Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.04.002
Pierre Puygrenier , Bader Al Taweel , Astrid Herrero , Martin Gaillard
Decreasing the risk of unplanned hospital readmission in older adults is of major concern in public health. If this risk is heightened in comparison with the general population in those having undergone digestive surgery, it is due not only to more frequent occurrence of postoperative complications, but also to overall frailty, which combines comorbidities, functional disorders and dependency. Moreover, given that any unplanned readmission is a major event in the life of an elderly patient, counteraction to its consequences (immobilization syndrome, malnutrition, cognitive disorders, loss of autonomy…) must be considered by the entire surgical team, in coordination with geriatric specialists, as the priority. Readmission prevention is based on a dedicated, comprehensive geriatric assessment accompanied by an individualized, multidisciplinary prehabilitation program. The intervention of geriatricians before and after surgery is likely to improve perioperative management of the elderly patient, thereby reducing the frequency and impact of hospital readmission.
{"title":"Unplanned hospital readmission of older adults having undergone digestive surgery","authors":"Pierre Puygrenier , Bader Al Taweel , Astrid Herrero , Martin Gaillard","doi":"10.1016/j.jviscsurg.2025.04.002","DOIUrl":"10.1016/j.jviscsurg.2025.04.002","url":null,"abstract":"<div><div>Decreasing the risk of unplanned hospital readmission in older adults is of major concern in public health. If this risk is heightened in comparison with the general population in those having undergone digestive surgery, it is due not only to more frequent occurrence of postoperative complications, but also to overall frailty, which combines comorbidities, functional disorders and dependency. Moreover, given that any unplanned readmission is a major event in the life of an elderly patient, counteraction to its consequences (immobilization syndrome, malnutrition, cognitive disorders, loss of autonomy…) must be considered by the entire surgical team, in coordination with geriatric specialists, as the priority. Readmission prevention is based on a dedicated, comprehensive geriatric assessment accompanied by an individualized, multidisciplinary prehabilitation program. The intervention of geriatricians before and after surgery is likely to improve perioperative management of the elderly patient, thereby reducing the frequency and impact of hospital readmission.</div></div>","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages S16-S22"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144056341","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.04.006
Jeanne Vertier , Rémi Grange , François Casteillo , Clément Costanza , Loïc Campion , Bertrand Le Roy , Laura Ornella Perotto
Background
Data Rectal preservation strategies are being developed for small tumors in complete or good response on magnetic resonance imaging (MRI) after neoadjuvant treatment. Therefore, correlation between tumor regression on MRI and definitive histology is not clearly known. The aim of the present study is to show this correlation to see if MRI can be a reliable tool to propose a rectal preservation strategy.
Methods
All patients over 18 years of age with non-metastatic adenocarcinoma of the lower or middle rectum who have received neoadjuvant treatment followed by a re-assessment MRI prior to surgery, between 2015 and 2023 were retrospectively included. Tumor regression on MRI was defined using mrTumor Regression Grade (mrTRG) classification. Histological tumor regression grade (pTRG) was defined according to the Mandard classification. The statistical relationship between pTRG and mrTRG was determined by univariate logistic regression, with calculation of the odds ratio.
Results
76 patients were included. Most of the patients (57%) received chemoradiotherapy based on CAP50 and 26% received total neoadjuvant treatment. We found 63% concordance between mrTRG and pTRG. Moreover, among the 37% of patients for whom mrTRG and pTRG were not concordant, MRI overestimated the histological response in 71% of cases. MRI has a NPV of 81% (95% CI 73%–90%). Concordance of mrTRG and pTRG is significantly associated with mrT (P = 0.026), mrTRG (P = 0.002), endoscopic stenosing aspect (P = 0.034) and respect of fascia recti on MRI (P = 0.021).
Conclusion
In conclusion, this analysis reveals 63% concordance between mrTRG and pTRG. Moreover, MRI has a NPV of 81% and therefore MRI is more accurate with poor tumor regression. Thus, mrTRG must be used in association with other clinical or endoscopic outcomes to assess a rectal preservation strategy.
背景：数据对于新辅助治疗后在磁共振成像（MRI）上完全或良好反应的小肿瘤，直肠保存策略正在开发中。因此，MRI上肿瘤消退与明确组织学之间的相关性尚不清楚。本研究的目的是展示这种相关性，看看MRI是否可以作为一种可靠的工具来提出直肠保存策略。方法：回顾性纳入2015年至2023年间所有年龄在18岁以上且术前接受新辅助治疗并重新评估MRI的下直肠或中直肠非转移性腺癌患者。MRI上肿瘤消退采用mrTumor regression Grade （mrTRG）分类。根据标准分类确定组织学肿瘤消退分级（pTRG）。pTRG和mrTRG的统计关系采用单因素logistic回归确定，并计算优势比。结果：共纳入76例患者。大多数患者（57%）接受了基于CAP50的放化疗，26%接受了总新辅助治疗。我们发现mrTRG和pTRG之间有63%的一致性。此外，在37%的mrTRG和pTRG不一致的患者中，MRI高估了71%的病例的组织学反应。MRI的NPV为81% （95% CI 73%-90%）。mrTRG和pTRG的一致性与mrT （P=0.026）、mrTRG （P=0.002）、内镜狭窄方面（P=0.034）和MRI筋膜直肌方面（P=0.021）显著相关。结论：mrTRG与pTRG的一致性为63%。此外，MRI的NPV为81%，因此在肿瘤消退较差的情况下，MRI更准确。因此，mrTRG必须与其他临床或内镜结果联合使用，以评估直肠保存策略。
{"title":"Correlation between magnetic resonance imaging and definitive histological response in adenocarcinoma of middle and low rectum after neoadjuvant treatment","authors":"Jeanne Vertier , Rémi Grange , François Casteillo , Clément Costanza , Loïc Campion , Bertrand Le Roy , Laura Ornella Perotto","doi":"10.1016/j.jviscsurg.2025.04.006","DOIUrl":"10.1016/j.jviscsurg.2025.04.006","url":null,"abstract":"<div><h3>Background</h3><div>Data Rectal preservation strategies are being developed for small tumors in complete or good response on magnetic resonance imaging (MRI) after neoadjuvant treatment. Therefore, correlation between tumor regression on MRI and definitive histology is not clearly known. The aim of the present study is to show this correlation to see if MRI can be a reliable tool to propose a rectal preservation strategy.</div></div><div><h3>Methods</h3><div>All patients over 18 years of age with non-metastatic adenocarcinoma of the lower or middle rectum who have received neoadjuvant treatment followed by a re-assessment MRI prior to surgery, between 2015 and 2023 were retrospectively included. Tumor regression on MRI was defined using mrTumor Regression Grade (mrTRG) classification. Histological tumor regression grade (pTRG) was defined according to the Mandard classification. The statistical relationship between pTRG and mrTRG was determined by univariate logistic regression, with calculation of the odds ratio.</div></div><div><h3>Results</h3><div>76 patients were included. Most of the patients (57%) received chemoradiotherapy based on CAP50 and 26% received total neoadjuvant treatment. We found 63% concordance between mrTRG and pTRG. Moreover, among the 37% of patients for whom mrTRG and pTRG were not concordant, MRI overestimated the histological response in 71% of cases. MRI has a NPV of 81% (95% CI 73%–90%). Concordance of mrTRG and pTRG is significantly associated with mrT (<em>P</em> <!-->=<!--> <!-->0.026), mrTRG (<em>P</em> <!-->=<!--> <!-->0.002), endoscopic stenosing aspect (<em>P</em> <!-->=<!--> <!-->0.034) and respect of fascia recti on MRI (<em>P</em> <!-->=<!--> <!-->0.021).</div></div><div><h3>Conclusion</h3><div>In conclusion, this analysis reveals 63% concordance between mrTRG and pTRG. Moreover, MRI has a NPV of 81% and therefore MRI is more accurate with poor tumor regression. Thus, mrTRG must be used in association with other clinical or endoscopic outcomes to assess a rectal preservation strategy.</div></div>","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages 266-273"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144555527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.04.008
Malek Ben Rahal , Jules Le Pessot , Marion Demouron
{"title":"Peritoneal encapsulation, cause of intestinal occlusion","authors":"Malek Ben Rahal , Jules Le Pessot , Marion Demouron","doi":"10.1016/j.jviscsurg.2025.04.008","DOIUrl":"10.1016/j.jviscsurg.2025.04.008","url":null,"abstract":"","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages 316-318"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144790486","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.03.008
Bastien Le Floc’h, Louis Smits, Stylianos Tzedakis
{"title":"Laparoscopic left hepatectomy extended to the caudate lobe, middle hepatic vein and inferior vena cava for colorectal metastases (with video)","authors":"Bastien Le Floc’h, Louis Smits, Stylianos Tzedakis","doi":"10.1016/j.jviscsurg.2025.03.008","DOIUrl":"10.1016/j.jviscsurg.2025.03.008","url":null,"abstract":"","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages 319-322"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144056339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.04.001
Anaelle Guiraud , Charlotte Maulat , Jason Shourick , Charline Zadro , Emmanuel Cuellar , Nicolas Carrere , Bertrand Suc , Fatima Zohra Mokrane , Paul Boulard , Fabrice Muscari
Objectives
To evaluate our management practices after placement of a gallbladder drain for acute calculous cholecystitis and investigate predictive factors of secondary cholecystectomy.
Patients and methods
Single-center, retrospective study including all patients who underwent percutaneous gallbladder drainage for acute calculous cholecystitis between 01/01/2014 and 12/04/2022.
Results
A total of 152 patients were included, most of whom had multiple comorbidities (66% with Charlson Comorbidity Index [CCI] ≥ 5). Drain-related morbidity accounted for 47.4% of patients (including 27% with medical complications). The median duration of hospitalization after drainage was 10 days with 21% of patients requiring rehospitalization. A total of 41.4% of patients underwent secondary cholecystectomy with a 27% conversion rate to laparotomy. There was 34.9% post-operative complication rate including 6% repeat surgery with a mortality rate of 3.5%. Predictors of failure to perform secondary cholecystectomy were represented by age, CCI ≥ 5, neurological history and use of blood thinners.
Conclusion
Patients requiring gallbladder drainage for acute calculous cholecystitis often have numerous comorbidities. Less than half will have access to a secondary cholecystectomy which will be risky. We have proposed an algorithm for gallbladder drain management, taking into account the possibility of performing a secondary cholecystectomy or not, which will need to be validated in future studies.
目的：评价急性结石性胆囊炎置管引流后的处理方法，探讨继发性胆囊切除术的预测因素。患者和方法：单中心回顾性研究，纳入2014年1月1日至2022年4月12日接受经皮胆囊引流治疗急性结石性胆囊炎的所有患者。结果：共纳入152例患者，多数合并多种合并症（66%患者Charlson Comorbidity Index [CCI]≥5）。引流相关发病率占患者的47.4%（其中27%伴有内科并发症）。引流后住院时间中位数为10天，21%的患者需要再次住院。共有41.4%的患者接受了二次胆囊切除术，其中27%的患者转行剖腹手术。术后并发症发生率34.9%，其中重复手术6%，死亡率3.5%。继发性胆囊切除术失败的预测因素包括年龄、CCI≥5、神经病史和血液稀释剂的使用。结论：急性结石性胆囊炎需要胆囊引流术的患者常伴有多种合并症。只有不到一半的人有机会进行二次胆囊切除术，这将是有风险的。我们提出了一种胆囊引流管理算法，考虑到是否进行二次胆囊切除术的可能性，这需要在未来的研究中进行验证。
{"title":"What postoperative management to offer after gallbladder drainage for acute calculous cholecystitis?","authors":"Anaelle Guiraud , Charlotte Maulat , Jason Shourick , Charline Zadro , Emmanuel Cuellar , Nicolas Carrere , Bertrand Suc , Fatima Zohra Mokrane , Paul Boulard , Fabrice Muscari","doi":"10.1016/j.jviscsurg.2025.04.001","DOIUrl":"10.1016/j.jviscsurg.2025.04.001","url":null,"abstract":"<div><h3>Objectives</h3><div>To evaluate our management practices after placement of a gallbladder drain for acute calculous cholecystitis and investigate predictive factors of secondary cholecystectomy.</div></div><div><h3>Patients and methods</h3><div>Single-center, retrospective study including all patients who underwent percutaneous gallbladder drainage for acute calculous cholecystitis between 01/01/2014 and 12/04/2022.</div></div><div><h3>Results</h3><div>A total of 152 patients were included, most of whom had multiple comorbidities (66% with Charlson Comorbidity Index [CCI]<!--> <!-->≥<!--> <!-->5). Drain-related morbidity accounted for 47.4% of patients (including 27% with medical complications). The median duration of hospitalization after drainage was 10 days with 21% of patients requiring rehospitalization. A total of 41.4% of patients underwent secondary cholecystectomy with a 27% conversion rate to laparotomy. There was 34.9% post-operative complication rate including 6% repeat surgery with a mortality rate of 3.5%. Predictors of failure to perform secondary cholecystectomy were represented by age, CCI<!--> <!-->≥<!--> <!-->5, neurological history and use of blood thinners.</div></div><div><h3>Conclusion</h3><div>Patients requiring gallbladder drainage for acute calculous cholecystitis often have numerous comorbidities. Less than half will have access to a secondary cholecystectomy which will be risky. We have proposed an algorithm for gallbladder drain management, taking into account the possibility of performing a secondary cholecystectomy or not, which will need to be validated in future studies.</div></div>","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages 255-265"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144795917","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.05.001
Claire Blanchard , Benjamin Menahem
Bariatric surgery is a standard treatment for obesity and a number of its complications. Although surgical complications are relatively rare, some patients must return to the emergency department or to a facility far removed in place and time from the original surgery. The purpose of this update is to outline the main reasons for short, medium, and long-term emergency department visits and re-hospitalizations in patients who have undergone bariatric surgery. In the short term, patients may experience non-specific (pulmonary embolism, rhabdomyolysis) and specific (hemorrhage, fistula) complications. Their management is based on a multidisciplinary medical, nutritional, and interventional strategy, with an increasingly important role for surgical endoscopy. In the medium and long term, the reasons for emergency consultation and re-hospitalization are relatively non-specific (abdominal pain, vomiting, excessive or inadequate weight loss). In all cases, complete clinical, laboratory and nutritional assessments are essential. Some long-term postoperative complications are non-specific and require appropriate management: symptomatic gallstones, trocar orifice hernia. Other complications are more specific to each type of bariatric surgery. For gastric banding, these are mainly intragastric band migration and tilting; for sleeve gastrectomy, these are severe reflux, stricture, and delayed fistula; finally, for gastric bypass, these are intestinal obstructions, particularly due to mesenteric breaches, strictures, and anastomotic ulcers. The management of these complications also relies on a multidisciplinary strategy. In conclusion, re-hospitalizations after bariatric surgery are not infrequent and may occur for relatively non-specific reasons. Appropriate clinical, laboratory, and morphological assessments allow for an accurate diagnosis and appropriate management.
{"title":"Unplanned re-hospitalization after bariatric surgery","authors":"Claire Blanchard , Benjamin Menahem","doi":"10.1016/j.jviscsurg.2025.05.001","DOIUrl":"10.1016/j.jviscsurg.2025.05.001","url":null,"abstract":"<div><div><span><span>Bariatric surgery is a standard treatment for obesity and a number of its complications. Although </span>surgical complications<span> are relatively rare, some patients must return to the emergency department<span> or to a facility far removed in place and time from the original surgery. The purpose of this update is to outline the main reasons for short, medium, and long-term emergency department visits and re-hospitalizations in patients who have undergone bariatric surgery. In the short term, patients may experience non-specific (pulmonary embolism, rhabdomyolysis) and specific (hemorrhage, fistula) complications. Their management is based on a multidisciplinary medical, nutritional, and interventional strategy, with an increasingly important role for surgical endoscopy. In the medium and long term, the reasons for emergency consultation and re-hospitalization are relatively non-specific (abdominal pain, vomiting, excessive or inadequate weight loss). In all cases, complete clinical, laboratory and </span></span></span>nutritional assessments<span> are essential. Some long-term postoperative complications are non-specific and require appropriate management: symptomatic gallstones<span><span><span><span><span>, trocar orifice hernia. Other complications are more specific to each type of bariatric surgery. For gastric banding, these are mainly intragastric band migration and tilting; for </span>sleeve gastrectomy, these are severe reflux, stricture, and delayed </span>fistula; finally, for </span>gastric bypass, these are </span>intestinal obstructions<span>, particularly due to mesenteric breaches, strictures, and anastomotic ulcers. The management of these complications also relies on a multidisciplinary strategy. In conclusion, re-hospitalizations after bariatric surgery are not infrequent and may occur for relatively non-specific reasons. Appropriate clinical, laboratory, and morphological assessments allow for an accurate diagnosis and appropriate management.</span></span></span></div></div>","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages S23-S33"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144610154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-08-01DOI: 10.1016/j.jviscsurg.2025.07.006
Nadia Fathallah , Mathilde Aubert , Diane Mege
Proctological surgery is widely practiced in France, with over 100,000 procedures recorded in 2022. More than half of patients are treated as outpatients. Re-admissions or conversion from outpatient surgery to in-patient status are not uncommon and can occur in up to 18% of cases. The main reasons for early readmission are pain, acute urinary retention, bleeding, constipation, infection, anal fissure or hemorrhoid thrombosis. Later re-admissions can also occur due to anal stenosis, anal incontinence, and delayed healing. Prevention of complications is therefore essential to avoid these readmissions. This is based primarily on preoperative patient education regarding signs that may require emergency consultation, as well as on the identification of those patients at risk of bleeding, acute urinary retention, and infectious complications. Intraoperatively, adherence to the quality criteria of proctological surgery is essential, ranging from the choice of techniques to the control of hemostasis and certain technical details, such as respecting mucosal bridges in patients undergoing tripedicular hemorrhoidectomy, or chemical or surgical sphincterotomy in the case of fissurectomy. Pre- and postoperative therapeutic education is essential, as the systematic preparation of prescriptions preoperatively, and software-based patient support (e.g. text message reminders).
{"title":"Unplanned re-hospitalizations in proctology. An update","authors":"Nadia Fathallah , Mathilde Aubert , Diane Mege","doi":"10.1016/j.jviscsurg.2025.07.006","DOIUrl":"10.1016/j.jviscsurg.2025.07.006","url":null,"abstract":"<div><div>Proctological surgery is widely practiced in France, with over 100,000 procedures recorded in 2022. More than half of patients are treated as outpatients. Re-admissions or conversion from outpatient surgery to in-patient status are not uncommon and can occur in up to 18% of cases. The main reasons for early readmission are pain, acute urinary retention, bleeding, constipation, infection, anal fissure or hemorrhoid thrombosis. Later re-admissions can also occur due to anal stenosis, anal incontinence, and delayed healing. Prevention of complications is therefore essential to avoid these readmissions. This is based primarily on preoperative patient education regarding signs that may require emergency consultation, as well as on the identification of those patients at risk of bleeding, acute urinary retention, and infectious complications. Intraoperatively, adherence to the quality criteria of proctological surgery is essential, ranging from the choice of techniques to the control of hemostasis and certain technical details, such as respecting mucosal bridges in patients undergoing tripedicular hemorrhoidectomy, or chemical or surgical sphincterotomy in the case of fissurectomy. Pre- and postoperative therapeutic education is essential, as the systematic preparation of prescriptions preoperatively, and software-based patient support (e.g. text message reminders).</div></div>","PeriodicalId":49271,"journal":{"name":"Journal of Visceral Surgery","volume":"162 4","pages":"Pages S46-S52"},"PeriodicalIF":2.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144790489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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