Laparoscopic surgical treatment for sliding hiatal hernia is associated with an owner-perceived improvement in clinical outcome in dogs

Ameet Singh Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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William Hawker Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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Krista Mitchell Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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Ryan Appleby Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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Alexa Bersenas Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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Allison Collier Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

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Abstract

OBJECTIVE

To report perioperative complications and client-perceived outcome following laparoscopic surgical treatment for sliding hiatal hernia (SHH) in dogs.

ANIMALS

Client-owned dogs (n = 9).

METHODS

Medical records were reviewed and perioperative data collected including preoperative diagnostic imaging, operative details, complications, and need for conversion to open celiotomy. A single-incision, multicannulated port was inserted in the subumbilical region followed by placement of an additional 2 or 3 instrument portals. Hiatal plication, esophagopexy, and left-sided gastropexy were performed laparoscopically. Follow-up information was collected with telephone interview with the owners and/or referring veterinarian. A standardized questionnaire was completed by dog owners postoperatively.

RESULTS

Intraoperative pneumothorax occurred in 5 of 9 (55.6%) dogs and resulted in conversion to open celiotomy in 2 (22.2%) dogs. In 4 dogs, pneumothorax was suspected to be the result of progressive leakage of capnoperitoneum through the suture bite holes of the esophageal hiatal plication sutures. Hiatal plication was performed using intracorporeal simple interrupted sutures (n = 4) or a simple continuous pattern with barbed suture (4). Esophagopexy was performed using barbed suture in all dogs. Gastropexy was performed using a total laparoscopic technique (n = 4) or laparoscopic-assisted technique (3). Using a standardized questionnaire, dog owners perceived a postoperative improvement in regurgitation after eating and regurgitation after excitement/increased activity.

CLINICAL RELEVANCE

Laparoscopic treatment of SHH resulted in owner-perceived improvement in clinical signs. Intraoperative pneumothorax occurred in a high proportion of dogs but did not result in long-term sequelae.

Abstract

OBJECTIVE

To report perioperative complications and client-perceived outcome following laparoscopic surgical treatment for sliding hiatal hernia (SHH) in dogs.

ANIMALS

Client-owned dogs (n = 9).

METHODS

Medical records were reviewed and perioperative data collected including preoperative diagnostic imaging, operative details, complications, and need for conversion to open celiotomy. A single-incision, multicannulated port was inserted in the subumbilical region followed by placement of an additional 2 or 3 instrument portals. Hiatal plication, esophagopexy, and left-sided gastropexy were performed laparoscopically. Follow-up information was collected with telephone interview with the owners and/or referring veterinarian. A standardized questionnaire was completed by dog owners postoperatively.

RESULTS

Intraoperative pneumothorax occurred in 5 of 9 (55.6%) dogs and resulted in conversion to open celiotomy in 2 (22.2%) dogs. In 4 dogs, pneumothorax was suspected to be the result of progressive leakage of capnoperitoneum through the suture bite holes of the esophageal hiatal plication sutures. Hiatal plication was performed using intracorporeal simple interrupted sutures (n = 4) or a simple continuous pattern with barbed suture (4). Esophagopexy was performed using barbed suture in all dogs. Gastropexy was performed using a total laparoscopic technique (n = 4) or laparoscopic-assisted technique (3). Using a standardized questionnaire, dog owners perceived a postoperative improvement in regurgitation after eating and regurgitation after excitement/increased activity.

CLINICAL RELEVANCE

Laparoscopic treatment of SHH resulted in owner-perceived improvement in clinical signs. Intraoperative pneumothorax occurred in a high proportion of dogs but did not result in long-term sequelae.

Introduction

Sliding hiatal hernia (SHH) occurs when the lower esophageal sphincter moves cranially through the esophageal hiatus and into the thoracic cavity, resulting in gastroesophageal reflux.15 While gastroesophageal reflux disease is likely the result of a complex, multifactorial disease process, an association between upper airway obstruction and SHH has been suggested in brachycephalic dogs.3,4,6 Increased upper airway resistance and negative intrathoracic pressure is suspected to create a physiologic pressure gradient that predisposes to cranial translation of the lower esophageal sphincter into the thoracic cavity through the esophageal hiatus.3,4,6 Surgical treatment of SHH in dogs was first reported by Prymak et al,1 who described a combination of open surgical techniques consisting of hiatal plication, esophagopexy, and left-sided gastropexy in an attempt to prevent cranial translation of the lower esophageal sphincter into the thoracic cavity and prevent gastrointestinal reflux.

Minimally invasive surgery is the standard of care in people for the treatment of refractory gastroesophageal reflux disease and hiatal hernia with a variety of described surgical techniques.79 In dogs, 2 studies have reported laparoscopic surgical techniques and resultant clinical outcomes following laparoscopic treatment of SHH with intracorporeal suturing for hiatal plication, esophagopexy, and left-sided gastropexy.10,11 The objective of this study was to report on perioperative complications and owner-perceived outcome using a standardized questionnaire following laparoscopic surgical treatment for SHH in dogs. We hypothesized that owner-perceived clinical outcome related to SHH would improve postoperatively.

Methods

Case selection and medical record review

Medical records were searched of dogs undergoing laparoscopic treatment of SHH at the Ontario Veterinary College Health Sciences Centre between January 2019 and January 2023. Data collected included signalment, presenting clinical signs, physical examination findings, preoperative diagnostic imaging results, and preoperative medical management details. Operative data collected from medical records were reviewed, and collected data included surgical and anesthesia time, type and number of laparoscopic ports, intraoperative surgical complications, and need for conversion to open laparotomy.

Surgical technique

Owner consent for surgery was obtained for all dogs. The dogs were initially placed in dorsal recumbency, and laparoscopic treatment for SHH was performed as previously described with hiatal plication, left-sided esophagopexy, and left-sided gastropexy.10,11 Briefly, a single-incision, multichanneled port (SILS port; Medtronic Inc) was inserted in a subumbilical area12 and a carbon dioxide pneumoperitoneum was established to 8 mm Hg. An instrument portal was introduced 3 to 5 cm cranial to the single-incision port on ventral midline.10 A second instrument portal was inserted in the right paramedian region.10 If a laparoscopic-assisted gastropexy was to be performed, this instrument portal was placed at the location of the gastropexy, 3 to 5 cm lateral to midline and 2 to 3 cm caudal to the costal arch. If a total laparoscopic gastropexy was performed, the second instrument portal was placed 3 to 5 cm lateral of midline at the same level of the single-incision port. Following port placement, the dogs were rotated into oblique right lateral recumbency to allow for visualization of the esophageal hiatus. Using a blunt probe, the left lateral hepatic lobes were manipulated axially to visualize the esophageal hiatus, and the left hepatic triangular ligament was incised using a J-hook monopolar electrosurgery probe (Medtronic Inc). An orogastric tube was inserted to reduce the hiatal hernia and provide caudal displacement of the stomach to allow for clear visualization of the left and right crus of the diaphragm during hiatal plication and esophagopexy. Hiatal plication was performed using intracorporeal suturing with either simple interrupted sutures10 of 2-0 polypropylene (PROLENE; Medtronic Inc) or a simple continuous suture pattern11 with a 2-0 unidirectional, barbed suture (VLOC 90, 6 inch; Medtronic Inc) to appose the right and left diaphragmatic crural muscles to reduce hiatal diameter. Plication was assessed subjectively and deemed adequate when the gastric cardia could not be manipulated through the hiatus. Esophagopexy was performed using intracorporeal suturing in a simple continuous pattern with a 2-0 unidirectional, barbed suture (VLOC 90, 6 inch; Medtronic Inc). The esophagopexy began as a final hiatal plication suture between the left and right diaphragmatic crural muscles and then continued with bites through the left crus and distal esophagus and gastric cardia. The same strand of barbed suture was used for esophagopexy if barbed suture was used for hiatal plication. Left-sided gastropexy was performed using either a total laparoscopic13 or laparoscopic-assisted14 approach, based on surgeon discretion, as previously described.

Postoperative care

All dogs were recovered from anesthesia and carefully monitored in the ICU and received supportive care in hospital postoperatively until time of discharge. Postoperative treatments including methods of analgesia were provided according to the discretion of the attending clinician.

Adverse event and complication classification

Surgical complications and adverse events were described and classified using the Veterinary Cooperative Oncology Group–Common Terminology Criteria for Adverse Events scheme.15 If conversion to open celiotomy occurred, the reason for conversion was recorded and it was graded (1 to 4) on the basis of a previously published classification scheme.16 Summarily, grade 1 = strategic conversion to hand-assisted or open approach due to anticipated operative difficulty, grade 2 = reactive extension of an incision or conversion because of operative difficulty or non–life-threatening operative error, grade 3 = reactive conversion to open approach because of operative difficulty or non–life-threatening operative error, and grade 4 = reactive conversion to open approach due to life-threatening operative error.

Follow-up

Follow-up information was obtained from dog owners via telephone interview or email. A standardized questionnaire that was previously reported to evaluate clinical outcome following surgical treatment for hiatal hernia was administered.10 Owners were given questions pertaining to their dog and asked for a graded response from 0 to 4, with 0 being clinically normal and 4 being severe.10

Statistical analysis

Median and range were reported for summary statistics. Pre- and postoperative data from the owner questionnaire were compared statistically. Questionnaire scores were treated as continuous variables. Normality was tested using the Shapiro-Wilk test and appearance of histograms when necessary. Significance between pre- and postoperative values was determined using the Wilcoxon signed-rank or paired t test, dependent on normality. In instances when distributions were mixed between groups, the distribution of the differences was analyzed. If the distribution of the differences was normally distributed, a paired t test was performed to compare groups. P values of < .05 were considered statistically significant. Statistical analysis were performed using standard software (RStudio version 2023.3.1.446; The R Project for Statistical Computing).

Results

Study population

Nine dogs (5 French Bulldogs and 1 each of English Bulldog, Mudi, Boston Terrier, and mixed breed) were included in the study. Median age of dogs was 13 months (IQR, 10 to 21 months). Median weight of dogs was 13.2 kg (10 to 13.7 kg). Six dogs were intact males, 2 were spayed females, and 1 was an intact female.

Preoperative evaluation and concurrent procedures

All dogs presented for further evaluation and treatment of gastroesophageal reflux. Six dogs were treated medically with various combinations and durations of metoclopramide, maropitant, cisapride, omeprazole, famotidine, and ranitidine. All dogs were diagnosed with an SHH following an esophageal videofluoroscopic swallowing study reviewed by a diplomate of the American College of Veterinary Radiology.

Prior or concurrent surgery for brachycephalic obstructive airway syndrome

Three of the 7 brachycephalic dogs included in the study had prior surgery for brachycephalic obstructive airway syndrome (BOAS; alar fold vestibuloplasty, 1; bilateral alar fold vestibuloplasty + folded-flap palatoplasty + bilateral tonsillectomy + bilateral laryngeal sacculectomy, 2). Four of the 7 brachycephalics had concurrent BOAS surgery (bilateral alar fold vestibuloplasty + folded-flap palatoplasty + bilateral tonsillectomy + bilateral laryngeal sacculectomy) and laparoscopic treatment of SHH. One brachycephalic dog had revision of the folded-flap palatoplasty at the time of laparoscopic treatment of SHH due to suspected chronic dehiscence.

Intraoperative complications and adverse events

Grade 3 conversions to open celiotomy occurred in 2 of 9 (22.2%) dogs in which conversion was performed as a result of pneumothorax.16 In 1 dog, pneumothorax occurred following iatrogenic trauma to the tendon of the diaphragm from the needle of the suture used for hiatal plication. Conversion to open celiotomy was performed and diaphragmatic repair, hiatal plication, esophagopexy, and left-sided gastropexy were performed without complication using open surgical techniques. In a second dog, progressive pneumothorax was suspected to have occurred from leakage of carbon dioxide through the suture holes of the hiatal plication, which was performed with barbed suture in this dog. Conversion to open celiotomy was performed, and esophagopexy and left-sided gastropexy were performed without complication using open surgical techniques.

Intraoperative pneumothorax occurred in 3 additional dogs and were classified as grade 2 complications.16 In 2 dogs, pneumothorax was managed by the placement of a thoracic drainage catheter (MILA International Inc) to allow for continuous evacuation of the thoracic cavity. Following completion of all surgical procedures and withdrawal of capnoperitoneum, air accumulation within the thoracic cavity ceased. In 1 dog, pneumothorax was detected postoperatively during recovery in the ICU and thoracocentesis was performed to alleviate respiratory compromise. Intraoperative leakage of capnoperitoneum into the thoracic cavity around the suture holes of the hiatal plication was once again suspected. Following thoracocentesis, no further episodes of pneumothorax occurred and this dog recovered uneventfully.

Surgical procedure

Hiatal plication was performed using intracorporeal, simple interrupted sutures of 2-0 polypropylene in 4 dogs and 2-0 barbed suture in 4 dogs (including 1 dog that was converted to open celiotomy after hiatal plication). In 1 dog that was converted to open celiotomy, hiatal plication was performed with 2-0 Prolene. Esophagopexy was performed in all dogs using barbed suture. In dogs for which barbed suture was used for hiatal plication, the same strand of barbed suture was used for esophagopexy. When intracorporeal, simple interrupted sutures were used for hiatal plication, the barbed suture was used to create a final suture in the hiatal plication and then continued for esophagopexy. Left-sided gastropexy was performed using a total laparoscopic technique in 3 dogs and a laparoscopic-assisted technique in 4 dogs. Surgical times were separated for surgical treatment of BOAS and laparoscopic treatment of hiatal hernia. Median total surgical time for the BOAS surgical treatments was 60 minutes (IQR, 45 to 75 minutes) and for the laparoscopic treatment of hiatal hernia was 105 minutes (IQR, 90 to 120 minutes). Median total anesthesia time, including all procedures, was 255 minutes (IQR, 180 to 345 minutes).

Follow-up and outcome

All 9 dogs were alive at time of follow-up (median, 413 days [IQR, 282 to 490 days] postoperatively), at which time the standardized questionnaire was administered to owners.

When pre- and postoperative results were compared, there were 2 categories/questions for which statistically significant improvement was found postoperatively: regurgitation following eating (P < .0009) and regurgitation during excitement/increased activity (P = .001). There were no questions for which clinical decline was reported by any owner (Table 1).

Table 1

Pre- and postoperative results of an owner questionnaire10 evaluating 9 dogs undergoing laparoscopic surgery for the treatment of sliding hiatal hernia. Owners were given questions pertaining to their dog and asked for a graded response from 0 to 4, with 0 being clinically normal and 4 being severe. A P value < .005 was considered significant.

Question Median grade (IQR) P value
Preoperative Postoperative
Does your dog have a problem swallowing water? 0 (0–2) 0 (0–0) .09
Does your dog have a problem swallowing food? 1 (0–3) 0 (0–0) .057
Has the swallowing problem caused your dog to lose weight? 1 (0–2) 0 (0–0) .057
Does the swallowing problem occur with canned food? 0 (0–2) 0 (0–0) .18
Does the swallowing problem occur with dry kibble? 2.5 (0.5–3) 0 (0–0) .095
Does your dog appear painful when eating? 0 (0–0) 0 (0–0) > .99
Has your dog’s bark changed in pitch or sound? 0 (0–0) 0 (0–0) .586
Does your dog regurgitate after eating? 3 (3–4) 0 (0–1) .008
Does your dog regurgitate during increased activity/excitement? 3 (3–4) 1 (0–2) .012
Does your dog smack its lips? 1 (0–2) 0 (0–1) .134

Discussion

Sliding hiatal hernia was successfully treated in the predominantly brachycephalic cohort of dogs in this study using laparoscopic techniques. Furthermore, in accordance with our hypothesis, an owner-perceived postoperative improvement/reduction in regurgitation following eating and regurgitation during excitement/increased activity was found. Intraoperative pneumothorax was encountered in 5 (55.6%) dogs and resulted in conversion to open celiotomy in 2 (22.2%) dogs. Surgeons performing laparoscopic treatment of SHH should be aware of this potential intraoperative complication.

Intraoperative pneumothorax was the only high-grade complication encountered in the dogs of this study. Intraoperative pneumothorax during laparoscopic treatment of SHH has been described in the 2 previous reports describing this technique in dogs.10,11

In 1 dog of this report, pneumothorax occurred as a result of iatrogenic trauma to the diaphragm from the needle of the suture used to perform hiatal plication. This resulted in conversion to open celiotomy for diaphragmatic repair and completion of hiatal plication, esophagopexy, and left-sided gastropexy. Caution must be exercised when manipulating the needle during intracorporeal suturing, and blind movement of the needle should be avoided. Endoscopic guidance should be used to perform any needle manipulation during intracorporeal suturing to avoid any iatrogenic trauma to the diaphragm or surrounding abdominal organs. An additional consideration to reduce the risk of iatrogenic trauma by the needle to surrounding structures would be to cut the swaged end of the needle and remove it from the abdomen once suture bites have been taken, prior to tying the knot.

In the remaining 4 dogs, pneumothorax was suspected to be a result of leakage of insufflated carbon dioxide into the thoracic cavity through suture bites during hiatal plication of the crural muscles of the diaphragm. Bellowing of the diaphragm, indicative of pneumothorax, was not evident in any dog during laparoscopy despite concerns of pneumothorax expressed by the anesthesia team as hiatal plication progressed. A standard intra-abdominal pressure of 8 mm Hg was used during the initial laparoscopic approach, and the pressure was dropped to 6 mm Hg following port placement. In some dogs of this report, once intraoperative pneumothorax was detected by the anesthesia team, attempts were made to drop intra-abdominal pressure further to reduce the progression/severity of pneumothorax; however, this compromised visualization of the hiatus and could not be maintained. Lift or gasless laparoscopy, alone or in combination with low-level capnoperitoneum, may mitigate the risk of intraoperative pneumothorax and should be evaluated clinically in future cases.17,18

For 2 dogs in which intraoperative pneumothorax occurred, a thoracic drainage catheter was placed intraoperatively and the pneumothorax evacuated to allow for completion of surgical techniques laparoscopically. Once the capnoperitoneum for laparoscopy was removed, pneumothorax resolved, providing more evidence to the theory of pneumoperitoneum leakage through the crural muscle suture bites during hiatal plication. In 1 dog with intraoperative pneumothorax, conversion to open celiotomy was elected after hiatal plication was performed due to progressive pneumothorax and concerns for cardiovascular demise by the anesthesia team. In 1 dog, pneumothorax was diagnosed during postoperative recovery. Thoracocentesis was promptly performed, and pneumothorax was resolved without recurrence. Postoperative thoracic radiographs prior to anesthetic recovery in dogs undergoing laparoscopic treatment of SHH, as has been previously suggested,10 may have prevented this complication from occurring.

Hiatal plication was performed with intracorporeal simple interrupted, nonabsorbable sutures in 4 dogs and with a simple continuous pattern with barbed suture in 4 dogs. The change to barbed suture was made in an attempt to reduce surgical time related to intracorporeal knot tying and minimize the risk of intraoperative pneumothorax. Meaningful statistical comparison between both hiatal plication techniques and risk of pneumothorax could not be performed due to the small number of dogs in this study. Esophagopexy was performed using the same strand of barbed suture if this method was used for hiatal plication and subjectively reduced surgical time as introduction of a second strand of suture and locking of the suture line by threading the needle through the welded loop was not required. Further studies are required to evaluate the ideal method for hiatal plication that would minimize surgical time and possible risk of pneumothorax.

In this cohort of dogs, left-sided gastropexy was performed using a totally laparoscopic technique in 3 of 7 dogs and with a laparoscopic-assisted technique in 4 of 7 dogs. A totally laparoscopic technique was performed in the initial dogs of this study, while a laparoscopic-assisted technique was elected in subsequent dogs. Concerns for intraoperative pneumothorax likely influenced the decision for which gastropexy technique was selected. In both dogs that had an intraoperative thoracic drainage catheter inserted to resolve pneumothorax, a laparoscopic-assisted gastropexy was performed. This technique was likely selected to reduce the time required for pneumoperitoneum and allow for resolution of pneumothorax.

Five dogs underwent concurrent surgery for BOAS, which resulted in prolonged anesthesia times. While all dogs recovered from anesthesia without complication, prolonged anesthesia time has been associated with an increased risk in complications in brachycephalic dogs.19,20 This finding should be discussed with dog owners if single-staged surgery for BOAS and SHH is being considered. In all brachycephalic dogs of this report, staged surgery for BOAS and SHH was recommended to mitigate possible perioperative complications. A recent study21 showed that the owners of brachycephalic dogs undergoing conventional multilevel surgery for BOAS perceived a reduction in clinical signs related to gastroesophageal reflux. Based on the results of the study by Mayhew et al,21 dogs with gastroesophageal reflux may improve with upper airway surgery alone and may not require surgery for SHH. Further evaluation is required of the role of upper airway surgery and its effect on the reduction of clinical signs related to SHH.

Postoperative clinical outcomes pertaining to gastroesophageal reflux were evaluated in the dogs of this study using a previously published owner questionnaire.10 Similar to previous reports that used an owner questionnaire to evaluate dogs following laparoscopic treatment of SHH, an improvement in regurgitation following eating and increased activity/excitement was found in the dogs of this report.10 Postoperative esophageal videofluoroscopic swallowing studies were not performed of the dogs of this report, representing a limitation of this study. However, a previous study21 reported that videofluoroscopic evidence of SHH can persist following surgery despite clinical improvement.

Limitations to this study included its small sample size and retrospective nature, which prevented standardization of preoperative treatment. Additionally, a nonuniform population of dogs was included, which may have compromised postoperative evaluation. A final limitation was that the questionnaire administered to owners was only administered at the time of postoperative follow-up. Answers provided by owners pertaining to the preoperative clinical status of dogs may have been susceptible to recency bias.

In conclusion, laparoscopic treatment of SHH was successful in this cohort of dogs but associated with a high rate of intraoperative pneumothorax. Surgeons performing this procedure should consider this possible intraoperative complication with their anesthesia and recovery team.

Acknowledgments

None reported.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.

References

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  • 1.

    Prymak C, Saunders HM, Washabau RJ. Hiatal hernia repair by restoration and stabilization of normal anatomy. An evaluation in four dogs and one cat. Vet Surg. 1989;18(5):386391. doi:10.1111/j.1532-950x.1989.tb01106.x

    • Search Google Scholar
    • Export Citation
  • 2.

    Callan MB, Washabau RJ, Saunders HM, Kerr L, Prymak C, Holt D. Congenital esophageal hiatal hernia in the Chinese Shar-Pei dog. J Vet Intern Med. 1993;7(4):210215. doi:10.1111/j.1939-1676.1993.tb01009.x

    • Search Google Scholar
    • Export Citation
  • 3.

    Freiche V, German AJ. Digestive diseases in brachycephalic dogs. Vet Clin North Am Small Anim Pract. 2021;51(1):6178. doi:10.1016/j.cvsm.2020.09.006

    • Search Google Scholar
    • Export Citation
  • 4.

    Reeve EJ, Sutton D, Friend EJ, Warren-Smith CMR. Documenting the prevalence of hiatal hernia and oesophageal abnormalities in brachycephalic dogs using fluoroscopy. J Small Anim Pract. 2017;58(12):703708. doi:10.1111/jsap.12734

    • Search Google Scholar
    • Export Citation
  • 5.

    Guiot LP, Lansdowne JL, Rouppert P, Stanley BJ. Hiatal hernia in the dog: a clinical report of four Chinese Shar Peis. J Am Anim Hosp Assoc. 2008;44(6):335341. doi:10.5326/0440335

    • Search Google Scholar
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