperative sequential transcatheter arterial chemoembolization and portal vein embolization for right hepatectomy in patients with solitary hepatocellular carcinoma. Korean J Hepatobiliary Pancreat Surg 19(2):59–65. doi:10.14701/kjhbps.2015.19.2.59 CrossRefPubMedPubMedCentral

31.

Vauthey JN, Pawlik TM, Ribero D, Wu TT, Zorzi D, Hoff PM, Xiong HQ, Eng C, Lauwers GY, Mino-Kenudson M, Risio M, Muratore A, Capussotti L, Curley SA, Abdalla EK (2006) Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Clin Oncol 24(13):2065–2072. doi:10.1200/JCO.2005.05.3074 CrossRefPubMed

32.

Shindoh J, Tzeng CW, Aloia TA, Curley SA, Zimmitti G, Wei SH, Huang SY, Mahvash A, Gupta S, Wallace MJ, Vauthey JN (2013) Optimal future liver remnant in patients treated with extensive preoperative chemotherapy for colorectal liver metastases. Ann Surg Oncol 20(8):2493–2500. doi:10.1245/s10434-012-2864-7 CrossRefPubMed

33.

Karoui M, Penna C, Amin-Hashem M, Mitry E, Benoist S, Franc B, Rougier P, Nordlinger B (2006) Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases. Ann Surg 243(1):1–7CrossRefPubMedPubMedCentral

34.

Ribeiro HS, Costa WL Jr, Diniz AL, Godoy AL, Herman P, Coudry RA, Begnami MD, Mello CA, Silva MJ, Zurstrassen CE, Coimbra FJ (2013) Extended preoperative chemotherapy, extent of liver resection and blood transfusion are predictive factors of liver failure following resection of colorectal liver metastasis. Eur J Surg Oncol 39(4):380–385. doi:10.1016/j.ejso.2012.12.020 CrossRefPubMed

35.

Truty MJ, Vauthey JN (2010) Uses and limitations of portal vein embolization for improving perioperative outcomes in hepatocellular carcinoma. Semin Oncol 37(2):102–109. doi:10.1053/j.seminoncol.2010.03.013 CrossRefPubMedPubMedCentral

36.

Madoff DC, Hicks ME, Vauthey JN, Charnsangavej C, Morello FA Jr, Ahrar K, Wallace MJ, Gupta S (2002) Transhepatic portal vein embolization: anatomy, indications, and technical considerations. Radiographics 22(5):1063–1076. doi:10.1148/radiographics.22.5.g02se161063 CrossRefPubMed

37.

Denys A, Bize P, Demartines N, Deschamps F, De Baere T, Cardiovascular, Interventional Radiological Society of E (2010) Quality improvement for portal vein embolization. Cardiovasc Intervent Radiol 33(3):452–456. doi:10.1007/s00270-009-9737-x CrossRefPubMedPubMedCentral

38.

Avritscher R, de Baere T, Murthy R, Deschamps F, Madoff DC (2008) Percutaneous transhepatic portal vein embolization: rationale, technique, and outcomes. Semin Intervent Radiol 25(2):132–145. doi:10.1055/s-2008-1076686 CrossRefPubMedPubMedCentral

39.

Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunven P, Yamazaki S, Hasegawa H, Ozaki H (1990) Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 107(5):521–527PubMed

40.

Madoff DC, Hicks ME, Abdalla EK, Morris JS, Vauthey JN (2003) Portal vein embolization with polyvinyl alcohol particles and coils in preparation for major liver resection for hepatobiliary malignancy: safety and effectiveness—study in 26 patients. Radiology 227(1):251–260. doi:10.1148/radiol.2271012010 CrossRefPubMed

41.

Cazejust J, Bessoud B, Le Bail M, Menu Y (2015) Preoperative portal vein embolization with a combination of trisacryl microspheres, gelfoam and coils. Diagn Interv Imaging 96(1):57–64. doi:10.1016/j.diii.2013.07.004 CrossRefPubMed

42.

Madoff DC, Abdalla EK, Gupta S, Wu TT, Morris JS, Denys A, Wallace MJ, Morello FA Jr, Ahrar K, Murthy R, Lunagomez S, Hicks ME, Vauthey JN (2005) Transhepatic ipsilateral right portal vein embolization extended to segment IV: improving hypertrophy and resection outcomes with spherical particles and coils. J Vasc Interv Radiol 16(2 Pt 1):215–225. doi:10.1097/01.RVI.0000147067.79223.85 CrossRefPubMed

43.

Kodama Y, Shimizu T, Endo H, Miyamoto N, Miyasaka K (2002) Complications of percutaneous transhepatic portal vein embolization. J Vasc Interv Radiol 13(12):1233–1237CrossRefPubMed

44.

Shindoh J, Tzeng CW, Aloia TA, Curley SA, Huang SY, Mahvash A, Gupta S, Wallace MJ, Vauthey JN (2014) Safety and efficacy of portal vein embolization before planned major or extended hepatectomy: an institutional experience of 358 patients. J Gastrointest Surg 18(1):45–51. doi:10.1007/s11605-013-2369-0 CrossRefPubMed

45.

Malinowski M, Stary V, Lock JF, Schulz A, Jara M, Seehofer D, Gebauer B, Denecke T, Geisel D, Neuhaus P, Stockmann M (2015) Factors influencing hypertrophy of the left lateral liver lobe after portal vein embolization. Langenbeck’s Arch Surg 400(2):237–246. doi:10.1007/s00423-014-1266-7 CrossRef

46.

Saad WE, Davies MG, Darcy MD (2008) Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Tech Vasc Interv Radiol 11(1):60–71. doi:10.1053/j.tvir.2008.05.007 CrossRefPubMed

47.

Winick AB, Waybill PN, Venbrux AC (2001) Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 4(3):200–206CrossRefPubMed

48.

Loffroy R, Favelier S, Chevallier O, Estivalet L, Genson PY, Pottecher P, Gehin S, Krause D, Cercueil JP (2015) Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes. Quant Imaging Med Surg 5(5):730–739. doi:10.3978/j.issn.2223-4292.2015.10.04 PubMedPubMedCentral

49.

Di Stefano DR, de Baere T, Denys A, Hakime A, Gorin G, Gillet M, Saric J, Trillaud H, Petit P, Bartoli JM, Elias D, Delpero JR (2005) Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 234(2):625–630. doi:10.1148/radiol.2342031996 CrossRefPubMed

50.

Shindoh J, Truty MJ, Aloia TA, Curley SA, Zimmitti G, Huang SY, Mahvash A, Gupta S, Wallace MJ, Vauthey JN (2013) Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg 216(2):201–209. doi:10.1016/j.jamcollsurg.2012.10.018 CrossRefPubMed

51.

Tanaka K, Kumamoto T, Matsuyama R, Takeda K, Nagano Y, Endo I (2010) Influence of chemotherapy on liver regeneration induced by portal vein embolization or first hepatectomy of a staged procedure for colorectal liver metastases. J Gastrointest Surg 14(2):359–368. doi:10.1007/s11605-009-1073-6 CrossRefPubMed

52.

Deipolyi AR, Zhang YS, Khademhosseini A, Naidu S, Borad M, Sahin B, Mathur AK, Oklu R (2017) Portal vein embolization: impact of chemotherapy and genetic mutations. J Clin Med 6(3). doi:10.3390/jcm6030026

53.

Simoneau E, Hassanain M, Shaheen M, Aljiffry M, Molla N, Chaudhury P, Anil S, Khashper A, Valenti D, Metrakos P (2015) Portal vein embolization and its effect on tumour progression for colorectal cancer liver metastases. The British Journal of Surgery 102(10):1240–1249. doi:10.1002/bjs.9872 CrossRefPubMed

54.

Hoekstra LT, van Lienden KP, Doets A, Busch OR, Gouma DJ, van Gulik TM (2012) Tumor progression after preoperative portal vein embolization. Ann Surg 256(5):812–817; discussion 817-818. doi:10.1097/SLA.0b013e3182733f09 CrossRefPubMed

55.

Broering DC, Hillert C, Krupski G, Fischer L, Mueller L, Achilles EG, Schulte am Esch J, Rogiers X (2002) Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant. J Gastrointest Surg 6(6):905–913 discussion 913CrossRefPubMed

56.

Iida H, Aihara T, Ikuta S, Yoshie H, Yamanaka N (2012) Comparison of percutaneous transhepatic portal vein embolization and unilateral portal vein ligation. World J Gastroenterol 18(19):2371–2376. doi:10.3748/wjg.v18.i19.2371 CrossRefPubMedPubMedCentral

57.

Robles R, Marin C, Lopez-Conesa A, Capel A, Perez-Flores D, Parrilla P (2012) Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases. Eur J Surg Oncol 38(7):586–593. doi:10.1016/j.ejso.2012.03.007 CrossRefPubMed

58.

Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Horbelt R, Kroemer A, Loss M, Rummele P, Scherer MN, Padberg W, Konigsrainer A, Lang H, Obed A, Schlitt HJ (2012) Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 255(3):405–414. doi:10.1097/SLA.0b013e31824856f5 CrossRefPubMed

59.

Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R, Soubrane O, Schnitzbauer AA, Raptis D, Tschuor C, Petrowsky H, De Santibanes E, Clavien PA, Group AR (2014) Early survival and safety of ALPPS: first report of the international ALPPS registry. Ann Surg 260(5):829–836; discussion 836-828. doi:10.1097/SLA.0000000000000947 CrossRefPubMed

60.

Guiu B, Chevallier P, Denys A, Delhom E, Pierredon-Foulongne MA, Rouanet P, Fabre JM, Quenet F, Herrero A, Panaro F, Baudin G, Ramos J (2016) Simultaneous trans-hepatic portal and hepatic vein embolization before major hepatectomy: the liver venous deprivation technique. Eur Radiol 26(12):4259–4267. doi:10.1007/s00330-016-4291-9 CrossRefPubMed

61.

Hwang S, Ha TY, Ko GY, Kwon DI, Song GW, Jung DH, Kim MH, Lee SK, Lee SG (2015) Preoperative sequential portal and hepatic vein embolization in patients with hepatobiliary malignancy. World J Surg 39(12):2990–2998. doi:10.1007/s00268-015-3194-2 CrossRefPubMed

62.

Brouquet A, Abdalla EK, Kopetz S, Garrett CR, Overman MJ, Eng C, Andreou A, Loyer EM, Madoff DC, Curley SA, Vauthey JN (2011) High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol 29(8):1083–1090. doi:10.1200/JCO.2010.32.6132 CrossRefPubMedPubMedCentral

63.

Abulkhir A, Limongelli P, Healey AJ, Damrah O, Tait P, Jackson J, Habib N, Jiao LR (2008) Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg 247(1):49–57. doi:10.1097/SLA.0b013e31815f6e5b CrossRefPubMed

64.

Yamashita S, Sakamoto Y, Yamamoto S, Takemura N, Omichi K, Shinkawa H, Mori K, Kaneko J, Akamatsu N, Arita J, Hasegawa K, Kokudo N (2017) Efficacy of preoperative portal vein embolization among patients with hepatocellular carcinoma, biliary tract cancer, and colorectal liver metastases: a comparative study based on single-center experience of 319 cases. Ann Surg Oncol. doi:10.1245/s10434-017-5800-z

Title: Portal vein embolization in extended liver resection
Authors: Nisha Narula
Thomas A. Aloia
Publication date: 01-08-2017
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 5/2017
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-017-1591-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Portal vein embolization in extended liver resection

Abstract

Background

Purpose

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Purpose

Conclusions

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