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Clinical Outcomes Improvement and Perioperative Management of Surgical Patients: 2nd Edition

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "General Surgery".

Deadline for manuscript submissions: closed (12 October 2025) | Viewed by 18117

Special Issue Editors


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Guest Editor
Department of Surgery, University of Thessaly, Biopolis, 41 110 Larissa, Greece
Interests: pancreatic surgery; liver surgery; bariatric surgery; surgical oncology
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

The art and science of clinical outcome analysis, quality improvement, perioperative management of surgical patients and patient safety continue to evolve at an increasingly rapid pace. In fact, over the years, novel concepts have arisen (risk stratification, shared decision making, interdisciplinary meetings, prehabilitation, etc.), new initiatives have taken shape (e.g., state/nation-wide or international clinical databases), and new technologies and methods have been adopted across all surgical specialties (e.g., minimally invasive or robotic approaches).

In order to care for our patients, raise the standards of healthcare services, and be successful in today’s and tomorrow’s rapidly changing healthcare environment, understanding and evolving these topics represents an essential duty of all surgeons, physicians and professionals related to surgical patients. In this context, we call all surgeons, physicians and professionals from all associated disciplines involved in the perioperative pathway of surgical patients (surgeons, anesthesiologists, radiologists, intensivists, cardiologists, oncologists, pulmonologists, nurses, physiotherapists, nutritionists, etc.) to contribute to this Special Issue. Following the big success of the first volume of the Special Issue: https://www.mdpi.com/journal/jcm/special_issues/0IO98MY01D, we decided to launch a second volume to discuss a greater number of relevant topics. Our vision remains to provide the best currently available evidence in this field, thus providing all the necessary information to clinicians on core concepts in the perioperative management of surgical patients.

Dr. Dimitrios E. Magouliotis
Prof. Dr. Dimitris Zacharoulis
Guest Editors

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Keywords

  • clinical outcomes
  • surgery
  • quality
  • quality of life
  • quality improvement
  • postoperative
  • morbidity
  • postoperative care

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Related Special Issue

Published Papers (10 papers)

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Editorial

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3 pages, 148 KB  
Editorial
He Lives and He Reigns
by Dimitrios E. Magouliotis, Vasiliki Androutsopoulou and Dimitrios Zacharoulis
J. Clin. Med. 2025, 14(22), 8191; https://doi.org/10.3390/jcm14228191 - 19 Nov 2025
Viewed by 190
Abstract
Among the most enduring legends of the Greek seas is that of Thessalonike [...] Full article

Research

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14 pages, 508 KB  
Article
Outcomes of Prolonged Biliary Plastic Stent Dwell Time in Patients with Choledocholithiasis Undergoing ERCP Followed by Cholecystectomy
by Tal Weiss, Oren Gal, Miri Elgabsi, Neev Tchernin, Veacheslav Zilbermints and Boris Kessel
J. Clin. Med. 2025, 14(19), 6869; https://doi.org/10.3390/jcm14196869 - 28 Sep 2025
Cited by 1 | Viewed by 1110
Abstract
Introduction: ERCP with temporary biliary stenting followed by elective cholecystectomy and postoperative ERCP is commonly used to treat choledocholithiasis. While early stent removal (within 3–6 months) is generally recommended, some studies suggest that longer dwell time may not increase morbidity. This study aims [...] Read more.
Introduction: ERCP with temporary biliary stenting followed by elective cholecystectomy and postoperative ERCP is commonly used to treat choledocholithiasis. While early stent removal (within 3–6 months) is generally recommended, some studies suggest that longer dwell time may not increase morbidity. This study aims to evaluate outcomes associated with prolonged stent dwell time of more than six months. Methods: We conducted a retrospective study of all patients who underwent ERCP with plastic biliary stent insertion, followed by elective cholecystectomy and postoperative ERCP at a single tertiary center between 2018–2024. Patients were divided into early-ERCP (≤6 months) and late-ERCP (>6 months) groups. The primary outcome was the rate of recurrent biliary episodes. Secondary outcomes included urgent postoperative ERCP, stent reinsertion, and the need for additional ERCP’s. Results: A total of 203 patients were included (mean age 58.3 ± 19.8 years). Thirty-one patients (15%) had a stent dwell time of more than six months. Demographic and presenting characteristics were comparable between groups, except for acute cholecystitis, which was more frequent in the early-ERCP group (18% vs. 3.2%, p = 0.034). Recurrent biliary episodes were significantly more frequent in the late-ERCP group (19.4% vs. 5.8%, p = 0.021), as were urgent postoperative ERCP (16.1% vs. 5.2%, p = 0.044), stent reinsertion (35.5% vs. 14.5%, p = 0.008), and additional ERCPs (38.7% vs. 15.7%, p = 0.006). Conclusions: Prolonged biliary stent dwell time beyond six months is associated with significantly higher rates of recurrent biliary episodes, urgent postoperative ERCP, postoperative stent reinsertion, and additional ERCP’s. Full article
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9 pages, 359 KB  
Article
Clinical Impact of Appendiceal Morphology on Surgical Outcomes and Readmissions: Does Size Matter?
by Miri Elgabsi, Gal Malkiely, Tal Weiss, Neev Tchernin, Boris Kessel and Veacheslav Zilbermints
J. Clin. Med. 2025, 14(16), 5635; https://doi.org/10.3390/jcm14165635 - 9 Aug 2025
Cited by 1 | Viewed by 857
Abstract
Background: While the severity of acute appendicitis is routinely evaluated, the significance of its morphological characteristics remains underexplored. This study aimed to evaluate the clinical impacts of appendiceal dimensions. Methods: This retrospective study included patients who underwent appendectomy. Data on demographics, appendiceal morphology, [...] Read more.
Background: While the severity of acute appendicitis is routinely evaluated, the significance of its morphological characteristics remains underexplored. This study aimed to evaluate the clinical impacts of appendiceal dimensions. Methods: This retrospective study included patients who underwent appendectomy. Data on demographics, appendiceal morphology, time from admission to surgery, postoperative complications, and readmission rates were analyzed. Statistical tests, including correlation analysis and multivariate regression, were used. p-value ≤ 0.05 was considered statistically significant. Results: Appendix diameter demonstrated positive correlations with age, complicated appendicitis, and surgery duration. Multivariate analysis showed that appendix diameter was found to be a significant predictor of readmission rates, regardless of clinical factors, and has a significant positive association with age in both univariate/multivariate analyses. Conclusions: Our findings demonstrate the significance of appendicular morphology in the prediction of readmission rates and the importance of age-specific diagnostic thresholds. The observed age-related changes may warrant re-evaluation of recent diagnostic criteria. Full article
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14 pages, 2853 KB  
Article
Skin-Dwelling Bacteria Survive Preoperative Skin Preparation in Reconstruction Surgery
by Hannah R. Duffy, Nicholas N. Ashton, Porter Stulce, Abbey Blair, Ryan Farnsworth, Laurel Ormiston, Alvin C. Kwok and Dustin L. Williams
J. Clin. Med. 2025, 14(10), 3417; https://doi.org/10.3390/jcm14103417 - 14 May 2025
Cited by 1 | Viewed by 1056
Abstract
Background/Objectives: Accurately determining the bacterial bioburden that survives preoperative skin preparation (PSP) is critical in understanding PSP efficacy and its limitations. Clinical PSP approval relies on a bacterial sampling method described in the American Society for Testing and Materials (ASTM) standard E1173-15. Though [...] Read more.
Background/Objectives: Accurately determining the bacterial bioburden that survives preoperative skin preparation (PSP) is critical in understanding PSP efficacy and its limitations. Clinical PSP approval relies on a bacterial sampling method described in the American Society for Testing and Materials (ASTM) standard E1173-15. Though common, this technique may overlook deep-dwelling skin bacteria. The objective of this study was to test the hypothesis that deep-dwelling skin flora would survive PSP, and more growth would be detected using a destructive sampling method compared with ASTM E1173-15. Methods: Twelve female participants with a scheduled deep inferior epigastric perforator (DIEP) artery flap procedure at the Huntsman Cancer Institute in Salt Lake City, UT, were enrolled between January and August 2024. PSP was performed using three 26 mL ChloraPrep applicators (2% CHG), and excess tissue was collected. Bacteria in the skin were quantified using a destructive sampling method and ASTM E1173-15, and bioburden outcomes were compared. Two participants were excluded from the quantitative analysis. Results: Bacteria survived PSP in every participant. A greater diversity and more bacteria were quantified with destructive sampling than ASTM E1173-15 (p < 0.01). Generally, anaerobic bioburden values were higher than aerobic bioburden values. Higher bioburden correlated with processing more skin from a participant. Genotypic identification of select isolates identified Staphylococcus epidermidis and Cutibacterium acnes (formerly known as Propionibacterium acnes) as surviving bacteria, among others. Immunofluorescence revealed bacteria in all skin layers. No participant exhibited clinical signs of infection in the abdominal region. Human data corroborated previous porcine data collected using destructive skin sampling after PSP. Conclusions: Clinical PSP application does not create a sterile field. Destructive skin sampling techniques may be more effective than ASTM E1173-15 at resolving bacterial PSP survivors contributing to SSI risk. Full article
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14 pages, 1358 KB  
Article
Impact of Dexmedetomidine-Based Opioid-Sparing Anesthesia on Opioid Use After Minimally Invasive Repair of Pectus Excavatum: A Prospective Randomized Controlled Trial
by Minju Kim, Jaewon Huh, Hoon Choi and Wonjung Hwang
J. Clin. Med. 2024, 13(23), 7264; https://doi.org/10.3390/jcm13237264 - 29 Nov 2024
Cited by 3 | Viewed by 4292
Abstract
Background: Opioid-sparing anesthesia (OSA) using dexmedetomidine has gained attention as an alternative to opioid-based anesthesia (OBA) due to its potential to reduce opioid consumption and the associated side effects. This study aimed to investigate the effect of dexmedetomidine-based OSA on postoperative pain intensity, [...] Read more.
Background: Opioid-sparing anesthesia (OSA) using dexmedetomidine has gained attention as an alternative to opioid-based anesthesia (OBA) due to its potential to reduce opioid consumption and the associated side effects. This study aimed to investigate the effect of dexmedetomidine-based OSA on postoperative pain intensity, opioid consumption, and recovery outcomes in patients undergoing a minimally invasive repair of pectus excavatum. Methods: Eighty-four patients undergoing a minimally invasive repair of pectus excavatum were randomized to either the OSA group, receiving dexmedetomidine, or the OBA group, receiving remifentanil. The primary outcome was the total amount of analgesics administered within 24 h postoperatively. The secondary outcomes included pain intensity and analgesic consumption over 48 h, recovery outcomes, intraoperative hemodynamics, and opioid-related complications. Results: The OFA group reported a significantly reduced total morphine-equivalent dose within 24 h (55.4 ± 31.1 mg vs. 80.2 ± 26.7 mg, p < 0.001) and lower VAS scores at 24 h (3.9 ± 1.5 vs. 5.4 ± 2.1, p < 0.001). Pain intensity was lower, and analgesic consumption was reduced in the OSA group 1–6, 6–24, and 24–48 h after surgery. Recovery times and intraoperative hemodynamics were comparable between the groups, with no significant differences in opioid-related complications. Conclusions: Dexmedetomidine-based OSA effectively reduces postoperative pain and opioid use without compromising recovery or hemodynamic stability. These findings support its use as a viable alternative to OBA, particularly in the minimally invasive repair of the pectus excavatum. Full article
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15 pages, 916 KB  
Article
Aortic Stent Graft Treatment in a Medium-Size Aortic Center Performed by a Cardiac Surgeon Only—The 9 Years Experience in Poland
by Marian Burysz, Jakub Batko, Krzysztof Greberski, Artur Słomka and Radosław Litwinowicz
J. Clin. Med. 2024, 13(21), 6517; https://doi.org/10.3390/jcm13216517 - 30 Oct 2024
Cited by 1 | Viewed by 1358
Abstract
Background: The incidence of thoracic aortic aneurysms is estimated at 3.0–8.3/100,000 persons per year. There is a lack of reports in the literature on the outcomes of small- and medium-sized thoracic endovascular aortic repairs. The aim of this study is to present [...] Read more.
Background: The incidence of thoracic aortic aneurysms is estimated at 3.0–8.3/100,000 persons per year. There is a lack of reports in the literature on the outcomes of small- and medium-sized thoracic endovascular aortic repairs. The aim of this study is to present the results of thoracic endovascular aortic repairs at a single medium-sized center performed exclusively by a cardiac surgeon. Methods: Ninety patients who had undergone aortic stent graft implantations for the treatment of thoracic aortic anomalies were comprehensively, retrospectively evaluated. The detailed preoperative, surgical, and postoperative parameters of the patients, including the survival rate up to five years, were recorded and further analyzed. Results: The patients’ Euroscores were four (2.1–9). The 30-day mortality rate was 8.9%, the 1-year mortality rate was 15.6%, and the 5-year mortality rate was 38.9% for all causes. Postoperative complications were observed in 10% of the patients. Statistically significant differences were observed between the urgency of surgery at 30 days and survival at one year, but not at five years. The most common complications were related to respiratory (4.4%), renal (3.3%), and neurological (3.3%) dysfunction. Conclusions: Thoracic endovascular aortic repair can be safely performed in small- and medium-sized centers with optimal long-term results. Full article
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13 pages, 1603 KB  
Article
Transthoracic Cross Clamp versus Endoaortic Balloon Occlusion in Minimally Invasive Mitral Valve Surgery: A Pooled Study with Subgroup Analyses
by Dimitrios E. Magouliotis, Serge Sicouri, Massimo Baudo, Yoshiyuki Yamashita, Andrew Xanthopoulos, Arian Arjomandi Rad, Thanos Athanasiou and Basel Ramlawi
J. Clin. Med. 2024, 13(17), 4989; https://doi.org/10.3390/jcm13174989 - 23 Aug 2024
Cited by 1 | Viewed by 2512
Abstract
Objective: We assessed the available literature regarding patients undergoing minimally invasive mitral valve surgery (MIMVS) with either transthoracic clamping (TTC) or endoaortic balloon occlusion (EABO). Methods: Original research studies that evaluated the perioperative outcomes of TTC versus EABO group were identified [...] Read more.
Objective: We assessed the available literature regarding patients undergoing minimally invasive mitral valve surgery (MIMVS) with either transthoracic clamping (TTC) or endoaortic balloon occlusion (EABO). Methods: Original research studies that evaluated the perioperative outcomes of TTC versus EABO group were identified from 2000 to 2024. The incidence of all-cause mortality, cerebrovascular accidents (CVA), and aortic dissections were the primary endpoints. The cardiopulmonary bypass (CPB), cross-clamp, and ventilation time, along with the incidence of conversion to sternotomy, re-exploration, new-onset atrial fibrillation (AF), postoperative acute kidney injury (AKI), ICU stay, and LOS were the secondary endpoints. Subgroup analyses were performed regarding the EABO cannulation approach (femoral and aortic) and MIMVS approach (video-assisted and robotic-assisted). Sensitivity analyses were performed with the leave-one-out method and by including risk-adjusted populations. Results: Sixteen studies were included in both the qualitative and quantitative syntheses. After pooling data from 6335 patients, both groups demonstrated similar outcomes on all primary and secondary endpoints in the non-adjusted and adjusted total cohort analyses. These outcomes were further validated by the leave-one-out sensitivity analysis. In addition, the aortic cannulation EABO was associated with a lower cross-clamp time, followed by TTC and the femoral cannulation EABO approach. Furthermore, in the video-assisted subgroup analysis, the EABO approach was associated with a higher incidence of CVA, conversion to sternotomy, and longer ICU stay compared to the TTC group. Conclusions: The present meta-analysis indicates that both aortic occlusion techniques are safe and feasible in the context of MIMVS. A future well-designed randomized-control trial should further validate the current outcomes. Full article
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12 pages, 1202 KB  
Article
Contemporary Use of Sodium Glucose Co-Transporter 2 Inhibitors in Hospitalized Heart Failure Patients: A “Real-World” Experience
by Andrew Xanthopoulos, Nikolaos Katsiadas, Grigorios Giamouzis, Kleoniki Vangelakou, Dimitris Balaskas, Michail Papamichalis, Angeliki Bourazana, Nikolaos Chrysakis, Sotirios Kiokas, Christos Kourek, Alexandros Briasoulis, Niki Skopeliti, Konstantinos P. Makaritsis, John Parissis, Ioannis Stefanidis, Dimitrios Magouliotis, Thanos Athanasiou, Filippos Triposkiadis and John Skoularigis
J. Clin. Med. 2024, 13(12), 3562; https://doi.org/10.3390/jcm13123562 - 18 Jun 2024
Cited by 1 | Viewed by 1522
Abstract
Background/Objectives: The aim of this study was to examine the association between in-hospital initiation of sodium glucose co-transporter 2 inhibitors (SGLT2is) and outcomes in hospitalized heart failure (HHF) patients utilizing data from a Greek center. Methods: The present work was a [...] Read more.
Background/Objectives: The aim of this study was to examine the association between in-hospital initiation of sodium glucose co-transporter 2 inhibitors (SGLT2is) and outcomes in hospitalized heart failure (HHF) patients utilizing data from a Greek center. Methods: The present work was a single-center, retrospective, observational study of consecutive HF patients hospitalized in a tertiary center. The study endpoint was all-cause mortality or HF rehospitalization. Univariate and multivariate Cox proportional-hazard models were conducted to investigate the association between SGLT2i administration at discharge and the study endpoint. Results: Sample consisted of 171 patients, 55 of whom (32.2%) received SGLT2is at discharge. Overall, mean follow-up period was 6.1 months (SD = 4.8 months). Patients who received SGLT2is at discharge had a 43% lower probability of the study endpoint compared to those who did not receive SGLT2is at discharge (HR = 0.57; 95% CI: 0.36–0.91; p = 0.018). After adjusting for age, gender, smoking, hemoglobin (Hgb), use of SGLT2is at admission, use of Angiotensin-Converting Enzyme Inhibitors (ACEI-Is)/Angiotensin Receptor Blockers (ARBs) at discharge and Sacubitril/Valsartan at discharge, the aforementioned result remained significant (HR = 0.38; 95% CI: 0.19–0.73; p = 0.004). The 55 patients who received SGLT2is at discharge were propensity score matched with the 116 patients who did not receive SGLT2is at discharge. Receiving SGLT2is at discharge continued to be significantly associated with a lower probability of the study endpoint (HR= 0.43; 95% CI: 0.20–0.89; p = 0.024). Conclusions: Initiation of SGLT2is in HHF patients may be associated with better outcomes. Full article
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Review

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22 pages, 985 KB  
Review
The Role of Anesthetic Management in Lung Cancer Recurrence and Metastasis: A Comprehensive Review
by Jaewon Huh and Wonjung Hwang
J. Clin. Med. 2024, 13(22), 6681; https://doi.org/10.3390/jcm13226681 - 7 Nov 2024
Cited by 5 | Viewed by 2389
Abstract
Lung cancer remains a leading cause of cancer-related mortality worldwide. Although surgical treatment is a primary approach, residual cancer cells and surgery-induced pathophysiological changes may promote cancer recurrence and metastasis. Anesthetic agents and techniques have recently been shown to potentially impact these processes [...] Read more.
Lung cancer remains a leading cause of cancer-related mortality worldwide. Although surgical treatment is a primary approach, residual cancer cells and surgery-induced pathophysiological changes may promote cancer recurrence and metastasis. Anesthetic agents and techniques have recently been shown to potentially impact these processes by modulating surgical stress responses, immune function, inflammatory pathways, and the tumor microenvironment. Anesthetics can influence immune-modulating cytokines, induce pro-inflammatory factors such as HIF-1α, and alter natural-killer cell activity, affecting cancer cell survival and spread. Preclinical studies suggest volatile anesthetics may promote tumor progression by triggering pro-inflammatory signaling, while propofol shows potential antitumor properties through immune-preserving effects and reductions in IL-6 and other inflammatory markers. Additionally, opioids are known to suppress immune responses and stimulate pathways that may support cancer cell proliferation, whereas regional anesthesia may reduce these risks by decreasing the need for systemic opioids and volatile agents. Despite these findings, clinical data remain inconclusive, with studies showing mixed outcomes across patient populations. Current clinical trials, including comparisons of volatile agents with propofol-based total intravenous anesthesia, aim to provide clarity but highlight the need for further investigation. Large-scale, well-designed studies are essential to validate the true impact of anesthetic choice on cancer recurrence and to optimize perioperative strategies that support long-term oncologic outcomes for lung cancer patients. Full article
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Other

25 pages, 3496 KB  
Systematic Review
Antiepileptic Drugs for De Novo Seizure Prevention After Craniotomy: A Systematic Review and Network Meta-Analysis of Current Evidence
by Georgia Tsaousi, Adriani Nikolakopoulou, Parmenion P. Tsitsopoulos, Chryssa Pourzitaki, Dimitrios Mavridis and Anna Bettina Haidich
J. Clin. Med. 2025, 14(21), 7854; https://doi.org/10.3390/jcm14217854 - 5 Nov 2025
Cited by 1 | Viewed by 998
Abstract
Objective: We aimed to systematically evaluate the available clinical evidence concerning the comparable efficacy and safety of currently used anti-epileptic drugs (AEDs) for seizure prophylaxis in patients undergoing craniotomy for brain tumor excision and synthesize this with a network meta-analysis (NMA). Methods [...] Read more.
Objective: We aimed to systematically evaluate the available clinical evidence concerning the comparable efficacy and safety of currently used anti-epileptic drugs (AEDs) for seizure prophylaxis in patients undergoing craniotomy for brain tumor excision and synthesize this with a network meta-analysis (NMA). Methods: A systematic literature review was performed to identify randomized controlled trials (RCTs) relevant to the prophylactic use of AEDs in seizure-naïve patients subjected to brain tumor excision. Total, early, or late post-craniotomy seizures constituted primary outcome measures, while mortality and treatment-related adverse effects served as secondary endpoints. Pairwise and network meta-analysis were conducted for each pair of interventions to obtain ‘direct’ treatment effect estimates, while NMA was employed to assess the relative efficacy and safety of prophylactic use of AEDs in post-craniotomy epilepsy management in brain tumor cases. Results: Twelve eligible RCTs involving 10 interventions were retrieved. Levetiracetam (OR 0.08; 95%CI 0.02–0.43) and phenytoin (OR 0.43; 95%CI 0.20–0.91) showed superior efficacy over placebo on early seizure control, while none of the applied interventions demonstrated any significant effect on late seizures versus placebo. With the single exception of carbamazepine (OR 3.29; 95%CI 1.21–8.91), none of the implemented AEDs exerted a notable effect on mortality. Phenytoin presented a higher incidence of treatment-related AEs, imposing drug discontinuation compared to other treatment regimens, yet this effect did not reach statistical significance. Conclusions: Our NMA indicates that, in seizure-naive individuals subjected to brain tumor excision, levetiracetam and phenytoin effectively prevent postoperative short-term seizure activity. Notwithstanding the fact that levetiracetam presents an enhanced safety profile over other AEDs, no statistical superiority could be demonstrated. PROSPERO registration CRD42022377136. Full article
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