Papers from the French Society for Vascular Surgery 1989 Meeting

Ren6 Leriche and His Work As Time Goes By Ren6 Kieny, MD, Strasbourg, France

Although greatly admired during his lifetime, Ren6 Leriche was constantly challenged in his work and in his ideas regarding vasomotricity, functional and physiological surgery, and postoperative disorders. This was mainly because his ideas did not coincide with the classical anatomic and clinical beliefs which predominated at that time. In the field of vascular surgery, which started to develop at the end of his career, many authors restrict Leriche's contributions to sympathectomy only, arguing that he favored the nerve theory in the interpretation of facts, rather than the hemodynamic theory which prevails today. He, himself, denied any responsibility for promoting the technique of sympathectomy. It is a difficult undertaking to analyze with objectivity the works left by Ren6 Leriche, author of 15 monographs and more than 1400 publications, which form the basis for his position as one of the most famous French surgeons of his time. Universally recognized as exceptionally creative and a man of ideas, he left the impression of being an enlightened researcher and a pragmatic physician to all who came into contact with him. However, the most characteristic qualities of the man were his exceptional ability to make analyses and his extreme kindness. He was, indeed, a genuine man of heart. Born on October 12, 1879, in Roanne, France, he From the Service de Chirurgie Cardio-Vasculaire, HOpital Central, Strasbourg, France. Presidential address delivered at the Annual Meeting of the SociOtd de Chirurgie Vasculaire de Langue Franqaise, Strasbourg, France, June 23-24, 1989. Reprint requests: Rend Kieny, MD, Service de Chirurgie Cardio- Vasculaire, HOpital Central, Strasbourg, France.

went to medical school in Lyon, where he was a student of Jaboulay, assistant surgeon to Antonin Poncet and the contemporary of Alexis Carrel. Leriche was deeply impressed by his trips to foreign countries, four of which were decisive in his career: he visited Kocher in Bern, Switzerland in 1906; Halsted in Baltimore in 1913, where he discovered meticulous surgical technique; and Cushing in Boston from whom he learned gentle surgery at a time during which all that seemed to matter was the rapidity of the surgical act. Last, he visited Carrel in Chicago, where he admired the French-American's experimental work and the organization of his laboratory working conditions. At Carrel's suggestion, Leriche considered emigrating to the United States. When he was ready to go, however, the Great War of 1914 broke out and he remained in France. As surgeon in La Houleuse camp, he became involved in bone and joint surgery. From this experience, he started his research with Policard on osteogenesis and analyzed calcic mutation. From that moment, he became interested in the posttraumatic changes in vasomotricity and attempted to understand the mechanisms of pain in nerve wounds and amputated stumps. Although he was favored for a key post on the Strasbourg Faculty at the time of the Armistice in 1918, he gave his place to Sencert, who died in 1924. In November of that same year, he became Head of the First Surgical Clinic of Strasbourg where he lived in the Contades Hotel, also called Maison Voltaire, because the famous philosopher once lived there for a while. Perfectly integrated into the social and intellectual life of Strasbourg, where he became a prominent figure, he presented his Inaugural Address in 1925 which became known as the "Manifesto of

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Fig. 1. The Clinique Chirurgicale A in 1931.

Strasbourg." " . . . i f I am here, it is because the future of surgery holds more than the ablation of fibroma or ulcers... We are taking part in the birth of a new surgery, a physiological surgery in which the objectives are to domesticate the organic nervous regulation to our will". He was to remain that platform all his life (Fig. 1.). He lived in Strasbourg for approximately 12 years, which were interrupted only by a brief stay in Lyon. In 1932, Edouard Herriot, the mayor of Lyon, asked him to return to the city where he had studied. He accepted the proposition, but stayed only a few months when he returned to the banks of the Rhine at the friendly insistence of the entire City of Strasbourg. He remained there until he was named to the Chair of Claude Bernard, his spiritual master, at the College of France, in I936. For a few years thereafter, he divided his time between Paris and Strasbourg, and after 1939, remained in the capital, reducing his surgical activity

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because it was impossible for him to practice in the Parisian public hospitals. Later on, his nearly exclusive activity was teaching at the College of France. The courses and lectures he gave there were published every year by Masson Editions. His contact with surgery became more and more sparse. He then became severely ill, and he retreated to his property in Cassis, a small fishing port near Marseilles in the south of France where he died on December 28, 1955, at the age of 76. Leriche's overall Strasbourg legacy, which contains his enormous experience in surgery and research, is immense, especially if one includes the work he inspired his disciples: Stricker, Froehlich, Fontaine, Kunlin, Dos Santos, Orhan, Arnulf, Jung, Stulz, De Bakey, to name only a few (Fig. 2). It would not be appropriate to question the validity of Ren6 Leriche's beliefs today. I remind you that I spent a large part of my career, raised in the cult of my prestigious predecessor, under the guidance of one of his spiritual sons, dean Fontaine. In addition to documents and letters made available to me, I have had access to numerous anecdotes and notes released by The First Surgical Clinic of Strasbourg. A different aspect of the life and works of Leriche has been brought forth by Jean Kunlin, who, from 1930 to the end of Leriche's life, was his nearest collaborator and has honored us with his presence at this meeting today (Fig. 3). From the very beginning of his career as a surgeon, Leriche was preoccupied with trying to understand the mechanisms of pain in order to treat it with rational efficacy. It is with this chapter in his life, which encompasses most of his contributions to vascular surgery, that we shall begin. I shall attempt to underscore Leriche's principal contributions to vascular surgery, while overviewing his formidable accomplishments in other fields of surgical pathology. One of my goals is to show that the equation, Ren6 Leriche = surgery of the sympathetic nerve, is by far too simplistic.

LERICHE AND THE STUDY OF PAIN

Fig. 2. R. Leriche (right) and M.E. DeBakey (left) in restaurant near Strasbourg in 1935,

The study of pain is one of the best examples of the "Lerichian" approach to medical problems. It leads us to examine the reflections of Leriche the humanist and the decisions of the physician that he was. The humanistic aspect of his works could not be better exemplified than by the series of lectures he gave in 1936 at the College of France, where he began by stating: "Pain can occur at any moment in life and no one is spared. We, as surgeons, who encounter pain continuously while dealing with disease, we, who more than anyone else should know its deepest secrets, we do indeed know very little about it".

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tive to pain and even pusillanimous. Not only did he observe that two individuals could react differently to pain, but the same individual could respond differently according to the situation in which he found himself. (3) Pain as a " s y m p t o m " must be distinguished from pain as a "disease". As early as 1917, he became skeptical about interpreting pain from solely an anatomical point of view. At this time, he had already performed 14 radicotomies. Later on, he concluded that, being different from pain as a symptom, pain as a disease did not only travel through the sensory pathways but involved the organism as a whole and particularly, the sympathetic nervous system. He thus introduced the notion of pain as an pathologic entity. Unknowingly, he had opened the chapter of psychosomatic disorders. One of his most important qualities was that he always tried to add to our knowledge of surgical pathology by looking at a new, functional aspect of the problem, in this particular setting, the expression of pain. He attempted to unify all the pathological conditions he encountered. This is exemplified when one considers the following t w o pathologic situations he was fond of using for examples. Phantom stumps

Fig. 3. R. Leriche (left) and J. Kunlin (right) in the surgical laboratory of the Clinique Chirurgicale A.

No surgical textbook at that time dealt with the treatment of pain any more than they did with the idea of death. Both of these subjects were taboo. His approach to the question was to consider pain as "informative", and to analyze it in the light of his experience, because there was at that time no scientific approach available. He came to the following conclusions: (1) Pain is not natural and is not in man's best interest. It does not warn him of something nor can he use it to defend or exalt himself. The stoic value of pain, founded on moral issues, was not adopted by Leriche, who said, "There is only one type of pain that is easy to support, that is the pain of others..." and "... always useless, pain impoverishes man. It is a morbid and pathologic manifestation that must be minimized, not respected." (2) All people do not respond to pain in the same manner. He observed how the soldier, in the battlefield, submitted to surgical intervention without anesthesia and seemed resistant and even oblivious to pain. In civilian life, on the other hand, people were sensi-

In 1920, Leriche realized that when stump neuroma were anesthetized or sectioned more proximally, it was possible to prevent or improve the powerful sensation that amputees occasionally experienced, i.e. perception of their amputated limb. Leriche showed that this was due to neuroglioma, which transmitted the impulses created by movement of the stump to the brain. He distinguished stump pain associated with vasomotor disorders due to sympathetic disturbances, which could benefit from periarterial sympathectomy, arterectomy, section of nerve radicles, infiltrations or gangliectomies, from genuine pain of the phantom limb, which was a problem of sensitive pathways. In these cases, it was more appropriate to perform posterior radicotomies, cordotomies, commissural myelotomies, and even operations involving the cortex, i.e. leucotomies. Causalgia Looking back at the observations on nerve lacerations made by Weir Mitchell during the American Civil war in 1864, Leriche noted that causalgia could also be caused by arterial injury. The classical case was that of a man who sustained a fire arm wound to the fight axilla. Although he did not appear to have any ischemic disorders, this patient complained of "permanent pins and needles and

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ing approximately 10 seconds followed by peripheral vasodilatation which lasted much longer. Even if Leriche was the first to foresee the therapeutic potential of sympathectomy, he never pretended to be the inventor. In 1852, Claude Bernard, whom he succeeded in the College of France, had described vascular tumescence in the ear of the rabbit after removal of the sympathetic ganglion. His teacher, Jaboulay, had observed trophic changes in the foot after division of the nerves located in front of the femoral artery. Neither of these two men, however, had gone any further than simple observation, nor had they established a possible cause and effect relationship. Leriche set forth the rule and said that it dated from 1852 (Claude Bernard), adding, "What a pity that all this time has been lost between then and now... Until 1915, no one had thought that the nerve element of the arterial wall could be very important. There had been no mention of periarterial sympathectomy or even the paravertebral chains. No one has yet talked of vasomotricity in surgery..." Even if his works had been limited to this chapter only, his contribution to surgery would have been immense. The creation of pain clinics in the 1970s is one of the outcomes.

LERICHE AND FUNCTIONAL SURGERY Fig. 4. Front page of L'arterictomie dans ies arterites obliterantes (Arteriectomy for Peripheral Occlusive Vascular Disease), coauthored by P. Stricher.

bullets going through my hand." At operation, August 27, 1917, Leriche identified and removed 12 cm of nerve filaments surrounding the brachial artery. Fifteen days later, the patient no longer complained of pain. One of Leriche's major contributions to therapy was born: periarterial sympathectomy. He was then able to attirm that causalgia was a functional rather than anatomical disorder, and he condemned those who doubted this theory or who treated causalgia by amputation. Not all surgeons amputated these patients, however, because many did not even believe in causalgia and stated that "it does no good to operate on these patients because most complaints should cease once the War is over". The work of Leriche focused predominantly on the role of the sympathetic system. The operation described above, performed for causalgia in I917, was the fruit of an observation he had made two years earlier, when he accidently pinched an artery intraoperatively and noted a vasoconstriction last-

Before dealing with Leriche's contributions to vascular surgery, we cannot leave aside his interest in visceral surgery and vasomotor and metabolic problems. Based on personal observations, Leriche conceived the notion of postoperative disease, under which he regrouped the nonspecific disorders created by surgery. This idea raised very severe criticism. Several years later, however, the works of Reilly and Selye on the syndromes of adaptation and stress lent support to this theory. In addition, by his physiological approach to disease, he aimed at correcting disorders early in the course of disease, ideally at onset. Moreover, he attempted to explain a disorder on the basis of sympathetic or circulatory derangement which had to be reversed before genuine organic disorders occurred. His conclusions were forerunners to therapeutic procedures such as stripping of the auriculotemporal nerve in the treatment of salivary fistulas and the treatment of duodenal ulcer by vagotomy as proposed by Dragstedt 30 years later. Admittedly, his belief that most disorders were due to a sympathetic derangement led him to make hasty deductions, followed by therapeutic failures, and, not surprisingly, more sharp criticism from his opponents.

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LERICHE AND VASCULAR PATHOLOGY Along with Alexis Carrel, Leriche was a pioneer in animal experimentation on grafts, and, in the beginning of his career, was a proponent of the triangulation technique for vascular anastomoses. However, at this time, he focused all his efforts on research in vasomotricity, a field in which surgical treatment of pain and peripheral arterial disease converged, while he left aside ischemia and the problem of revascularization. After a few operations on nonatheromatous arteries to try to heal variceal ulcerations, he enlarged his conception of periarterial sympathectomy to that of arterial circulatory disorders. He noted that thromboses were segmental in nature. He then proposed that arterectomy be associated with arterial sympathetectomy in these cases to counter the vasospastic effects related to irritation provoked by the thrombosis (Fig. 4). All this must be placed in the context of that time in which pregangrenous symptoms of arterial disease were practically unknown and, as Kunlin reminds us, the limits of thrombosis were difficult to define. At the same time he expanded the indications for sympathectomy to vasomotor disorders, Raynaud's phenomenon, and other trophic disorders. He also improved the modalities and techniques of local anesthesia and infiltrations (Fig. 5). Angina pectoris was another battlefield for Leriche. Right from the start, the problem of angina intrigued and seduced him: the disease was totally ignored by the medical profession at that time, and there were only two manifestations associated with it, pain or death. Leriche was the first to believe that angina would "someday be treated by the scalpel." As early as 1913 he proposed to divide the nerves coursing in front of the aortic arch in aortitis and angina. In 1925, just after he moved to Strasbourg, he healed a prominent 53 year-old industrial leader who had subintrant bouts of angina by injecting novocaine into the stellar ganglion. In 1932, with Fontaine, he reported his results in 27 patients undergoing stellectomy before an audience of totally indifferent cardiologists. Later, he encouraged Dr. Arnulf, who is also present in this room today, to study the preaortic plexus. Although he did not go as far as to propose myocardial revascularization, it should be noted here that after a quarter of a century of surgical aortocoronary bypass, vasospastic phenomena are still held responsible for certain postoperative failures. This has led several teams, and we among them, to perform routine preaortic plexus resection with aortocoronary bypass. Simultaneously, his ideas on neuroendocrine surgery under the influence of Von Oppel led him to propose adrenalectomy in Buerger's disease, which

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was advocated by most of his disciples for a long time. Without any doubt, the neuroendocrine theory did not meet the test of time and the etiology and pathogenesis of thrombangiosis remain a mystery. Arterial restorative surgery remained outside Leriche's field of action. Why? There is probably no precise answer to that question, but several elements must be taken into consideration. First of all, vascular techniques were employed at that time on healthy vessels in animal models with the intention of performing grafts. Bringing this technique into clinical practice to apply to pathologic vessels tempted Leriche on two occasions, but he remained very circumspect about it later on. In 1909, he attempted to restore arterial flow in a thrombosed artery with a vein graft operation which was reported in the thesis of Louis B~rard. In 1912, once again he attempted the same procedure with Murard, but the operation was curtailed as they could not identify the distal limit of the obliteration. One must remember, however, that, at that time, the concept of segmental arteritis was not established and that the absence of investigational methods to delineate the site and extent of lesions was a major obstacle to effective surgery. With this experience, Leriche combined the anatomic and clinical concept of aortoiliac arteritis and the techniques of angiography learned from Reynaldo dos Santos in Lisbon and brought to his ward by Dos Santos" son, and laid the foundations for arterial reconstructive surgery. Kunlin mentioned that during a resection performed for thrombosis of the common iliac artery, Leriche once said that "it would be a good thing if we could reunite the two ends of the arterial section with a graft." Leriche never spoke to Kunlin about this again. In 1947 Cid Dos Santos reported his technique of thromboendarterectomy in Paris. At that time Kunlin thought of replacing that technique using a saphenous vein graft without obtaining Leriche's approbation. Performed in 1948 when Leriche was absent from the hospital unit, the operation turned out to be a success. Leriche later reported the results of the first eight patients treated by this technique to the Academy of Sciences: there were six spectacular successes in the treatment of distal gangrene. According to Kunlin, Leriche was deeply disturbed by these results because long-term patency remained good in spite of the absence of sympathetic chain resection and without direct surgery on the involved artery, defeating the very concept of a spastic origin of arterial lesions. In spite of this, direct vascular procedures were already an integral part of the diversified surgery being performed in Strasbourg at that time. Ischemic syndromes due to embolism were being reversed, though final outcome was often compromised by unremovable secondary thrombosis and the absence of efficient anticoagulant therapy.

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syndrome which bears his name. His thinking on this entity began in 1923 and lasted for a quarter of a century. In 1923, he described the clinical manifestations of the syndrome associating claudication with the absence of arterial oscillations and pulsations after exposure of the femoral artery. Although the exact nature of the disease was unknown, the offending lesion was most likely localized and perifemoral arteriotomy was ineffective. In the words of a prophet, and as early as 1923, Leriche stated that the ideal treatment would be resection graft, unfortunately impossible at that time. In his second report on the subject 17 years later, he described sexual impotence, walking fatigability, atrophy of leg muscles and integumental paleness. He stated that diagnosis should be made by arteriography, and he advocated the resection of the occluded aortoiliac segment and bilateral lumbar sympathectomy. In his third report in 1948, Leriche described a series of 20 patients and observed that this syndrome was not rare. He attributed the syndrome to atheroma of the aortic wall associated with intense peripheral arteritis. He defined the therapeutic indications based on severity of symptoms and advocated resection-graft associated with bilateral sympathectomy in favorable cases or uni- or bilateral sympathectomy alone otherwise.

WHAT IS L E R I C H E ' S IMPACT ON VASCULAR SURGERY TODAY? Fig. 5. Front page of R. Leriche's main book on his favorite topic: vasomotricity and its role in arterial disease.

In the dramatic setting of severe pulmonary embolism, Leriche advocated stellar infiltration as the initial step. In case of failure, he proposed a direct approach to the pulmonary artery to remove the clot. The first attempt at pulmonary embolectomy was made in 1935 in his department, but the attempt failed. Arterial aneurysms were treated by Matas' endoaneurysmorrhaphy technique. The procedure was described in minute detail along with the general principles of surgery of aneurysms in two books, Pathologic Physiology and Surgery of Arteries and then Arterial Aneurysms and Arteriovenous Fistulas. In these books there were at least 14 precepts describing with great precision all the important aspects of the problem, with details of the techniques of approach still advocated today. L E R I C H E ' S SYNDROME Leriche's major contribution, in the opinion of physicians worldwide, was the description of the

At the end of his life, already undermined by his illness, Leriche saw restorative surgery develop in the hands of his proteges, Cid dos Santos, Jean Kunlin, Dean Fontaine and Michael De Bakey. Upholding the idea that the sympathetic chain was central to pathological states, he published a synthesis of his beliefs on physiological surgery which was vigorously criticized later. In fact, negative criticism of Leriche's works has always proceeded in the same fashion: his contributions to the clinical, etiologic, pathogenic, and morphological aspects of vascular surgery have been forgotten and only his ideas about sympathectomy are remembered. Because sympathectomy now occupies a very limited place in the current therapeutic armamentarium, his bad image has spread, by prejudice, to the rest of his works. Some of Leriche's interpretations indeed seem questionable today; several diagnostic or therapeutic propositions have become outmoded. There is, however, increased interest in sympathetic therapy because of better selection of patients due to progress in functional investigations and the "probably abusive" practice of chemical sympathectomy. Indisputably, Leriche's enthusiasm for analysis made him occasionally favor style to the detriment

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of content. His hypotheses were taken as indisputable facts because Leriche was well liked, knew how to use language, and was an excellent writer. According to Kunlin, Leriche did, however, "open horizons that were not mirages". He encouraged reflection and reason in his pupils who alone would have been unable to accomplish their practice. If Leriche cannot be considered as the father of vascular surgery, he was the spiritual father of many ideas that contributed to it. He was among the first, nearly 80 years ago, to attempt it. He made physicians aware of vascular pathology and contributed in a large measure to the prominent place that France held in the early 1950s in restorative surgery. This was exemplified by the successes of Jacques Oudot in the treatment of aortoiliac obliteration in 1950, and of Charles Dubost who, in 1951, repaired the first abdominal aortic aneurysm. In spite of the enormous progress made in traumatic vascular surgery and the availability of heparin in other countries, especially the USA, direct surgery of arterial disease was born in France. Without the problems created worldwide during the troubled 1940s, which greatly changed his life, it is highly likely that restorative surgery would have come to Leriche's unit. Although he appeared dubious, he was not negative about Kunlin's research on femoral bypass, vein disobliteration, and arteriovenous fistulas. His apparent disinterest was probably due to his illness which he hid from everybody because of his pride. In spite of his illness, he did perceive the exceptional value of heparin, and he was greatly frustrated when, during his last days in the College of France, he could not present his own personal results. How difficult it is to look ahead and foresee the future! Who, among the present practitioners of cardiovascular surgery, could have imagined or defended ten years ago the present or future development of endoluminal vascular techniques, procedures that were proposed in 1964 by Dotter and improved by Gruntzig? Can a man be a prophet in his own country? Apparently no because Leriche's name has perpetuated throughout the world in association with a syndrome, a stage of arterial disease, and a valve invented by his friend Ettore Bugatti. Even in his

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own City of Strasbourg, a street bearing his name has existed but a few years. Avenue Rend Leriche is located in the district of Hautepierre where the new University Center was built. Since the road is circular, it does not have the majesty of a large fairway, bordered by trees, which crosses the city, but, in fact, its location and shape can be said to have a double meaning. Located in the most recently developed part of the city, it reflects the modernism of the man's reflection. By its form, it suggests continuity and return to the initial hypothesis, which corresponds so well to the spirit of Rend Leriche.

REFERENCES 1. LERICHE R. Du syndrome sympathique consdcutif ~ certaines oblitdrations artdrielles traumatiques et de son traitement par la sympathectomie pdri-artdrielle. Bull M ( m Soc Chit Paris 1917;43:301. 2. LERICHE R. Des oblitdrations artdrielles hautes (oblitdrations de la terminaison de l'aorte) comme causes des insuffisances circulatoires des membres infdrieurs. Bull MOm Soc Chir Paris 1923;49:1404-1406. 3. LERICHE R. De la rdsection du carrefour aortico-iliaque avec double sympathectomie lombaire pour thrombose artdritique de l'aorte; le syndrome de t'oblitdration. Presse Med 1940;48:601--604. 4. LERICHE R, MOREL A. The syndrome of thrombotic obliteration of the aortic bifurcation. Ann Surg 1948;127: 193-206. 5. LERICHE R, KUNLIN J. Possibilit6 de greffe veineuse de grande dimension (15 b. 47 cm) dans les thromboses artdrielles 6tendues. Comptes-rendus des sOances de/'Acad~rnie des Sciences 1948;227:939-940. 6. KUNLIN J. Le traitement de l'ischdmie artdritique par la greffe veineuse longue. Rev de Chir 1951;70:206-235. 7. LERICHE R, STRICKER P. L'artdriectomie dans les artdrites onlitdrantes. Etude expdrimentale et thdrapeutique. Paris, Masson et Cie, 1933. 8. LERICHE R. La chirurgie de la douleur. Paris, Masson et Cie, 1940, 2nd edition. 9. LERICHE R. Physiologie pathologique et chirurgie des artdres. Principes et mdthodes de la chirurgie artdrielle. Paris, Masson et Cie, 1945. 10. LERICHE R. Physiologie pathologique et traitement chirurgical des maladies artdrielles de la vasomotricitd. Paris, Masson et Cie, 1945. 11. LERICHE R. Les embolies de l'artdre pulmonaire et des art~.res des membres. Paris, Masson et Cie, 1949. 12. LERICHE R. An~vysmes artdriels et fistules artdrioveineuses. Paris, Masson et Cie, 1949. 13. LERICHE R. Bases de la chirurgie physiologique. Essai sur la vie v6gdtative des tissus. Paris, Masson et Cie, 1955.

René Leriche and his work. As time goes by.

Papers from the French Society for Vascular Surgery 1989 Meeting Ren6 Leriche and His Work As Time Goes By Ren6 Kieny, MD, Strasbourg, France Althou...
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