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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 1-9

Approach to management of submucous fibroids by gynaecological endoscopy surgeons/trainees in Nigeria


1 Medison Specialist Women's Hospital, Lagos; Fertility Assyst, Lagos, Nigeria
2 Gynescope Specialist Hospital, Port Harcourt, Nigeria; Madonna University, Port Harcourt, Nigeria
3 Nnamdi Azikiwe University, Awka, Nigeria
4 South Shore Women and Children's Hospital, Lagos, Nigeria
5 Lagos State University Teaching Hospital, Lagos, Nigeria

Date of Submission24-Dec-2021
Date of Acceptance17-Mar-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajiac.ajiac_5_21

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  Abstract 

Hysteroscopic myomectomy is the treatment of choice for submucous fibroid. Studies have shown positive impacts on recurrent pregnancy loss and infertility. Our survey documents approach to managing submucous fibroids by gynaecologists with special endoscopy skills among members of the Association of Gynaecological Endoscopy Surgeons of Nigeria (AGES). Materials and Methods: A questionnaire-based-cross-sectional survey of members of the Association of Gynaecological Endoscopy Surgeons of Nigeria between December 31, 2019, and January 21, 2020, using the SurveyMonkey platform. Results: One hundred and forty-one of 210 members participated; a response rate of 67.1%. Of the respondents, 130 (92.2%) were consultants, 10 (7.1%) were senior registrars. Hysteroscopy training varied from basic/advanced certificate courses to post-fellowship training in endoscopy. Sixty-nine (53.1%) had been in practice for >10 years. Monthly, 60.7% (82/135) performed <5 hysteroscopic procedures; 25.2% (34/135) 6–10; 9.6% (13/135) 11–20; 3.7% (5/135) performed 21–30 and 0.7% (1/135) >40. Up to 64.2% (86/134) use 2D transvaginal scans to diagnose submucous fibroid, 37.5% (51/136) combine ultrasound and hysterosonography or hysterosalpingography. About 65.1%, (82/126), 35.9% (47/131), 12.2% (16/131), respectively, use FIGO, the International Society for Gynaecologic Endoscopy/ European Society of Human Reproduction and Embryology (ISGE/ESHRE) or use none of these for classifying submucous fibroids. Glycine was preferred for monopolar resection by 52.5% (62/118), while 59.7% (71/119) use saline for bipolar resection. About 93.2% (109/117) will not consider sterile water for bipolar resection. About 70.5% (86/122) regularly monitor fluid deficit, 17.6% (22/125) do not (due to lack of a monitoring device). Also, 14.4% (18/125) do not (because they use <3 L of distention media). For uterine cavity distention, 52% (64/123) use fluid pressure pumps, 28.6% (34/129) use gravity, while 25.4% (31/122) use Hysteromat or other fluid management equipments. About 3.7% (4/109) conveniently resect type-2 submucous fibroids in >2 hysteroscopic procedures, while 20.2% (23/114) and 23.2% (26/112), respectively, in one or two hysteroscopic approaches. Notably, 50.4% (63/125) refer such patients to experienced gynaecologists. None use barrier gels-only anti-adhesion therapy; 78.5% (95/121) combine balloon catheter/intrauterine device with oestrogen/progesterone tablets. About 38% (40/105) offers no 2nd-look follow-up. About 45% (52/115) had experienced complications, including uterine perforation during operative hysteroscopy. Conclusion: Hysteroscopic myomectomy is increasingly being used by AGES-registered gynaecologists to manage submucous fibroids, a very common cause of morbidity and subfertility in women. AGES can significantly and positively impact the trends of gynecologic endoscopic training, skills and practices among Nigerian doctors.

Keywords: Gynaecology, hysteroscopic myomectomy, hysteroscopy, minimal invasive surgery, myomectomy, submucous fibroids, uterine fibroids


How to cite this article:
Akinola LA, Okohue J, Ikechebelu J, Alabi CO, Olumodeji AM. Approach to management of submucous fibroids by gynaecological endoscopy surgeons/trainees in Nigeria. Afr J Infertil Assist Concept 2021;6:1-9

How to cite this URL:
Akinola LA, Okohue J, Ikechebelu J, Alabi CO, Olumodeji AM. Approach to management of submucous fibroids by gynaecological endoscopy surgeons/trainees in Nigeria. Afr J Infertil Assist Concept [serial online] 2021 [cited 2022 Sep 30];6:1-9. Available from: https://www.afrijiac.org/text.asp?2021/6/1/1/350734




  Introduction Top


Uterine fibroids or leiomyomas are benign tumours that arise from the smooth muscle cells of the uterus.[1] They are estimated to occur in 20–40% of women in the reproductive age group.[2]

Fibroids can be categorized, based on location, into subserous, intramural, and submucous components.[3] The European Society of Gynaecological Endoscopy (ESGE) classified submucous fibroids into three categories: Type 0, 1, and 2. The Type 0 fibroids are entirely within the endometrial cavity; type 1 fibroids extend less than 50% into the myometrium, while the Type 2 fibroids extend 50% or more into the myometrium.[3] A recent FIGO classification of uterine fibroids incorporates the ESGE classification in addition to Types 3 to 8 fibroids (intramural and subserous fibroids), and fibroids in other locations.[4]

Submucous fibroids account for 5.5–16.6% of fibroids and can be associated with abnormal menstrual bleeding, especially menorrhagia and intermenstrual bleeding, infertility, and recurrent miscarriages.[5],[6] Diagnosis of submucous fibroid can be via a transabdominal (TAS) and transvaginal ultrasound scan (TVS), hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, and magnetic resonance imaging (MRI).[6]

Historically, myomectomy or hysterectomy was performed to treat fibroids, including submucous fibroids. Hysteroscopic myomectomy is now the treatment of choice and constitutes the standard minimal access procedure for most cases of submucous fibroids. Neuwirth and Amin performed the first reported case of hysteroscopic myomectomy in 1976.[7]

Hysteroscopic myomectomy is a minimally invasive procedure associated with high patient satisfaction.[8] Hysteroscopic myomectomy can be performed with a resectoscope, using bipolar or monopolar diathermy. While bipolar diathermy uses electrolyte-containing fluid, like normal saline, electrolyte-free fluid such as 1.5% glycine is used for monopolar diathermy. Other available options include hysteroscopic morcellators, which use rotatory blades to cut the fibroid into automatically removed chips, leaving a clear field. The morcellator is associated with a decreased learning curve and shortened operating time.[9] Mazzon et al.[10] described the cold loop technique for hysteroscopic myomectomy. Cold loop hysteroscopic myomectomy, which does not involve applying energy to the myometrium, was found to be a safe technique, allowing the removal of submucous fibroids while respecting the surrounding healthy myometrium.[9] The fibroid chips are then removed from the uterus with the aid of an Ellick’s evacuator or manual vacuum aspirator

Another option for hysteroscopic myomectomy is the use of the Versapoint. This uses bipolar energy to vaporise the fibroid, leaving a clear field. While it is technically easier than using the resectoscope, it leaves no tissue for histology.[9] The use of the neodymium-yttrium-aluminium-garnet (NdYAG) laser technique for hysteroscopic myomectomy is gaining popularity, and unfortunately, just like the Versapoint, it does not leave tissue for histology.[11] Occasionally, small type 0 submucous fibroids can be removed with hysteroscopic scissors, either as an office-based or a theatre procedure.[9]

Generally, single fibroids 3 cm or less are the easiest to resect hysteroscopically.[12] While the resectoscope is commonly used for the type 0,1 or 2 fibroids, data are limited regarding the use of the morcellators for type 2 submucous fibroid.[8]

The choice of hysteroscopic myomectomy technique depends on the size and number of the fibroid and the availability of the equipment and experience of the surgeon.[9],[11] Unfortunately, the cost of procuring equipment necessary for an effective hysteroscopic unit is exorbitant and not within reach of the average gynaecologist in most resource-poor countries.[12],[13] Training and re-training are prerequisites for the improvement of skills and expertise in hysteroscopic procedures, but these are not readily available in developing countries[13] We, therefore, set out to analyse the approach of gynaecological endoscopy surgeons and trainees in Nigeria, a low-resource country, to the management of submucous fibroid [Appendix 1][Additional file 1].


  Materials and Methods Top


This was a questionnaire-based, cross-sectional survey of registered gynaecological surgeons of the Association of Gynaecological Endoscopy Surgeons (AGES) of Nigeria, carried out between December 31, 2019, and January 21, 2020, using the SurveyMonkey platform. The weblink was posted on the group’s WhatsApp page for easy access (https://www.surveymonkey.com/r/BCG3H3C) [Appendix 2][Additional file 2]. The members are consultants and senior residents in obstetrics and gynaecology. One hundred and forty-one of 210 members listed on the AGES WhatsApp platform completed the survey, giving a response rate of 67.14%, despite a series of reminders sent to participants to encourage participation. Data were analysed using SPSS 22.0 statistical software. Percentages and proportions were determined for categorical variables.


  Results Top


One hundred and forty-one of 210 members listed on the AGES WhatsApp platform took part in the survey, giving a response rate of 67.1%. Of the respondents, 130 (92.2%) were consultants, 10 (7.1%) were senior registrars. Hysteroscopy training varied from basic/advanced certificate courses to post-fellowship training in endoscopy. The levels of hysteroscopy training indicated by the participants varied from basic or advanced certificate courses to post-fellowship or Euro Bachelors training in endoscopy. Sixty-nine (53,1%) consultants had been in practice for greater than 10years [Table 1]. Regarding the self-declared level of proficiency questionnaire in gynaecologic endoscopy, 70.2% (99/131) respondents indicated they could perform diagnostic procedures or minor/intermediate procedures, and 14.9% (21/131) can perform advanced hysteroscopy procedures. Out of 130 respondents, about 40.7%, 31.5% and 10.7%, respectively, had basic introductory, advanced, or post-fellowship training in minimal access surgery [Table 1]. Eighty-two out of 135 respondents (60.7%) performed less than five hysteroscopic procedures monthly, 34 (25.2%) did 6 – 10 times monthly, 13 (9.6%), 11 – 20 times monthly, 5 (3.8%) 21 – 30 times monthly and 1 (0.7%) greater than 40 times monthly.
Table 1: Demographic characteristics of the participants

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Eighty-six out of 135 respondents (64.2%) use the 2-D transvaginal scan to diagnose submucous fibroid. About 51 out of 136 respondents (37.5%) use a combination of ultrasound with hysterosonography or hysterosalpingography for evaluation and diagnosis of submucous fibroids [Figure 1].
Figure 1: Choice of evaluation and diagnosis of submucous fibroid

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Regarding the choice of classification of submucous fibroids, 65.1%, (82 / 126), 35.9% (47/131), 12.2% (16/131) respondents, respectively, preferred using the FIGO classification, the International Society for Gynaecologic Endoscopy/ European Society of Human Reproduction and Embryology (ISGE/ESHRE) or use none of these classifications [Figure 2].
Figure 2: Choice of classification of submucous fibroids

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To manage asymptomatic submucous fibroids, 75.9% of respondents (104 /137) claimed they would only follow up and monitor the patient without prompt recourse to surgery [Table 2]. About 59.5% (78/131) will not consider using GnRHa pre-hysteroscopic treatment of submucous fibroid, while others will consider GnRHa pretreatment for about 1–3 months. The reasons behind the latter were not explicitly the focus of the questionnaire. Only 25.4% (31) use automatic fluid management equipment or Hysteromat to distend the uterine cavity during hysteroscopy [Table 2].
Table 2: Management of submucous uterine fibroids

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About 52.5% (62/118) prefer to use glycine for monopolar resection, and 59.7% (71/119) will use saline for bipolar resection. Up to 93.2% (109/117) of the respondents does not consider sterile water for bipolar resection [Table 2]. During operative hysteroscopy, it is advisable to monitor the fluid deficit closely to avoid complications from fluid overload; our survey showed that 70.5% (86/122) respondents regularly monitor fluid deficit while 17.6% (22/125) do not monitor fluid deficit because due to lack of a monitoring device. Interestingly, about 14.4% (18/125) of respondents do not monitor fluid deficit because they use less than 3 litres of distention media. About 52% (64 / 123) of participants said they use a fluid pressure pump, 28.6% (34/129) respondents make use of gravity for uterine cavity distention. In comparison, only 25.4% (31/122) use Hysteromat or other automatic fluid management equipment to distend the uterine cavity during hysteroscopy [Table 2].

Respondents gave their preferences in treating multiple submucous fibroids, as observed in [Figure 3]. Almost all respondents, 99.2% (131/132) and 98.5% (130/132), use neither laser nor Dormie basket to remove multiple submucous fibroids. Just 3% of the respondents (4 /133) would use laparoscopic myomectomy as a treatment choice for multiple submucous fibroids. Open myomectomy is the treatment of choice in about 45.9% of respondents (61/133) for multiple submucous fibroids. About 3.7% (4/109) respondents will conveniently resect type 2 submucous fibroids in more than two hysteroscopic procedures, while 20.2% (23/114) and 23.2% (26/112) of respondents, respectively, will resect in one or two hysteroscopic procedures (s). Notably, 50.4% (63/125) do not do any hysteroscopic myomectomy procedures will instead refer such patients to a more experienced gynaecologist [Figure 4].
Figure 3: Choice of treatment of multiple submucous fibroids

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Figure 4: Choice of treatment of type 2 submucous fibroid

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Concerning choices of hysteroscopic cervical priming; the majority of the respondents, 99.2% (126/127) participants would not use laminaria, while about 24.6% (31/126) participants often dilate the cervix without the use of misoprostol, and 57.5% (73/127) of the respondents routinely use misoprostol as a choice of preoperative cervical priming. For preoperative cervical priming to ease dilatation, about 57.5% (73/127) routinely administered misoprostol [Figure 5]. The majority of the respondents, 47.5 (56/118), will administer misoprostol cervical priming overnight before surgery, while the others administer at various times ranging from 1 to 12 hours presurgery [Figure 6].
Figure 5: Choice of preoperative cervical priming

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Figure 6: Duration of misoprostol before surgery

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The use of antibiotics during or after hysteroscopy is not uncommon, and in our survey, 50.8% (63/124) administer both intraoperative and postoperative antibiotics. In comparison, 3.2% (4/124) do not administer antibiotics at all during operative hysteroscopy [Figure 7]. In [Figure 8], about 16.5% (20/121) participants would permit complete intubation anaesthesia for operative hysteroscopy. In comparison, 46.3% (56/121 respondents) would give anaesthesia based on the patient’s preference, and 55.3% (68/123) respondents select the subarachnoid block as their choice of anaesthesia for operative hysteroscopy. It is significant to note that no respondent supported using barrier gels only for post-hysteroscopy anti-adhesion therapy [Figure 9]. In contrast, about 78.5% (95/121) respondents use a combination of a balloon catheter or intrauterine contraceptive device (IUCD) with oestrogen/progesterone tablets. About 38% (40/105) offers no 2nd-look follow-up [Figure 10]. The relevance of follow-up hysteroscopy after an initial submucous fibroid resection includes completing the resection or managing any developing endometrial adhesions. About 34% of our respondents do not offer second-look hysteroscopy, while the majority offer such procedures after one month (15%), twomonths (16%) and three months (35%) [Figure 11]. About 45% (52/115) had experienced complications, including uterine perforation during operative hysteroscopy. [Figure 12].
Figure 7: Use of antibiotics for operative hysteroscopy

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Figure 8: Anaesthesia for operative hysteroscopy

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Figure 9: Post-hysteroscopy anti-adhesion therapy

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Figure 10: Approach to follow up after hysteroscopic myomectomy

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Figure 11: Timing of second look follow up after hysteroscopic myomectomy

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Figure 12: Complications encountered in operative hysteroscopy

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  Discussion Top


The practice of gynaecologic endoscopy in Nigeria, a low- to middle-income country, is increasing.[14] The Association of Gynaecological Endoscopy Surgeons (AGES) was founded to improve standards, promote training and encourage the exchange of information in minimal access surgery techniques for women with gynaecological problems. AGES is rapidly gaining relevance in the training and practice of gynaecological endoscopic procedures among its members and other Nigerian doctors. Respondents in our survey were members of AGES.

More than 90% of the participants in our survey were consultant gynaecologists, and about 3/4th of the respondent’s self-declared competency in at least minor/intermediate gynaecologic endoscopic procedures [Table 1]. However, the gap in endoscopic surgical training and practice remains enormous compared to surveys from developed countries. Liu et al., in their survey, found that more than 50% of myomectomies performed by Canadian gynaecologists were via endoscopy.[15] Taylor et al. found among United Kingdom gynaecologists that about 56% performed myomectomy via hysteroscopy.[16] These figures are much higher than our findings of 14.9% Nigerian gynaecologists with self-declared competency in advanced endoscopic procedures such as hysteroscopic myomectomy.

The original surgical training model of William Halsted (1904), “see, do, teach”, which has produced generations of good surgeons, has little or no place in modern laparoscopic surgical practice.[17] Experience in basic laparoscopy is not currently considered a mandatory requirement for eligibility at the postgraduate surgical examination in Nigeria, and well-structured competency-based training modules by postgraduate medical colleges or relevant medical associations are lacking.[17] Despite these, we found that less than 20% of gynaecologists in AGES have no certified training in endoscopy, more than 80% have at least a basic certified training in gynaecologic endoscopy, and about 30% have certified advanced training [Table 1]. This is at variance with Balogun et al. in Lagos, Nigeria, who found that only 11.2% of the respondents in a related cross-sectional survey had any knowledge of a local endoscopy training program.[17] This huge disparity is most likely because most of the respondents in the study by Balogun et al. were resident doctors in gynaecology; in contrast, more than 90% of our study participants were gynaecologists who were already members of an association related to minimal access surgery.

We found that 1.5% of respondents will perform laparoscopic myomectomy [Figure 3] for submucous fibroids; this is much lower than 16% of United Kingdom consultants, reported by Taylor et al., to perform laparoscopic myomectomy for uterine fibroids.[16] This reflects the considerable gap in endoscopic practices between developing and developed countries; however, restriction of our survey to the management of the submucous variant of uterine fibroids, unlike in the study by Tailor et al. in which the fibroids were not categorised, may explain the much lower findings in our research, as hysteroscopy is generally preferred to laparoscopy for the removal of submucous fibroids.[16] A significant number (45.9%) of our respondents prefer to perform open myomectomy for submucous fibroids [Figure 3]. A similar survey of gynaecologists in the United Kingdom by Sirkeci et al. found that open myomectomy was similarly the procedure performed by the vast majority (74%) of consultants.[18]

The joint Royal College of Obstetricians and Gynaecologists (RCOG) and British Society for Gynaecological Endoscopy (BSGE), and the American Association of Gynaecologic Laparoscopists (AAGL) have remained at the forefront of providing recommendations in the practice and training of hysteroscopy internationally.[19] The British Society for Gynaecological Endoscopy, in collaboration with the Royal College of Obstetricians and Gynaecologists, has a special skill training module for advanced hysteroscopic surgery.[19] More than 60% of our survey participants performed less than five hysteroscopic procedures monthly. This low-performance rate may be related to the unavailability of widespread, well-structured, local competency-based training in Nigeria. About 37% of participants in our study had certified foreign training in endoscopy. This is higher than the reported 11.1% of respondents in a Nigerian survey who were only aware of, let alone participate in, any local training program in endoscopy.[17] They also reported that 90.7% of respondents had not attended any training program in laparoscopy.[17] The disparity in the cadre of doctors in both surveys may partly explain this significant difference. However, our respondents were members of AGES, which indicates their flair for minimal access surgery.

About 60% of gynaecologists in this study claim to have used gonadotrophin-releasing hormone agonists (GnRHa), at least once, treatment before hysteroscopic myomectomy. In a survey of UK gynaecologists, 44.0% use GnRHa before hysteroscopic myomectomy.[18] In their survey, Taylor et al. reported that 87.0% of UK gynaecologists prescribed preoperative GnRHa.[16] The higher percentage reported by Taylor is probably due to the inclusion of all forms of myomectomy (open abdominal myomectomy, laparoscopic myomectomy, and hysteroscopic myomectomy). The possible benefits of GnRHa use before myomectomy include correction of anaemia before surgery and reduction in the fibroid size. However, GnRHa use may obliterate tissue planes, thus might render surgery more challenging especially at laparoscopic and open myomectomy.[18]

Hysteroscopy remains a relatively safe procedure.[20] Diagnostic hysteroscopy has the fewest risks, followed by operative hysteroscopic adhesiolysis, metroplasty, and myomectomy.[20] The preoperative use of misoprostol or laminaria decreases the risk of uterine perforation.[20],[21] We found that less than 31 (25%) of 126 survey respondents dilated the cervix without cervical priming with misoprostol [Figure 5]. Necessary precautions should be taken pre-and intra-operatively to avoid complications: preoperative thinning of the endometrium, continuous control of fluid balance, minimal intrauterine pressure, reduction of operating times, and concurrent use of ultrasound when cutting into the myometrium.[9],[20] More than 50% (68) use subarachnoid anaesthesia for hysteroscopic myomectomy. Administration of antibiotics intra- and post-operatively to prevent infection for operative hysteroscopy is practised routinely by more than half of the respondents [Figure 8]. Intrauterine balloon catheter and intrauterine device (IUD) with estrogen/progesterone tablets are the commonly used following hysteroscopic myomectomy for adhesion prevention by the respondents in our survey [Figure 9]. Expert preoperative evaluation is essential in determining the surgical skill and expertise, needed surgical time, and the likelihood of completing the operative procedure.[21] Overall, complications in operative hysteroscopy are infrequent and are usually easy to manage.[21] About 45% (52/115) had experienced complications, including uterine perforation during operative hysteroscopy, and 29.6% (34/115) had experienced severe uterine bleeding. Various studies showed complication rates ranging between 0.3 to 28%, with fluid overload and uterine perforation being the most frequent complications occurring during hysteroscopic surgery.[22],[23],[24]

Despite challenges mitigating the advances of endoscopy in Nigeria, the practice of hysteroscopy by gynaecologists is gradually growing. There is a need for formal training and re-training of Nigerian gynaecologists in the use of endoscopy. AGES can be steered to significantly and positively impact the trends of gynaecologic endoscopic training and practices among Nigerian doctors.

Study limitations and strength: The overall response rate by the participants was 67.14%, which might have impacted the validity of the study. Furthermore, the questionnaires deployed were not pre-tested or pre-validated; this may have reduced validity too. However, this was the first survey of endoscopic practice by gynaecologists in Nigeria. Participants were required to remember previous events or experiences accurately, and thus, there is a risk of recall bias. Also, respondents were required to self-assess themselves rather than use an objective assessment of competency, which could not be achieved with the study design.

Financial support and sponsorship

Nil.

Conflicts of interest

Some authors of this work are members of AGES and took part in this survey.



 
  References Top

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[PUBMED]  [Full text]  
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