Updates in Surgery最新文献

{"title":"PROsthetic MEsh Reinforcement in elective minimally invasive paraesophageal hernia repair (PROMER): an international survey.","authors":"Alberto Aiolfi, Davide Bona, Andrea Sozzi, Luigi Bonavina","doi":"10.1007/s13304-024-02010-2","DOIUrl":"10.1007/s13304-024-02010-2","url":null,"abstract":"<p><p>The optimal treatment for paraesophageal hiatus hernia (PEH) is controversial. While crural buttressing with mesh shows promises in reducing recurrences, the decision to use mesh during minimally invasive PEH repair is largely subjective. Due to these uncertainties, we conducted a survey to examine current clinical practices among surgeons and to assess which are the most important determinants in the decision-making process for mesh placement. Thirty-five multiple-choice Google Form-based survey on work-up, surgical techniques, and issues are considered in the decision-making process for mesh augmentation during minimally invasive PEH repair. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Consensus was defined as > 70% of participants agreed (agree or strongly agree) on a specific statement. Overall, 292 surgeons (86% from Europe) participated in the survey. The median age of participants was 42 years (range 29-69). The median number of PEH procedures was 25/year/center (range 5-400), with 67% of participants coming from high-volume centers (> 20 procedures/year). Consensus on use of mesh was reached for intraoperative findings of large (> 50% of intrathoracic stomach) PEH (74.3%), crural gap with > 4 cm distance between right and left crus (77.1%), and/or crural atrophy with < 0.5 cm thickness of one or both pillars (73%), and for redo surgery (71.9%). Further, consensus was reached in defining recurrence as a combination of refractory symptoms and anatomical/radiological evidence of > 2 cm hernia. This survey shows that large PEH, wide crural transverse diameter, fragile crura, and redo surgery are the most influential issues driving the decision for mesh-reinforced cruroplasty.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":"2675-2682"},"PeriodicalIF":2.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142378269","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Augmented reality improving intraoperative navigation in minimally invasive liver surgery: an interplay between 3D reconstruction and indocyanine green.","authors":"Francesca Ratti, Matteo Serenari, Diletta Corallino, Luca Aldrighetti","doi":"10.1007/s13304-024-01857-9","DOIUrl":"10.1007/s13304-024-01857-9","url":null,"abstract":"<p><p>Technology have helped surgeons to increase MILS feasibility, so that currently liver surgery evolution is strongly based on technological advances and the same trend is expected even further soon. Aim of the present technical report is to provide insights regarding the possible interplay between 3D reconstructions based on augmented reality and intraoperative navigation by indocyanine green fluorescence. Augmented reality methods based on reconstructions created through artificial intelligence interact synergistically. The better the understanding of the anatomy and characteristics of the lesion, the more accurate the preoperative planning may be scheduled. On the other hand, the better the intraoperative navigation, the more reproducible the preoperative planning becomes.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":"2701-2708"},"PeriodicalIF":2.4,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140860185","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nutritional support via feeding jejunostomy in esophago-gastric cancers: proposal of a common working strategy based on the available evidence.","authors":"Riccardo Caccialanza, Valentina Da Prat, Raffaele De Luca, Jacopo Weindelmayer, Amanda Casirati, Giovanni De Manzoni","doi":"10.1007/s13304-024-02022-y","DOIUrl":"https://doi.org/10.1007/s13304-024-02022-y","url":null,"abstract":"<p><p>Malnutrition is common in patients affected by esophago-gastric cancers and has a negative impact on both clinical and economic outcomes. Yet not all patients at risk of malnutrition are routinely assessed and receive appropriate support. Further, available research does not provide a mean for standardization of timing, route, and dosage for nutritional support, and this is particularly true for enteral nutrition via feeding jejunostomy. Herein, we provide an overview of the current evidence and use the gathered knowledge as a starting point for a consensus proposal. As a result, we aim to facilitate the development of appropriate and uniformed interventions, thus fulfilling the need for a multimodal therapeutic approach in these set of cancer patients.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142558881","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The small-for-size syndrome in living donor liver transplantation: current management.","authors":"Luca Del Prete, Cristiano Quintini, Teresa Diago Uso","doi":"10.1007/s13304-024-01964-7","DOIUrl":"https://doi.org/10.1007/s13304-024-01964-7","url":null,"abstract":"<p><p>Small-for-size syndrome poses a significant challenge in living donor liver transplantation, with potentially severe consequences including liver failure and death. This review explores the management strategies for SFSS, starting from the pathophysiology of the disease. SFSS arises from insufficient liver mass in the graft and hyperdynamic circulation in cirrhotic recipients, leading to portal hyperperfusion and subsequent liver injury. Risk factors include graft size, quality, recipient factors, and hemodynamic changes during transplantation.Hemodynamic monitoring is crucial during living donor liver transplantation to optimize portal vein and hepatic artery flow. Prevention strategies focus on donor-recipient matching and intraoperative graft inflow modulation. Optimizing venous outflow and avoiding portal hyperperfusion is essential. Management of established small-for-size syndrome involves supportive care, pharmacologic interventions, and radiological and surgical options. Pharmacotherapy includes somatostatin analogues, beta-blockers, and vasopressin analogues to reduce portal flow and pressure. Surgical interventions aim to modulate portal flow and mitigate complications. Retransplantation may be necessary in severe cases, guided by persistent graft dysfunction despite liver flow modulations. In conclusion, preventing and managing small-for-size syndrome in living donor liver transplantation requires comprehensive assessment and tailored interventions. Advancements in graft/recipient matching, hemodynamic monitoring, pharmacologic and surgical techniques aiming to inflow modulation have improved outcomes, enabling successful transplantation even with ultra-small grafts.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142547747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transmanubrial osteomuscular sparing approach: different indications for non-pulmonary malignancies.","authors":"Leonardo Duranti, Luca Tavecchio","doi":"10.1007/s13304-024-02027-7","DOIUrl":"https://doi.org/10.1007/s13304-024-02027-7","url":null,"abstract":"<p><p>The transmanubrial osteomuscular sparing approach (TMA) is recommended for surgeries involving or originating from the thoracic outlet structures. We present a series of consecutive patients treated from 2014 to 2024 who underwent oncological thoracic outlet surgery for primary or metastatic (non-pulmonary) malignancies. Overall, 33 patients were included. Our procedures resulted in no mortality, seven complications (21.2%) and all surgeries achieved radical (R0) status. In the hands of experienced professionals, the TMA approach proves to be safe and conservative, enabling radical surgery for tumors of the thoracic outlet. For low-grade tumors, it avoids the need for additional combined surgical access, while for high-grade tumors, it allows for more extensive en bloc resection.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142508883","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery.","authors":"Maurizio De Luca, Monica Zese, Giulia Bandini, Marco Antonio Zappa, Ugo Bardi, Maria Grazia Carbonelli, Francesco Maria Carrano, Giovanni Casella, Marco Chianelli, Sonja Chiappetta, Angelo Iossa, Alessandro Martinino, Fausta Micanti, Giuseppe Navarra, Giacomo Piatto, Marco Raffaelli, Eugenia Romano, Simone Rugolotto, Roberto Serra, Emanuele Soricelli, Antonio Vitiello, Luigi Schiavo, Iris Caterina Maria Zani, Benedetta Ragghianti, Valentina Lorenzoni, Gerardo Medea, Valentina Antognozzi, Rosario Bellini, Giovanna Berardi, Fabio Cesare Campanile, Enrico Facchiano, Mirto Foletto, Paolo Gentileschi, Stefano Olmi, Massimiliano Petrelli, Vincenzo Pilone, Giuliano Sarro, Donatella Ballardini, Dario Bettini, Andrea Costanzi, Francesco Frattini, Giovanni Lezoche, Barbara Neri, Debora Porri, Andrea Rizzi, Roberto Rossini, Luca Sessa, Rossella D'Alessio, Gianluca Di Mauro, Salvatore Tolone, Paolo Bernante, Ludovico Docimo, Diego Foschi, Luigi Angrisani, Nicola Basso, Luca Busetto, Nicola Di Lorenzo, Olga Disoteo, Pietro Forestieri, Mario Musella, Barbara Paolini, Gianfranco Silecchia, Matteo Monami","doi":"10.1007/s13304-024-01996-z","DOIUrl":"https://doi.org/10.1007/s13304-024-01996-z","url":null,"abstract":"<p><p>Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m²), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142475857","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety and feasibility of pure laparoscopic living donor right hepatectomy.","authors":"Sang-Hoon Kim, Ki-Hun Kim, Fernando Rotellar, Daniel Aliseda","doi":"10.1007/s13304-024-01920-5","DOIUrl":"https://doi.org/10.1007/s13304-024-01920-5","url":null,"abstract":"<p><p>Pure laparoscopic living-donor right hepatectomy (PLDRH) has emerged as a significant advancement in liver transplantation, offering reduced donor morbidity and improved recovery times. However, PLDRH is still performed in only a limited number of centers. This retrospective study reports on the outcomes of 215 living donors who underwent PLDRH at Asan Medical Center in Seoul, Korea between November 2014 and December 2021. We reviewed donor and recipient demographics and anatomical characteristics of the donor grafts. Donor complications were classified and evaluated based on the Clavien-Dindo classification. The incidence of early donor complications within 30 days of surgery was 0.9% (n = 3), with minor complications in 0.3% (n = 1) patients and major complications in 0.6% (n = 2). No biliary complications were observed and no late complications had been reported by 30 days after surgery. The mean length of postoperative hospital stay was 7.2 days. PLDRH was a safe and feasible surgical technique characterized by a low complication rate and short hospital stays. PLDRH has the potential to become the standard procedure for the retrieval of right liver grafts from living donors.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142475856","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Italian survey about intraperitoneal drain use in distal pancreatectomy.","authors":"Nicolò Pecorelli, Claudio Ricci, Alessandro Esposito, Giovanni Capretti, Stefano Partelli, Giovanni Butturini, Ugo Boggi, Alessandro Cucchetti, Alessandro Zerbi, Roberto Salvia, Massimo Falconi","doi":"10.1007/s13304-024-01987-0","DOIUrl":"10.1007/s13304-024-01987-0","url":null,"abstract":"<p><p>Intraperitoneal prophylactic drain (IPD) use in distal pancreatectomy (DP) is still controversial. A survey was carried out through the Italian community of pancreatic surgeons using institutional emails, Twitter, and Facebook accounts of the Italian Association for the Study of the Pancreas (AISP) and the Italian Association of Hepato-biliary-pancreatic Surgery (AICEP). The survey was structured to learn surgeons' practice in using IPD through questions and one clinical vignette. Respondents were asked to report their regrets for omission and commission regarding the IPD use for the clinical scenario, eliciting a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were built to identify respondents' attitudes. One hundred six surgeons completed the survey. Sixty-three (59.4%) respondents confirmed using at least 1 drain, while 43 (40.6%) placed 2 IPDs. Only 13 respondents (12.3%) declared a change in IPD strategy in patients at high risk of clinically relevant postoperative pancreatic fistula (CR-POPF), while 9 (9.4%) respondents changed their strategy in low-risk POPF situations. Thirty-five (35.5%) respondents declared they would remove the IPD within the third postoperative day (POD) in the absence of CR-POPF suspicion. The median omission regret, which proved to be the wrong decision, was 80 (50-100, IQR). The median regret due to the commission of IPD, which turned out to be useless, was 2.5 (1-20, IQR). The CR-POPF probability threshold at which drainage omission was the less regrettable choice was 7% (1-35, IQR). The threshold to perceive drain omission as the least regrettable choice was higher in female surgeons (P < 0.001), in surgeons who modulated the strategies based on the risk of CR-POPF, and in high volume centers (p = 0.039). The threshold was lower in surgeons who performed minimally invasive distal pancreatectomy (P < 0.001), adopted a closed system (P < 0.001), placed two IPDs (P < 0.001), or perceived the IPD as important to prevent reintervention (p = 0.047). Drain management after DP remains very heterogeneous among surgeons. The regret model suggested that IPD omission could be performed in low-risk patients (7% of CR-POPF), leading to low regret in the case of the wrong decision, making it an acceptable clinical decision.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142475854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparison of survival between lobectomy and trisegmentectomy for clinical stage T1c-2aN0M0 non-small cell lung cancer in the left upper segment of the lung.","authors":"Tatsuo Nakagawa, Ei Miyamoto, Yuki Ohsumi, Masashi Gotoh, Tomoaki Matsuoka, Masashi Kobayashi, Mitsugu Omasa, Norihito Okumura","doi":"10.1007/s13304-024-02007-x","DOIUrl":"https://doi.org/10.1007/s13304-024-02007-x","url":null,"abstract":"<p><p>Left upper trisegmentectomy is expected to be as curative as lobectomy for lung cancer because the left upper lobe is anatomically the same as the combined upper and middle lobes of the right lung and the procedure can provide a sufficient surgical margin. In the present multicenter study, we compared the results of trisegmentectomy and lobectomy in patients with clinical stage T1c-2aN0M0 left upper lung cancer. We retrospectively analyzed the outcomes of patients with clinical stage T1c-2aN0M0 lung cancer in the left upper segment who underwent lobectomy or trisegmentectomy between January 2006 and June 2022. The trisegmentectomy group (S group) and lobectomy group (L group) comprised 33 and 132 patients, respectively. Comparisons of postoperative survival revealed no significant differences in overall survival (p = 0.761) or disease-free survival (p = 0.508) between the two groups. There were also no significant differences in survival after adjustment for clinical factors by Cox proportional hazards models and propensity score matching. Local recurrence was significantly more predominant in the S group than in the L group (p = 0.006). The S group had a worse postoperative survival than the L group when the tumor was located in anterior segment. Trisegmentectomy can provide an equivalent postoperative survive to lobectomy in patients with clinical stage T1c-2aN0M0 left upper segment lung cancer except in patients with tumor in anterior segment.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142393709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enhanced recovery after bariatric surgery: a comprehensive survey-based analysis of ERABS actual clinical implementation in Italian bariatric centers.","authors":"Lidia Castagneto-Gissey, Maria Francesca Russo, Annalisa Diddoro, Maurizio De Luca, Mario Musella, Giuseppe Navarra, Luigi Piazza, Marco Antonio Zappa, Marco Raffaelli, Nicola Di Lorenzo, Giovanni Casella","doi":"10.1007/s13304-024-02009-9","DOIUrl":"https://doi.org/10.1007/s13304-024-02009-9","url":null,"abstract":"<p><p>The escalating global prevalence of bariatric procedures necessitates an enhanced focus on optimizing perioperative care for improved patient outcomes. This study focuses on the implementation of Enhanced Recovery After Bariatric Surgery (ERABS) protocols in Italian bariatric centers to optimize perioperative care. An online survey comprising 19 items was conducted in October 2023, targeting managing surgeons in 139 registered bariatric centers. This survey explored geographic and center-type variations, knowledge, and application of ERABS protocols, along with perioperative, intraoperative, and postoperative practices. Statistical analysis employed included one-way ANOVA and Tukey post hoc tests. Responses from 72 centers (51.8%) revealed a strong awareness of ERABS protocols among managing surgeons. Adherence rates varied geographically (46.3-63%) and among center types (60.8-56.3%). Perioperative practices, including the abandonment of antibiotics for perioperative prophylaxis by 77.5% of surgeons and the adoption of the TAP block technique in 69% of centers, aligned well with ERABS recommendations. However, inconsistencies were noted in abdominal drain usage (61.5% after SG; 70.5% after RYGB/OAGB), with a substantial percentage not adhering to ERABS guidelines. Intraoperative habits generally adhered to ERABS protocols, yet preferences for certain tests, particularly the methylene blue test (70.4%), deviated. Postoperative practices displayed positive trends, with early reintroduction of oral feeding (71.8%) and opioid-free pain management (71.8%). Variations existed in discharge timing and patient monitoring, indicating areas for further improvement. This study offers a comprehensive snapshot of ERABS protocol adherence in Italy, emphasizing the positive trend toward optimizing recovery and reducing patient stress. Despite variations, a majority of centers demonstrated commitment to ERABS principles. Ongoing education, interdisciplinary collaboration, and nationwide dialogue are essential for standardizing ERABS protocols and advancing bariatric-metabolic surgery outcomes in Italy.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2024-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142372980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}