1
|
Wang L, Wang D, Zhang Y. Comparison of postoperative pulmonary complications and intraoperative safety in thoracoscopic surgery under non-intubated versus intubated anesthesia: a randomized, controlled, double-blind non-inferiority trial. Updates Surg 2024:10.1007/s13304-024-01935-y. [PMID: 39126533 DOI: 10.1007/s13304-024-01935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 07/02/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE Traditional anesthesia for video-assisted thoracoscopy (VATS) such as double-lumen tracheal intubation (DLT) and one-lung ventilation (OLV), may lead to post-operative pulmonary complications (PPCs). Non-intubation VATS (NIVATS) is an anesthetic technique that avoided DLT and OLV, maybe avoiding the PPCs. So we hypothesized that NIVATS would non-inferiority to intubation VATS (IVATS) in the risk of developing PPCs and some safety indicators. METHODS This study is a randomised, controlled, double-blind, non-inferiority trial, 120 patients were randomly assigned to the NIVATS group and IVATS group according to 1:1. The primary outcome was the incidence of PPCs with a pre-defined non-inferiority margin of 10%. The second outcome was the safety indicators, including the incidence of cough/body movement, hypoxemia, malignant arrhythmia, regurgitation and aspiration, and transferring to endobronchial intubation intraoperatively (The malignant arrhythmia was defined as an arrhythmia that caused hemodynamic disturbances in a short period of time, resulting in persistent hypotension or even cardiac arrest in the patient). RESULTS There was no significant difference in demographic indicators such as gender and age between the two groups. The incidence of PPCs in the NIVATS group was non-inferior to that in the IVATS group (1.67% vs. 3.33%, absolute difference: - 1.67%; 95%CI - 7.25 to 3.91). In additionan, no significant differences were found between the two groups for the incidence of cough/body movement (10.00% vs. 11.67%, p = 0.77), the incidence of hypoxemia (25% vs. 18.33%, p = 0.38), the incidence of malignant arrhythmia (1.67% vs. 6.67%, p = 0.36), the incidence of regurgitation and aspiration (0% vs. 0%, p > 0.999) and the incidence of transferring to endobronchial intubation intraoperatively (0% vs. 0%, p > 0.999). CONCLUSION We conclude that when using the non-intubation anesthesia for VATS, the incidence of PPCs was not inferior to intubation anesthesia. Furthermore, NIVATS had little effect on perioperative safety.
Collapse
Affiliation(s)
- Lingfei Wang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China
| | - Dan Wang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China
| | - Yanmei Zhang
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, 110042, Liaoning, China.
| |
Collapse
|
2
|
Safi S, Gysan MR, Weber D, Behnisch R, Muley T, Allgäuer M, Winter H, Hoffmann H, Eichhorn M. Peri- and postoperative morbidity and mortality in older patients with non-small cell lung cancer: a matched-pair study. World J Surg Oncol 2024; 22:213. [PMID: 39118130 PMCID: PMC11311962 DOI: 10.1186/s12957-024-03491-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/17/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Reports from case series suggest that operative outcomes are comparable amongst different age groups following surgery with curative intent for non-small cell lung cancer (NSCLC). The purpose of this study was to compare morbidity and mortality after NSCLC surgery in older patients (≥ 75 years) versus younger patients (< 75 years) and identify independent predictive risk factors. METHODS We identified 2015 patients with postoperative stages IA to IIIA according to AJCC/UICC 7th edition who had undergone NSCLC surgery with curative intent at a single specialized lung cancer center from January 2010 to December 2015. A matched-pair analysis was performed on 227 older patients and corresponding 227 younger patients. Short-term surgical outcomes were postoperative morbidity, length of hospital stay, 30-day and 90-day mortality. Long-term operative outcomes were disease-free and overall survival. RESULTS 454 patients were included in the matched-pair analysis. 36% of younger patients developed postoperative complications versus 42% in older patients (p = 0.163). Age was not significantly associated with the occurrence of postoperative complications. Median length of hospital stay was 14 days in older patients and 13 days in younger patients (p = 0.185). 90-day mortality was 2.2% in younger patients compared to 4% in older patients (p = 0.424). In patients aged 75 and older impaired performance status (ECOG ≥ 1) was associated with decreased overall survival (HR = 2.15, CI 1.34-3.46), as were preoperative serum C-reactive protein / albumin ratio ≥ 0.3 (HR = 1.95, CI 1.23-3.11) and elevated preoperative serum creatinine levels ≥ 1.1 mg/dl (HR = 1.84, CI 1.15-2.95). In the younger cohort male sex (HR = 2.26, CI 1.17-4.36), postoperative stage III disease (HR 4.61, CI 2.23-9.54) and preoperative anemia (hemoglobin < 12 g/dl) (HR 2.09, CI 1.10-3.96) were associated with decreased overall survival. CONCLUSIONS Lung resection for NSCLC in older patients is associated with postoperative morbidity and mortality comparable to those of younger patients. In older patients, physical activity, comorbidities and nutritional status are related to survival and should influence the indication for surgery rather than age alone.
Collapse
Affiliation(s)
- Seyer Safi
- Division of Thoracic Surgery, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian Robert Gysan
- Department of Thoracic Surgery, Heidelberg University Hospital, Thoraxklinik, Heidelberg, Germany
- Division of Pulmonology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Rouven Behnisch
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Thomas Muley
- Translational Lung Research Center Heidelberg (TLRCH), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
- Translational Research Unit, Heidelberg University, Thoraxklinik, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Heidelberg University Hospital, Thoraxklinik, Heidelberg, Germany
| | - Hans Hoffmann
- Division of Thoracic Surgery, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martin Eichhorn
- Department of Thoracic Surgery, Heidelberg University Hospital, Thoraxklinik, Heidelberg, Germany.
| |
Collapse
|
3
|
Zhao J, Niu N, He Z. Effect of Thymosin on Inflammatory Factor Levels, Immune Function, and Quality of Life in Lung Cancer Patients Undergoing Radical Thoracoscopic Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:8749999. [PMID: 35832513 PMCID: PMC9273385 DOI: 10.1155/2022/8749999] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 12/01/2022]
Abstract
Purpose To explore the effect of thymosin on inflammatory factor levels, immune function, and quality of life in patients undergoing radical thoracoscopic lung cancer surgery. Methods One hundred and twenty patients admitted to the Surgical Oncology Department of the First Hospital of Jiaxing from January 2018 to January 2019 were randomized into the study group and the control group using the random number table method, with 60 cases in each group. The control group was treated with radical thoracoscopic lung cancer surgery, and the study group was treated with radical thoracoscopic lung cancer surgery combined with thymosin. The clinical efficiency, inflammatory factors, immune function, and quality of life between the two groups of patients were compared. Results There was no significant difference between the two groups in terms of pathological stage, tissue type, maximum tumor diameter, and perioperative indicators such as operative time, intraoperative bleeding, pleural drainage, hospital stay, and the number of intraoperative lymph nodes removed. The levels of CD4 (+%), CD8 (+%), CD4+/CD8+, and natural killer cell (NK) (%) were significantly decreased in both groups after treatment, with significantly higher results in the study group than in the control group. The study group had significantly lower serum interleukin-6 (IL-6) levels and higher interleukin-10 (IL-10) levels than the control group. After treatment, patients in the study group had better postoperative physiological status and overall score than the control group. There was no significant difference in postoperative survival and adverse reactions between the two groups. Conclusion The use of thymosin treatment in lung cancer patients undergoing radical thoracoscopic surgery significantly improves immune function, mitigates inflammatory response, and enhances the quality of life, which is worthy of clinical application.
Collapse
Affiliation(s)
- Junjie Zhao
- Department of Thoracic Surgery, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Niu Niu
- Department of Thoracic Surgery, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Zhengfu He
- Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| |
Collapse
|
4
|
Tan HX, Drake BC, Chaudhuri N, Kefaloyannis M, Milton R, Papagiannopoulos K, Tcherveniakov P, Brunelli A. A risk model to predict 2-year survival after video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer. Eur J Cardiothorac Surg 2020; 57:781-787. [PMID: 31722375 DOI: 10.1093/ejcts/ezz304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/19/2019] [Accepted: 10/02/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We sought to identify the risk factors associated with mortality post-video-assisted thoracoscopic surgery (VATS) lobectomy over a 2-year period. METHODS Analysis was performed using a sample from an institutionally maintained database. All lobectomies for non-small-cell lung cancer from April 2014 to March 2018 started with VATS approach and with a complete follow-up were included (n = 732). Several clinical variables were screened using the Cox univariate analysis for their association with 2-year survival. Those with a P-value <0.1 were included in a Cox proportional hazard model. RESULTS After multivariable analysis, the following variables showed significant association with 2-year survival: age >75 [hazard ratio (HR) 1.527, P = 0.043], carbon monoxide lung diffusion capacity <70 (HR 1.474, P = 0.061), body mass index (BMI) <18.5 (HR 2.628, P = 0.012), American Society of Anesthesiologist Physical Status >2 (HR 1.518, P = 0.047), performance status >1 (HR 1.822, P = 0.032) and male gender (HR 2.700, P < 0.001). A score of 2 was assigned to the male gender and BMI <18.5, with all other variables assigned a score of 1. Each patient was scored and placed into their risk class. A Kaplan-Meier estimate for 2-year survival was calculated for each class. These were collapsed into the following 3 classes of risk based on their similar 2-year survival: class A (score 0) 97%, 95% CI 88-99, class B (score 1-3) 84%, 95% CI 80-88, class C (score > 3) 66%, 95% CI 57-74. CONCLUSION Our scoring system can serve as an adjunct to a clinician's experience in risk-stratifying patients during multidisciplinary tumour board discussion and the shared decision-making process.
Collapse
Affiliation(s)
- Hui Xian Tan
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | | | - Nilanjan Chaudhuri
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | - Manos Kefaloyannis
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | - Richard Milton
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | | | | | | |
Collapse
|
5
|
Nakamoto S, Hirose M. Prediction of early C-reactive protein levels after non-cardiac surgery under general anesthesia. PLoS One 2019; 14:e0226032. [PMID: 31790508 PMCID: PMC6886833 DOI: 10.1371/journal.pone.0226032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/17/2019] [Indexed: 11/19/2022] Open
Abstract
Background Early detection of postoperative increase in C-reactive protein (CRP) correlates with postoperative complications. The present study examined the association between preoperative / intraoperative factors and postoperative CRP levels, with development and validation of a prediction model of early postoperative CRP level, for prophylactic management of postoperative complications in patients undergoing surgery under general anesthesia. Material and methods Multivariate regression analysis was retrospectively performed to determine the independent factor of CRP levels on postoperative day (POD) 1 and to develop a prediction model. Validation of the prediction model was prospectively performed. Data from 316 adult patients on perioperative variables were retrospectively obtained in a training cohort in patients undergoing elective non-cardiac surgery. In a validation cohort, 88 patients undergoing mastectomy and 68 patients undergoing laparoscopic colon surgery were prospectively utilized to evaluate the value of the prediction model. Major complications after surgery were defined as the Clavien-Dindo grade IIIa or greater. Results Duration of surgery, mean nociceptive response (NR) during surgery as intraoperative nociception level, and preoperative CRP level were selected to set up the prediction model of CRP level on POD1 (P < 0.0001). In the validation cohort, the predicted CRP levels on POD1 significantly correlated with the measured CRP after mastectomy (P < 0.0001) and laparoscopic colon surgery (P = 0.0001). Receiver-operating characteristic curve analysis showed that the predicted CRP levels on POD1 was significantly associated with major complications after mastectomy (P = 0.0259) and laparoscopic colon surgery (P = 0.0049). The measured and predicted CRP levels significantly increased in the order of severity of postoperative complications (P < 0.01). Conclusion Increases in duration of surgery, intraoperative nociceptive level and preoperative CRP level were selected to predict early increases in CRP level after non-cardiac surgery under general anesthesia. Predicted CRP levels on POD1 were likely associated with severity of postoperative complications.
Collapse
Affiliation(s)
- Shiroh Nakamoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
- * E-mail:
| |
Collapse
|
6
|
Kaufmann KB, Loop T, Heinrich S. Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry. Acta Anaesthesiol Scand 2019; 63:1009-1018. [PMID: 31144301 DOI: 10.1111/aas.13388] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/28/2019] [Accepted: 04/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients. METHODS Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of Thoracic Surgery. Univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs were conducted. RESULTS We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. One-hundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m2 ; a pre-operative forced expiratory volume in 1 second (FEV1 ) ≤ 60%; a pre-operative arterial oxygen partial pressure (pa O2 ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV1 ≤ 60% (1.9[1.1-3.4] OR [95% CI], P = 0.029); pa O2 ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023). CONCLUSION Intraoperative amount of crystalloid fluids should be kept below 6 mL/kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.
Collapse
Affiliation(s)
- Kai B. Kaufmann
- Faculty of Medicine, Department of Anesthesiology and Critical Care Medicine Medical Center ‐ University of Freiburg Freiburg Germany
| | - Torsten Loop
- Faculty of Medicine, Department of Anesthesiology and Critical Care Medicine Medical Center ‐ University of Freiburg Freiburg Germany
| | - Sebastian Heinrich
- Faculty of Medicine, Department of Anesthesiology and Critical Care Medicine Medical Center ‐ University of Freiburg Freiburg Germany
| | | |
Collapse
|
7
|
Kawaguchi Y, Hanaoka J. How to predict the risk of post-lobectomy complications in elderly lung cancer patients. J Thorac Dis 2019; 11:S1432-S1433. [PMID: 31245152 DOI: 10.21037/jtd.2019.04.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yo Kawaguchi
- Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science, Shiga, Japan.,Division of General Thoracic Surgery, Kusatsu General Hospital, Shiga, Japan
| | - Jun Hanaoka
- Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| |
Collapse
|
8
|
Ibrahim K, Burt BM. The impact of insight on post-lobectomy complications. J Thorac Dis 2019; 11:S289-S290. [PMID: 30997200 DOI: 10.21037/jtd.2019.01.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kareem Ibrahim
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Bryan M Burt
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
9
|
Okami J. Treatment strategy and decision-making for elderly surgical candidates with early lung cancer. J Thorac Dis 2019; 11:S987-S997. [PMID: 31183181 DOI: 10.21037/jtd.2019.04.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Among elderly cancer patients of the same chronological age, there is a wide range of heterogeneity in their ability to tolerate surgery. When an elderly patient comes to a thoracic surgeon, the surgeon first considers how healthy the patient is. If the patient looks healthy or in fit condition, the surgeon offers lobectomy plus mediastinal lymph node dissection. On the other hand, if the patient looks frail, the surgeon may offer, instead of a standard treatment, lobectomy without lymph node dissection, sublobar resection, or radiotherapy or may not offer any kind of treatment. This review was conducted to obtain an overview of these options and compare the treatment outcomes reported in the literature for the purpose of making a good decision for elderly surgical candidates with early lung cancer.
Collapse
Affiliation(s)
- Jiro Okami
- Department of General Thoracic Surgery, Osaka International Cancer Institute, Osaka, Japan
| |
Collapse
|
10
|
Zhang R, Dippon J, Friedel G. Refined risk stratification for thoracoscopic lobectomy or segmentectomy. J Thorac Dis 2019; 11:222-230. [PMID: 30863592 DOI: 10.21037/jtd.2018.12.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Given the wide adoption of thoracoscopic lobectomy and positive effect of the thoracoscopic approach for improving postoperative outcomes, questions have arisen regarding the validity of previously published risk assessment models. We sought to review the reliability of the established predictors for patients undergoing thoracoscopic lobectomy. Methods From January 2009 to May 2017, 606 patients (275 women, 331 men; median age 67 years) underwent thoracoscopic lobectomy or segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Logistic regression analyses were performed to determine the predictors of postoperative complications, followed by assessments of causal inference. Results The postoperative mortality, pulmonary complication, cardiovascular complication and overall morbidity rates were 1.0%, 8.9%, 5.8% and 18.0%, respectively. While the American Society of Anesthesiologists physical status (ASA-PS) emerged as an independent morbidity predictor, only a slightly significant association between lung function determinants and overall morbidity was found in the univariable regression analyses. Regarding causal inference, inverse probability of treatment weighting using propensity scores revealed 2- and 1.7-fold increases in the odds of cardiopulmonary complications and overall morbidity in patients with ASA-PS grade 3 or 4 compared with those with ASA-PS grade 1 or 2 (OR =2.116, 95% CI: 1.252-3.577, P=0.005; OR =1.740, 95% CI: 1.095-2.765, P=0.019, respectively). Conclusions Our results suggested that the current physiologic evaluation algorithm is also applicable to major lung resection via thoracoscopic approach. ASA-PS is an easily assessable factor capable of predicting major complications following thoracoscopic lobectomy in patients properly selected in compliance with the current guideline. It is recommended to incorporate the ASA-PS into the existing algorithm for more accurate risk stratification in this patient population.
Collapse
Affiliation(s)
- Ruoyu Zhang
- Department of General and Thoracic Surgery, Justus-Liebig-University Giessen, Giessen, Germany.,Department of Thoracic Surgery, Chest Hospital Schillerhoehe, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Jürgen Dippon
- Department of Mathematics, University Stuttgart, Stuttgart, Germany
| | - Godehard Friedel
- Department of Thoracic Surgery, Chest Hospital Schillerhoehe, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| |
Collapse
|
11
|
Risk assessments for broncho-pleural fistula and respiratory failure after lung cancer surgery by National Clinical Database Japan. Gen Thorac Cardiovasc Surg 2018; 67:297-305. [DOI: 10.1007/s11748-018-1022-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
|