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An Y, Gao J, Xu J, Qi W, Wang L, Tian M. Efficacy and safety of 13 surgical techniques for the treatment of complex anal fistula, non-Crohn CAF: a systematic review and network meta-analysis. Int J Surg 2024; 110:441-452. [PMID: 37737881 PMCID: PMC10793738 DOI: 10.1097/js9.0000000000000776] [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: 06/15/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Considering the difficulty of treating complex anal fistula (CAF), various surgical techniques exist in clinical work. However, none are ideal. Evidence on the efficacy and safety of different surgical treatments is scarce. The authors aimed to compare the outcomes of the 13 surgical techniques and tried to find the best surgical method for treating CAF. MATERIALS AND METHODS The authors searched worldwide databases, including Pubmed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and SinoMed, from inception to March 2023. All randomized controlled trials comparing the outcomes of 13 surgical techniques were included according to the PICO principles. The indicators of the cure rate, the recurrence rate, the complication rate, the operating time, the postoperative pain on day 1 (VAS), and the postoperative incontinence in month 1 (Wexner) were extracted and analyzed using STATA software 15.1, Review Manager 5.4, and GeMTC14.3. RESULTS Twenty-eight randomized controlled trials with a total of 2274 patients were included in the network meta-analysis. There was no statistically significant difference in the comparison among any surgical interventions in terms of the cure rate ( P >0.05 Table 2) and recurrence rate ( P >0.05 Table 3). However, in terms of complication rate, fistulectomy was lower than FPS (Median: 0.14; 95% CI: 0.02-0.70) or fistulotomy (Median: 0.09; 95% CI: 0.01-0.55), and fistulotomy was lower than EAFR (Median: 0.24; 95% CI: 0.05-0.84), LIFT (Median: 0.17; 95% CI: 0.02-0.66) or LIFT-EAFR (Median: 0.11; 95% CI: 0.01-0.69) ( P >0.05 Table 4). The surface estimated the advantages and disadvantages under the cumulative ranking (SUCRA). The ranking results indicated that fistulectomy might have the lowest complication rate (SUCRA=7.9%). Because the network results of the operating time, the postoperative pain, and the postoperative incontinence contained no closed loops, the results of their probability ranking could only be referenced, demonstrating that fistulectomy might have the shortest operating time (SUCRA=23.4%), video-assisted modified ligation of the intersphincteric fistula tract (VAMLIFT) might have the lowest postoperative pain on day 1 (VAS) (SUCRA=0.4%) and LIFT might have the lowest postoperative incontinence in month 1(Wexner) (SUCRA=16.2%). CONCLUSION Fistulectomy might have the lowest complication rate, which might be the relatively superior surgical technique for treating CAF.
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Affiliation(s)
- Yongkang An
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
- The First Affiliated Hospital of Henan University of Traditional Chinese Medicine
| | - Jihua Gao
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
- Key Laboratory of Integrated Chinese Medicine and Western Medicine for Gastroenterology Research (Hebei), Shijiazhuang, People’s Republic of China
| | - Jiancheng Xu
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
| | - Wenyue Qi
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
| | - Linyue Wang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
| | - Maosheng Tian
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
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An Y, Chen X, Tian M, Qi W, Gao J. Comparison of clinical outcomes of anal fistula plug and endoanal advancement flap repair treating the complex anal fistula: a systematic review and meta-analysis. Updates Surg 2023; 75:2103-2115. [PMID: 37882975 PMCID: PMC10710391 DOI: 10.1007/s13304-023-01674-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023]
Abstract
Anal fistula (AF) is a common disease with high prevalence and surgical operations are effective treatments in clinical work. There exist many well-known surgical techniques treating complex anal fistula (CAF), however, none is ideal. To compare the superiority of Anal fistula plug (AFP) and Endoanal advancement flap repair (EAFR) for complex anal fistula. We searched worldwide databases including Pubmed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and SinoMed from their inception to March 2023. Studies comparing the outcomes of AFP and EAFR were included according to the PICO principles. The indicators of the healing rate, recurrence rate, wound infection rate, and complication rate, et al. were extracted and compared between different surgical methods. 5 RCTS and 7 non-RCTs were included in the meta-analysis with a total of 847 patients (341 patients conducted with AFP and 506 patients with EAFR). By combining the total effect of the 12 articles, we found that there was a statistical difference reporting the healing rate of AFP 48.3% and EAFR 64.4% treating the CAF (OR 0.68, 95% CI 0.30,1.55, P = 0.03), and EAFR has a better healing rate. However, there was no significant difference in terms of the recurrence rate (OR 1.68, 95% CI 0.80,3.54, P = 0.17), the wound infection rate (OR 1.82, 95% CI 0.95,3.52, P = 0.07), and the complication rate (OR 1.06, 95% CI 0.70,1.61, P = 0.77) either in the 12 articles or in the subgroup. The meta-analysis indicated that the EAFR was superior to AFP in terms of the healing rate treating the CAF, however, there were no significant differences between the two groups when it came to the recurrence rate, the wound infection rate, and the complication rate. EAFR might be one initial treatment for the complex cryptoglandular anal fistulas compared with AFP.
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Affiliation(s)
- Yongkang An
- The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, China
| | - Xueqing Chen
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine, 389, Zhongshan East Road, Shijiazhuang, 050000, Hebei Province, China
| | - Maosheng Tian
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine, 389, Zhongshan East Road, Shijiazhuang, 050000, Hebei Province, China
| | - Wenyue Qi
- Staff Hospital of Hebei Normal University, Shijiazhuang, China
| | - Jihua Gao
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine, 389, Zhongshan East Road, Shijiazhuang, 050000, Hebei Province, China.
- Key Laboratory of Integrated Chinese Medicine and Western Medicine for Gastroenterology Research (Hebei), Shijiazhuang, China.
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MEI P, FENG W, SHI P, ZHANG W, ZHUANG Y. Clinical research progress in Traditional Chinese Medicine in treating wound healing after anal fistula surgery. J TRADIT CHIN MED 2023; 43:1047-1054. [PMID: 37679994 PMCID: PMC10465834 DOI: 10.19852/j.cnki.jtcm.20230630.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/18/2022] [Indexed: 09/09/2023]
Abstract
In the study of the mechanism of wound healing after anal fistula surgery, how to scientifically and efficiently promote wound healing is of great significance. At present, modern medical treatment of wounds after anal fistula surgery mostly focuses on physical therapy intervention, new wound dressing and packing, and external application of growth factors. However, these therapies have many problems, and there is still no consensus on their clinical use. Traditional Chinese Medicine (TCM) has several methods to promote wound healing, such as oral administration, rubbing, and fumigation, which have a long history and obvious efficacy, but research in this area is relatively scattered and lacks classification and summarizing. Therefore, this paper analyzes and summarizes the existing research on TCM for promotion of wound healing after anal fistula surgery, carries out targeted analyses according to different clinical syndromes and treatment methods, and analyzes the defects in current research and anticipates future research trends in order to provide theoretical support for the advantages of TCM in promoting wound healing after anal fistula surgery.
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Affiliation(s)
- Pingping MEI
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
| | - Wenzhe FENG
- 2 Department of anorectal, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang 712000, China
| | - Peng SHI
- 2 Department of anorectal, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang 712000, China
| | - Wenxiu ZHANG
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
| | - Yu ZHUANG
- 1 the First Clinical Medical College Department, Shaanxi University of Chinese Medicine, Xianyang 712046, China
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Bhat S, Xu W, Varghese C, Dubey N, Wells CI, Harmston C, O'Grady G, Bissett IP, Lin AY. Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis. Tech Coloproctol 2023; 27:827-845. [PMID: 37460830 PMCID: PMC10485107 DOI: 10.1007/s10151-023-02845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
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Affiliation(s)
- S Bhat
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - W Xu
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - C Varghese
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - N Dubey
- Department of General Medicine, Tauranga Hospital, Te Whatu Ora, Tauranga, New Zealand
| | - C I Wells
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - C Harmston
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - G O'Grady
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - A Y Lin
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.
- Department of Surgery, Wellington Regional Hospital, Te Whatu Ora, Wellington, New Zealand.
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Kang J, Liu Y, Peng S, Tang X, Liu L, Xie Z, He Y, Zhang X. Efficacy and safety of traditional Chinese medicine external washing in the treatment of postoperative wound of diabetes complicated with anal fistula: Study protocol of a randomized, double-blind, placebo-controlled, multi-center clinical trial. Front Pharmacol 2022; 13:938270. [PMID: 36588737 PMCID: PMC9795008 DOI: 10.3389/fphar.2022.938270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction: Anal fistula is one of the commonest ailments seen by anorectal surgeons as surgery is currently the preferred treatment for it. Diabetes mellitus is a risk factor that can lead to slow wound healing after anal fistula surgery. Because of the large postoperative wound surface of anal fistula, patients with diabetes can have an increased probability of wound infection, which makes it hard to heal. There is an extensive clinical experience for wound healing in traditional Chinese medicine (TCM). The Jiedu Shengji decoction (JSD) is a widely used external washing decoction in clinical practice. However, the current evidence on it is still insufficient. Therefore, we report this carefully designed clinical trial to assess the efficacy and safety of JSD in the treatment of postoperative wounds in diabetic patients with anal fistula. Methods and analysis: This study was designed to be a randomized, double-blind, placebo-controlled, multi-center clinical trial. There were 60 eligible participants who were randomized at a 1:1 ratio to the intervention and placebo groups. Both groups received the same standard treatment. The intervention group was given external washing decoction of TCM (JSD), while the placebo group was given the placebo made of excipients and flavoring agents. The main outcome measures include wound healing, distribution of wound pathogens, levels of inflammatory mediators, and blood glucose. The secondary outcome measures included lipids, the quality of the life evaluation scale (Short-Form Health Survey 36). Assessments were performed before the start of the study, at 1st, 2nd, 3rd, and 4th weeks after the intervention, and at 8th, 12th, and 16th follow-up weeks. Discussion: The clinical study we proposed will be the first randomized, double-blind, placebo-controlled, multi-center clinical trial study to assess the efficacy and safety of TCM external washing (JSD) in the treatment of postoperative wounds in diabetic patients with anal fistula. Ethics and dissemination: The Medical Ethics Committee of Hospital of Chengdu University of Traditional Chinese Medicine has reviewed this study protocol and gave its approval and consent on 17 March, 2022 (Ethical Review Number: 2022KL-018).
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Affiliation(s)
- Jian Kang
- Department of Anorectal, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ya Liu
- Hospital of Chengdu University of Traditional Chinese Medicine, TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Chengdu, China
| | - Sihan Peng
- Hospital of Chengdu University of Traditional Chinese Medicine, TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Chengdu, China
| | - Xiao Tang
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lu Liu
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ziyan Xie
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuchi He
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiyu Zhang
- Hospital of Chengdu University of Traditional Chinese Medicine, TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Chengdu, China,*Correspondence: Xiyu Zhang,
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Tian Z, Li YL, Nan SJ, Xiu WC, Wang YQ. Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:783-795. [PMID: 35347492 DOI: 10.1007/s10151-022-02614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients. METHODS The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies. RESULTS Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I2 = 37.9%), 16% (95% CI 14-18%, I2 = 4.8%), 11% (95% CI 7-15%, I2 = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I2 = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I2 = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I2 = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias. CONCLUSIONS According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.
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Affiliation(s)
- Z Tian
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y L Li
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - S J Nan
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - W C Xiu
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y Q Wang
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China.
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Zhi C, Huang Z, Liu D, Zheng L. Long-term follow-up study of loose combined cutting seton surgery for patients with high anal fistula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1160. [PMID: 34430601 PMCID: PMC8350621 DOI: 10.21037/atm-21-3242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
Background The treatment of high anal fistula (HAF) is still difficult for clinical surgeons. Our previous study demonstrated the short-term benefit of loose combined cutting seton (LCCS) for patients with HAF. This study aimed to evaluate the long-term effectiveness of LCCS for treating HAF patients. Methods We retrospectively enrolled consecutive HAF patients who received LCCS therapy in our hospital between March 2014 and July 2017. After enrollment, all patients were followed up by clinical review. The patients’ clinical information and most recent follow-up results were collected. Pain was assessed by the visual analog scale (VAS), and the severity of fecal incontinence was assessed by the Wexner Continence Grading Scale. We also assessed the patients’ quality of life (QOL) using a the MOS item short from health survey (SF-36) questionnaire. HAF healing was considered the primary outcome, while the fistula recurrence rate, severity of fecal incontinence, and QOL were the secondary outcomes. Results In total, 22 patients (18 male, four female) were enrolled in the final analysis. The mean duration of follow-up was 3.65 years (interquartile range: 3.55–4.22; range, 3.50–5.43). All patients were cured and there was no recurrence during the follow-up period. Eight patients reported a Wexner score of 1, while the remaining patients reported a score of 0 at the final follow-up. Furthermore, one patient had a VAS score of 1, while the remaining patients had a VAS score of 0, which indicated almost no postoperative pain. The QOL of all patients improved significantly. Conclusions LCCS is an effective method to treat HAF patients. Large, multicenter randomized controlled trials are warranted.
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Affiliation(s)
- Congcong Zhi
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Zichen Huang
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Dun Liu
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Lihua Zheng
- Proctology Department, China-Japan Hospital, Beijing, China
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