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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 380-386

Superiorly based septal mucosal flap for endoscopic repair of nasal septal perforation


Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt

Date of Submission12-Feb-2018
Date of Acceptance22-Mar-2018
Date of Web Publication17-Apr-2019

Correspondence Address:
Ahmad M Hamdan
Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_72_18

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  Abstract 


Objective
To assess the outcome of endoscopic superiorly based septal mucosal flap technique in the repair of nasal septal perforation.
Background
Septal perforations are a common problem with many surgical options for closure using either closed or open approach.
Patients and methods
This case series study included 14 patients with anterior septal perforation with idiopathic or iatrogenic etiology recruited from Otorhinolaryngology Department, Menoufia University, during the period from July 2015 to July 2017. The patients were assessed using history taking, anterior rhinoscopy, endoscopic examination, and computed tomography. Preoperative symptoms were assessed using visual analog scale. All patients were subjected to superiorly based septal mucosal flap. The success rate was assessed with operative duration, operative blood loss, and postoperative symptom scores. The success of the operation was correlated with vertical and anteroposterior diameters of the perforation.
Results
The success rate of the technique was 71.4%. The mean operative duration was 2.23 ± 0.44 h. The mean blood loss was 93.6 ± 13.9 ml. There was a highly significant improvement in all symptom scores except for whistling, which showed a significant improvement (P < 0.001 and P = 0.002, respectively). There was a significant relationship between the success of the operation and the anteroposterior diameter (P = 0.002) but not the vertical diameter (P = 0.7).
Conclusion
Our flap technique is a new and good option for repair of septal perforations with a success rate of 71.4%. It is most effective with limited anteroposterior diameters. Large anteroposterior diameters need other flap designs or an open approach.

Keywords: endoscopic repair, mucosal flap, septal flap, septal perforation, superiorly based flap


How to cite this article:
Atallah AT, Khalil YA, Abdelshafi IA, El-Demerdash AA, Hamdan AM. Superiorly based septal mucosal flap for endoscopic repair of nasal septal perforation. Menoufia Med J 2019;32:380-6

How to cite this URL:
Atallah AT, Khalil YA, Abdelshafi IA, El-Demerdash AA, Hamdan AM. Superiorly based septal mucosal flap for endoscopic repair of nasal septal perforation. Menoufia Med J [serial online] 2019 [cited 2019 May 23];32:380-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/380/256142




  Introduction Top


Nasal septal perforations are a very frequent nasal disorder. They have a wide variety of causes including idiopathic, iatrogenic (after septal surgery), or nasal granuloma. Fortunately, most septal perforations are asymptomatic especially posterior ones. However, anterior septal perforations can cause a variety of symptoms including crusting, whistling, discharge, or epistaxis. Moreover, the impairment of nasal airflow can produce a sense of nasal obstruction. Medical treatment for septal perforation is the primary treatment option for such pathology including nasal lavage and local ointments to prevent crusting. However, surgical intervention to repair the perforation is the alternative option for failed medical treatment with persistence of symptoms [1].

All surgical procedures, aimed at repair of nasal septal perforations, are based on two main principles, namely, repair using mucosal, mucoperichondrial, and/or mucoperiosteal flaps with or without interposition of a graft material between mucosal flaps. Surgical repair of septal perforation can be carried out using either closed intranasal approach or open approach. The advantage of the former is that it does not leave any external scar. However, the 'open' technique offers a wider operating field, thus allowing better access to large and/or posterior perforations, and offering binocular vision. The open approach includes a variety of techniques including open rhinoplasty, sublabial, and midfacial degloving approaches [2].

Different designs of mucosal flaps have been described for the repair of nasal septal perforation. The most popular of which is the bipedicled advancement flaps whether unilateral or bilateral. Other designs for mucosal flaps include inferior turbinate advancement flap (unilateral or bilateral), upper lateral cartilage, inner mucoperichondrial flap, middle turbinate flap, facial artery musculomucosal pedicled flap, oral mucosal flap, and also radial forearm free flap [3]. The aim of this study was to assess the outcomes of endoscopic superiorly based septal mucosal flap technique in repair of nasal septal perforation repair with operative details and factors affecting the outcome.


  Patients and Methods Top


The current study is a case-series study evaluating endoscopic superiorly based septal mucosal flap technique in repair of nasal septal perforation repair. After approval of the ethical committee of the hospital, the patients of this study were recruited from Otorhinolaryngology Department, Menoufia University, during the period from July 2015 to July 2017. A written consent was taken from every patient before surgical intervention.

To be included in the study, every patient should be older than 18 years of age and with anterior nasal septal perforation involving the cartilaginous septum. The cause of the perforation should be idiopathic, traumatic, or postoperative, and the nasal septal perforation should be symptomatizing, indicating surgical intervention for repair. The main presenting symptoms include crusting, epistaxis, discharge, whistling, and nasal obstruction. Failure of response to medical treatment is an indication for surgical intervention.

Any patient with history of systemic diseases interfering with healing including diabetes mellitus, liver diseases, and autoimmune diseases was excluded from the study. In addition, exclusion criteria included self-inflicted nasal septal perforation and local conditions of the nose interfering with repair of the perforation including granulomata (syphilis, scleroma, Tuberculosis (TB), sarcoidosis, or Wagner's granulomatosis), and nasal and paranasal neoplasia. Any patient with surgical unfitness including bleeding tendencies or uncontrolled cardiac diseases was excluded from the study.

Fourteen patients were included in the study. Every patient was subjected to the following protocol:

Preoperative assessment

All patients were assessed by history taking to define the cause of the perforation and the presence or absence of symptoms of perforation. Seven symptoms were assessed using visual analog scale including crusting, epistaxis, pain, discharge, obstruction, whistling, and overall discomfort, with the patient giving his/her symptoms a score of 10.

Anterior rhinoscopy was performed for every patient: to define the presence of nasal septal perforation, its site whether bony or cartilaginous, and the condition of nasal mucosa with any associated pathology. Endoscopic examination of the nasal cavity was done to confirm the findings of anterior rhinoscopy and to assess the size of the perforation using a ruler or a piece of radiography film cut to match the size of the perforation [Figure 1]d. Computed tomography of nose and paranasal sinuses, coronal and axial cuts, was performed for every patient to define the site and size of perforation and to exclude any other intranasal pathology.
Figure 1: Superiorly based septal mucosal flap technique: (a and b): Septal perforation with the removal of crustations. c: Injection of the edge. d: Measuring the size . e: Cautery of the planned flap incisions. f: Incision of the septal mucosa (g and h): Raising the flap i: Freshening of the superior edge. (j and k): Reversal of the flap towards the perforation. (l and m): Passing the flap to the contralateral side. (n and o): Stitching the flap to the anterior edge. p: Completed suturing of the flap to the edges of the perforation. (q and r): Insertion of silicone stents. s: Merocel packing. t: Postoperative complete closure of the perforation.

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Operative technique

Patients of the study were subjected to superiorly based septal mucosal flap technique [Figure 1]. This technique has been proposed, described, and named as reverse Hadad flap by Dr. Prahalda N.B. of Karnataka ENT Hospital and Research Center, Chitradurga, Karnataka, India, through his medical education channel. However, up to our best knowledge, this technique has not been evaluated in a study in the literature.

Patients were operated under general anesthesia after taking a written consent from every patient. The nasal mucosa was decongested with a solution containing 2 ml epinephrine 1% and 1 ml sodium bicarbonate 8.4% and will be infiltrated with 2% lidocaine and epinephrine 12.5 μg/ml to reduce intraoperative bleeding [Figure 1]c.

We used an endoscopic approach with the aid of telescopes 0 and 30. A hemitransfixion incision was done at the anterior end of the septum at the wider nasal cavity. Separation of the mucoperichondrial flaps with trimming of the anterior edge of the perforation was done. Incision of the septal mucosa was done posterior to the perforation to raise the septal mucosal flap [Figure 1]f, [Figure 1]g, [Figure 1]h.

For raising the flap, a superior incision was extended posteriorly from a point 0.5 to 1 cm posterior to the posterosuperior angle of the perforation, and 1 cm below the nasal roof to a point 1 cm in front of the anterior sphenoidal wall. Inferiorly, an incision was extended posteriorly from a point 0.5 to 1 cm posterior to the posteroinferior angle of the perforation, and 0.5 cm above the nasal floor to a point 1 cm in front of the anterior sphenoidal wall. Posteriorly, a vertical incision was made connecting the superior and inferior incision located 1 cm in front of the anterior sphenoidal wall. Anteriorly, the mucosal flap was continuous through the perforation with the septal mucosa at the contralateral side of the nasal septum posterior to the perforation and with the septal mucosa above the perforation [Figure 2]. This flap is based on the anterior and posterior ethmoidal arteries above the perforation [Figure 3].
Figure 2: Superiorly based septal mucosal flap is elevated, reversed and sutured to the anterior, superior and inferior edges of the perforation.

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Figure 3: Design of our superiorly based septal mucosal flap with its blood supply derived from anterior and posterior ethmoidal arteries.

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Trimming of the superior and inferior edges of the perforation was performed. The flap was reversed and sutured to the anterior, superior, and inferior edges of the perforation on the contralateral side of the donor site with absorbable sutures (Monocryl 5–0) [Figure 1]l, [Figure 1]m, [Figure 1]n, [Figure 1]p and [Figure 2] (Ethicon, Cornelia, Georgia, USA). The amount of blood loss was calculated by measuring the amount of intraoperative suctioned fluid with subtraction of intraoperative saline wash. Silicone stents were placed bilaterally and sutured with absorbable sutures (Monocryl 4–0) to prevent synechiae and to preserve the humidity of the sutured flaps [Figure 1]q and [Figure 1]r. Merocel nasal packing was done [Figure 1]s. The pack was removed 2 days postoperatively.

Postoperative assessment

Removal of the stents was done 2 weeks postoperatively. Endoscopic assessment was performed at weekly intervals after removal of the stents till complete healing of the edges of the perforation occurs for a maximum duration of 3 months. After healing of the perforation, the seven preoperative symptoms were assessed using visual analog scale to be compared with the preoperative symptom scores.

Outcome measures

They included the success of the surgical operation in repair of septal perforation defined as complete closure or partial closure, operative details including operative time and intraoperative blood loss, and comparison between the preoperative and postoperative symptom scores. Moreover, relationship between the success of the procedure on the one hand and anteroposterior diameter and vertical diameter at the other hand were evaluated.

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM personal computer with IBM statistical package of the social sciences (SPSS), version 23 (Armonk, NY, USA). Descriptive statistics for quantitative data were presented as mean and SD. Qualitative data were presented as numbers and percentages. Data turned out to be non-normally distributed according to Kolmogorov–Smirnov test. Wilcoxon Signed-Rank test was used to compare preoperative and postoperative symptom scores for the study patients. Mann–Whitney U-test was used to compare quantitative data of both groups of success and failure. Two-sided P value of less than 0.05 was considered statistically significant, whereas P value of less than 0.001 was considered highly significant.


  Results Top


The current study included 14 patients, comprising seven males and seven females, with age range from 24 to 42 years (mean ± SD 33.5 ± 6.63). The vertical diameter of the perforations ranged from 0.5 to 2 cm (mean ± SD 1.38 ± 0.47 cm). The anteroposterior diameter of the perforation ranged from 1 to 2.5 cm (mean ± SD 1.63 ± 0.51 cm). The most distressing symptom for the patients was crusting, with mean score of 9.14 ± 0.77, followed by discharge and overall discomfort [Table 1].
Table 1: Comparison between preoperative and postoperative symptom scores in study patients

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The success rate of superiorly based flap technique was 71.4%, with 10 of 14 patients showing complete closure of the perforation. The mean operative duration was 2.23 ± 0.44 h. The mean blood loss was 93.6 ± 13.9 ml.

In the current study, there was a highly significant improvement in all symptom scores, with P value of less than 0.001 for all, except for whistling, which had significant improvement (P = 0.002) [Table 1]. There was a significant relationship between the anteroposterior diameter and success of the operation (P = 0.002). However, the vertical diameter had no statistical relationship with the success of the operation (P = 0.7) [Table 2].
Table 2: Assessment of the relationship between vertical and anteroposterior diameters of septal perforation and successful repair

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  Discussion Top


In the current study, we evaluated the use of a unilateral mucosal flap for repair of nasal septal perforation which is the superiorly based septal mucosal flap, which has been proposed, described, and named as reverse Hadad flap by Dr Prahalda N.B. This name of the technique has been based on the fact that it is the reverse of the Hadad–Bassagasteguy flap, which has been descried for repair of skull base defects [4]. Both flaps are septal mucosal flaps, but they are different regarding the direction of flap elevation and blood supply. Reverse Hadad flap is raised from posterior to anterior in contrary to Hadad flap, which is raised from anterior to posterior. On the contrary, Hadad flap is based on the posteriorly located nasoseptal artery, a branch of the posterior septal artery, in contrary to our flap, which is based on the anteriorly and superiorly located anterior and posterior ethmoidal arteries.

The success rate of our technique was 71.4%. This success rate is lower than previous studies in the literature evaluating different designs of septal mucosal flaps for repair of septal perforation using endoscopic approach [Table 3]. The lower success rate of our technique can be explained by the need for more experience regarding this new technique. In addition, this technique needs adequate septal mucosa posterior to the perforation to allow for adequate sealing of the perforation. This was not always met in all cases. This makes the selection of our technique limited to more anteriorly located perforations and those with small anteroposterior diameter allowing for abundant posterior nasal mucosa.
Table 3: Review of previous studies evaluating the endoscopic approach with septal mucosal flap for closure of nasal septal perforation

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The advantages of endoscopic approach when compared with open approaches include the minimal invasiveness with minimal scars and less cosmetic burden on the patient. In addition, the endoscopic approach offers a detailed visualization of different intranasal structures with better control of the perforation margins. On the contrary, the drawbacks of this approach include the difficult control of large and posteriorly located perforations and the need for extensive training to gain the endoscopic experience reacquired to master this approach [23].

The use of an endoscopic approach has allowed very high percentage of success even in cases of unilateral flap repair, which is classically considered insufficient by some authors [12],[24]. Kridel [1] stated that three-layer reconstruction of the nasal septum is essential for successful repair of septal perforation. However, many authors achieved a high success rate using unilateral mucosal flaps including Castelnuovo et al. [14] who reported a success rate of 100% using an anterior ethmoidal artery unilateral septal flap without any interposition graft. Teymoortash et al. [25] achieved a success rate of 94.5% using a nasal mucosal flap consisting of the defect-corresponding mucosa of the floor of the nose, inferior nasal meatus, and inferior turbinate in 55 patients. The unilateral nasal flap has the advantage of avoiding enlargement of the perforation and development of any other perforations during the operation, as well as decreased surgical time, as only a one stage procedure is performed (5).

In the curren tstudy, the mean operative time was 2.23 ± 0.44 h. The average blood loss was 93.6 ± 13.9ml. This blood loss is much less than open rhinoplasty approach. Tabrizi et al. [26] stated that the average blood loss during open rhinoplasty approach was 132.12 ± 78.53 ml. Eftekharian and Rajabzadeh [27] reported that the average blood losswas 199.6 ± 73.05 ml. This lower blood loss in our study, which allows better operative environment, is in favor for our technique when compared with open rhinoplasty approach.

In the current study, there was a highly significant improvement in all symptom scores. This finding matches the findings of previous studies evaluating different endoscopic approaches with different mucosal flap designs which showed symptomatic improvement ranging from significant and highly significant with Giacomini et al. [12] and highly significant with Çomoglu et al. [20], to complete improvement with Lee et al. [9] and Teymoortash et al. [25]. However, we noted a considerable degree of crustation during the healing period after the operation owing to the large raw area exposed till remucosalization occurs.

In the current study, we found a significant relationship between the anteroposterior diameter and success of the operation (P = 0.002). However, the vertical diameter had no statistical relationship with the success of the operation (P = 0.0.7). Many previous studies stated that the size of the perforation is one of the most important predictive factors for successful repair for nasal septal perforation [28]. Kridel [1] stated that vertical diameter is the most important perforation dimension. This principle is applicable to any technique involving the use of an advancement flap from the nasal floor or nasal roof whether endoscopic as Fairbanks [5] or by open approach as Kridel et al. [29]. However, our technique is based on the rotation of mucosal flap in a posteroanterior direction with better outcomes when there is abundant mucosa posterior to the perforation. This is met with a small anteroposterior diameter of the perforation.


  Conclusion Top


Superiorly based septal mucosal flap technique is a new and good option for repair of septal perforations with a success rate of 71.4%. This technique is most effective with limited anteroposterior diameters. Large anteroposterior diameters need other flap designs or an open approach. So, in repair of septal perforations, tailoring of operations according to the site and size is crucial.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin North Am 2004; 12:435–450.  Back to cited text no. 1
    
2.
Romo T, Toffel PH. Nasal septal perforation. In: Gates GA, editor. Current therapy in otolaryngology-head and neck surgery. St Louis: Mosby; 1998. pp. 339–344.  Back to cited text no. 2
    
3.
Re M, Paolucci L, Romeo R, Mallardi V. Surgical treatment of nasal septal perforations. Our experience. Acta Otorhinolaryngol Ital 2006; 26:102–109.  Back to cited text no. 3
    
4.
Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116:1882–1886.  Back to cited text no. 4
    
5.
Fairbanks DNF. Closure of nasalseptal perforations. Arch Otolaryngol Head Neck Surg 1980; 106:509–513.  Back to cited text no. 5
    
6.
Yousef-Mian M. Repair of nasal septal perforation. Am J Rhinol 1997; 11:35–40.  Back to cited text no. 6
    
7.
Meghachi AS, Jankowski R, Védrine PO, Dugny O. Endoscopic closure of septal perforations by mucosal rotation flaps. Ann Otolaryngol Chir Cervicofac 2004; 121:222–228.  Back to cited text no. 7
    
8.
Presutti L, Alicandri Ciufelli M, Marchioni D, Villari D, Marchetti A, Mattioli F. Nasal septal perforations: our surgical technique. Otolaryngol Head Neck Surg 2007; 136:369–372.  Back to cited text no. 8
    
9.
Lee HR, Ahn DB, Park JH, Kim YH, Sin CM, Youn SJ, et al. Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap. Clin Exp Otorhinolaryngol 2008; 1:154–157.  Back to cited text no. 9
    
10.
Lee KC, Lee NH, Ban JH, Jin SM. Surgical treatment using an allograft dermal matrix for nasal septal perforation. Yonsei Med J 2008; 49:244–248.  Back to cited text no. 10
    
11.
Islam A, Celik H, Felek SA, Demirci M. Repair of nasal septal perforation with 'cross-stealing' technique. Am J Rhinol Allergy 2009; 23:225–228.  Back to cited text no. 11
    
12.
Giacomini PG, Ferraro S, Di Girolamo S, Ottaviani F. Large nasal septal perforation repair by closed endoscopically assisted approach. Ann Plast Surg 2011; 66:633–636.  Back to cited text no. 12
    
13.
Li F, Liu Q, Yu H, Zhang Z. Pedicled local mucosal flap and autogenous graft for the closure of nasoseptal perforations. Acta Otolaryngol 2011; 131:983–988.  Back to cited text no. 13
    
14.
Castelnuovo P, Ferreli F, Khodaei I, Palma P. Anterior ethmoidal artery septal flap for the management of septal perforation. Arch Facial Plast Surg 2011; 13:411–414.  Back to cited text no. 14
    
15.
Ma YX, Tao AZ, Lu C, Tian H, Dong BC. Endoscopic repair of nasal septal perforation with acellular dermal matrix and pedicled mucoperichondrial flap. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2011; 46:455–458.  Back to cited text no. 15
    
16.
Chhabra N, Houser SM. Endonasal repair of septal perforations using a rotational mucosal flap and acellular dermal interposition graft. Int Forum Allergy Rhinol 2012; 2:392–396.  Back to cited text no. 16
    
17.
Chen FH, Rui X, Deng J, Wen YH, Xu G, Shi JB. Endoscopic sandwich technique for moderate nasal septal perforations. Laryngoscope 2012; 122:2367–2372.  Back to cited text no. 17
    
18.
Cassano M. Endoscopic repair of nasal septal perforation with 'slide and patch' technique. Otolaryngol Head Neck Surg 2014; 151:176–178.  Back to cited text no. 18
    
19.
Kaya E, Cingi C, Olgun Y, Soken H, Pinarbasli Ö. Three layer interlocking: a novel technique for repairing a nasal septum perforation. Ann Otol Rhinol Laryngol 2015; 124:212–215.  Back to cited text no. 19
    
20.
Çomoglu Ş, Şahin B, Polat B, Aydemir L, Orhan KS. Unilateral inner mucoperichondrium flap from upper lateral cartilage and inferior mucosal advancement flap technique for repair of septal perforations. J Craniofac Surg 2016; 27:e323–e327.  Back to cited text no. 20
    
21.
Morera Serna E, Ferrán de la Cierva L, Fernández MT, Canut SQ, Mesquida JA, Purriños FJG. Endoscopic closure of large septal perforations withbilateral Hadad–Bassagasteguy flaps. Eur Arch Otorhinolaryngol 2017; 274:1521–1525.  Back to cited text no. 21
    
22.
Dayton S, Chhabra N, Houser S. Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps. Am J Otolaryngol 2017; 38:179–182.  Back to cited text no. 22
    
23.
Cassano M. Endoscopic repair of nasal septal perforation Acta Otorhinolaryngol Ital 2017; 37:486–492.  Back to cited text no. 23
    
24.
Schulz-Coulon HJ. Three-layer repair of naso-septal repair. Eur Arch Otorhinolaryngol 2007; 264:S265.  Back to cited text no. 24
    
25.
Teymoortash A, Hoch S, Eivazi B, Werner JA. Experiences with a new surgical technique for closure of large perforations of the nasal septum in 55 patients. Am J Rhinol Allergy 2011; 25:193–197.  Back to cited text no. 25
    
26.
Tabrizi R, Eftekharian H, Pourdanesh F, Khaghaninejad MS. Does oral clonidine premedication decrease bleeding during open rhinoplasty? J Craniofac Surg 2014; 25:1101–1103.  Back to cited text no. 26
    
27.
Eftekharian HR, Rajabzadeh Z. The efficacy of preoperative oral tranexamic acid on intraoperative bleeding during rhinoplasty. J Craniofac Surg 2016; 27:97–100.  Back to cited text no. 27
    
28.
Kim SW, Rhee CS. Nasal septal perforation repair: predictive factors and systematic review of the literature. Curr Opin Otolaryngol Head Neck Surg 2012; 20:58–65.  Back to cited text no. 28
    
29.
Kridel RW, Appling D, Wright W. Septal perforation closure utilizing the external septorhinoplasty approach. Arch Otolaryngol Head Neck Surg 1986; 112:168–172.  Back to cited text no. 29
    


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    Tables

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