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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 89-97

Abdominosacral resection versus abdominoperineal resection in patients with low rectal carcinoma in terms of exposure/operating time/bleeding


1 Department of General Surgery and Colorectal Surgery Clinic, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
3 Department of General Surgery, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
4 Department of Surgical Oncology, Netaji Subhas Chandra Bose Cancer Hospital, Kolkata, West Bengal, India
5 Department of General Surgery, Arambagh Super Specialty Hospital, West Bengal, India

Date of Submission22-Jan-2019
Date of Decision16-May-2019
Date of Acceptance16-Sep-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Sujitesh Saha
DL 50, Sector II, Salt Lake, Kolkata - 700 091, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_2_19

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  Abstract 


Background: Comprising nearly 30% of all colorectal cancers, rectal cancer continues to be a significant medical and social problem. Abdominiperineal resection (APR) remains the procedure of choice for patients with rectal carcinoma. An alternative to APR is abdominosacral resection (ASR). Objective: We aim to assess the various modes of presentation, demographic profiles, and histopathological characteristics of tumors, and evaluate the efficacy of ASR over APR in terms of exposure, operating time, bleeding, etc., especially in the perineal/sacral part of the procedure. Design: This was a prospective observational study.Setting: This study was conducted at a superspeciality government hospital in eastern India. Patients and Methods: Patients diagnosed with low rectal carcinoma were included in the study. Two groups were formed using a stratified model of sampling theory; one group underwent APR while the other ASR. Main Outcome Measures: For patients with low rectal cancer, ASR is a feasible approach with reduced bleeding, lesser operating time in the perineal/sacral part of dissection, better exposure, and good oncological outcome.Sample Size: Thirty participants were included in the study. Results: Of the total study participants, 63% were males and 36% females. Patients in their 30s and 40s were the most commonly affected age group. Per-rectal bleeding was the most common presentation. The most common histological tumor encountered was well-differentiated adenocarcinoma. The mean operating time and mean blood loss with regards to the perineal/sacral part of the dissection was less in ASR than that in APR. In addition, the exposure was better in ASR. Ninety-three percent of the patients undergoing ASR had total mesorectal excision. Conclusion: ASR is a feasible approach for low rectal carcinoma and performs better in certain aspects than APR. Limitations: This study had a short duration and included less number of patients. Conflict of Interest: None.

Keywords: Abdominoperineal resection, abdominosacral resection, rectal carcinoma


How to cite this article:
Dutta R, Saha S, Saha ML, Basu A, Das S, Saha D. Abdominosacral resection versus abdominoperineal resection in patients with low rectal carcinoma in terms of exposure/operating time/bleeding. World J Colorectal Surg 2019;8:89-97

How to cite this URL:
Dutta R, Saha S, Saha ML, Basu A, Das S, Saha D. Abdominosacral resection versus abdominoperineal resection in patients with low rectal carcinoma in terms of exposure/operating time/bleeding. World J Colorectal Surg [serial online] 2019 [cited 2020 Feb 21];8:89-97. Available from: http://www.wjcs.us.com/text.asp?2019/8/4/89/274283




  Introduction Top


Rectal and colon carcinoma is a major cause of mortality and morbidity worldwide. Colorectal cancer ranks fourth among men (after prostate, lung, and esophagus cancer) and third among women (after breast and lung cancer)[1],[2] and represents the second leading cause of cancer-related mortality.[3] Colorectal carcinoma predominates in the more industrialized countries. Lower rates are found in Africa, South America, and Asia.[4] Migrants acquire a high rate of colorectal cancer prevalent in their adopted countries. The mode of presentation varies with the anatomical location of the tumor. Rectal carcinoma is often associated with hematochezia, tenesmus, narrowing of the stool caliber, and infrequently anemia. Colorectal carcinoma may mimic a wide spectrum of diseases that include hemorrhoids, ulcerative colitis, Crohn's proctocolitis, etc.

Until 1930, a two-staged operation was commonly used for the treatment of colorectal malignancy. In the initial stage, laparotomy and colostomy were done followed by perineal excision at the later stage. In 1908,[5] Miles first described abdominoperineal resection (APR), and since then, APR has remained the procedure of choice for rectal carcinoma. There has been a decrease in the rates of APRs being performed until recently due to certain advances in the surgical technique.[6],[7] However, in patients with low rectal carcinoma and poor sphincter function, APR along with total mesorectal excision (TME) remains the gold standard treatment. The extralevator approach significantly reduces the rate of local recurrence.[8]

Abdominosacral resection (ASR), an alternative to APR, is particularly helpful in locally advanced tumors involving the sacrum or lateral pelvic walls. ASR provides better exposure in such scenarios which helps attain a complete resection. ASR involves positioning the patient prone to continue dissection in the posterior pelvis after completing the abdominal section.

During the course of our study, we noticed that rectal cancer constitutes a significant proportion of malignant cases in general surgical wards. In this study, we will review the efficacy of ASR compared to APR in terms of exposure, operating time, bleeding, etc.


  Patients and Methods Top


Design

This study was conducted over a period of 24 months, and included patients admitted with low rectal carcinoma in the Department of General Surgery de novo or those who received radiotherapy and/or chemotherapy in the Department of Radiotherapy. A total of 30 patients were recruited as per our inclusion and exclusion criteria.

A questionnaire was prepared, and data were collected from the patients through interviews, clinical examinations, and test reports. Using a stratified model of sampling theory, the patients were grouped into two categories: one group underwent ASR (n = 15) and the other underwent APR (n = 15). Overall, the two groups were similar at study entry. Confounding factors such as age, sex, and smoking habit were adjusted to minimize selection bias.

Surgical techniques

Abdominosacral resection

ASR is a sequential procedure where the sacral part is dissected after the abdominal part, which involves a lower midline incision, and assessment for distant spread and resectability. Sigmoid colon and rectum were mobilized in standard fashion, and the abdominal dissection was continued down as low as possible, taking care of presacral nerves. Colonic transection was done at the mid-sigmoid level, and the end colostomy was performed. The abdomen was then closed in layers leaving the tumor behind along with the stump of the rectum in the pelvis. The position of the patient was then changed from supine to prone jackknife [Figure 1]. The buttocks were kept apart by adhesive tapes. A purse-string suture was applied around the anus. A posterior sacral incision was made extending below and around the anus. The glutei muscles were then cut at their insertion over the last two sacral vertebrae. Subsequently, coccygectomy or sacrectomy (S5) was done, following which the Waldeyer's fascia and the pelvic fascia (parietal lamina) were cut. The rectum along with the mesorectum and the tumor were then removed. Care was taken to separate the rectum from the prostate or vagina. Levators of the anal canal were then cut and blood vessels ligated. Finally, the perineum was closed with a drain which was removed postoperatively depending on the drain collection.
Figure 1: Prone jackknife position in ASR

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Abdominoperineal resection

APR is a synchronous procedure where the abdominal and perineal part of the surgery is performed simultaneously. The incision in the perineal dissection extended from the mid-point of the perineal body in males or the posterior vaginal introitus in females to a point that lies mid-way between the coccyx and the anus and was continued till the ischiorectal fat. The anococcygeal raphe was divided. Subsequently, a sharp entry into the pelvis was made anterior to the coccyx and was guided by the abdominal surgeon to avoid any inadvertent injury to the presacral plexus. The specimen was removed by detaching the rectum from the prostate or vagina, followed by a thorough irrigation of the pelvis. Finally, the perineal wound was closed and a drain was placed. The abdominal wound was also closed simultaneously.

Statistical analysis

The sample size was calculated using Morgan's table. The tests used for statistical significance were one-way analysis of variance (ANOVA) test, Chi-square test, Mann–Whitney's test, Fischer's test, and Student's t-test. A P< 0.05 was considered significant.

Follow-up

Follow-up included a periodic history, physical examination, investigations like complete hemogram, liver function test, carcinoembryonic antigen (CEA) test, colonoscopy, chest skiagram, abdominal ultrasound, computed tomography (CT) scan, and positron emission tomography (PET)/magnetic resonance imaging (MRI) scan. Although CT/MRI/PET scan was not part of the routine follow-up, it was advised when there was suspicion of local recurrence or in patients who had elevated CEA levels postoperatively.

Serum CEA estimation was done every 8 weeks for the first year and then every 3 months for the next year. The first colonoscopy was advised within 6–12 months of the surgery.


  Results Top


Demographic factors

  • Age distribution


In this study, patients in their 30s and 40s were the most affected (30%), followed by those in their 50s (20%) [Table 1].

  • Sex distribution


  • Out of 30 patients, 19 (63%) were males and 11 (37%) were females. The disease affected males and females in the ratio of 1.7:1 [Table 2].


  • Religion


The number of Hindus affected were 21 (70%) and Muslims were 9 (30%). The ratio of Hindus and Muslims who underwent APR was 4:1, and those who underwent ASR was 3:2 [Table 3].

  • Diet and habits


Nonvegetarians constituted a majority of patients with colorectal cancer. Among the 30 patients, 7 (23%) were vegetarians and 23 (77%) were nonvegetarians [Table 4].

Further, there was a dominant nonsmokers predilection. There were 11 (37%) smokers and 19 (63%) nonsmokers in the study population [Table 5].

Family history of any malignancy

The study population had an equal division of family history with 15 (50%) patients having a positive family history and 15 (50%) a negative family history of any malignancy [Table 6].
Table 1: Age distribution

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Table 2: Sex distribution

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Table 3: Religion

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Table 4: Diet

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Table 5: Habit

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Table 6: Family history of any malignancy

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Presenting symptoms

The symptoms associated with carcinoma rectum are pain in the abdomen, pelvic pain, per-rectal bleeding, loss of weight, mucus in stool, and tenesmus. In our study, per-rectal bleeding (86.67%) was the most common presenting symptom, followed by tenesmus (50%) [Figure 2].
Figure 2: Distribution of presenting symptoms

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Histopathological frequency

The study incorporated well-differentiated (53.33%), moderately differentiated (36.67%), and poorly differentiated adenocarcinoma (10%). Well-differentiated adenocarcinoma, being the most common tumor, affected 16 patients [Table 7].
Table 7: Histopathological frequency

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Preoperative carcinoembryonic antigen

The preoperative CEA level was within the normal range, i.e., <2.5 ng/mL for 13% of the study population. The CEA value was within >2.5–5 ng/mL for 26.67% patients, >7.5–10 ng/mL for 20% patients, and >10 ng/mL for 26.67% patients [Table 8].
Table 8: Preoperative CEA

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Distribution of various Dukes' stage

A majority of 15 patients (50%) fell under stage C, followed by 8 patients (26.67%) under stage A, and 7 patients (23.33%) under stage B of Dukes' classification [Table 9].
Table 9: Distribution of various Dukes' stage

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Mean CEA levels in various Dukes' stage

In ASR, the mean CEA level in Dukes' stage A was 3.9 ng/mL, stage B was 8.04 ng/mL, and stage C was 9.2 ng/mL (P = 0.01499). In APR, the mean CEA level in stage A was 3.34 ng/mL, stage B was 8.47 ng/mL, and stage C was 8.66 ng/mL (P = 0.044932) [Table 10].
Table 10: Mean CEA levels in various Dukes' stage

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Tumor grade-wise mean preoperative CEA level

The mean CEA level was the highest in poorly differentiated carcinoma (12.57 ng/mL), and the lowest in well-differentiated adenocarcinoma (6.65 ng/mL) [Table 11]. In conclusion, the higher the histological grade, the higher the preoperative CEA level [Figure 3].
Table 11: Tumor grade wise mean preoperative CEA level

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Figure 3: Tumor grade vs. mean preoperative carcinoembryonic antigen level. Non-significant (NS) = P = 0.9983, *= P = 0.0429

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Operative procedures undertaken

The patients were proportionately divided between the modes of surgery. Fifteen patients (50%) underwent ASR and 15 (50%) underwent APR [Figure 4].
Figure 4: Mode of surgery

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Different modes of treatment offered

Fifteen patients (50%) were proposed adjuvant chemoradiation along with surgery, followed by 10 patients (33.33%) proposed surgery along with neoadjuvant chemoradiation, and 5 patients (16.67%) proposed surgery along with neoadjuvant chemotherapy [Table 12].{Table 12}

Comparison of the average duration required for complete operative procedure

ASR required 100–120 min in eight patients, >120–140 min in six patients, and >140–160 min in one patient. APR required 100–120 min in seven patients and >120–140 min in eight patients [Figure 5].
Figure 5: Comparison of average duration required for complete operative procedure

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In our study, the mean operating time for ASR was 120.26 min, whereas for APR it was 116.33 min [Figure 6].
Figure 6: Mean operating time

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Comparison of the average duration required for perineal/sacral part of the operative procedure

The sacral/perineal part of the operative procedure required 50–75 min in 14 patients and >75–100 min in 1 patient for ASR; for APR, it required 50–75 min in 5 patients, >75–100 min in 9 patients, and >100–125 min in 1 patient [Figure 7].
Figure 7: Comparison of average duration required for sacral/perineal part of the operative procedure

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The mean operating time for the perineal/sacral part of the dissection was significantly lower (P = 0.0074) for ASR (57.53 min) than APR (72.27 min) [Figure 8].
Figure 8: Mean operating time (in min) in sacral/perineal part of the dissection

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Comparison of peroperative blood loss in sacral/perineal part of the dissection

The mean peroperative blood loss was more in APR (152.33 mL) compared to ASR (103.66 mL) (P = 0.0019) [Table 13] and [Figure 9].{Table 13}
Figure 9: Mean peroperative blood loss (in mL) in sacral/perineal part of the dissection

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Morbidities in the postoperative period

All the postoperative complications were lower in patients undergoing ASR [Table 14] and [Figure 10].{Table 14}
Figure 10: Different morbidities in postoperative period

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Postoperative blood transfusion

Postoperative blood requirements were lower in patients undergoing ASR [Figure 11].
Figure 11: Units of blood transfused in postoperative period

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Comparison of curative resection among APR and ASR

In our study, complete TME was achieved in 93.33% of the patients who underwent ASR [Table 15] and 80% of the patients who underwent APR [Figure 12].{Table 15}
Figure 12: Comparison of curative resection

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Recurrence in different histological types

The recurrence of poorly differentiated adenocarcinoma was found in 66.67% cases, whereas for moderately differentiated adenocarcinoma and well-differentiated adenocarcinoma, recurrence was seen in 27.27% and 12.25%, cases respectively. So, the poorer tumor differentiation, the more chances of recurrence [Figure 13].
Figure 13: Recurrence in different histopathological variety

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Comparison of recurrence among ASR and APR

There was no significant difference (P = 0.563703) in recurrence rates of poorly differentiated adenocarcinoma among ASR and APR [Table 16]. In cases of moderately differentiated adenocarcinoma, there was no recurrence in patients who underwent ASR whereas recurrence was found in 42.85% of the patients who underwent APR. In cases of well-differentiated adenocarcinoma, recurrence was seen in 11.11% and 14.28% of the patients who underwent ASR and APR, respectively.{Table 16}

Therefore, with poor tumor differentiation, recurrence is not related to the surgical procedure [Figure 14].
Figure 14: Recurrence in ASR vs. APR

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Exposure with regards to perineal/sacral part of the dissection

Exposure was better in ASR than APR, especially in the perineal/sacral part of the dissection.

[Figure 1] shows the prone jackknife position used in ASR.


  Discussion Top


Carcinoma rectum affected males and females in the ratio of 1.7:1 in our study. According to the Global Cancer Observatory, in 2018, the male:female ratio for colorectal cancer in India was 1.8:1. The most common age group affected in our study was patients in their 30s and 40s. Carcinoma rectum was more commonly found among Hindus comprising 70% and Muslims comprising 30% of the total study population. Larger studies are required to determine if there is any relation between the religion of the patient and the incidence of rectal carcinoma.

As 23% of the patients were vegetarians and 77% were nonvegetarians, carcinoma rectum appears to be more common among nonvegetarians. A meta-analysis[9] of 15 prospective studies reported an increased risk of colorectal cancer with high intake of ready/processed meat.

Thirty-seven percent of our patients were smokers compared to 63% nonsmokers, however, this data is not sufficient to prove that smoking is protective.

There have been reports of a high incidence of colorectal cancer in Indians migrating to the United Kingdom and United States, highlighting that lifestyle and dietary habits are important risk factors of colorectal cancer.[10],[11],[12]

In addition, we found that 50% of the patients had a positive family history of malignancy pointing toward the genetic predisposition in patients with carcinoma rectum. Slattery et al.[13] show that the familial association of malignancy is strong for proximal colonic tumors and weak for rectal tumors.

Eighty-six percent of our patients presented with per-rectal bleeding followed by tenesmus in 50% of the patients. In a study by Macrae et al.,[14] alteration in bowel habit was found to be the most common presentation (74%). The same study showed rectal bleeding along with an alteration in bowel habits as the most common symptom combination (affecting 51% of all cancers and 71% among patients with rectal bleeding).

The most common histological tumor was well-differentiated adenocarcinoma affecting 53.33% of the study population. More than 90% of colorectal malignancies reported in colorectal cancer studies are found to be adenocarcinomas originating from epithelial cells of the colorectal mucosa.[15] In a study on adenocarcinoma of colorectal origin,[16] moderately differentiated adenocarcinomas were found to be the most common histological variety (60–70% of all carcinomas), followed by well-differentiated and poorly differentiated adenocarcinoma, each constituting 15–20% of all carcinomas.

It was found that 13.33% of our study population had preoperative CEA level within the normal range, i.e., <2.5 ng/mL whereas 26.67% had very high preoperative CEA (>10 ng/mL). A study[17] correlating preoperative CEA and prognosis of colorectal cancer showed 27.34% of the patients to have high preoperative CEA level, strongly correlated with our findings of high preoperative CEA in 26.67% of our patients.

Further, the CEA level increases as the Dukes' stage increases. In another study by Rahman et al.,[18] it was found that serum CEA level is directly proportional to the tumor stage.

Poorly differentiated adenocarcinoma had a higher mean preoperative CEA level (P = 0.0429) compared to well-differentiated and moderately differentiated adenocarcinomas, signifying that higher the histological grade, higher is the preoperative CEA level. Ng et al.[19] also reported a higher preoperative CEA in tumors showing moderate and poor differentiation.

The mean operating time in cases of ASR was 120.26 min (range: 100–160 mins), whereas in cases of APR it was 116.33 min (range: 100–140 mins). As ASR is a sequential procedure and APR is a synchronous one, the total duration for APR was slightly less than that required for ASR. In addition, the ASR patient needs a change of position from supine to prone jackknife adding to the time required for ASR.

Considering the duration for perineal/sacral dissection, the mean operating time required for ASR was significantly lower (P = 0.0074) than APR.

The mean peroperative blood loss in the perineal/sacral dissection was also less in ASR (103.66 mL) than APR (152.33 mL).

With regards to the perineal/sacral part of the dissection, exposure was better in the case of ASR than APR.

Complete TME was achieved in 93.33% of the patients who underwent ASR. A study by Ulrich et al.[20] concluded TME as the gold standard for rectal cancer surgery. In conclusion, patients undergoing ASR have a good oncological outcome.

It was also seen that postoperative morbidities such as local wound infection, secondary hemorrhage, perineal herniation, fistula formation, and urinary dysfunction were much lower in the ASR group. Local recurrence was also much lower in the ASR group (13.33%) compared to the APR group (33.33%). The percentage of local recurrence after rectal cancer surgery, especially after APR, varies from 5–47%.[21]

In the follow-up period, it was observed that recurrence for poorly differentiated adenocarcinoma was not associated with the surgical procedures undertaken. However, for well and moderately differentiated adenocarcinoma, the recurrence rate was lower in patients undergoing ASR.


  Conclusion Top


ASR is a feasible approach for low rectal carcinoma and has shown better results over APR, for example, less mean blood loss, shorter mean operating time, and better exposure, especially in the perineal/sacral part of the procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Ahnen DJ, Macrae FA, Bendell J. Clinical presentation, diagnosis and staging of colorectal cancer. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. 2016. Available from: https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-staging-of-colorectal-cancer. [Last accessed on 2019 Sep 26].  Back to cited text no. 14
    
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Gonzalez RS, Cates JM, Washington MK, Beauchamp RD, Coffey RJ, Shi C. Adenoma-like adenocarcinoma: A subtype of colorectal carcinoma with good prognosis, deceptive appearance on biopsy and frequent KRAS mutation. Histopathology 2016;68:183-90.  Back to cited text no. 16
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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