1
|
Morikawa K, Tanishima Y, Igarashi T, Ohki Y, Takahashi K, Kurogochi T, Yano F, Ojiri H. Evaluation of the Usefulness of Contrast-Enhanced Computed Tomography for the Early Detection of Anastomotic Leakage After Esophagectomy. J Comput Assist Tomogr 2024; 48:719-726. [PMID: 38346793 DOI: 10.1097/rct.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
OBJECTIVE Anastomotic leakage is one of the most severe complications after esophagectomy. However, a diagnostic gold standard for anastomotic leakage has not been established yet. This retrospective cohort study aimed to evaluate the potential use of routine postoperative contrast-enhanced computed tomography findings as an early predictor of anastomotic leakage in patients who underwent esophagectomy for esophageal cancer. METHODS This study included 75 patients who underwent Mckeown esophagectomy, of whom 22 developed anastomotic leakage after surgery. The computed tomography findings for this patient cohort were categorized into 3 grades based on mural enhancement patterns observed at the anastomotic site. Both semiquantitative and quantitative analyses were performed, and the interobserver agreement between the 2 experienced radiologists was assessed. RESULTS It was found that poor enhancement in both the early and portal venous phases (grade 2) had a robust association with the occurrence of anastomotic leakage. The computed tomography enhancement ratio that is used to estimate wall degeneration and ischemia was significantly higher in patients with anastomotic leakage. CONCLUSIONS Routine postoperative contrast-enhanced computed tomography could be beneficial for the early detection of anastomotic leakage, even in asymptomatic patients, after esophagectomy.
Collapse
Affiliation(s)
| | - Yuichiro Tanishima
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | - Keita Takahashi
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Kurogochi
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | | |
Collapse
|
2
|
Sugita S, Miyata K, Shimizu D, Ebata T, Yokoyama Y. A risk scoring system for early diagnosis of anastomotic leakage after subtotal esophagectomy for esophageal cancer. Jpn J Clin Oncol 2023; 53:936-941. [PMID: 37370213 DOI: 10.1093/jjco/hyad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most critical postoperative complications after subtotal esophagectomy in patients with esophageal cancer. This study attempted to develop an optimal scoring system for stratifying the risk for AL. METHODS The study included 171 patients who underwent subtotal esophagectomy for esophageal cancer followed by esophagogastrostomy in the cervical region from January 2011 to April 2021 at Nagoya University Hospital. AL was defined by radiologic or endoscopic evidence of anastomotic breakdown using some modalities. A risk scoring system for an early diagnosis of AL was established using factors determined in the multivariate analysis. A score was calculated for each patient, and the patients were classified into three categories according to the risk for AL: low-, intermediate- and high-risk. The trend of the risk for AL among the categories was evaluated. RESULTS Twenty-nine patients (17%) developed AL. Multivariate analysis demonstrated that sinistrous gross features of drain fluid (P < 0.001; odds ratio (OR), 10.2), radiologic air bubble sign (P < 0.001; OR, 15.0) and the level of drain amylase ≥280 U/L on postoperative Day 7 (P < 0.001; OR, 9.0) were significantly associated with AL. According to the matching number of the above three risk factors and categorization into three risk groups, the incidence of AL was 6.1% (8/131) in the low-risk group, 45.5% (15/33) in the intermediate-risk group and 85.7% (6/7) in the high-risk group (area under curve, 0.81; 95% confidence interval, 0.72-0.90). CONCLUSIONS The present AL-risk scoring system may be useful in postoperative patient care after subtotal esophagectomy.
Collapse
Affiliation(s)
- Shizuki Sugita
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Shimizu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Preoperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
3
|
Yatabe K, Koyanagi K, Higuchi T, Shoji Y, Yamamoto M, Ninomiya Y, Kazuno A, Oguma J, Mori M, Ozawa S. Effectiveness of computed tomography scoring for the early diagnosis of anastomotic leakage after esophagectomy. Langenbecks Arch Surg 2023; 408:259. [PMID: 37392344 DOI: 10.1007/s00423-023-03007-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Anastomotic leakage after esophagectomy is associated with increased mortality; therefore, early diagnosis is highly important. This study aimed to identify the characteristic computed tomography (CT) findings of cervical anastomotic leakage after esophagectomy for esophageal cancer and evaluate the effectiveness of CT scoring in screening the anastomotic leakage. METHODS Overall, 91 patients who underwent thoracoscopic esophagectomy with cervical esophago-gastric anastomosis were included. We investigated the correlation between anastomotic leakage and the presence of the microbubble sign, evident air retention, and fluid collection in the cervical and mediastinal regions. CT findings were scored, and the cutoff value was set to 2 points on the receiver operating characteristic curve. The patients were divided into two groups based on the CT score (≥ 2 points and ≤ 1 point). RESULTS CT findings of the microbubble sign (p = 0.01; odds ratio [OR], 8.545; 95% confidence interval [CI], 1.596-45.73), cervical air retention (p < 0.01; OR, 12.43; 95% CI, 2.084-74.17), and cervical fluid collection (p < 0.01; OR, 9.359; 95% CI, 1.753-49.96) significantly correlated with anastomotic leakage. The ≥ 2-point CT score group showed a significantly higher incidence of anastomotic leakage than the ≤ 1-point group (p < 0.01; OR, 16.28; 95% CI [4.704-56.38]). A ≥ 2-point CT score had higher sensitivity (84.2%) than upper gastrointestinal series (36.8%). CONCLUSION The presence of microbubble sign, air retention, and fluid collection in the cervical area correlated with anastomotic leakage after cervical anastomosis in thoracoscopic esophagectomy. CT scores are useful early anastomotic leakage detectors.
Collapse
Affiliation(s)
- Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Tadashi Higuchi
- Department of Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yoshiaki Shoji
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Surgery, Tamakyuryo Hospital, Tokyo, Japan
| |
Collapse
|
4
|
Lu CY, Liu YL, Liu KJ, Xu S, Yao HL, Li L, Guo ZS. Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments: A case report. World J Clin Cases 2022; 10:7609-7616. [PMID: 36157983 PMCID: PMC9353917 DOI: 10.12998/wjcc.v10.i21.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrografin swallow, methylthioninium chloride test, and computed tomography (CT) are the main methods for postoperative anastomotic fistula detection. Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy, which are conducive to postoperative recovery.
CASE SUMMARY A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer. The patient developed a fever after surgery. The methylthioninium chloride test and early CT suggested no anastomotic fistula, but gastrografin swallow and late CT showed the opposite result. The fistula was successfully closed using an endoscopic clip. The methylthioninium chloride test, gastrografin, and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different. The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.
CONCLUSION The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy. The size of the leakage of the anastomosis is an important basis for selecting the repair method.
Collapse
Affiliation(s)
- Chen-Yang Lu
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Ya-Li Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Kui-Jie Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Shu Xu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Lun Li
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Zhu-Shu Guo
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| |
Collapse
|
5
|
Early detection of anastomotic leakage after esophagectomy using drain amylase levels. Esophagus 2021; 18:522-528. [PMID: 33641017 DOI: 10.1007/s10388-021-00827-z] [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: 11/17/2020] [Accepted: 02/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early diagnosis of anastomotic leakage (AL) after esophagectomy is essential to minimize postoperative complications. In this study, we hypothesized that drain amylase levels may be useful for early AL detection, and measuring drain amylase levels could reduce severe postoperative AL incidence. We, therefore, analyzed the usefulness of measuring drain fluid amylase levels after esophagectomy, in esophageal cancer patients. METHODS From January 2016 to March 2020, 134 patients with esophageal cancer who underwent surgical resection with esophagogastric anastomosis in the cervical region were included. The patients were divided into a group whose cervical drain fluid amylase levels were not measured (No-AMY Group) and a group whose cervical drain fluid amylase levels were measured daily until postoperative day (POD) 7 (AMY Group). The incidence of severe AL was compared between groups. In the AMY Group, we also investigated the association between AL and drain amylase levels. RESULTS Drain amylase levels were significantly higher in AL-positive cases than in AL-negative cases (P < 0.001). Receiver operating characteristic curve analysis revealed the drain amylase level cut-off value for AL diagnosis was 1800 U/L on POD 2 (Area under the curve = 0.835; P = 0.027). The incidence of ≥ grade III AL was significantly lower in the AMY Group than in the No-AMY Group (2 vs. 10%, P = 0.047). CONCLUSIONS Cervical drain fluid amylase levels can be a useful screening method for early detection of AL after esophagectomy for esophageal cancer and may help reduce incidence of severe postoperative AL.
Collapse
|
6
|
Barbaro A, Eldredge TA, Shenfine J. Diagnosing anastomotic leak post-esophagectomy: a systematic review. Dis Esophagus 2021; 34:5889927. [PMID: 33565590 DOI: 10.1093/dote/doaa076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/13/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Esophagectomy is the gold-standard treatment for esophageal cancer; however, postoperative anastomotic leakage remains the primary concern for surgeons. No consensus exists on the optimal investigations to predict an anastomotic leak. This systematic review aims to identify a single test or combination of tests with acceptable sensitivity and specificity to identify anastomotic leak after esophagectomy and to formulate a diagnostic algorithm to facilitate surgical decision-making. A systematic review of PubMed and EMBASE databases was undertaken to evaluate diagnostic investigations for anastomotic leak post-esophagectomy. Each study was reviewed and where possible, the sensitivity, specificity, positive predictive value, and negative predictive value were extracted. The review identified 3,204 articles, of which 49 met the inclusion criteria. Investigations most commonly used for diagnosis of anastomotic leak were: C-reactive protein (CRP), oral contrast imaging, computed tomography (CT), pleural drain amylase concentration, and the 'NUn score'. The sensitivity of CRP for detecting anastomotic leak varied from 69.2% to 100%. Oral contrast studies sensitivities varied between 16% and 87.5% and specificity varied from 20% to 100%. Pleural drain amylase sensitivities ranged between 75% and 100% and specificity ranged from 52% to 95.5%. The NUn score sensitivities ranged from 0% to 95% and specificity from 49% to 94.4%. No single investigation was identified to rule out anastomotic leak in asymptomatic patients. However, the authors propose a diagnostic algorithm incorporating CRP, pleural drain amylase concentration, and CT with oral contrast to aid clinicians in predicting anastomotic leak to facilitate safe, timely discharge post-esophagectomy.
Collapse
Affiliation(s)
- Antonio Barbaro
- Department of Surgery, The Royal Adelaide Hospital, Adelaide, Australia
| | - Thomas A Eldredge
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Department of Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jonathan Shenfine
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Division of Surgery, Flinders Medical Centre, Bedford Park, Australia
| |
Collapse
|
7
|
Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus 2021; 34:doaa039. [PMID: 32476017 PMCID: PMC7801633 DOI: 10.1093/dote/doaa039] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.
Collapse
Affiliation(s)
- M Fabbi
- Fondazione IRCCS Cà Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - E R C Hagens
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Daniel VT, Alavi K, Davids JS, Sturrock PR, Harnsberger CR, Steele SR, Maykel JA. The utility of the delphi method in defining anastomotic leak following colorectal surgery. Am J Surg 2020; 219:75-79. [DOI: 10.1016/j.amjsurg.2019.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/09/2019] [Accepted: 05/22/2019] [Indexed: 02/07/2023]
|
9
|
Kawata S, Hiramatsu Y, Shirai Y, Watanabe K, Nagafusa T, Matsumoto T, Kikuchi H, Kamiya K, Takeuchi H. Multidisciplinary team management for prevention of pneumonia and long-term weight loss after esophagectomy: a single-center retrospective study. Esophagus 2020; 17:270-278. [PMID: 32026048 PMCID: PMC7316685 DOI: 10.1007/s10388-020-00721-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/23/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND In April 2017, we launched the multidisciplinary Hamamatsu Perioperative Care Team (HOPE) for all surgical patients. We developed a reinforced intervention strategy, particularly for esophagectomy. We herein report the outcomes of the HOPE at 2 years after commencement. METHODS A total 125 patients underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between January 2014 and December 2018 at the Department of Surgery in Hamamatsu University School of Medicine. The patients were divided into the pre-HOPE group including 62 patients who underwent esophagectomy before the introduction of the HOPE and the HOPE group including 63 patients who underwent esophagectomy after the introduction of the HOPE. The outcomes of surgery were compared between the two groups. RESULTS There were no significant differences in the clinicopathological characteristics between the two groups. The incidence rates of atrial fibrillation and pneumonia were significantly lower in the HOPE group than in the pre-HOPE group (6% vs. 19%, p = 0.027 and 14% vs. 29%, p = 0.037, respectively). The estimated calorie doses at the time of discharge were approximately 750 and 1500 kcal/day in the pre-HOPE group and the HOPE group, respectively. The body weight loss was significantly less in the HOPE group than the pre-HOPE group at 1, 3, 6, and 12 months postoperatively than that before the surgery (p < 0.001). CONCLUSIONS The introduction of the multidisciplinary HOPE was associated with a significant reduction in the incidence of postoperative pneumonia and significantly less weight loss.
Collapse
Affiliation(s)
- Sanshiro Kawata
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan ,Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuka Shirai
- Department of Nutrition, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kouji Watanabe
- Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Japan ,Department of Rehabilitation, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tetsuyuki Nagafusa
- Department of Rehabilitation, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Kinji Kamiya
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| |
Collapse
|
10
|
Shoji Y, Takeuchi H, Kitagawa Y. Air Bubble Sign: ANew Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2018; 25:713-714. [PMID: 30276644 DOI: 10.1245/s10434-018-6821-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Yoshiaki Shoji
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan. .,Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|