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Enteroatmospheric fistula (EAF) is a feared and
challenging complication for both the patient and care team. EAF is a subset
form of enterocutaneous fistula (ECF) and characterized by the absence of the
soft tissue overlying the bowel. The open abdomen (OA) is the leading cause of
EAF with a high risk of fistula formation during dressing changes. The
multidisciplinary approach is the key successful management. The principles EAF
treatment is based on the correction of intravascular fluid deficit to reverse
catabolic state, control of deep abdominal infection using image-guided
drainage, control of fistula effluent, protection of the skin and the
surrounding granulating tissue by using negative pressure wound therapy (NPWT)
and achieving a good nutritional condition by providing PN and enteral
nutrition if possible. The spontaneous closure of EAF is extremely rare and
definitive reconstructive surgery is almost required. Prevention is the best
way to reduce the risks of EAF to occur. This review article discusses
diagnosis, etiology, management aspects and prevention of EAF with specific
attention dedicated to effluent control, wound care, nutrition and definitive
fistula surgery and abdominal wall reconstruction.
Keywords:
Enterocutaneous fistula, Enteroatmospheric fistula, Open abdomen, Effluent
control, Wound care, Nutrition-Definitive fistula surgery, Abdominal wall
reconstruction
INTRODUCTION
An enterocutaneous fistula (ECF) is defined
as an abnormal communication between the intra-abdominal GI tract and skin and
is traditionally considered as one of the most feared complications in
gastrointestinal surgery. The mortality of ECF largely varied from 5% to 20%
and this variation was due to the heterogeneity of the published studies [1,2].
The associated morbidity is excessive with prolonged hospital stay particularly
intensive care unit stay, increased hospital cost and negative important psychological
impact on the patient health [3]. The entroatmospheric fistula (EAF) is a
subset form of ECF with several unique characteristics that merit to be
highlighted. Oppositely to many postoperative complications, the diagnosis of
EAF is often obvious. The typical predisposing situation is the management of
the open abdomen for at least several days or months. The bowel is exposed
directly to the environment and dressing is made to cover the exposed bowel,
keep it moist and avoid visceral trauma (Figure
1). The dressing is changed regularly and so a small erosion of exposed and
fragilized bowel can occur leading to the fistula formation with drainage of
intestinal content into the wound. When occurred, any closure attempt of EAF by
performing simple intestinal suture is highly avoided and may result in larger
bowel wall opening with aggravating management difficulties. The EAF management
scheme is similar to that used in ECF and is based on a few sound tenets
including recognition, stabilization, anatomic definition and definitive
surgery if needed [4,5]. However major differences are the difficulty in
controlling fistula effluent, skin protection, potential prevention and the
complexity of abdominal wall reconstructive surgery. I importantly, a
well-organized multidisciplinary approach and evaluation of these patients in a
specialized centre dealing with ECFs are the keys to successful management with
improved outcomes. This review article discusses diagnosis, etiology,
management aspects and prevention of EAF with specific attention dedicated to
effluent control, wound care, nutrition and definitive fistula surgery and
abdominal wall reconstruction.
The reported overall incidence of EAF varied
from 5%-19% [6-9] in damage control laparotomy. This variation in reported
incidence was due to the indication for damage control laparotomy (trauma vs.
non-trauma), the number of re-operations for abdominal procedures and the time
to definitive closure. The increase in incidence was linked to the wide use of
damage control laparotomy in the surgical community. Depending on location
within the abdomen cavity, the enteroatmospheric fistulas are two types, deep
and superficial. Deep EAFs drain directly into the abdominal cavity and so is
more likely a cause of peritonitis. Superficial EAFs are completely extra
peritoneal realizing a primary stoma by draining on the top or the side of the
granulating abdominal wound. As the same as ECF, EAF can be classified on the
basis of an involved segment of GI tract (i.e., enteroatmospheric,
coloatmospheric gastro atmospheric, etc.) and on the daily output as low-output
<200 mL, high output >500 mL and moderate from 200 to 500 ml.
ETIOLOGY
EAF develops more commonly following an open
abdomen surgery performed for trauma, after damage control and decompressive
laparotomies, and in the setting of elective surgery. However, Trauma is
largely the leading cause of EAF. EAF also can occur in patients who received
surgery for abdominal septic process resulting in the open abdomen secondary to
difficulties to achieve abdominal wall closure due to bowel edema or large
fascial dehiscence’s. The physical characteristics of an open abdomen
predispose to the development of EAF. Usually, the bowel is directly exposed to
the environment, requiring repeated complicated abdominal dressing changes and
so this condition is more likely favorable to EAF development. Despite the
utmost care taken to prevent trauma during dressing changes, the multiples
manipulations can be traumatic to already edematous and friable bowel resulting
in bowel wall erosion and fistula formation. Moreover, the etiologies of
postoperative EAF are often related to the condition that necessitated
surgeries including malignancy, inflammatory intestinal diseases, adhesiolysis,
abdominal sepsis, anastomotic leaks, bowel ischemia and obstruction and
emergency abdominal procedures [10,11].
PREVENTION
Clearly, prevention is the best way to reduce
the risk of EAF. Therefore take precautions and preventive measures at the
first laparotomy are highly recommended to prevent EAF in high-risk patient.
Before closing the abdominal cavity, the greater momentum should be placed in
order to cover the bowel if at all possible, and when non-absorbable mesh is
used, it should never be in direct contact with bowel. The use of any temporary
closure device should protect the underlying bowel and allowing access to the
peritoneal cavity. As reported, damage control laparotomies were associated
with a high rate of EAF if the abdomen was left open for more than 8 days
[8,12]. Therefore every effort should be made to achieve closure of the open
abdomen as soon as possible to decrease the EAF risk. However, it is difficult
for the surgeon to determine the timing of abdomen closure. Typically, the
fascia closure should be achieved without leading to intra-abdominal
hypertension after the resolution of visceral edema. Several methods have been
reported to reduce time to closure including Covering the viscera with a
non-adherent drape and achieving skin – only closure when fascial
reapproximation is not feasible, however, repetitive skin trauma may occur if
multiple reoperations are needed prior to definitive closure [12]. The planned
ventral hernia (PVH) approach consists of covering the bowel with an absorbable
polyglactin mesh fixed to the fascia edges. If enough available, the skin can
be closed over drains placed between absorbable material and skin. Therefore
the peritoneal cavity is closed with guaranteed future ventral hernia. This
method became less favorable after the availability of NPWT, biologic meshes,
and other early fascial closure techniques. The use of NPWT systems to achieve
closure of an open abdomen has shown superior results compared to absorbable
mesh [13-16] with statically no significant slightly higher rate of fistula
formation (21% vs. 5%) [17].
When early closure is impractical after
several days, the use of biologic mesh bridges to achieve fascial closure with
skin reapproximation over drains or NPWT placed over the top of biologic
material seems to be an attractive indication. This method achieves the goal of
closure over viscera option with a lower rate of bowel fistulization [18].
However, it is associated with a high rate of incisional hernia formation [19,20].
The progressive retraction of the rectus and oblique muscle laterally in the
open abdomen can plague any effort made to achieve early closure. Therefore
many techniques to prevent abdominal wall retraction have been described and
some have been shown to facilitate the achievement of early abdominal wall
closure [21-25]. The use of mesh material fixed to the fascial edges associated
with progressive tightening at the midline as visceral edema resolves is common
in all these methods. A non-adherent layer or sheet is placed over the viscera
inside the peritoneal cavity to prevent adhesions to the anterior abdominal
wall that potentially results in the frozen abdomen. The NPWT device is applied
over the top of the mesh bridge to control fluids and exudate.
The dressing of an open abdomen should be
constructed by experienced surgical team members avoiding to place gauze or
negative pressure devices directly on the exposed bowel [26]. The presence of
an experienced member of the surgical team during the dressing changes of an
open abdomen is imperative to unsure avoidance of underlying viscera trauma and
to early recognize areas of deserolization which are likely precursors of an
EAF. Finally, the surgical team should always have in mind the greater risk of fistula
formation when attempting to achieve a definitive fascial closure of an open
abdomen [8,9,27]. As previously stated, nutritional optimization is central in
the treatment and prevention of Efate open abdomen is a source of extreme
catabolic state and increased nutritional requirements. It is well demonstrated
that enteral nutrition is more benefit than parenteral nutrition in surgical
patients. The early enteral nutrition (less than or equal to 4 days after
surgery) has been associated with a significant reduction of EAF rate and time
to abdomen closure [28].
MANAGEMENT
The management of EAF involves a lengthy and
labor-intensive process broken down into phases of treatment so-called
step-by-step approach [5,26]. This management scheme is similar to that used in
case of ECF and is based on diagnosis and stabilization, anatomic definition
and fistula reconstructive surgery if needed. Therefore, the management of EAF
requires a multidisciplinary team involving surgeons, nursing wound care and
nutritionist. The objectives of EAF treatment are control of intestinal
effluent, limiting the exposure of surrounding viscera and granulation tissue,
eliminating infection, and achieving the best physical condition before
definitive reconstructive surgery. However, the major treatment particularities
of EAF are the effluent control difficulties and complexity of reconstructive
surgery. Once EAF is diagnosed, the control of sepsis and fluid resuscitation
constitute the priority because these patients may have already a protein loss
with frequently sepsis from localized wound infection or abdominal deep abscess
[26]. The first step in presence of EAF is to eliminate deep abdominal sepsis
and an unrecognized concurrent deep EAF. Abdominal CT scan should be performed
as soon as possible after EAF diagnosis to exclude intra-abdominal sepsis, if
present; the sepsis should be drained with radiological assistance [29,30].
Importantly, the second step is to define the fistula mapping and evaluate how
much contiguous bowel is available for eventual introduction of enteral
nutrition [5]. To achieve this goal, some investigations such as fistulography
and oral dye ingestion (as bleu methyl) may be more helpful when used in
combination with a CT scan [5].
EFFLUENT
CONTROL/SKIN PROTECTION
Controlling the effluent, protecting the
exposed bowel, the granulation tissue and the skin surrounding fistula from
erosion, inflammation and potential infection should be planned very early to
limit consequences. A poorly controlled EAF constitutes a source of
embarrassment and discomfort for the patient and frustration for the medical
team. Subsequently, it results in the consumption of a tremendous amount of
nursing and disposable medical resources. The intestinal content is very
corrosive, so early the control of EAF output is critical to limit skin damage
that may limit options for subsequent control. The first step is to stop oral
intake and bowel rest decreases the fistula output significantly. The second
step is to use techniques that allow fistula effluent control and protection of
the surrounding tissue and skin. Several methods and systems have been
developed to achieve effluent control and skin protection [31-35]. Agents such
as cellular dermal matrix and fibrin glue have been used to attempt local
fistula closure; however, the failure in clinical practice was due to the
moisture and continuous intestinal peristalsis [36]. Also performing local
extra peritoneal repair of fistula hole followed by split-thickness skin graft
to cover the exposed bowel to transform thus EAF to stoma has been described
with limited clinical success [37]. Creation of a “floating stoma” which
consisted of suturing the perforated wall bowel to a plastic silo piece with a
hole in it, allowing separation of draining intestine from the peritoneum
beneath it [38]. This technique has been reported to be useful in specific
circumstances particularly in case of deep EAF [38].
The techniques combining negative-pressure
wound management systems with ostomy appliances are more promising with the
objective to control fistula effluent, allow granulation of the surrounding
tissue, protection of skin and prevention of underlying bowel from trauma
[34,39,40]. The original technique initially described by Goverman et al. [41]
consisted of covering the open area and exposed bowel and applying a negative
pressure system to the dressing. So the open abdomen area is covered with a
thin layer of impregnated gauze with a hole cut out for fistula opening. In a
similar fashion, sponges with a hole to accommodate the fistula opening and
then a polyurethane drape is placed. Once placed, a hole is cut on the drape
and an ostomy appliance or catheter is placed over or within the fistula
opening, and then the negative pressure is applied to the entire dressing. Over
the years, a few modifications have been added to the original technique. As
demonstrated by published reports, the negative pressure wound therapy system
(NPWT) is very useful to control EAF output and to protect and improve
surrounding granulation tissue healing (Figure
2) [42,43]. However, the involvement of the stoma therapist or an
experienced wound care team is highly required [44]. The wound care team is
more familiar with the akin protection materials such as stoma paste and powder
which should be used early. Stoma paste and powder can be used to improve
isolation of the fistula. In absence of these care resources, transfer to
high-level care should be considered. More recently, negative pressure wound
management system has been adapted and used to control the effluent and stop
ongoing peritoneal contamination in deep EAF [44,45]. “Floating stoma” method
has been used to control deep effluent and limit peritoneal diffusion of
infection [38]. As a reminder, deep EAF with an open abdomen is a surgical
emergency in critically illness situation. The goal of surgery is to strictly
achieve drainage control of digestive content and to transform such fistula to
superficial EAF without an attempt to perform any sort of surgical fistula procedure.
Therefore performing fistula surgery in such case can result in increasing
intestinal wall defect and aggravating already complicated clinical situation
because of bowel edema, mesenteric shortening, and vascularized adhesions [41].
There is no specific system designed for the purpose of EAF, however,
considerable efforts of the care team are required to design a custom device
for a patient with EAF and to ensure its effective use on a daily basis. Once
the surrounding tissue granulation is achieved, the granulating area is covered
by a split-thickness skin graft and thus EAF is managed much likely as a
conventional stoma until the time of fistula and abdominal wall reconstructive
surgery.
NUTRITION
The introduction of early nutrition is the
key of success in a patient with EAF. Nutritional troubles are present in 50%
to 90% of patients with an ECF and contribute significantly to the overall
morbidity and mortality [46,47]. Therefore adequate nutrition is essential for
these patients to achieve an acceptable nutritional condition. The goal of
nutrition support in patients with EAF is to prevent malnutrition while
controlling fistula effluent and not to promote fistula closure [35]. Therefore
immediately upon diagnosis, correction of fluid and electrolyte imbalances is
required to normalize acid-base balance and quit the inflammatory process. The
fluid needs can be very high in the early phase depending principally on the GI
tract losses and secondarily on losses due to sepsis and fever. However, the GI
tract losses can vary widely depending on the site of EAF. When fistula site is
on the proximal jejunum, the fluid losses are important and so knowledge of GI
fluids composition is necessary to effectively treat and prevent abnormalities (Table 1). The development of PN was
the most important advances made in ECF management. The PN should be introduced
as soon as the EAF diagnosis has been established and the patient had been
resuscitated and sepsis treated. The purpose of nutrition support is to meet
the patient metabolic needs while definitive management is planned [5,48]. The
high fistula output and fluid losses from an open abdomen should be taken into
consideration when calculating the patient nutrition needs. Up to 75 g/d of
protein is normally absorbed by the small bowel [49]. The fluid loss from open
abdomen contains up to 2 g of nitrogen per litter and so it should not be
underestimated [49]. The calorie and protein needs may reach kcal/kg/d and 1.5-2.5
g/kg/d in case of a high-output fistula [30]. However, care should be taken to
avoid overfeeding consequences. Supplementation in copper, folic acid, vitamin
B12 and C and trace minerals may be necessary for a patient with long-standing
small-bowel fistulas [48]. As shown, the spontaneous fistula closure rate was
doubled after nutritional supplementation addition [1,48,50]. However, the
heterogeneity of population involved in the studies and the predominance of the
retrospective nature of these studies made more difficult to predict accurately
the timing and rate of spontaneous healing [1,48]. As suggested by some
studies, the fistula closure rates and mortality have been positively affected
by PN [51] but until to date, there is no strong evidence that ECF closure is
increased with PN alone [52]. Although in some cases, PN may be the only
nutritional support that patient tolerates, enteral feeding is possible in
large series of patients with ECF [53,54]. Enteral nutrition should be
attempted once the fistula anatomy is defined and feasibility of enteral
feeding is determined by the management team. The enteral nutrition is
beneficial by preserving the mucosal barrier and immunologic function of the
intestine resulting in decreasing infectious complications. The absolute
contraindication to enteral nutrition is insufficient length (usually <75
cm) of usable bowel. The quality of the remaining small bowel is also
important. The length of usable bowel can be difficult to estimate, however
upper GI series, magnetic resonance enterography and CT scan are useful to make
a reasonable estimation. Enteral nutrition can be administrated by surgical
tube-jejunostomy, a passage of tube distal to fistula and fistuloclysis.
However, establishing enteral feeding access can be difficult in some cases and
teamwork perseverance is required in these circumstances [5]. Fistuloclysis is
a technique which consists of providing an enteral feeding through the fistula
opening. The fistula effluent is collected from the proximal fistula limb and
reinstilled into the distal limb. This is very useful to maintain fluid and
electrolyte balance. Fistuloclysis technique can be used to introduce enteral
nutrition by inserting a tube through the distal intestinal limb and the tube
must be maintained in a stable position avoiding migration and obstruction.
Feeding a patient with EAF is reasonably started with standard polymeric
formula. Exceptionally, if the usable bowel has a very short length less than
120 cm and the patient does not tolerate the polymeric formula or experiences
high fistula output, the patient should be switched to an elemental or
semi-elemental feed. As reported, the use of fistuloclysis with polymeric or
elemental feeds resulted in patients with ECF resulted in the liberation of an
important number of them from PN [55].
The
introduction of Immunonutrition (glutamine) in critically ill surgical patients
showed a reduction in infectious complications without effect on mortality
[56]. Glutamine which is the primary nitrogen constitutes an energy source for
the enterocyte and has a large effect on immune function and overall outcomes
[56]. Glutamine has more pronounced positive effects when it is administrated
parenterally [57]. As reported, the combined use of oral glutamine with PN in
high output fistula had been associated with accelerating healing and
decreasing mortality without change in hospital stay length [58]. However
regarding the limit data in the EAF patients, the administration or oral
glutamine in the hope to decrease overall inflammation and fistula effluent
seems to be probably safe.
MEDICAL TREATMENT
Somatostatin is a hormone principally
produced by the delta cells of the pancreas. Somatostatin and its analogues
(octreotide) have an inhibitory properties including decrease of enteric
secretions, suppression of gastrointestinal hormones, reducing of gastric
emptying rate and having a splanchnic vasoconstrictive effect [59,60]. Based on
these inhibitory properties, the use of somatostatin has been advocated in the
treatment of ECFs to reduce the fistula output volume [61]. Oppositely to
somatostatin which has a short half-life (1-2 min) requiring continuous
infusion [62], Octreotide is a longer-acting analogue with a half-life of 113
min allowing intermittent subcutaneous dosing and it has wide use in ECFs
treating [61]. The efficacy of this medication has been evaluated by measuring
the impact on the fistula output volume, time to closure and fistula closure rates.
As demonstrated by investigations, both somatostatin and octreotide have an
effective effect in decreasing the fistula output volume by as much as 40%-93%
[60]. This reduction in output would be very beneficial in improving quality of
life and prognosis of a patient with high output fistula volume by facilitating
wound care and decrease damage to bowel and surrounding granulation tissue
[60,62]. The combined use of TPN with somatostatin has a synergistic effect on
the reduction of intestinal secretions and the improvement of fistula closure
rates [60]. Several controlled trials demonstrated the significant improvement
of these medications on the time to closure of ECFs [62-65].
On the other hand, most reports showed no
effect on the actual rate of closure after use of somatostatin and its
analogues [59,65]. This may be interpreted as a failure of conservative
treatment which can be more likely related to fistula nature, such as its
location, presence of a distal obstruction or malignancy. In addition, the
octreotide can have an adverse effect on immune function and can reduce the
splanchnic and portal blood flow [66]. So care must be taken when using this
medication. The use of Proton pump inhibitors and H2 receptor
antagonists did not show any positive effect on the fistula output and the
spontaneous closure rate [3,10].
Reconstructive
surgery
Timing of surgery: Defining the appropriate time to
perform definitive reconstructive surgery for EAF after the failure of
conservative treatment is unclear in the absence of level I data supporting any
specific period of delay. The timing of reconstructive surgery for EAF and AWR
should be individualized according to patient characteristics. Softening of
intra-abdominal adherences, resolution of inflammatory processes and abdominal
sepsis, achieving a best nutritional condition of the patient, providing
adequate wound care and reduction in the risk of bowel injury take more time
usually longer than 3 months before conditions become ideal for surgery.
Therefore, the surgical judgment based on these multiple factors is likely the
key to success. The longer time interval to surgery is associated with lower
rates of fistula recurrence, morbidity and mortality [67-74]. So at least a
waiting period of 6 months or longer after fistula formation is highly
recommended by specialized centre authors [71-74].
Fistula surgery
The risk factor that it can be modified is
the surgical technique. Bowel resection was superior to over sewing and wedge
repair, and complete resection of the affected intestinal segment was
associated with lower rates of fistula recurrence [67,72,75]. The preferred anastomosis
technique between stapled and hand-sewn types is not well defined due to the
lack of published studies comparing these two techniques. However, the stapled
anastomosis was found to be a significant risk factor for fistula recurrence
and one-year mortality [72,75]. Based on experience, the gastrointestinal
surgeons believe that hand-sewn anastomosis is superior to stapled anastomosis
in fistula surgery.
Abdominal wall
reconstruction
The EAF is associated with an abdominal wall
defect and reconstructive surgery is needed in most cases. However,
reconstruction of the abdominal wall is a complex and high-risk procedure. When
performing definitive surgery for EAF, all efforts should be made to obtain
closure of the abdomen over the bowel avoiding exposition to the environment
which is the leading factor to EAF formation. The decision to stage the repair
or not influences in part the choice of the abdominal wall closure approach.
There is no ideal technique or a simple approach to abdominal wall reconstruction
(AWR). However, it is so important to take into consideration the patient
functional status and expectations in determining the appropriate approach for
AWR. Simple mesh underlying fascial defects closure is an acceptable hernia
repair. However, the patient is left with a large area of laxity on the
anterior abdominal wall resulting in limitation of patient physical activities
in future with less cosmetic appearance. Component separation techniques (CST)
and flap reconstructions can provide a functional AWR. However, these
techniques are more demanding and they are associated with increased wound
complications. The original CST consists of separating the rectus muscle from
its posterior sheath and the external oblique muscle from the internal oblique
muscle allowing medial advancement of approximately 5 cm at the epigastrium, 10
cm at the waistline and 3 cm in the suprapubic region unilaterally [76,77]. So,
the ideal use of CST is in facilitating the reapproximation of rectus complex
to the midline. The reported rates of hernia recurrence after CST varied from
6% to 52%. [77-82]. However, very large abdominal wall defects are more likely
to require mesh-bridging techniques even following CST procedure. When the CST
procedure is reinforced with mesh placement, it perfectly restores a dynamic
and functional abdominal wall. Compared to simple CST, prosthetic mesh closure
is more frequently associated with wound complications, and recurrence rates
were similar in the two methods [78]. Several minor modifications have been
introduced on to the original CST technique with good results [81,82]. The
retrorectus space has been exploited for placement of mesh reinforcement and
many major proponents of the classic anterior CST have shifted to the posterior
approach [81-83]. As demonstrated by CT scans performed in preoperative and
postoperative setting following large abdominal wall hernias repair, the use of
CST resulted in a significant increase of the intra-abdominal volume without
pulmonary compromise [84]. So restoring the lost domain may be possible after
CST use without respiratory repercussions related to the loss of thoracic
volume. The major inconvenient of the anterior CST is large bilateral skin
flaps resulting from necessary dissection for exposure and flap complications
were the most wound matter noted in this procedure. The seroma and potential
infection are common after performing anterior CST. The use of fibrin sealant
has been shown to decrease seroma and wound infection rates [82]. Also
eliminating the dead space by performing numerous “quilting” mattress sutures
has been reported to reduce seroma formation. The use of the minimally invasive
technique has been described to achieve lateral release by creating small
tunnels from the midline incision instead of large flaps [85]. Although the use
of a large midline incision approaches with avoiding creating a large flap with
their attendant wound morbidity, this technique is the ideal method for a
single stage repair of EAF [85]. Therefore, laparoscopic and minimally invasive
approaches are likely useful to achieve a functional abdominal wall with
avoiding morbidity related to extensive open procedures [86-88].
SUMMARY
Enteroatmospheric fistula (EAF) is a feared
and challenging complication for the clinical team. The open abdomen (OA) is
associated with high risk of EAF formation. The multidisciplinary approach is
the key to successful management. The principles treatment is based on the
patient resuscitation, the elimination of abdominal infection, the control of
fistula effluent, the wound care and the introduction of nutritional support.
The spontaneous healing of EAF is extremely rare and definitive surgery should
be postponed until obtaining the best physical condition of the patient. The
abdominal wall reconstruction is a complex and high-risk surgery. The abdominal
wall repair can be staged or concomitantly performed with fistula surgery.
Several factors may influence the determination of the appropriate wall closure
approach. However, the prevention remains the best way to reduce the risks of
EAF.
CONFLICTS OF
INTEREST
None declared.
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