Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy

Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy Kengo Kuriyama, Akihiko Okamura, Jun Kanamori, Yu Imamura, Masahiro Tamura, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4187756/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jun, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background : Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgeries. However, whether robot-assisted minimally invasive esophagectomy (RAMIE) can overcome anatomical difficulties during thoracoscopic esophagectomy remains unclear. This study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region. Methods : Forty-five patients who underwent curative-intent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were included. Using preoperative computed tomography images, we calculated previously reported anatomical indices to assess the upper mediastinal narrowness and vertebral body projections in the middle thoracic region. The factors influencing thoracic operative time were then investigated. Results : During the thoracic procedure, the median operative time was 215 (124–367) min and the median blood loss was 20 (5–190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The multiple linear regression model revealed that a narrow upper mediastinum and greater blood loss during the thoracic procedure were significant factors associated with a prolonged thoracic operative time ( P = 0.025 and P < 0.001, respectively). Upper mediastinal narrowing was not associated with postoperative complications. Conclusions : A narrow upper mediastinum was significantly associated with a prolonged thoracic operative time in patients with RAMIE. esophageal cancer esophagectomy minimally invasive esophagectomy robot-assisted minimally invasive esophagectomy operative time Figures Figure 1 Figure 2 Introduction Minimally invasive esophagectomy (MIE) using thoracoscopic, laparoscopic, or both approaches is increasingly performed worldwide [ 1 , 2 ]. In Japan, more than two-thirds of esophagectomies are performed using MIE [ 3 ]. However, procedural difficulties are encountered occasionally, particularly during thoracoscopic procedures. In particular, anatomical factors such as a narrow mediastinum could influence operative difficulty in thoracoscopic esophagectomy [ 4 , 5 ]. Previously, we reported that the degree of vertebral body projection in the middle thoracic region was related to prolonged thoracic operative time in conventional MIE (cMIE) [ 6 ]. Robot-assisted minimally invasive esophagectomy (RAMIE) using the da Vinci surgical system was approved by the Japanese Health Insurance System in 2018. Since then, the RAMIE has spread rapidly. Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgery [ 7 ]. However, we still encounter challenging cases of RAMIE in clinical settings. To date, the factors influencing the thoracic operative time in RAMIE remain unknown, and whether anatomical factors could be related to the difficulty of RAMIE remains unclear. Therefore, this study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region. Materials and methods Patients and study design This single-center, retrospective cohort study was conducted at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (JFCR). Sixty-two patients underwent curative-intent RAMIE between August 2021 and July 2023. After excluding patients who underwent Ivor Lewis esophagectomy, total pharyngolaryngoesophagectomy, or two-stage surgery, 45 patients who underwent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were eligible. Clinicopathological and anatomical data were retrospectively collected from the medical records. Tumor staging was determined according to the 8th edition of the Tumor, Node, and Metastasis System Classification of the Union for International Cancer Control [ 8 ], and postoperative complications were graded according to the Clavien-Dindo (CD) classification [ 9 ]. In this study, thoracic operative time was selected as a variable representing technical difficulty, and the factors influencing thoracic operative time in RAMIE were assessed. The study protocol was approved by the Institutional Review Board of the JFCR (approval number 2023-GB-074) and followed the principles of the 1964 Declaration of Helsinki and its later versions. Anatomical factors and indices calculation We previously reported the influence of a narrow upper mediastinum or middle to lower thoracic esophagus hidden by the projection of the vertebral body on prolonged duration of the thoracic procedure in patients with cMIE [ 6 ]. In the current study, as in a previous study, the upper mediastinal index (UMI) which was calculated as the degree of upper mediastinal narrowness by the ratio of the esophageal side shift (a; the distance from the midline to the left edge of the esophagus) to the space between the vertebral body and trachea (b: the distance from the vertebral body and trachea) at the level of the azygos arch on axial computed tomography (CT) images (Fig. 1 A, B). The middle mediastinal index (MMI), which is the degree of vertebral body projection at the middle thoracic region, was calculated as the ratio of the vertebral body size (c; distance from the dorsal edge to the ventral edge of the vertebral body) to the esophageal prominence (d; distance from the level of the vertebral dorsal edge to the ventral edge of the esophagus) at the level of the aortic root in the axial CT images (Fig. 1 C, D). These indices increased with a narrower upper mediastinum and more robust vertebral body projections. A single researcher (K.K.) was blinded to patients’ clinical information. Surgical procedures of RAMIE A single surgical team of experts performed the RAMIE in all cases. For the thoracic procedure, the patient was placed in a semiprone position under general anesthesia with bilateral lung ventilation using a single-lumen spiral endotracheal tube. Artificial CO2 pneumothorax was accomplished at 6–8 mmHg pressure to collapse the right lung. RAMIE was performed using the da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). We placed the trocars for the 1st robotic arm in the 9th intercostal space (ICS) on the angular inferior scapular line, for the 2nd robotic arm in the 7th ICS on the posterior axillary line, for the 3rd and 4th robotic arms near the anterior or middle axillary line in the 5th and 3rd ICS, respectively. One 12-mm trocar for assistant use was inserted into the 5th ICS on the anterior or middle axillary line. During mediastinal dissection, the thoracic duct was preserved; however, advanced primary tumors were resected to achieve sufficient surgical margins. In the abdominal stage, gastric mobilization with abdominal lymph node dissection was performed using the conventional laparoscopic approach. Statistical analysis All data are presented as the median (range) or number (%). Spearman's rank correlation coefficient analysis or the Mann-Whitney U test was used to perform univariate analysis. Multivariable analysis was performed using stepwise multiple linear regression analysis. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP software (SAS Institute Inc., Cary, NC, USA). Results Patient characteristics and operative outcomes The patients’ characteristics and operative outcomes are described in Table 1. The median age of the 45 patients was 66 (45–85) years, and 77.8% were male. Thirty (66.7%) and 15 (33.3%) patients had pT1 and pT2-3 tumors, respectively. Regarding anatomical factors, the median upper mediastinal index was 2.13 (0.15–9.36), and the median middle mediastinal index was 0.84 (0.58–1.2). Thoracic duct resection was performed in seven patients (15.6%). The median operative time of the thoracic procedure was 215 (124–367) min and the median blood loss during the thoracic procedure was 20 (5–190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The incidence of CD grade II or higher complications requiring intervention and reoperation was 26.7% and 6.7%, respectively. No surgery-related mortalities occurred. Factors influencing the thoracic operative time in RAMIE The correlation between clinicopathological and anatomical factors and thoracic operative time in patients with RAMIE is described in Table 2. In the univariate analysis, higher UMI, thoracic duct resection, and incomplete resection were significantly correlated with prolonged thoracic operative time ( P = 0.013, 0.014, and 0.04, respectively). Although not statistically significant, a higher middle mediastinal index (MMI), greater blood loss, and advanced tumors (pT2-3) promoted a slightly prolonged operative time. The correlations between thoracic operative time and UMI and MMI are shown in Fig. 2 . Thoracic operative time was significantly correlated with UMI but not with MMI. Further multivariable analysis using the stepwise multiple linear regression model revealed that higher UMI and more blood loss during the thoracic procedure remained significant factors related to prolonged thoracic operative time in patients with RAMIE (Table 3; P = 0.025 and P < 0.001, respectively). There was no multicollinearity between these two factors. Association between UMI and operative outcomes The association between the UMI and operative outcomes was also investigated (Table 4). The UMI was not associated with pneumonia, anastomotic leakage, recurrent laryngeal nerve palsy, or reoperation. Moreover, the UMI did not influence the postoperative hospital stay. Discussion The present study revealed that the degree of upper mediastinal narrowness was significantly associated with prolonged thoracic procedure time, suggesting that particular anatomical features may influence the procedural difficulty in RAMIE of the thorax. This effect was similar to that observed for cMIE, as shown previously [ 6 ]. These findings suggest that even full articulation of instruments in the robotic surgical system has not yet overcome technical difficulties in cases with a narrow upper mediastinum. To the best of our knowledge, this is the first study to elucidate the factors that influence the difficulty of RAMIE in thoracic procedures. A flexible scope may have advantages over a rigid endoscope in obtaining a sufficient surgical view in cases with a narrow mediastinum, as the former can look into targets from various directions. Because the da Vinci Xi surgical system only utilizes a rigid endoscope, an insufficient surgical view may be a reason for the prolonged operative time in cases with a narrow mediastinum. Moreover, during upper mediastinal dissection, since the robotic arms face the same vector, the forceps are more likely to interfere with each other, and manipulation becomes more difficult. These factors may increase the thoracic surgery time for RAMIE in patients with narrow mediastinal spaces. The median UMI and MMI values in the present study were similar to those observed in a previous study [ 6 ]. Given that the indices of Japanese patients did not change between studies, a certain number of challenging cases remain. As prolonged operative time is correlated with the duration of the systemic inflammatory response and increased cytokine release after surgery [ 10 , 11 ], surgeons should focus on shortening the operative time. The preoperative prediction of anatomical difficulties may contribute to surgical planning, including patient positioning and trocar placement. Due to their short learning curve, young trainee surgeons have opportunities to perform RAMIE without sufficient experience with cMIE. Preoperative prediction of challenging cases enables appropriate case selection for trainee operators and contributes to patient safety. This study indicates that the UMI is a valuable indicator for preoperatively predicting the difficulty of RAMIE. Meanwhile, the da Vinci SP (Intuitive Surgical, Inc., Sunnyvale, CA, USA), another robotic surgical system, may overcome technical difficulties associated with challenging anatomical factors. This novel system can reduce the forceps interference. In addition, it utilizes a flexible endoscope that may improve visualization of the narrow mediastinum. In addition to improving surgical skills, the choice of surgical instruments and development of devices may solve this problem. In the present study, we showed that blood loss during the thoracic procedure remained a significant factor associated with prolonged thoracic operative time. This has also been reported in studies on other robotic operations [ 12 , 13 ]. Increased blood loss in the surgical area may result in poor surgical view and prolongation of each step of the procedure. Technical improvements to control minor bleeding and meticulous hemostasis may lead to a shorter operative time. This study has several limitations. First, this was a retrospective observational study conducted at a single institution with a limited number of patients. Second, because RAMIE was adopted at our institution in 2020, the results of this study are only the results of the introductory phase. These results should be validated when refining the RAMIE surgical technique. Third, long-term outcomes were not assessed because of the short observation period. In conclusion, anatomical factors were significantly associated with prolonged thoracic operative time in patients with RAMIE. Understanding that a narrow upper mediastinum is associated with procedural difficulty will allow us to safely perform RAMIE. Declarations Disclosures The authors have no related conflict of interest to declare. Funding information specific to this paper There are no funding resources to be reported or declared. Acknowledgments We would like to thank Editage for the English language editing. Author contributions All authors contributed to the conception and design of this study. Kengo Kuriyama, Akihiko Okamura, and Jun Kanamori collected and analyzed the data. The first draft of the manuscript was written by Kengo Kuriyama and Akihiko Okamura, and all authors commented on previous versions of the manuscript. All the authors have read and approved the final version of the manuscript. References Takeuchi H, Kawakubo H, Kitagawa Y (2013) Current status of minimally invasive esophagectomy for patients with esophageal cancer. Gen Thorac Cardiovasc Surg 61(9):513–521. Kawakubo H, Takeuchi H, Kitagawa Y (2013) Current status and future perspectives on minimally invasive esophagectomy. Korean J Thorac Cardiovasc Surg 46(4):241–248. Marubashi S, Takahashi A, Kakeji Y, Hasegawa H, Ueno H, Eguchi S, Endo I, Goi T, Saiura A, Sasaki A, Takiguchi S, Takeuchi H, Tanaka C, Hashimoto M, Hiki N, Horiguchi A, Masaki T, Yoshida K, Gotoh M, Konno H, Yamamoto H, Miyata H, Seto Y, Kitagawa Y (2021) Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011–2019. Ann Gastroenterol Surg 5(5):639–658. Yoshida N, Baba Y, Shigaki H, Shiraishi S, Harada K, Watanabe M, Iwatsuki M, Kurashige J, Sakamoto Y, Miyamoto Y, Ishimoto T, Kosumi K, Tokunaga R, Yamashita Y, Baba H (2016) Effect of esophagus position on surgical difficulty and postoperative morbidities after thoracoscopic esophagectomy. Semin Thorac Cardiovasc Surg 28(1):172–179. Okamoto K, Inaki N, Saito H, Shimada M, Yamaguchi T, Tsuji T, Moriyama, Kinoshita J, Makino I, Nakamra K, Takamura H, Ninomiya I (2023) Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study. BMC Surg 23(1):242. Okamura A, Watanabe M, Mine S, Nishida K, Imamura Y, Kurogochi T, Kitagawa Y, Sano T (2016) Factors influencing difficulty of the thoracic procedure in minimally invasive esophagectomy. Surg Endosc 30(10):4279–4285. Hosoda K, Niihara M, Harada H, Yamashita K, Hiki N (2020) Robot-assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications. Ann Gastroenterol Surg 4(6):608–617. Rice TW, Patil DT, Blackstone EH (2017) 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice. Ann Cardiothorac Surg 6(2):119–130. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, e Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196. Haga Y, Beppu T, Doi K, Nozawa F, Mugita N, Ikei S, Ogawa M (1997) Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery. Crit Care Med 25(12):1994–2000. Okamura A, Takeuchi H, Matsuda S, Ogura M, Miyasho T, Nakamura R, Takahashi T, Wada N, Kawakubo H, Saikawa Y, Kitagawa Y (2015) Factors affecting cytokine change after esophagectomy for esophageal cancer. Ann Surg Oncol 22(9):3130–3135. Violette PD, Mikhail D, Pond GR, Pautler SE (2015) Independent predictors of prolonged operative time during robotic-assisted radical prostatectomy. J Robot Surg 9(2):117–123. Haveman I, van Weelden WJ, Roovers EA, Kraayenbrink AA, Dijkhuizen F (2022) Robot-assisted total laparoscopic hysterectomy in different classes of obesity: A cohort study. JSLS 26(1):e2021.00077. doi: 10.4293/JSLS.2021.00077 Tables Table 1. Patients characteristics and operative outcomes Factors Value # Patient factors Median age: years (range) 66 (45-85) Sex male 35 (77.8) female 10 (22.2) Median BMI: kg/m 2 (range) 21.6 (15.5-30.5) Median upper mediastinal index (range) 2.13 (0.15-9.36) Median middle mediastinal index (range) 0.84 (0.58-1.2) Tumor factors Definitive chemoradiotherapy Yes 1 (2.2) No 44 (97.8) Histology SCC 43 (95.6) Others 2 (4.4) Tumor location Supracarinal 12 (26.7) Infracarinal 33 (73.3) pT category pT ≤ 1b 30 (66.7) pT ≥ 2 15 (33.3) pN category pN0 24 (53.3) pN ≥ 1 21 (46.7) pStage category pStage ≤ II 30 (66.7) pStage ≥ III 15 (33.3) Intraoperative factors Thoracic duct resection Yes 7 (15.6) No 38 (84.4) R0 resection Yes 41 (91.1) No 4 (8.9) Median thoracic procedure duration: min (range) 215 (124-367) Median blood loss during the thoracic procedure: mL (range) 20 (5-190) Postoperative factors Postoperative complications 16 (35.6) Pneumonia 8 (17.8) Anastomotic leakage 1 (2.2) Recurrent laryngeal nerve palsy 3 (6.7) CD grade ≥ II 12 (26.7) Re-operation 3 (6.7) In-hospital mortality 0 Postoperative hospital stay: days (range) 15 (12-70) # Data were provided as the median (range) or n (%) Abbreviations: BMI, body mass index; SCC, squamous cell carcinoma; CD, Clavien-Dindo * P < 0.05 Abbreviations: SCC, squamous cell carcinoma * P < 0.05 Table 3. Factors in the stepwise multiple linear regression model explaining variations in thoracic operative time Variables Standardized coefficient P value Upper mediastinal index 0.255 0.025* Blood loss during thoracic procedure 0.458 < 0.001* Thoracic duct resection 0.2 0.119 R0 resection -0.2 0.059 R 2 = 0.531 * P < 0.05 Abbreviations: CD, Clavien-Dindo Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jun, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 19 Apr, 2024 Reviews received at journal 19 Apr, 2024 Reviews received at journal 13 Apr, 2024 Reviewers agreed at journal 08 Apr, 2024 Reviewers agreed at journal 08 Apr, 2024 Reviewers invited by journal 08 Apr, 2024 Editor assigned by journal 07 Apr, 2024 Submission checks completed at journal 02 Apr, 2024 First submitted to journal 29 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4187756","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288945606,"identity":"100b7808-89a9-4e99-a91e-ddc73b26e57a","order_by":0,"name":"Kengo Kuriyama","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kengo","middleName":"","lastName":"Kuriyama","suffix":""},{"id":288945607,"identity":"15b2f00c-7fb0-4f45-8a6a-3cc2e43fc5cb","order_by":1,"name":"Akihiko Okamura","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDACHsY2hoQDIAaEL8fYfADCYmwgUosxY1sCIS0MbAwMSFoSG9gS8LuLv+dw24MHZ2wY+HkOP93Mu8cuvbmN+dkHhop7DMyzsVsjcbax3SDhRhqDZG+b2W2eZ8m5jW1sxjMYzhQzMM45gN2a84xtEgkfDjMYnGcAajnAnNs4v4eZAeQhxhnYXSiP0ML+DailPp2xjQe/FoOzjUAtN4BazvaAbDmcQFCL4ZmDQC1n0ngke86U3Zxz4LghyC8MCWcSeHD5Re5M+jPJH8ds5Ph50rfdeHOgWt6wjfkxw4eKBDlDHCEGAzwIe0EKgU7iMZyBVwcSkIczJIjVMgpGwSgYBcMcAACGm2BfBBDQkwAAAABJRU5ErkJggg==","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":true,"prefix":"","firstName":"Akihiko","middleName":"","lastName":"Okamura","suffix":""},{"id":288945608,"identity":"1ba4f38f-5266-458a-b3c6-b18098d812da","order_by":2,"name":"Jun Kanamori","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Kanamori","suffix":""},{"id":288945609,"identity":"b5a46a2f-89ac-4e79-9cb9-87fec005e25f","order_by":3,"name":"Yu Imamura","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Imamura","suffix":""},{"id":288945610,"identity":"8350766c-79e6-4dd6-b787-f30f4018e62f","order_by":4,"name":"Masahiro Tamura","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Tamura","suffix":""},{"id":288945611,"identity":"6521d7ff-c317-4dbd-b41f-981bb5abf885","order_by":5,"name":"Naoki Takahashi","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naoki","middleName":"","lastName":"Takahashi","suffix":""},{"id":288945613,"identity":"88e6034a-1273-4270-a5a0-223b38e273fd","order_by":6,"name":"Masayoshi Terayama","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masayoshi","middleName":"","lastName":"Terayama","suffix":""},{"id":288945616,"identity":"ac6545f9-03f7-4c96-93d4-f003e3798af2","order_by":7,"name":"Yasukazu Kanie","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasukazu","middleName":"","lastName":"Kanie","suffix":""},{"id":288945618,"identity":"3eb5fcff-e7b2-4b55-ab6b-31b7a51da2cd","order_by":8,"name":"Suguru Maruyama","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Suguru","middleName":"","lastName":"Maruyama","suffix":""},{"id":288945620,"identity":"8ccb068c-3167-4dd3-9400-3f19916ab874","order_by":9,"name":"Masayuki Watanabe","email":"","orcid":"","institution":"The Cancer Institute Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masayuki","middleName":"","lastName":"Watanabe","suffix":""}],"badges":[],"createdAt":"2024-03-29 11:57:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4187756/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4187756/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-024-03378-w","type":"published","date":"2024-06-19T15:43:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54446002,"identity":"23a26087-9524-4bef-bc43-f74cb9e1070e","added_by":"auto","created_at":"2024-04-10 16:19:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7243567,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchema showing upper mediastinal index and middle mediastinal index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe upper mediastinal index is defined as the ratio of a to b, (A:B). The middle mediastinal index is defined as the ratio of c to d (C:D). The upper and middle mediastinal indices indicate the degree of upper mediastinal narrowing and vertebral body projection, respectively.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4187756/v1/1d7f39c791b0f92032e56545.jpg"},{"id":54446001,"identity":"d18fd9e5-1c5f-411a-a082-410e1c7a19f0","added_by":"auto","created_at":"2024-04-10 16:19:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4149474,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between thoracic operative time and upper or middle mediastinal index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003er\u003csub\u003es\u003c/sub\u003e indicates Spearman's rank correlation coefficient.\u003c/p\u003e\n\u003cp\u003e(A) Thoracic operative time and upper mediastinal index.\u003c/p\u003e\n\u003cp\u003e(B) Thoracic operative time and middle mediastinal index\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4187756/v1/e8d1b10555e1194882541361.jpg"},{"id":58823571,"identity":"9fd9584a-b58d-45c8-85a8-8f9ab907540b","added_by":"auto","created_at":"2024-06-21 17:02:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11890704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4187756/v1/a1a1cef4-2e03-464b-8046-426dff1ddafe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMinimally invasive esophagectomy (MIE) using thoracoscopic, laparoscopic, or both approaches is increasingly performed worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Japan, more than two-thirds of esophagectomies are performed using MIE [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, procedural difficulties are encountered occasionally, particularly during thoracoscopic procedures. In particular, anatomical factors such as a narrow mediastinum could influence operative difficulty in thoracoscopic esophagectomy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Previously, we reported that the degree of vertebral body projection in the middle thoracic region was related to prolonged thoracic operative time in conventional MIE (cMIE) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Robot-assisted minimally invasive esophagectomy (RAMIE) using the da Vinci surgical system was approved by the Japanese Health Insurance System in 2018. Since then, the RAMIE has spread rapidly. Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, we still encounter challenging cases of RAMIE in clinical settings. To date, the factors influencing the thoracic operative time in RAMIE remain unknown, and whether anatomical factors could be related to the difficulty of RAMIE remains unclear. Therefore, this study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and study design\u003c/h2\u003e \u003cp\u003eThis single-center, retrospective cohort study was conducted at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (JFCR). Sixty-two patients underwent curative-intent RAMIE between August 2021 and July 2023. After excluding patients who underwent Ivor Lewis esophagectomy, total pharyngolaryngoesophagectomy, or two-stage surgery, 45 patients who underwent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were eligible. Clinicopathological and anatomical data were retrospectively collected from the medical records.\u003c/p\u003e \u003cp\u003eTumor staging was determined according to the 8th edition of the Tumor, Node, and Metastasis System Classification of the Union for International Cancer Control [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and postoperative complications were graded according to the Clavien-Dindo (CD) classification [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, thoracic operative time was selected as a variable representing technical difficulty, and the factors influencing thoracic operative time in RAMIE were assessed. The study protocol was approved by the Institutional Review Board of the JFCR (approval number 2023-GB-074) and followed the principles of the 1964 Declaration of Helsinki and its later versions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAnatomical factors and indices calculation\u003c/h2\u003e \u003cp\u003eWe previously reported the influence of a narrow upper mediastinum or middle to lower thoracic esophagus hidden by the projection of the vertebral body on prolonged duration of the thoracic procedure in patients with cMIE [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the current study, as in a previous study, the upper mediastinal index (UMI) which was calculated as the degree of upper mediastinal narrowness by the ratio of the esophageal side shift (a; the distance from the midline to the left edge of the esophagus) to the space between the vertebral body and trachea (b: the distance from the vertebral body and trachea) at the level of the azygos arch on axial computed tomography (CT) images (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B). The middle mediastinal index (MMI), which is the degree of vertebral body projection at the middle thoracic region, was calculated as the ratio of the vertebral body size (c; distance from the dorsal edge to the ventral edge of the vertebral body) to the esophageal prominence (d; distance from the level of the vertebral dorsal edge to the ventral edge of the esophagus) at the level of the aortic root in the axial CT images (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, D). These indices increased with a narrower upper mediastinum and more robust vertebral body projections. A single researcher (K.K.) was blinded to patients\u0026rsquo; clinical information.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedures of RAMIE\u003c/h2\u003e \u003cp\u003eA single surgical team of experts performed the RAMIE in all cases. For the thoracic procedure, the patient was placed in a semiprone position under general anesthesia with bilateral lung ventilation using a single-lumen spiral endotracheal tube. Artificial CO2 pneumothorax was accomplished at 6\u0026ndash;8 mmHg pressure to collapse the right lung. RAMIE was performed using the da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). We placed the trocars for the 1st robotic arm in the 9th intercostal space (ICS) on the angular inferior scapular line, for the 2nd robotic arm in the 7th ICS on the posterior axillary line, for the 3rd and 4th robotic arms near the anterior or middle axillary line in the 5th and 3rd ICS, respectively. One 12-mm trocar for assistant use was inserted into the 5th ICS on the anterior or middle axillary line. During mediastinal dissection, the thoracic duct was preserved; however, advanced primary tumors were resected to achieve sufficient surgical margins.\u003c/p\u003e \u003cp\u003eIn the abdominal stage, gastric mobilization with abdominal lymph node dissection was performed using the conventional laparoscopic approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll data are presented as the median (range) or number (%). Spearman's rank correlation coefficient analysis or the Mann-Whitney U test was used to perform univariate analysis. Multivariable analysis was performed using stepwise multiple linear regression analysis. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using JMP software (SAS Institute Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics and operative outcomes\u003c/h2\u003e \u003cp\u003eThe patients\u0026rsquo; characteristics and operative outcomes are described in Table\u0026nbsp;1. The median age of the 45 patients was 66 (45\u0026ndash;85) years, and 77.8% were male. Thirty (66.7%) and 15 (33.3%) patients had pT1 and pT2-3 tumors, respectively. Regarding anatomical factors, the median upper mediastinal index was 2.13 (0.15\u0026ndash;9.36), and the median middle mediastinal index was 0.84 (0.58\u0026ndash;1.2). Thoracic duct resection was performed in seven patients (15.6%). The median operative time of the thoracic procedure was 215 (124\u0026ndash;367) min and the median blood loss during the thoracic procedure was 20 (5\u0026ndash;190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The incidence of CD grade II or higher complications requiring intervention and reoperation was 26.7% and 6.7%, respectively. No surgery-related mortalities occurred.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing the thoracic operative time in RAMIE\u003c/h2\u003e \u003cp\u003eThe correlation between clinicopathological and anatomical factors and thoracic operative time in patients with RAMIE is described in Table\u0026nbsp;2. In the univariate analysis, higher UMI, thoracic duct resection, and incomplete resection were significantly correlated with prolonged thoracic operative time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013, 0.014, and 0.04, respectively). Although not statistically significant, a higher middle mediastinal index (MMI), greater blood loss, and advanced tumors (pT2-3) promoted a slightly prolonged operative time. The correlations between thoracic operative time and UMI and MMI are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Thoracic operative time was significantly correlated with UMI but not with MMI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFurther multivariable analysis using the stepwise multiple linear regression model revealed that higher UMI and more blood loss during the thoracic procedure remained significant factors related to prolonged thoracic operative time in patients with RAMIE (Table\u0026nbsp;3; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025 and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). There was no multicollinearity between these two factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between UMI and operative outcomes\u003c/h2\u003e \u003cp\u003eThe association between the UMI and operative outcomes was also investigated (Table\u0026nbsp;4). The UMI was not associated with pneumonia, anastomotic leakage, recurrent laryngeal nerve palsy, or reoperation. Moreover, the UMI did not influence the postoperative hospital stay.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study revealed that the degree of upper mediastinal narrowness was significantly associated with prolonged thoracic procedure time, suggesting that particular anatomical features may influence the procedural difficulty in RAMIE of the thorax. This effect was similar to that observed for cMIE, as shown previously [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These findings suggest that even full articulation of instruments in the robotic surgical system has not yet overcome technical difficulties in cases with a narrow upper mediastinum. To the best of our knowledge, this is the first study to elucidate the factors that influence the difficulty of RAMIE in thoracic procedures.\u003c/p\u003e \u003cp\u003eA flexible scope may have advantages over a rigid endoscope in obtaining a sufficient surgical view in cases with a narrow mediastinum, as the former can look into targets from various directions. Because the da Vinci Xi surgical system only utilizes a rigid endoscope, an insufficient surgical view may be a reason for the prolonged operative time in cases with a narrow mediastinum. Moreover, during upper mediastinal dissection, since the robotic arms face the same vector, the forceps are more likely to interfere with each other, and manipulation becomes more difficult. These factors may increase the thoracic surgery time for RAMIE in patients with narrow mediastinal spaces.\u003c/p\u003e \u003cp\u003eThe median UMI and MMI values in the present study were similar to those observed in a previous study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Given that the indices of Japanese patients did not change between studies, a certain number of challenging cases remain. As prolonged operative time is correlated with the duration of the systemic inflammatory response and increased cytokine release after surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], surgeons should focus on shortening the operative time. The preoperative prediction of anatomical difficulties may contribute to surgical planning, including patient positioning and trocar placement.\u003c/p\u003e \u003cp\u003eDue to their short learning curve, young trainee surgeons have opportunities to perform RAMIE without sufficient experience with cMIE. Preoperative prediction of challenging cases enables appropriate case selection for trainee operators and contributes to patient safety. This study indicates that the UMI is a valuable indicator for preoperatively predicting the difficulty of RAMIE.\u003c/p\u003e \u003cp\u003eMeanwhile, the da Vinci SP (Intuitive Surgical, Inc., Sunnyvale, CA, USA), another robotic surgical system, may overcome technical difficulties associated with challenging anatomical factors. This novel system can reduce the forceps interference. In addition, it utilizes a flexible endoscope that may improve visualization of the narrow mediastinum. In addition to improving surgical skills, the choice of surgical instruments and development of devices may solve this problem.\u003c/p\u003e \u003cp\u003eIn the present study, we showed that blood loss during the thoracic procedure remained a significant factor associated with prolonged thoracic operative time. This has also been reported in studies on other robotic operations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Increased blood loss in the surgical area may result in poor surgical view and prolongation of each step of the procedure. Technical improvements to control minor bleeding and meticulous hemostasis may lead to a shorter operative time.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this was a retrospective observational study conducted at a single institution with a limited number of patients. Second, because RAMIE was adopted at our institution in 2020, the results of this study are only the results of the introductory phase. These results should be validated when refining the RAMIE surgical technique. Third, long-term outcomes were not assessed because of the short observation period.\u003c/p\u003e \u003cp\u003eIn conclusion, anatomical factors were significantly associated with prolonged thoracic operative time in patients with RAMIE. Understanding that a narrow upper mediastinum is associated with procedural difficulty will allow us to safely perform RAMIE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no related conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information specific to this paper\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no funding resources to be reported or declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage for the English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of this study. Kengo Kuriyama, Akihiko Okamura, and Jun Kanamori collected and analyzed the data. The first draft of the manuscript was written by Kengo Kuriyama and Akihiko Okamura, and all authors commented on previous versions of the manuscript. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTakeuchi H, Kawakubo H, Kitagawa Y (2013) Current status of minimally invasive esophagectomy for patients with esophageal cancer. Gen Thorac Cardiovasc Surg 61(9):513\u0026ndash;521.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawakubo H, Takeuchi H, Kitagawa Y (2013) Current status and future perspectives on minimally invasive esophagectomy. Korean J Thorac Cardiovasc Surg 46(4):241\u0026ndash;248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarubashi S, Takahashi A, Kakeji Y, Hasegawa H, Ueno H, Eguchi S, Endo I, Goi T, Saiura A, Sasaki A, Takiguchi S, Takeuchi H, Tanaka C, Hashimoto M, Hiki N, Horiguchi A, Masaki T, Yoshida K, Gotoh M, Konno H, Yamamoto H, Miyata H, Seto Y, Kitagawa Y (2021) Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011\u0026ndash;2019. Ann Gastroenterol Surg 5(5):639\u0026ndash;658.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida N, Baba Y, Shigaki H, Shiraishi S, Harada K, Watanabe M, Iwatsuki M, Kurashige J, Sakamoto Y, Miyamoto Y, Ishimoto T, Kosumi K, Tokunaga R, Yamashita Y, Baba H (2016) Effect of esophagus position on surgical difficulty and postoperative morbidities after thoracoscopic esophagectomy. Semin Thorac Cardiovasc Surg 28(1):172\u0026ndash;179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamoto K, Inaki N, Saito H, Shimada M, Yamaguchi T, Tsuji T, Moriyama, Kinoshita J, Makino I, Nakamra K, Takamura H, Ninomiya I (2023) Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study. BMC Surg 23(1):242.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamura A, Watanabe M, Mine S, Nishida K, Imamura Y, Kurogochi T, Kitagawa Y, Sano T (2016) Factors influencing difficulty of the thoracic procedure in minimally invasive esophagectomy. Surg Endosc 30(10):4279\u0026ndash;4285.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosoda K, Niihara M, Harada H, Yamashita K, Hiki N (2020) Robot-assisted minimally invasive esophagectomy for esophageal cancer: Meticulous surgery minimizing postoperative complications. Ann Gastroenterol Surg 4(6):608\u0026ndash;617.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRice TW, Patil DT, Blackstone EH (2017) 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice. Ann Cardiothorac Surg 6(2):119\u0026ndash;130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, e Santiba\u0026ntilde;es E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187\u0026ndash;196.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaga Y, Beppu T, Doi K, Nozawa F, Mugita N, Ikei S, Ogawa M (1997) Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery. Crit Care Med 25(12):1994\u0026ndash;2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamura A, Takeuchi H, Matsuda S, Ogura M, Miyasho T, Nakamura R, Takahashi T, Wada N, Kawakubo H, Saikawa Y, Kitagawa Y (2015) Factors affecting cytokine change after esophagectomy for esophageal cancer. Ann Surg Oncol 22(9):3130\u0026ndash;3135.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViolette PD, Mikhail D, Pond GR, Pautler SE (2015) Independent predictors of prolonged operative time during robotic-assisted radical prostatectomy. J Robot Surg 9(2):117\u0026ndash;123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaveman I, van Weelden WJ, Roovers EA, Kraayenbrink AA, Dijkhuizen F (2022) Robot-assisted total laparoscopic hysterectomy in different classes of obesity: A cohort study. JSLS 26(1):e2021.00077. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4293/JSLS.2021.00077\u003c/span\u003e\u003cspan address=\"10.4293/JSLS.2021.00077\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTable 1. Patients characteristics and operative outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eValue\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePatient factors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian age: years (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66 (45-85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian BMI: kg/m\u003csup\u003e2\u003c/sup\u003e (range)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.6 (15.5-30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian upper mediastinal index (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.13 (0.15-9.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian middle mediastinal index (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.84 (0.58-1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eTumor factors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDefinitive chemoradiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (97.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHistology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43 (95.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTumor location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSupracarinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfracarinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epT category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epT \u0026le; 1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epT \u0026ge; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epN category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epN \u0026ge; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epStage category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epStage \u0026le; II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003epStage \u0026ge; III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eIntraoperative factors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic duct resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eR0 resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian thoracic procedure duration: min (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e215 (124-367)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian blood loss during the thoracic procedure: mL (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (5-190)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePostoperative factors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAnastomotic leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRecurrent laryngeal nerve palsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCD grade \u0026ge; II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRe-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIn-hospital mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative hospital stay: days (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (12-70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003csup\u003e#\u003c/sup\u003e Data were provided as the median (range) or n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: BMI, body mass index; SCC, squamous cell carcinoma; CD, Clavien-Dindo\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg 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3cZrOU36J46YLo7lh3QJthQp2UfkNy7x6jyn2xizGlP7NrX/fA6xzyi1c/UhGLXzWt8ouvo6xa00ZmJ/JEp5g5x23LGBNvs3YUdc8VzuYxg5PrkhzRDzT/i1vHDt9u3brXJImBH8sPuAKNVDBvdKg9kRlitCK8MyJ7dxarC8GK8TJcu++sKjrrEUiZ3sRVwi1lI0djFc7OUmLn9ih1vgX+HW3Cs8rul6JIYHWuJVuHFJWGkV8VrOk8Ih/uhf6Ynu+deSLde5JoN9jNMYszqxDZaIfRCob1IfxjHkc/ypPWNXaufYqZ3TJxCGwhHRPf8Kn3+5Uz+EXU6viH65XnIbwyilPbvP57GfK8WnY/yB+sGY51pesFeaIjFOyPVQIvsx28/a3w5jN9crV64sz462zY97fsRd5FlS7aMR9uMN2vqWOVnGru1GX6JvV3qWeJV2ZkDsgwZNObYzEsKPkNYSpIXwmbkxi4ncvXu3/Wf5uLSTLnlilkU6uU562IDu2rVrbVmTFmPM+unr29RPCZ3jj5UL2jDtttTO6RffeOON1k0zeC9t63T1dX19Jn51nXg5ruVtSNr7KMUXId3kmTjUpw7NS+T58+fLo5Pk+DI1f2Y7mawEoQjQEPKSLkIblz+Fts0/C/JyaaZvV3qWwGnA5DVu/Ea4dBBDOiugbGjgd+7caTuXsRAP6cSQZtIh5YdwjTHTWWffRrtXG1bbjdD/0A9xLU+uhtDX12VyHjMxb31pH0JffHt7eyfiUF87hrjZZolvvvlm8fnnn7f/kT5/ZruYrAQhnGjn8d4r8IAZqxl0JKx2SOhRFlhRmZPYQJmpiKzMMHMgvTX3rMyQTtyh7JS4efNm+6yAUL5KK0c1iJOOpKth08mWVpLI0/3795dnr14rxT3ljR/Nmowxq7Ouvk3+RGnCRf9T64NK1Pq6IeA39mn0JbW8DUl7H6X4IqQb5VP9mJ4JGgtp7VrV+a//+q/FX/3VX7Ur6QL3+DM7RKNlz0LTWbT3W2UizYB/bM8xNLOb9pz7upjoT9d+85vfHNvH8GN42OteL0ZhYR/DwuAOau4xcq90ZuRX965BfmJcMrr/rHPiw6/O5afkDqJbpUnnGNKDX+WD8Iwx8xH7Hkykr28rnUMME3+5ncfr8g86jn1jjhdDv5DD1DFhZ3QNo34y+lEckNNO/6NzTNd57ucwxBfDVJ+m89xn5rzoGvnPYKf8qHxUD3/605/asD766KP2HEphmO3G22YYY4zZSlhBqr0mzwoTq0CszLOyxy3Ehw8fDl5BM9uBlSBjjDFbC7f0uG0XX8LJ8CgEjzTkzyGY7ce7yBtjjDFm50D98UqQMcYYY3aStX8nyBhjjDFmE5lVCeJVx7HfpzDGmE2F50l4HACj18UzNTc8eCt7jjP0l/n1cGO2DbWBrs8c5C1fIjzPhX1uK7SpVT7RkJlVCeIbCyhB/k6NMWYb4Js2h4eHrcnfCxI1N3xRWfYcZ+L3dozZRlBunj171j57w04HJdAX+HAwbjDx4XT0CZQi7HmDL4KfOZhNCSKhfGmTT63HDxAaY8x5hM6ZTphOGYOCkyd4NTf0hxcvHm2+iuE4znCZwd5b4WvxxpwXkPf40U7kvbQiylZRKEj5Gm2E9lR6q49VIT5cPAezKUFsI8GXNq9evbp48ODB0vYVWuqSUYbpQDhHYzTGmE2ByVzcP4tJXp7g1dyg+ACdNYMBnbnsUJLee++99tiYbQWdIK6MslMDXx7PaLsqVkvjLS/2qIOsH2gyMWabmi5mU4JevHjRanw09HxLTLMeMso/hk3ssOfjVNhDSUs0xpjzCNtecMuLgSBuq/Po0aPeTTyN2RU0OUAP0C1i9Ie9vb12soA9K0rSD9g2Kt8am8JsShCJ1yoP+77EGVOc9aC9aT8XOom8I7oxxmwDzIR5HoJngvQAJx35rVu32mNjzEn29/fblZ5vv/22VY40WeDWF/oBytHce4+iZU2GvVswomn0r+3Bon1bYpTY4dYYYzYN+rS435f2sIrU3NCvRXv6OrlVPyhT2svLmPNO1gOQc+0dV0NtIbcr/N27d3JPPZnobhVmUYJKjVidAZB4HUfwF/2WwjHGmLNCE7XSxE6U3NDf0UEL7HMfSL+IMWZbiXpAbA8lcBfbQ2wzMRyBYjSHzjBZCSKhZC4mJu4ATKbiuYyIdnQixhizKdDx5v6Jf87VKZfcAH2f7EudtZUgs+2orWCiEsM5ekFsO3lFJ/ottZO5lKBT2TaD++DxQUA9NO3deo0xxhhzVpyKEsSDzzEaHhKMb0sYY4wxxpw2s34xusa9e/eO3xzD+BsZxhhjjDlrvIu8McYYY3aSU1kJMsYYY4zZNKwEGWOMMWYnmawEae+vaMbuA8aD0viLGwxuEqRv6JYevPlGXvK2/8aY8wd9kvq1rv6JPkJfhRb0ASW/9I+yN2bbkazHrbQijK0lNxpLMXE8rdmvymQliD099vb2jrfL1yNGuUPogjfFLl68uDzbPEjf0L1+eO2fB8GNMecf9v06PDxsTdwMMkJfp80ehZQe+kP6A/Y7AjrtO3futPb7+/veONpsNci3dAO2yCrBdhhcPzg4aHeUFzdu3Dj2y7ZcalM1+1VZy+0wGjn7ghljzHmFGScr3exhhEEJKs1mmSSVJj7a5PHdd99td5cH7PR9NPYQY89EY7YRlBMWSSTvtJF8RwU3+lzOpUuXjjdTBSYe8stCy8uXL9vjmv2qrEUJQpuLs6a43BWXr2QfV42yOzohTES34LQshv+4RCYIQ3YKT3Hyr3j5lx0mojAIX8e4iWkQnGMiVLLs8R/TqbRgpmqzxph5YRPoK1euLM8WrSITN4buInbm7Bpf2vUaN5u8Am7MFNhAOOoBbJ6eN0mP7YTV0vj9QBScqBtExadkvyqzKUHaDR5DxpQZBv2HDx+2S1davmLwZ9DXsjDfDUK7A87h6tWr7T8KFdpkRKtMXMM9S9E6poCkmBAXdoT94MGD1k5piZVBWrAjPRk6L8KMx9euXWvTgGarTjEu+xGvQAiwk/0bb7zRugM0XzpB0heFwRhz/tEEiP5Jk7AI/RS7Yxuz66idROXmiy++aO24xrGo2a/KbEqQFAAMaPUmz6ZQHFBAHj9+fNwB8LxNnBHhhuvw4sWL9r+ECgC/UYNkG34gLShcMWyUDQqPpWj5QckivfwPefaHe5dSWp4/f952dnnZD7BHwSE+DKAd444wSBdKmRUgY7YP2jV9EP2BJmGR2gqRMbsG7YQxEeVGMEnQOBmfnavZr8paboehYDD4a0UmwpJYH6wC0Wngn/vpq4Jig8KlVSZA8aHAWaGR1okCw8oOikq+HTYVKor4ZKRkodxxLT4IZozZHOh7nj59ujxbtMer9EclRYeVoevXry/PjNk+uNMRnw1mLO7aLSIvhvAANHa6E6SxuWa/KmtRgvQmBLd+6DTiE9wUBI0fZUi3jbRiIphBocAwU1r1fp/iiytEgOaolRtVEHERJ6tZ8TbZUPBL+lUZ6ji1wiN7lDqOda5KjEuAxpjNgL6HNkp/oT5jlf6Idp+fkQTCItzSrTJjzjsax7UYwipP150W2gLudcyYyn+kZj+J7ybSaG7c/3rNNArF0sV37Tb4sudYsA0+doQhIw46tslXnHt7e61R2AoP0xTUsbvoHjc6V1piGDHdEMNslLbj45gn0oo/nSs87KI98eocN6RR12p5NcacHbH90l5B7ZZrEPsCteNoR1sXsT+RUbjGbBtxjFN7Ac4ZNzG6zvgYiddiG6rZr8rG7h0m7XHVlSBjjDHGmC7WcjtsDnig2gqQMcYYY9aFd5E3xhhjzE6ysStBxhhjjDHrZLISxNPc+g5OfAtKdufpzSfSG787wPkUKIdVvmOgL1PruagIZTymTHOejDHD4S0U2hCm9kaK2mvNDe2Pa+of5bbLjzHnGcl2aQwTNTe0pzxm0XZq7jmfomdMVoJ4bXRv72gDVb3+xrM8h4eH7UfC8ivqmwx5iKxypzBWBuWwyhct41eqM5TxmDLNeTLGDIdX2+nLMPE1dyEFhr6C/k6fBxF02rwqzHXaLp05xzL7+/tLl8ZsBygwjDvId23T1JobFKC444Lg0zW4PTg4uckq7YuPI7OlDQsymmiMwbfDZoQOMX7x0hhzfmGGqW+IYVCCSjNbfQwxbpQKdPR5Ilj6Toq+J2bMeYcxMH5PC/nPikmXG9oSik4E92pDeZNVFCN2XUBx4rt/Xd8hqrF2JYhOA22NFRLdOkPbq9kL2WlZTOe45z+iazFMHUe3FKbsYlzEgV3cHJEwMUJxYAgH5I8KJL6Ly69dYve73/2u/Y9p4VjpV/wxncprDbnN5ZfDhFKeQPnI5cp5KRxjdpW85U9pA9XYIcdtMNTR8+FU2hRtK4ObqDQZc94ZsmnqEDeR2MbyJqu0Lb4gjSJFmBu5EoS2RwJZIUFTYwkMra1mD3QY2ugUyJi+7sxnt2UvdK1vQ1UKCTsMcdEJMeDT0WEXP5GvMIH45Zc0s68Zfqkc7NhQFVgyB+z+/u///lijjXkl/eRVcZFOLQvSaUrBKqFw4nEpzFqeSuVKnChvuKdDJszSZ/6NMWVos3TGtEVNIOjomWBok2iuqR8S9CNTtgUyZpdQG4sTCtrWhQsX2j08Gcs2biUo7hPGvW+UBgbvqJiU7FFAtCv9kydPTmiJXZns2lCVjgolhTAxQEfFHmXasb60izwQJ+GxWiJFjTRTIdhREaS/D/Kq9FNhQJrZXoQ0SYkaQynMWp5q5Yo/8oUgWQEyZhyaDDGB0Eap7A3IxEL9Au00ryLR3ob0G8aYI4WHhQXG3QhtKI73Y5lFCaIT0M7t4uXLl8uj1UAhINOYKRmMoBwpTMxQrVG3nlAotBIDhIEd1/IsbyhotVpl0u20dVIqVxRE4ka4ulaijNklxm6gGicQTABRcgSrrHFSaMw2MmTT1LEbq0YYs+ceJ2dRgsiAbgkJVhyikqHBlX9WHjQDKtmjFMS3LEr308eCoga6Z4jSwjFL1oorz9QE9ig/cdZGelkFwg7ttOa3D4QhCsQc1PJUK1fsKXvycRqKmDHnAdo27YK2nvutEvQptCWg74uTClaI6PwFfc/Qjt+Y8wLjLOOPFgVoA3mxYYibGrQn/M7KdzPRKAk8aHJsnoXN0rjWDK6vXavZg+wwh4evNkPdK2yYFq9h5G8/bFZIGISvc/wI2clvzAt22R//v/rVr07ERfig67/5zW+Or8V0xLCxj9fkN6dbNErKsf3HH398fJzDBJ3HPEV7TCxXjmN+jDH9G6jmviIS/dJ2I2qnxmwbah8Y2oCI7aDmJo5xak/RLo7bc3Eq22bwsCBLw/m2Vs3eGGOMMWbdrP3tMGOMMcaYTWTtK0Hc99MXIQ8ODo7v/dXsjTHGGGNOA+8ib4wxxpidxLfDjDHGGLOTTFaCeF2N7+To1fMMr5FzXa9jc5zhGvZ6nVREex6i5liv1Z0GxEWc+gos5+RnCuSpVlZdUM61VwPHhJnzZIypQ99De1E/VEJ9HKYEbS22N7mVqYVrzDYgOe8au2kfpbG15Fd6AWaWtsPtsKnwKlt+PRT0Gpxez+6CV9/0Cmok2hNHfJ3uNCDtQ9LfxRyvw1IGc70eOEeejNkF1P/U2h/tSH0S7bzUD8Y+UK8IC/yU+j1jtoE4ZtfUDdoG13LbKfml/agN4W+OMXGW22HaZDBreuyN0zTy5dlu4hUXY84n9GesvvJxNwwfQsx9HF+J1gcUb9261W5HE2HW2nTWyzPvIm92B1Zp4gdGaQelOxa0IV6OitT80n7UhvDXTCAmrwbN9kwQO7myi3IX+ZYOmWJJi44iUrOPkHEtiWVFg45K/rV0hp2OY7j4VTixMGUnFJ/8Kg5MXMbTOe7IB3ty8UVM8q248Ktj3HBN9hDTlPOWGRomKMxILseYL9UDZqqgGXPe4GvrmuBBaRf5CMpMMzNdnh31EV1fhaZNeRd5s62M3S0+MtQv7W3qJGI2JQjtLG7/QAeQ99mJ1+kAtMMyHQUaXZd9hgLCDUY7wgu0RzRHlA/CQMvkdXyFp3SQRj7WSBi4kYKDEvNsubN73DA1aqul3d9RGnBD+vUpcNLBahhu0Fz39vZa/zpmuxHSgzt1sMRJuKRVGzLWGBpmKU+Qy5HNXHEHfOYfISMdnq0a0w39yc2bN5dni3ZSWFr5Ed5F3pjVYcyNitKqzPp2GB2AVi7oALr22aEDUIdBR6EZVM0+QuYZmLVKAWiOGZQPwmCrfZQDdUhSrFAQUFYIA8WBpWzCzstwJUq7vxMP4RAuSsUQUJqkYGjDRfyiUJXyPoQcZi1PtXLEHWEQ/8OHD60AGTMA+jwmIkD75fZYF7TNrj7SGFOHfTDn2G1iViXo6tWr7coFg+u6l3kZoLWCgemacXWBQhDDGQqrRlpFkbJCh6YwpFSsAreyWPqTcrVOauX44sWL9horXsbsImN2kWfyd/369eXZop080H7oB1hhxcTb8MZsO1N2i+/zyyRjaFh9zKoEsWKAYoBBIeqCe3y6LaMVCajZR7QyQUEAy9A6HgMdmuICOinCJk6FFzvBCBUUKwnwQ2fIbJBVKNI1FvIMc+6nVstTrRx1zuoRuPM2uwiTGt3qxsTV1IjaC9dwRx/ASrEmFky0MLFN42euTtyYTYTxhQm9xsExu8V3+cUOpUjnk8enppFOopnttK+v8Q+80ra3fNWNf65heBVUx7ouO/zK1Oyj/2ZAb+PRufyJeK3pfI6Pu9KAwS1E/8pD3BUed9Ef8fN/cHBw7F5pUlg5D43ydXwc00gYCk//sRyVbjE0zFKesIv2xKdz3FDOukY8xuwasX3QHkDtgmux/WV3graovkW4PZldII4htBfBOeMS8C83cXwr+Y3jWr62Kt42wxhjjDE7yay3w4wxxhhjzgtWgowxxhizk1gJMsYYY8xOYiXIGGOMMTvJZCVI2zNEE7eR4HVR7FZ5XTyCf8LRxxgFr6Riv87XuAmbOPT6+lDwp9dn50BlMDWvqpM509bF3OUwN6TtNMvDnB/Uv3S1f/o7uYnITkb+1f6inTHbimS9SwfocqPxV2O/xkHMHH32ZCWIb2fs7e0db8mgl800UMdtHabANzjuFb7ezPcEDsJ2FuuA73tcXH4QcQz4W/UjjhEqncqulcFQ5q6TocxVDuuCtO3v+Ea/pgzfPDs8PGxN6RP9dMza5gcZ0gSQ9qr+UNdASg92tGW+emvMthK3a2LrqhJdblhkoc1wTV9jxw3nGHZomDqRWMvtMDqF/CFBszpzfLUZQeGDU8aYYTD5oBNmooVBCcozVTpmfUAx7iJfUvoJA9SZ87FWb6BqthXGnLxdU1656XLDpJ02x4dHBe0vTlhxz1ZbU1iLEsSgXZo1CS1l0cFE+uyHEpenpSVSsJzzrxURLbNhlysH5EfuQbf/QP7VWcot/1ry5lq8/SR36kz55zyaqNkSHh0rGm9MR4xHKGzNRiNayeK64oacHuAcwzVQ+hUn+ZAdppQGDMidwidvup7TqbIgHoWD/2ivfyjVM+Q0QEyv3CotyicoDuJU/eM3xq3rShemJD/mfMMegFN2kRfImZQdKUIQ9xozZtsYshN8lxtN2ulfNVZ8++23J/p63GvPzVWZTQliiUoDAg29tu0DAw5LyyxlkXllrmbPv5bK4hYXNRikbty40brnNpk6JfbywS5WAoWJHStXGa6VdrOPK1zxNpnscYufeMtJx6Xd3Umr8qfbirGjJA7syYvKFOEgHtxqCwzyrTxCHpSVfq5L6y6lp1QPSr/Ki1kudcExbrXTPWlAAcYe96QhlgMQpsLXhrVCt/vIH+kif8QT7fFHOdTquZQGlBUaitziBpQW4lKDi3Uab5NFe8IhTYqfMChLs9sgZ3EXeZF3i0fm6SeRuTiBMMYcQVui/9Z4ymoRfTl7isVxgz0up66mzqYEaSDHQJxdCyVcg7yWj7vs81JZHwxoFBQwiDFwUaCETcdD2FImCJt08p+Xr4fsZl8ihxNhAFYepb0yEAuuoen2wcCseEg7kG8popRd1rhL5PTU6kEw6AvqGaGM5UIalC6WMHNZED7lrfAJQ8cR8oc99U5DoP5kL2r1XEoDCh4DDmWDskKecKu0YGLYXWiTTPyj/BCmykDpNLtJbWUn7xaPvCH79GeaQBhjXsE4SDtRX85YzJiGHe2GPpe+l0lybVPjoazldhiDJwNE36BAhkrU7FdByhiKDx0PSodWAlAgGDQpzLxyclpQVlJeUBKy4jAGrbBgpOhNoaseKFeEkjgjUqRqSGmbG9UzlNJAw1HZYOYABS2GGQc6c/6hc111F/khlBQmY7aFIbvI19xcuHDhRD/ObS+t+NBu6G8Ze1CGpva7a1GC9MbDG2+80f4LDapaAkZJ0qwfSvZkVApKbUf3SFRygEGXQuK2DoUqxQe0EsAqVl45qe1mHxWDaL8qpFWDaHwAbCzkO75pEstgKLV6yEg4s6JFGuJDanmpX+FLOeZfxxGFr/oqCXmtnktpYOCKt1Lxh2xqRQhiQ4wKVbSPEFf0r9tuZnugjpEr5LBLFtU/cQ13Ue65ljt+gbwgr8ZsI/T39KXqF1mNz5P8mhu1PdnzqEe+pYwCVOufR9EMvpNoEsK0+jXTKBbt9WYQPbZrFIYTO8PiV9TsCUf2zcy7/VfYEK83s/3WLqaJcIF0yF7uFB4mhimUdvzJgPzJTsf8cw1ivpsB+PiYuHV8cHBwwh1G/iPyozgwMRzCAJ1jlO+I/Mc4c3pK9RDdKNxavuVObmNcnMf6UvgR4lKYGNxHP6RRRHcxv7KL9jnPQFiyU53iPuZX9j/96U+P7UT2b7aPKHuSJf4551puv9EdqG2KLFvGbDNqKxjai+BcfXnNTbRXn632WBo7VsW7yJ8xzBSjdswscpeXyck/z1DMcTvPGGOM6WItt8PMMFjqY5kvogemjTHGGLNevBJ0xvCsUnwD6/Dw8MRzR7sESqG+GHpwcDDpIXFjjDGmj0FKEG8uGWOMMcZsC6g/XgkyxhhjzE7iZ4KMMcYYs5PMpgTxVg+3zTAcY3iX/yzhezD6hscq4F8fMZwT0tT1HR++m1C6Baky1rcTzG4T25y2mUFWZdclY8bMSZS72OfSV1kezUbD7bCp8C2M+N6+voUR3/nPcC1+82VTIV/xux+ngb6PUIJvi3SVq9k98jczaH+nLbPGgL6bFOWPY33nxZhNY/JKEDMAvvIYv9zId254u6cLNrk0xkyHtqRZtlYtd/UNQ3P2NAqPv4Rtzg2TlSC2KGhmoq91uvr0Nej2DoZOmg6b18LZzFKdt9xoWR+4Jn/xGsutsuOWAMi//ORbRzENuh7tY7wKX2nLxLgAv5xDjEd5lVv++Qgg/4o/LhfHNIDykO1F9KslaKWd/1r6zXZBW2MSgrzRHvPHNksyrnPLiJkb5A+ZUx+XUX+JkdJuzFkxyzNBCHwNBmNmBd99d7RrMp00isDe3l67WsQxHTEfDcSN/DDA07Fjd7jcKI29tbCXWwx7QuFeK1Haep+GSByCXWixf/bsWWvP9VK8NMo7d+60doRF3Bn2NAF91Rj3hFvLK2kH7ImTa4JZPH65pn2KIrIn7Ay7unOdNKJQgvKT90Iz2w1yhOyx512kJOMY2h5yyyquMXNDv0ffrEmoQB7VbyGD6huNOSvW/nYYs1QaBNp/3MQyggKjndRZIWIAjxsVssokZeSrr75aXLlypT0GFIo44Nc+sKfZMfFoo9JSvCguKExAWLVGur+/f9zA2faf9HbltbbDNGlhM0/SkBUupZkBLis1xI17/CmN2FFW2LE7vZQ0s/0ge8hDlv+SjLNDM0ozbUnKkTFzQj+EkqOPnwrkkZ3DQf1rVpSMOU0mK0Hs7ErnmlcwEGyWQ/mnA2bWGVdAMnTgdMgYDd4oI/jF1J4xyjPfLlixyopGKd4hoNTk55qG5jXCzEirR2NnRaxoKe0YFDHywDFhErYxWcaRE44BeTVmHaDkMFns6oe67iIYcxpMVoLoUBF0Bt0IS56sZDDbRCGIKzsZ/N6/f395dqQYoFSxj5Y6b81wUbpYZZHSxcy2tsoSIUyUFmYo+NWtqxwvSpVWcXCXlSZBfnSbSjObIXnNMDPCdIFSlfNIHCifmkWRDo5ZhSLdpK0vXLP9lGQcWWGCQvuMK5rGzA1Ktx4fgDw549qY/tKY2WkUjFnQq5Eygte5ZXfx4sX2/+Dg4Pg1evyB3GAaxeM1Owz+QH4xHIPC5hVyiOn51a9+dXwso7CineKVX8KUKUHc8Vopr9EA8eqc45hO+Sm5g+iWtEY3Md8KR2VjthtkQXKAkRyLfA25QV44r8m2MWORTEnOBP1i7Iti35hl1ZjTZmO3zWA14+XLlydmCZq9GmOMMcZMZe0PRq8KS/g8cCxYsh/z/I8xxhhjTBfeRd4YY4wxOwfqj3eRN8YYY8xOsrG3w4wxxhhj1slkJUif5Oe12xL6RHp8LTKirSH8mq4x44lbEGRoc6V2pzZb8iN4MYGwRS0soA1jMjV7obaPIb6M8qa+RW6jH30SwmwGNXms2ffJgBgij7U4xBR5HBofdpbHk6iMamM89nIT64fyln0s09h/YSbrDtwOmwqvRuoV7Yhe3e17VRu/vEZpjBkO7Urthk8jxDaozynwH+H1+L7XkgkzvjpfC0vU2nhX2ycNusZ/DjvHp89ECK4pH6TV/cfZU5PHmn2fDIgh8liLI7KqPI6Nz/L4CspFZUEZlojlhRvqgvauNk9Zq/5xp3YPsR5WZRYliITEzAoJE/9dlPwaY4ZDx5A7GbW/CJ0J7rraWxxwRCksUPvObbxmL2JHRlqiO/qDmj9RypfZHEryCNG+SwYiY+QRSnFPkUcYG5/l8ahcYjlQhnkyA7HsaroAbmIdiVqdjGG2Z4L4QvSjR4+WZ2Xisldc2oyw7CU3XUuXxphX8CX0psNZntXhK+JNZ9Lu6VS6hU0bzV9/r4FbNhnO1OwjpFfQb+j7X7R/viL89OnTtg/ItyAAN2+99dby7AjSPHlZ3MxGTR6jfU0GImPkUeS4p8jjEEp5tTwuFl9//fWJuuMTN3kPTGgUnxPtvPQFcco31tGczKYEsa1F3KYBAWCLi0jfjulAoXEdE7fHMMbUob1p498u6EgwKEJsx5Jh65esYNRgsMgbtkLNPqMJDzvZa8JDx8k9f9JGH8C1PJiwyXHuW0gzaTebQU0es31JBiJj5FHkOKbI4xBKebU8DodNxClzyl6bm0eol5IizCSuT7kdwqxvhyEIEh4EL2t0XTumA5nFnusYoFM0xnSzyuy1tHkl+/UNgQ7o1q1by7NX1OxLkAYUnXv37i0ePHjQ2r148WJx5cqV475jf3//tcGENJZmi0PTbtZPTR6zfUkGIqvUaYxjqjwOoZZXy+MwUCIPDg7a1Z7SHSI+nFza3JxVpSHKbR+zKkFXr15thQdlpqS9s+SllZ68fCiw57rMHJk0Zpth4jFkE+EMnX5m6Kz74cOHbVtlssKKLYb2XbPHaHKTZ9lxAGHJPA4epGfol+LHrhiY9VCTxy45LSkRMLZOcxxT5bGPrjztujyysXi8O4TSUlq54VEaxnlttBtv08+12tPFrEoQnSpKDgaFKEOBdO1srk5ZhYCGGAvEGHMStQ9WRph85A69Rq1z4TbTkBksq7qaqDBzxjBbq9ljZJ8HGdq5lrvpDFkaJy/ApIrOVNTSTZrzLTJz+tTksU9OowxEhsojlOKYKo9ddOXJ8ng0nrPaTHkC7TovalBu3P3hP4O/uNqD4iq4NpuS2QjBJBotu31ym3/gyW6e8Ab+uYbhKW6MzuUv2jWF0fqPbowxZWLbkaENQdPZH9vhDngzI9uVoN0pHCiFFeE6JlOzhxim+gsR+4D8Nkkt3e4rzp6aPNbsu2QgMkQea3FEVpXHVeKzPB5Bmah84ltfnKttx35JZR/LXCb653qu31XxthnGmBMwy2KJWsvTmw6zTW57MCM324fl0ayTWW+HGWPOP3Te3LaufcZikyCNpNUDzvZieTTrxCtBxhhjjNlJvBJkjDHGmJ3ESpAxxhhjdpLJShAPgel7C9Hotbg+9L0GwuFYrx3WINzaveEh/ldBedxEVH56xXBMGVCW+MWPOZ/QFqjDknzGtpmRv5qsIE9qZ+uKY45wOS69XmvOhq46pZ8p9TVddS2iPEIprK64gVfY86v5Ea7Jf0mmotyB3EY/lsfXUfnUdALKs+SmZi+of6511ekgeCZoKrzWFl9f0+uD+fXWDNf1yiGvFMYwhiL/60Sv+W0q+RXSPih3lTWvGp5GGZr5oe5Uj9RhfLWXOq7JBLLcVeeEqVd81xXHnOGu2neYeemqU85LdddV1yLKI5TC6opb4Ad3JUiDrvGf05njI90RrikflsdXUA8qC8qwhMqVMs0yA9keKONSHa/CWpQgIANRcEsgbDWhHEJJWNcBwl2rwE2Acu7rSCKxkZ5WGZr1kmWUOuY8t0vaal+bq7XbOeOIzBFuLc3mbCj1maW+plbXkVLddvVbpbhxi5+a/OBHkJbobog8l/K161CmsRwow6w8xnLnWOVYsweOc3lPYW3PBLFfS5P446VBLXlqSZOlLH3GXEtaWvbSMcth8oc9YXGMX67hl69Q4qbkHwNaVuNfYWBqy2i15VnCxo7rIsZF2Fqiy27lBnsRl2/xKz8Kg3/ZYVR2oDzhRsQygJhX+eWfemEX8Zh/xRntVA7yq3O5jXaYmP9cLsqrwpI7rpnp8HXWpsNZnpV3i6es+3ZoR3ZqX8udK47MHOGS5ti2zNmS67RGqa4jXfJYI8dNGH1bL+BHxL3AhsgzbvLXiy2Pw3aRj+Ue9wir2QNjPlAfGk8msVSGJlFaCWoE+1jDR2vTddxKG8yaeQyHY/wTTnSHX2mB2EWNMPrHPmqd8t80jvYfFH4k+lNalRfOgTCwU94Ad/G6ilb5gJiPGA//0Y2OIeZJ8WKUD/lVPqL7HI7Sil+5UXyEg53ygFu5wY7rKoeYboUZ80b4MRy5UThA2EqzmQ7lqfKPZFmhDlSv1KWORazHzFxxZOYItyvd5vQp1Snn6gsysa4jtXrtCivHXeqjSpAG5Aojd0PbTMmuK65dgLKLdZTPIyr3fD3bU85xHEFmdLwqa387jF3j0fbR9NHcnjx58po2WKPJ3LFGOHT/GMGmdooHTZ19XPhvBL1NBwbyLvWkVXuVsO9M3OuEc/Hy5ct2d2u0UsK6du1amzfRVFb7T/rJh1A+iEd7IhFHU5nHM4emwtt/IM688/7jx4/bHftBfjOE1QjL8myxuHPnThtnCeJTPvVV1q46k1v+0dDRxlmVixAfsCKoeLHjS6pA2UVt30yjtpM1ZazVyKE7tNeYK47MaaTdnC61Oq0R6zqySp3GuFldmrKL/FC5K30c0fI4HMqdcVKrPCLbf/vtt209aQxiHByqT9RYmxLEEhaDMwkGBnAyhIlLW+sCoWTwRfFB0ZGQkialA6PCjOBnKDSYGN6qlDoAYPmVJUXCLik7Q0GRGktfnaFooSSh3FAOfVAHKFljytf0w63H2k7WoDY4ZIf22qaEU+NAjpEVTLzlehppN6dLX53WUF1HxtZpjnvqLvJD5K7Grsvj0F3kBWNxaYyL9hcuXDgxflAXU8t5LUoQAobmplk/gzhKkeD6aYCWyKqJUCPTvWcG8XwfmrRGP7mBRFhdiisgY/JFPNE9ykFpNoEQRUECKl7xanUrQ1is4Ch/KIJaPRrCkDpjRoTyU0o3GjvEVSvgmLCuXr26tDFTUP1SB8hClleuq+OhM6FdqhPJO7RDadfuOeJAiZZCHWfpMEfaSfOu79q9CfTVaY1Y15GSPNYoxT11F/k+uaul2/J4NN4yudcdDsqR8qxBGZcWA6I9dctYqTDRMSaXcyMEk2g0tOP7dtE0A/PSxRH52v7+q114uccXz5sB/vi4Edrj448//viEPfcHOSYN0b/i5p/zeL9WfuSvhK5jCEN5JJ0YXYMYL2nK5zqO9rqHGcuOeGLa5Cb6k/toj51MdJvDI91C7qL7nFbQOSaXA+Sy5J90Kz2yjygcM51YfzKUL3Wgc9WlKMlYhvohHFhXHHOHa5k6e2p1CqX+pauuI1EeoRRWV9wCf5gSMczYV0KX3NXSbXk8gjpQ2VGOQmUZZSCWWc0eYpi1+hyD9w4zs4PW3rWLMjO0Mc8LmNOFWZZ37TabguXRrJO1PxhtTITlY98K22zovLkFO8vrp2uGNJJWDzjbi+XRrBOvBJlZ4Xkf7v1CFC2UH96g29/fP5UH440xxpg+rAQZY4wxZifx7TBjjDHG7CSzKEE86KpvLpRei+RBsXg9v27dd90YU4ZnENR2MrSjWluijeZ2GqEdxmcwSmF1xQ19cXBN/okvo/D16rPcRj+4Kfk1Z0NNJmp1Td3KXq89l4jy2CV3JTkdGkdXuHGMEjFcyajl8XVURrWyr9UP9Sj7XKbIk+RhMtwOm4JeVxMcx9fW8jmvu8VX3vquG2PK0G702imv6tY+g1Ait7sIYcY2WAqrK27RFQf9hq7xn9OZ4yu9mqxXoElrfP3WnA01majVNfaSszyORKI81uIAzrPcDI2jK1xkD78ZwsI+h2t5fAXlqLKolb3qi3JWuXOsNk/dqA6Bc8KKdTSFcqpGEAUUEAgSCfyXEqpM9103xgyj1MHTvkptCTuuqZ1mYnsWtbCgFHdfHPgR9CHRHX1CzZ/IaSml2ZwdUSZqdc0gF+uZOtXAF6nV7RCZHxpHJIdL/JxHxQY3MV0cx3xaHl8vI+ohl30sM45zuxaUf3RLOHMpQZNvh+lVQJasgK9E6hswfF2TfVcyejuo77oxZhi0u6bDWZ7VYbm59IVbwXV9LXcoOe6+OEBfb4e41xPL3nwPxrt2n2+iTNTqmn258pYU2EW65HGIzA+JI5PD5ZX3ZgA+sdO98sRtGeSRNMZ8Wh6n7SKfoT6i2zmZ5ZkgOi0SSaeV79P17bMydB8WY0wdOtwh26IwCHV9up6tUMbuxZPj7otDMHjQZ/BJBT07RMfJ8xfsR9dM0tpreTBhK5b8qXzS3LdRqzk9skyU6po61Oc0AGUljwdd8jhE5ofEkcnhMvhiUIS0MTSgHLF9EQN9Hrwtj+OQbNQmPTVFeA5mezsMRYhOi/2qShkxxqyPOMOuwSy2b0ftOGseSox7SByCgYU+494979q9bWR5LNU1dUj9MgBqEMx72XXV6RCZHxJHphYueUBBFyjsz549a5Wj0phneRwOsnFQ2EUeulaI5mCyEoTWrCVCQCDQkAHtTZuoRhAYaXdd140x/TCzHrJrN21NK7bMYDG58x67CpTjrsWB0UCklQARBxxm6XHwID1DV4vHpt2shy55zMoFgxsDIMrE3t5eq2hEanU6VOahFEdNHvvCVfoYn7Q1BmEz5uUVy12XR5RN6QKwyi7y6BZ9t9anMstKEF8CFlrOBoSPlaEoZGQK4UCY+q4bY7rRBITOmI45tqVMbUftCLcPhs5gS3F71+7dpk8eY10L7HjeBtnJlORxjMyLHEdJHvvCjbL38uXLduyqYXl8tXIm5ZB2PWYXefyhOMlPnrDNRiMEk+CJeZ7UJiiZ+BQ3xGulp7/7rhtjXoe2EtsORm2vUT6O7UptiuuYEs1s7EQbLoXVFbfoiiOGmd/yoE/Rtfw2Sa1/IM3mbKnJRK2uNW70veUT5bFL7kpyOjSOWrhxbMuyV4pPWB6PoAxVRrRrwTllG8s3llksWxn5j3766nUI3jbDGHMCZmDetdtsCpZHs05mezDaGLMd0HlzL3+2L7KuEdJIWj3gbC+WR7NOvBJkjDHGmJ3EK0HGGGOM2UmsBBljjDFmJ5msBPEQGN9a0OuFGe6Rcr3r9Tau1fxvGrw2SX702t9pQ9xz3BunvIe+ckicmCGvok6FeMZCXZxW+jYNta9SuVG/tTqWv1q743XVKGelsLriBuqjq07UljDEl8lplNvoBzclv+Zs6JKJmjxqDCn5EUPkUWHIZLnI8pTpksdSfKW8Wh67UXnVxs8oC9kd9RNlYDZ4JmgqvKZWelVNr8fxutuc6LX8s4K8xtf9ppJfr+yCeMe8Fjgm7BLKK2aTX/tExuaWs02H/EoOqecoF5zT9kr1X7MXua5LYXXFLbraPn2DrvGf05Pjy+2da3o1mrQqLebsWEUeqVfVY40h8tglH1CKO9Ilj6X4uvJqeSyjsQQozwzXYp3FMuYYP6V+ZiqzKEEkMGZQSJj4nxPi2hYliEovCUQN4h0qCGPDLkGDjoK5qSBjc8vZeaJU12p/EWSnr5zigCNKYYlS3Gr3tbiiTCHT0d2QNOa0lNJszo6h8ki94a6rPx0rjxCvDZGnLnmErvhKebU8noQyimVCefaN4bm8cT907BvDbM8E8R0H9lzpQrctMFrW0hIk13TMcqWWxfKyGUuSfKmTr1TLjZYpOcZO8WgJU+HoWO6BuLDDED/EcPnvQ/7xJ1gSlb3yWsp/IxjtP3Zcj/6UHsA9drVN+YaELeSW8HUcy0rxctwIbxtOLhP+S3GC6hGjpWf5k12MV//EoTLEjmPVTwyfcxlzBF9nVX3XQLb6dminXsZuVpjjJgzvIr/bDJFH4HVy+pi4Q3tkFXmM8jFEnqAmj0Mo5dXyeJIhO8qfFbMpQXzaGoEWCED+bPjdu3fb/Vsa5asVTAQUYWu0u/a6jlFwCKvRFl8b9PncOW4arbANAzeCsIFvNGDPZ7rpjHFLI+OYBqd0kkY+akV6MOxzREPUddxj3wUDNWHijkrWYM2x7FHayGsp/7gB7Eg3/jjGkB7coFSwqSR2NOYSQ8IWKp94rLIiDMWBPxo34aiscYc99VCKkzLFP3aUO+WLPWWKHe71IbEcXpQf3BEvDYXr+kQ9ZYE/7JqZQrHj3EUo974dtYfs0N61a3eNHDeDSNfn8QVywcBEOqR4exf57WCIPAIKBIa2HndoF6vIY5SPIfIkSvI4hFJeLY/ToF/vm0jNxaxvhyEIEh46wjjwAvu2vPHGG62gaYAuweApzXzoPkYlGCTpjC9cuNAqTuqYFTdCinIhGFyjdtrXkdNoQGll92wpPDQ82dP4OO7LP/6w5zoGaMTsn3T16tX2vNRRwNCyraGyAhSaGrgTpTgpU1YFgfBwQ94JE9lAGY3E8DIoYChHgvJBUcZQvnRW5oghs9ehO7SPJcZN5+Vd5M0qqym06cwqdRrlY4g8iZI8DqGWV8vj6sQ9w9bNrEoQAzXCw2BV0t5ZitRKx5Cl0tNm6G7VNWhEoqRIDMk/9lyXGSoIZ1G2tTjpeDJS6ljhmQKDLGGxatSlQO0SKJdDdtQeskP72Fl3jptVPmSBOvIu8rvJUHnMxP5TTK3TmjwNlcc+uvJqeXzF2B3lT5NZlSCEmEERo5WLCIUQC2IOYgdZ0/BrsGSqW05AxYxpvGq0akQsizIwy17Lrvxj+vIvf7rFgx+OmSHdv3+/tavlcR1l20cpTso0zqIoG/LBStyYzqUGdRRXCncdyQozXeQ4d+gRFGpWzyTv1FPcoR2ov6Ez2FLcrPxJgWdGjWE1DyP7LAfIB30G9KWROEudJ2nOt8jM6TNGHiO1eh0jj5DDqcnTUHnsoiuvlseT0F8zjlG2QJ3UJvi4OVUFshGCSTSzvvbJeP6hmekfP8HNP9cwjXLQGp3LX7RrFJLj46bzPD5uBr02PKFr+D1cPpmPUXw//elPj+1iODEupTFe5xiUNrmJxDCIO8avMgDKIduX8g86xk/JH8hOeVRaxZCwBeUptx9//PHxca2s8rnqoxZntFc6szv9YxSezrPcRD8x7bKPeciyss3kOsIgj5DrUkT5qpUV5apwoBRWV9wCf6r/TAwzt7OuNMa8REizOVvGymNsy7V6hSHyKErhDJH5Lnksxce/7GRiGi2Pr0P5qKzieMR5rBfKO/clUVZK4/IUvHeYMeYEzMS8a7fZFCyPZp3MejvMGHP+ofPmNmf8LMGmQhpJqwec7cXyaNaJV4KMMcYYs5N4JcgYY4wxO4mVIGOMMcbsJFaCjDHGGLOTWAkyxhhjzE5iJcgYY4wxO8nalKD4WfJoSvvDzAWvJyoeY3aBmsz3tQW+btv1NV++gBtfSdbWFxnacymemn2E+OVGX/SNKA/6Mq/cRj+4Kfk1Z0NN7qijWG+CupW96rmE6lqU5LEWt+iT+T55LPnP6bA8vo7KVF+LLlFzE+tU5RplpivMwfCK/Drgi5r66mP84ufcX3sUfGVSX6Ek7nXFY8ymUJP5IW2Bpo+7EviNX7zV13H5j/AV1/xlV6jZR7iu+PnPYef48pd+uRb7l/gFWnM2dMmdxgBMlC3qWfa14WiIPE6VeeLvkkfI/kvpAMvjK6gHlUWtfmtusCuVo8qbPqFUz2NZmxIUUQMYwj/8wz+0hgz+6U9/WtqOo6tBGbON1GS+ZE8nQmdeGxDigCNKAwPuCDt3VDX7SOwPcBfTQsdWS5sopcVsDlHuqN84WFF32OEm1hvHUS5EqW5L8ihWkfkueYSaf85L6bA8HpVpLAfKKk9mutwgM9Rj9BPrieOaDIxh8u0wLXtrKXHq7S6Wuv7lX/5l8X//93+Lf/3Xf23D/eyzz0YtMbJZW1OwyzNjtp+azGd7lo+7dm/m+pDNI4Ev4zYd0eLy5csnbmXU7CNxA9xHjx4db2JJO2d7hKdPn7b9SekWHG7yBoukeZalcTMLUe7Y9PnKlSvtMVB32EkG6OOpU+owygWMkUcxVuahJo8wxH/G8rhYfP311yfqjs3O2QA70uVGm9xeu3bt+DZkrCc2FcfNVCYrQXR4ggRD173dIfDJ8X/6p39qM9hog4sXL14s3nnnneXVfhC+mzdvLs+M2X5qMp/t6eBruzcDg9PQHZzpkDAoPHfu3Fna1u0zDHwoOuworU6OTpGJFP7oT7iWB5PHjx+/tkO3BlazGQztgxk/bt++3Q6EpQFtjDyKsTIvSvIIQ/1HLI/TkcJDP4CMRFRPpUnSWGZ7MFqa8927d1/T9sby+eeft5n767/+68U//uM/ttrh//zP/yyv9pM1eWO2nZrMR3smJ7du3WqPazx//nx5NBw6q9IKcM1ecJ0O7t69e4sHDx60dkx4WDXQ3kv7+/uvDSaksbQ30yppN+thaB+M0vvs2bNWYS4NaKvU6ViZFyV5HOM/Y3mcD/oBlFRBPR0cHLSK0FQ27hV5ngb/t3/7t8X/+3//r1V8/vu//7tdFZJW2Aca/PXr15dnxmw/NZnP9uxszW0CZlHMrDB54Bk76xa19il74iFeTJxlQxwsmfDEwYP0YDeEVdNu5iXLHat23N4UHGPHoKbd1hnUWBXKq35j63SozA+VxyFtpsauy+OlS5dO3ClicSTfVhziRuQ+htW5eNtzVWZTgqSlITRTlRCUn3/+538+Fj6ZPnQbjkZFerJwG7Nt1GS+ZP/FF1+0g41mu5h8C4LBaewMlrhKHVe01/19TF4hYODTcwF0bMzu1J8wI6ejFLW4SHO+RWZOn5LcccxzXpxjOMbu5cuXiydPnrTua4yRxzEyP1Qeh7SZEpbHI6WFlWAptrTrfFtxiBuulRRK6rhrpXkwTeVO4vDw6En8RmFp//PT2tjJ8NT9uiDeGBeGtBmzrdRkfkhbaDrz1950EbTl6B53Ckftmzc2sh3U7DMxzPyaK/2ErsU3Q6AWJmk2Z0uX3MU67ZOtzBB57Ipb4A9TokseRfYf/eS0Wx6PoA5URnH851xtu+Qmykusj9i/zFXG3+OnCXBl0MaaxLSasjHm/MPM68aNG+2M/TzAbFC3Vcz2YXk062TjngkyxpwtdN7cp49f6N1USCNp9YCzvVgezTqZvBKE1nt4eNi+ys79U2OMMcaY88BkJcgYY4wx5jzi22HGGGOM2UmsBBljjDFmJ7ESZIwxxpidxEqQMcYYY3YSK0HGGGOM2UmsBBljjDFmJ7ESZIwxxpidZC1KEFtpaNNTbWoHfP5c9kN34l0FxWPMtsMXatWmIjV7weaS2my1BG04fqFXO29n+FhqjkfnMoRVgvhrbkrxlfKEXS18c/p0yV2pTuNY0VWPXOuTx664oU/mu+QRFL7GNLmNfiyPr6PyYVyuQdnH+o1Q3l11Pbm8+VjiutCmdnEjO45rm9jNQdx4zZhthnakDQdpa9posGYfoX3U2iF+4+aEasd5k0g2M4xtG0obnmY3EPsB/mPYpfi68kRadc2cHV11VKpToO6QBUxtQ8wh8tgVt+iS+S55hBxfl5xbHl9BPagsKMMSlDfXSnUGlGcse8Kbs3zXrgSRwSjAUdhqkMF33nnnu48++ui7P/zhD0vb4RBHrcCN2UZqMl+yV7ustcPSYITb2BEB7gi7q0PKfoQGDMB/TkspPlHKUynN5uwo1VGuU+o9K0olWRoqj2IVme+SR9JY8ydyWiyPR2Uay4EyzMqjwL6kBKnOYvnijvqthTWWybfDtByupUTOIx9++GFr17UMmWHzud/+9reLH/7wh4snT560S2H4//zzz5cujDGRt99+e9F0OMuzV2R7lqTfe++95dnrcP39999fnnXDRpFNR7e4fPnyidvegmXqt956a3l2EtIlHj161PYTQynllTR3Lbeb06Umj5GvvvpqceXKleXZopUV7CJj5FGMlXmoySMyzO71T58+bce3fFsGSnJueVwsvv766xN19+abby6+/PLL5Vk/us2Fv8gnn3yChru4du3aKL2ixmQliI5QkDDIHSKJvn379iihQCh//OMft8L4y1/+si2IX//617Nk2phtg7Z18+bN5dkrsj0d/AcffLA8ex0GoZrikqGNYlCE7ty5s7R9xePHjxfvvvvu8ux16OQYWD799NNR7bqU19IAas6OmjyOZYw8irEyL0ryyEDOJB75ZnzjGuFHSnJueZzO/fv3i5MjKazUB3rFVGZ7MFqJvXv37mvaHok+ODhoZ4xDQSA/++yzxQ9+8IPF97///TbMn//856NmjMbsCrXVlGjP5OTWrVvtcY3nz58vj4ZD+84rwEBYrOrWwB8d2b179xYPHjxY2vZTy+sqaTfroVZHY1mlTsfKvCjJ44sXL9rVKsnx/v7+a8pNTc4tj6uDonn9+vXlWR3qQytGq3Jqr8ijiZPg0nJihgJ45513Ft98883iF7/4xeLPf/5zu5rEypAx5iTMWksdRrZ/+PBhe5uA2S4zKExuj2Nn3UKzsxrEQ7yYvOozZrCs5RVWTbuZl646irB6wm0mwXFpRWUMQ2V+qDxyByIqM6Qn356psevyeOnSpRN3iljI6LstKVBkWTShfrjtxQpc7e2xvr6nj9mUIGljCF2tAaDIcH91CH/5y1/ajP/kJz85FtaSwBqzy+jWMzNR2qDaR8n+iy++aGe6mu1iaJMRBqGxM1jiyp1bttN9fExWepj0DHnuo5ZXIM1dt97M6dBVRxncMB7gDsMxdpEx8jhG5ofKI5N3xiHCA1aIGNxFSfbB8vhqhVi3DynHIbclIdYPd5FYQKEuI4Q7i6LZRDIJPYnfaNvtv57i1hPcmK4n7+dG6ZExZluhrUVZxyD/NfsIbbDWDmnL0T3uFI7aN29mZLtIyS4Sw8xvhZTi68sTaTZnS1cdleoUGA+y28wQeeyTD8AfpkQMM8tjTGN+IynmJWJ5PII6UNnFN/9iWca+pPSGGNdVzrEuSm5X4Xv8NAGuDBpyU+GtxmaMOf8ww7px48bgVduzhtkmK9B5FcFsB5ZHs05O7ZkgY8z5gM6be/m1e/CbBGkkrR5wthfLo1knk1eC0HoPDw8Xe3t7r92zM8YYY4zZVCYrQcYYY4wx5xHfDjPGGGPMTmIlyBhjjDE7iZUgY4wxxuwkVoKMMcYYs5NYCTLGGGPMTmIlyBhjjDE7iZUgY4wxxuwka1WC2MBOG59qQ7vzAJvixU1b+86NOSv4Qm1JDmv2grbY1R5pr/ELvdp5O8PHUnM8OpfR5pOZ3D9ESvGV8oRdLXxz+nTJXalOqTu576pHrvXJY1fc0CfzXfIICl8btcpt9GN5fB2VjzZSLUHZx/qNUM/4V93pXGU+GT6WuA60cZrgOG5eV9t4blNgo7a4CV7fuTGnDe1JmxLSnrShYM0+kttjJMs2YeA+t1k2NsybVJY2mMxuADvFz38MuxRfV55Iq66Zs6Orjkp1CtQdsoCp9adD5LErbtEl813yCDm+Ljm3PL6CelBZUIYlKG+uleqMsoz2lLvKHn81mRnD2pSgLLh9QrYOSMM777zz3UcfffTdH/7wh6XtMHL6+86NOUtoX6VOpmRP26MNqj1mSnJdarO4I2zaQo1aO9eAAfjPaenqI0p5clvcLEp1lOuUes+KUkmWhsqjWEXmu+SRNNb8iZwWy+NRmcZyoAyz8iiwz0oQZVqrY0E9x7pbhcm3w7QcrqVEzkEbyGEHb7/99uLDDz9slxJv3769+PTTT4/dxiV1LW+xdCa7eA2j866lTSANv/3tbxc//OEPF0+ePGmX0fDz+eefL10Ysx3QvpoOZ3n2imxPu3rvvfeWZ6/D9ffff3951g0bRTYd0OLy5cvHtwgitNW33npreXYS0iUePXrU9g1DKeWVNHctt5vTpSaPka+++mpx5cqV5dmilRXsImPkUYyVeajJIzLM7vVPnz5tx5x8Cw5Kcm55XCy+/vrrE3X35ptvLr788svlWT/oCEC5126VUc+x7lZhshJERygapar9V4eI8JDImIkPPvhg0WiEi0bDa6/jloLCL/aPHz9u3d24cWPRaOStfaMhtsdkVm4xKFMIYBf4+fGPf9wK9S9/+cu2In7961/3KlDGnCfocG/evLk8e0W2p4OnDdZgEKopLhnaFgZF6M6dO0vbV9CW33333eXZ62hCQ2c3pj2W8loaQM3ZUZPHsYyRRzFW5kVJHhnImaQj34w5XCP8SEnOLY/ToIwZ91FeKXfpChHqa6yCXGK2B6OlOd+9e/eEtkfiyYRWYjII5yeffNIqSSg1ImaOjvbbb79tM02Hi6BiACHtAj+fffbZ4gc/+MHi+9//fpu2n//856NmnsZsOrXVlGhPJ3Lr1q32uMbz58+XR8OhfWpVN0JYWhEugT/6BiY/Dx48WNr2U8vrKmk366FWR2NZpU7HyrwoyeOLFy/a1SrJMZP3rNzU5NzyuDqM99SHlFeU2ryKdP/+/VZ3mMra3g5Dk4uaG8pLXDUSuEOhQdNG+ASCyzI711BkVBisLCGoMl0aPmG/8847i2+++Wbxi1/8YvHnP/+5LTRWhozZFpi1Xr9+fXn2imz/8OHD45VZJhyYPDEZO+sWdFhdxDc68qrPmMGylldYNe1mXrrqKMLqCbeZBMelFZUxDJX5ofLInYOozJAe7Iaw6/J46dKlE2M+SkzfbUlx4cKFdtwXlHksT3SLoWH1MZsSpAQjdBLCa9eutf+gZcUMWjXKT9akEVIpOl988UVrp45WylVWtEr85S9/aZcwf/KTnxwLfUnwjTmPSP5pP7RByXXJnnakNkWbw+SZFIPQ2BlsqUPKdsSjuLPSQzsesqxdyyuQ5q5bb+Z06KqjDG64U4A7DMfYRcbI4xiZHyqPTLIZPwgPWCFicBcl2QfL46sVYsoTKMeuRYuIZEN+0StUntihUCmsPJEbTSMEk+DJbIJptO32X09z84Q9T3xjJ4NbXZMfHeucf/wRjuwxenI8u18HOd1958acBbmNYGhjNftIMxhU33ihXUX3uFM4at+xDcguUrKLxDDzWyGl+PrytK6+wAynq45KdQqxP88yKobIY598AP4wJWKYWR5jGpH7SMxLxPJ4BHWgsqMcRSzL2JfEso9+VW+xnmRiuKvwPX6agFYGDbmp8FajnhM07Kg1otWPWTY3xqwGMy1eTGAmdh5gtslMMa8imO3A8mjWydqeCZoCQo8QRcYu0RtjVoPOm3v5tddSNwnSSFo94GwvlkezTiavBKH1Hh4etq+z6dmdOUCYeKNMEEffw5fGGGOMMUOZrAQZY4wxxpxHNvJ2mDHGGGPMurESZIwxxpidxEqQMcYYY3YSK0HGGGOM2UkmK0Hx8+PR8NYY3/bhWF/yXDekZZW4SON5eP2yC/I9+cuZ5tyB3KrNRWQnoy/eCvmrtRfcq03U4sBNLXzoi0P9w1D/chv94Kbk15wNNVkB+qfcR3W5j6iuxSphIW+YGjV55LhkL7t4zfJ4hMpEX3wuUXNDPcS6jpTGOfxnu1HwdtgU+GKmvswZv+ypLz/yn7+yuWnwxcn8ldCh1L4YehqcZdzm7OHrqfpaKrIgGS591VbtEmj2XbJDmPribS0OUHvH5C/k9sWBn/gV2Ow2++/KE3FP/WqsmU6XrHCe67TLfSTKI6waFn4kc5kueSzJueWxDmWv/FPmJWpuKHvOa7JA2ca6wS11gT+uraJrzLrng4QlQmZWSdhpQmXUCr0L8lqr5HVzlnGbzaNLHmKngZzXBgKhjj4T48hthjjUqQ2JI/YT+Ivuh/iPeYJams3ZUJJH6jTXm+iS31Ldjg0Lt/ipyVVNHrvkPGJ5PIJyjHmnHPP43+eG41jmQvWXyxq31HeswzGc2jNB3B7LS19aDuMaaDmSpS3+WfqKS5RxKVPhYUDuFH5cwqwtrWn5lE1cAb+ca2mNY6UNcpxNRbb/nMd8Kf3655rCxmh5n3+dK86SO+iKm80A+Y/lE5eGKYuYN6UrujfnGz4kKpmIUPfafZljth5gt27JQgY5qW1mGuOgzVy5cqU9BuLAbkgcED98+ujRo+MtcYb4j3kSpJm0m82gJo81au675LFGDosw+nYcr8ljTc4jlsdXsFF6rC92f2ez08gQNxnKGPIO/vQRbKnSKEdtmHHMHMqpKEHsJs+nxEmoBIhBvdHcUNfbxDNoI3iNVtdmGHv2Drt9+3Z7jFt28AU6xrt377b2uCfj8isIU+Hz5WkVokABQLi5TocLfOqcNIpG418eleMkfMAufiYdpUSNUNeoKI7xo9312RoEuygAJXd9cXM9pptzhdNo1W1alDd28qVDIG/Ktzn/0OHevHlzefaKx48fH+++TOdDu7tz504rG8hC7qhpn7lDF7U4IkPiELRJOjHcSCEf4j/mSZQGJ3N2DJGVSM19lzzWyGGh1AzZvbwkj0OwPK6f+/fvF/cOpY+4cOFCu60Wk6ehu9RHTkUJYiCWpk1ipZDI7tatWye2yGAAF2SSQT9q9ihUyixbdeSMEz4dqcInjKjpAwrV1atX22M63D764ixx/fr19p9GidJCA1M+sCNN2JF/FKeau7Fx4/7SpUvtMW4Ji3Bgf3//2P952ZDQ9BNnrxHamxT0Fy9etIq/zpGF3FF37dFXiyMyJA6B/NM2Uc41wRmaRl2PdKXdnC5DZCXSJb9jiWExdtC/DqEkj0OwPK4Xxi6NpSUoe8bPVdmIV+SzghJBmWGlRCsfIq/sZNYxwPfF2QUrODQwGVUcx6xasXpTcwdT4qYMzfbCrLWrkxAsJceOmdlqXl6uzbpzHMx840oix9jV4kC+Ue4xeZYdB78haaxRS7s5XYbKo+hyP7ZOc1istjMJRO64q4BBFofKY03Oh7CL8sjkm0m4YOzOtyKHuImg1F6+fLmtK+6OsFJXe8RlFc5ECZLSI+FD02PGl9HAn7U8lAaWIEUWYoWv1Q/+dSxQDFhigzjTjB1utO+LswsUGVa6lAZmJxxTkeQRhQ2hqLkbG3dUqoDwpUyZ7QIZAeoXWYqywbXYubACSAeidsVsVyuGgg4+z2BLcXCMXHEuGcauFocUfkye8UvGoS+NOU+CNA8dnMz66JLHEn3uS/JYoxQWK+eSO1Z4MMjiUHmsybmwPJ6EsZexVWMYbVl3HsQQN5FYV9xVQleYc7N2Ap4FgpLR0/ONwB3bxWOe/j5cPsGPaTT119xzHbgmN/zvLZ8alzu5bQrmxDlp0LnCz+g6YfJP/DFdsifs6B6T0xffGIhpEeRZdsoD7uSfuKHkDmSHyXF//PHHx9fwH6/JfSyPWM7Kmzl/RDmTkWxAqW6jHEhWMsiOwumKI4YV4x0SR5TBKOfQ5b8mr6TZnC1dslLqc7rcR6I8wqph4Q9TYqg85jAVf2aX5ZEyUnlRdoJzteeaG67LPtcDcL1W5qviXeSNMSdghsZzecx6zwPMKrntEWfoZnuwPJp1shHPBBljNgc6b27PznnffV2QRt1KNtuJ5dGsE68EGWOMMWYn8UqQMcYYY3YSK0HGGGOM2UkmK0E8BKbvLdS+u8CrhbrG8SbAK+R6pdKY8wrPIKhtZfQ9lMjQtsi1+AxGKayuuIF+oOsVaa51paXkP6eDNGxKn2L6ZULXc99bsxdRHrviKMmpmCqPOY1yG/3gxvJ4EpWPXokv0eWG8s51irtaPY+GZ4Kmwqtses1NrxPG1970iiPmLF8dnPvVOmPOEl7rVTtDtuMrpXplOMv8kLZImPFaKayuuAV+aq8kE7+u8Z/TCdl/KR1AWmN/Y86GPpko1R3U7EWUx644OO8KK8tTpE8ec7ilTzcQBlgeXxF1A8qwRJ8byjOWPW4of+qJa7kuxjK7EgQxYdhnQT0LASkJtjHbAh1w7kCyzA9tixpwIl3tpxQ3bvGDKaEBA0hDdlfzz3kpHaU0m7MjywRyV5KFmn2kVrdDZF5MkcchacxxWh6PyjSWA2WYFZY+N5xjcvlSJ9R9rLdVmf2ZIJaumoQdf+WVry737cKrW2osb/EPpaVJXScOLUmW3PEvO5Ynccvn0vkyJXHJT1x6k3uug9zgV+nrWs4z5izhK6xNZ7I8KzOkLSLj+lruUHLchNH1GXzQV90h7xs1xH+GNLt9bg5RJuiP+cYPW07Qj+o2Rs0+0iWPQ2QepsjjkDTiJm+RYXmcvqM85Qp52xzqge9GNcpR61e6wKrMpgRpbw/t/hyFqg++qwAIKn4RHj47znGjFZ5oNNhpw9OaOwoGRQx7tqFAIaPAGm2yFWgEvNEkW7eAkiP3+EVxkpvSDvjGbBq0hTG7dtdAxsfueZTjZhDp+gy+oD3TZzA5YdIhhvqPlBQ6c3ZEmWCgo4/V2EB9c71mH+mSx6EyP0Ueh6TRu8ivh3XuHB+ZTQl69uxZa6JWNxZlBuFB2BBIlBDtME+GEUhlvOQOQcaNlDAKrEshk7YpN3lHe5QrXRu6h40xp01eTVmVVWQ8xs2sbMqu3WP8Z9w+N4coEy9evGhXIPUBQSaj9N01+0hXnQ6R+anyODSNpY8jWh5XB0WzaxNeyjvvKboqs94OkyDE5Sk05FV24UUQEUgZQPlhVQalR3HU3K1Kl8JkzCbCrHXIrt1D2uLYVaAc99Rdu2v+hzA27WY9ZJngdkZUCKgn7Gr2kVqdDpX5qfI4JI01dl0euQOjuzwwZkd5FNx17hwfmf2ZILQzEi1QjFBKWHHBcFzSmiN0zAirUCeoFR5WnCiskjspMVqy5D8vX0bkXg0Bt2j7xpwHNBmgTdG+coceGdIWaVNDZ7CluKfu2l3z3wdpzgqdOX1KMsGqPYMY58AqC4NfzT5SkscxMj9VHvvSSFpKzxtZHo/GVsZsjb+Uo+72iJqbWD/cjWFMnnXn+EgTySQaLbt9Shujp7r5lx3wtL3OS09zKwye+BZNpo/9NILb2umJcAxhQsldjI+wox3n0Q/pwWT3hCW7eKw8GnPWRDmWUfuKMos70dcWgTYQr5XC6opb4A9TIoYZ230k+49+Yp5A7dacHV0yEeUu9qE1+0iUx644uuQDsjxFot8sj11pLMUDlscjqBuVHeUoYlnW3Ajc1cp5Drx3mDHmBMzKvGu32RQsj2adzH47zBhzvqHz5j79uu7BzwlpJK0ecLYXy6NZJ4NWgng4yRhjjDFmW0D98e0wY4wxxuwkvh1mjDHGmJ3ESpAxxhhjdpDF4v8HzyvcB1O99xoAAAAASUVORK5CYII=\" width=\"577\" height=\"286\"\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: SCC, squamous cell carcinoma\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 80%;\"\u003e\n \u003cp\u003eTable 3. Factors in the stepwise multiple linear regression model explaining variations\u0026nbsp;\u003cbr\u003e\u0026nbsp;in thoracic operative time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003eStandardized coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eUpper mediastinal index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e0.025*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eBlood loss during thoracic procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e\u0026lt; 0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eThoracic duct resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eR0 resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.9655%;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e = 0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.6228%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.4117%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003e\u003cimg 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nTjU126Db07Z4r//+78f/Nu//dv478z5C5fHVkoPwoj27c9OgRfCmK2g42A2Q0KOcsCMyT7xBsmdiKjKC3cGpLfnnpkX0ok7lJsWbInPs36hfLVmhnoQJx3HVEOmU23NFJGn58+fb87efuaJe8obP7orCiGs51B9m/yJ1g0W/U+vD2rR6+uWgF/v0+hLenlbkvY5WvE5pBtlU/2Y3unZFtI6NWvzX//1Xw/+/M//fJwpF7jHX7gyBs16a4bOYXxeKuMMA/ytPccw3L2M5zyXxbg/Xfvnf/7nW3sP38PDXs9qMQoLew8LgzvoucfIvdJZkV89ewb58bhk9PxY58SHX53LT8sduFulSecY0oNf5YPwQgj7w/sejDPXt7XOwcPEX23nfl3+QcfeN9Z4MfQLNUwdE3ZF1zDqJ92P4oCadvofnWOmzms/hyE+D1N9ms5rn1nzomvkv4Kd8qPyUT383//93xjW3//934/n0AojXD7ZhiKEEMLZwwxR77N1ZpCY5WHmnZk7Hgl+8cUXi2fIwuUQpSeEEMJFwCM6HsP5RzMVXm3gFYW6PEG4DrLLegghhBAuGqk6mekJIYQQwlWw13V6QgghhBBOla2UHi3t7YYXxM6VXR/l8fnlIctAn6gvQWnJJ+whrIP3QdSv6fPtFrTL3ufbtEP/LNu3iwjh0pGs98YhxrOem7q1iqA9cW1v8HhrG/RJIehTQ50vBff6nPE+OUS8lMd95GVJ2r1u5mh9yhrCNaNPnjG9z5n1uXWv/XBNn3zzr/aIe30+HcIl4uNPT7VQu2Es8/aAv9bYpSUL9tl2dnq8xRLfQ+dwZ9G/JWj7hfvmWPHug32mHS36VHdwDuEYcNfJTDZf9GBYVK91t8pXP0NHvDm7C7M/fo1Po/VJNNvdrNnGIYRzgDHFF8mkHdSnFLjRwr5so+JfzzG+seVS9UMbGhSkzdl+2EnpoVMY7opuV7VsTU9pOot/TQvT+NnLRVPE1R/hcsx1PVLzKWPZacpL57jn3+0whFnj5TrG3db0gB4bKZweCsM7SvlTPKA0Uh4Y+VM8cqtzwqtpV/lglkz71ThRVEHhex45xo3OvT64FsIlwo2b7z/F9gTb3MzRRn74wx9uzt6FDl7tLoRLg62afDVzdkJgZW/HlRx2GvCdDTj+9ttvxzHu0OPMKqVHm2Dyj0aHdsfAysJQJBzNTA2cBaCwUwGQuSdPnoxuOG75IzzCZTaC5dlfvHhxuxw67hUmMEBrCXc6HeyxowI4JhyWQa/x+rLvWswKe2CfLOKkI2OpcqWNuFtQUYRHXOooUV5QCPFLWqScoERgRxzg6cAeSD8aLumFmna0YtKHe9I+pYxBjZN0AXaUNWXLMfaff/75OINHXMSJoOKGc9IUQniX3/zmN5ObW9KXsK1NCNcOugNju4+nUogYh3zrk0OwSunRgIvRQMjg3dr5l8yQyd5u5j1/8OzZs9tBlwEYe9zXnceFOh3+iQtFY2kBEpfiffXq1RgnCsySXYZRCFRpKElSQmTnU9soKShE/HsnqXJEoakacmXbXZl7cQrq0WeAAHdSqCgX37MmhPAW2g5tfAqUotw0hPBmvGHM7L1iwVg8dyO/Czs93ppCj2lQPsgksx29mRJH/qbQDAqmpUgxSKMQbLOzORvstd6bwb/iwqxByg+gSKC4kT46yzVQjprJckWlx1yclDmKVlWgtOEqyh9KYAiXCo/ov/rqq83Zg/F46WaUzDzTDmlf3GRhvK9jun7fGy+HcEowccEYIxhPph73clM9NXb5mLlv9qb0VKWGgZaBktkWtDYNvJWeP5C2J//Y477uPF5hkEZZ2Wagxi1xoBRo5olOz2eKWnG1UIXp2SRKGNoroGBwndkyn9FRXulA5zpIyrFVlj16cYLibSmPT58+HR93+U71IVwiav+0B+9vlsDMq26K6Hcwak+6ySAsws17ceESYXxhnNHTEmZxWk8VBG2hNcGBf96nOyhDQ13MoJmNn49hbhqfT/v1l5vdbvlETfZDZzDa8c8516DlDzduPwzYoz3ITu7l7snmszbc6rqukV6PV9flBxSn426VfqHwdE3HxEW6dO5hEp/sSafcKZ0qE48XN552v+b+ZKcyFDVOkD/Odax/LxOOvexDuFS831AbUvtUG/B2rrbqcB0D3iZlatsM4VJQW8H4mME5YyJG1xlrhLc7H3vA/dRraznZbSi4I+L9mNYMxCWBxjsIwOpHZ4eGesi7CCGEEC6Bg73TE0IIIYRwSpzkTA/P9fhCC25ubiafDZ47PNd8+fLl+HUa7wacCryUCac6AxVCCCFsS3ZZDyGEEMJV8I7Sozv8EEIIIYRLQKpOZnpCCCGEcBXkReYQQgghXAWrlB4+Y+YxGIZjDJ9eHxMWDly7wjHgn/zsOx+kaWpRQ15kbj1SVBlrsadw3Xib833cZLd04cxwnbiseD9J/xIZClcFj7e2gQW3fGEhLdY1tYAd11hk6NQhX/e9eJgWdGqRhQFDxdse0P6y4F1YihZMdJnhWAsqhnDpbDXTw92Cdj4XLFzHZ+VTtPa0CiFsD21Jd+SalTzkPjXh8hgUnHE7nxCuka2UHjafZPXg2smyjo72qdHjGgydMh00O4yzS7k6a7nRND1wTf78GlOxsmOKH+RffuqjIE+Drru9x6vwlbaKxwX45Rw8HuVVbvlnNWn+Fb9PJXsaQHmo9sL9anpaaee/l/5wWdDWuOlA3miPdbXslozrPDISAJlBTtQvVdTHYaRYh3ApbP1OD42lB4Ovdv/mboJOmYGfhfeYDeKYjpdNNXEjPwzodOTYvXz5clSsWKgPe7nFsPkn7jXTxC6u2NOIiUOwOzj2L168GO253oqXBs1O7NgRFnFX2HgQtB0G7gm3l1fSDtgTJ9cEd+n45Zo2N3RkT9iVDz/8cLxOGlEgQfmpm4iGywY5QvbqRrAtGcfQ9pBbZmlDAPoq+lPdKApkSH0NcqP+LIRLYa9fb3EXSmPiTsF3J3dQWFhtmbsIZoAYsH03Y2aRpHywW/r7778/HgMKhA/wvZWadfdLPFrluBUvigoKEhBWr4E/e/bstnN49erVmN6pvPZ2SSctDx8+HNNQFSylmQGtKjHEjXv8KY3YUVbYffzxx7dKWbh8kD3kocp/S8YfPXo0Ksm0JSlDIdB3oNRo5XuBDH3/+98fj9UnVsUohHNmK6XnBz/4wdiZ1hkKGgVTpfzT4XJX6TMcFTpsOmCMBmuUD/xieu8I1TvbKZiRqopFK94loMTU95KW5tXhLkqzQ9veQTFjpbRjULzIA8eESdghVBlHTjgG5DUEgVLDDd1U3zE1sx/CObKV0kMHSiNhkHWYDmWmgrtJFACfuang9/nz55uzN4oAShQ7qquz1h0sShazKFKyuHPtzaI4hImSwt0MfvUoqsaLEqVZGtxVJUmQHz120l3QkrxWuIvCTIESVfNIHCibuuMiHRwzy0S6SdtcuOHyack4ssINCe3TZyxDABRjPcKHegPFtW36uBBOnkHJ2Bp99igj+Lxado8fPx7/b25ubj9rxx/IDWZQNN6xw+AP5BfDMShsPukGT88//dM/3R7LKCy3U7zyS5gyLYjbr7Xy6gaIV+ccezrlp+UO3C1pdTeeb4WjsgmXDbIgOcBIjkW9htwgL5z3ZDtcB5IDyYagL/P+w/uzKl8hnDsnsQ0FsxWvX7++c0ehu9MQQgghhH2w1xeZ18KUPC8IC6bgt3l/J4QQQghhjuyyHkIIIYSLRqpOdlkPIYQQwlVwEo+3QgghhBAOzVZKj5a4d8MnsefKOT3K0zYV+uRYn6zvyjmVwbXj2wP04KMAueFY0E5lP9Vm8SO56oVV4RNn/8xZeH/RY0m65tKhcsG/lnEIbZbIELTqVH1Qrx4E17aVISB8jLOtDPWWZJhLe2RoP8zVg0C2cKf6rrqFj3Oyq7KxGh5vbQOfPfKJI+gzap0vBff6NPs+OVa8+8LLfi3kf9cwwv3DJ8WqN5Yq0LIFFT435jNjjH+iTjuVfa/ZE7776YXlaGkF/h3kDH9zLEnXVDpaceMmMv4uS2WoVaeUvT5r57+WuVgjQ4I4/dP5JTLk4XLckiHsp9IeGdoPPj616kFQti57+PF6po4UjtcDYc7JwxJ2UnqARLmgLoEwjqF8HCvefVHLfg1pzOdPr3OnXr0zoSPHDvfUu+C41Xm4m15YLVoDCWGRxilZW5KuqXRg3+t7PNzwLj0ZErVOvV4o/yXlPlV3Fa4Rpoe7RIboz90P4dQ+firtkaH9UNsyZdoaa6kfl6sWft1llLqakoWl7PROD1NPQ2bHlZPBp041PaipR/41Zcrqwr7revWnKS2ua9rLp7ZkpylUnWvKzO0whFnj5TrG3db0wNy0KHa6rvTAVJ6UTux0rLiVFsWrNDqKU35A/jDC7fBDmqgv9tshfK57+D5NrPJWGEq/u+ecMD0d4fCw0vjQwWzO3lL3qnvvvfdGO9wDdYocsOqu7AT1i73ohbUUVgiXrCFXLZakq5cO3LNa8FdffTXKYZVBwiJPoU1Phnp4vfzmN79prqG2Vobwx4bPlSUy9M0334yr+QviwM7ppT0ytD++/vrrO3XPkjN1D0nQpscaO+YYFJ079bKP1cFXKT3a1JD/QaMbE0LCWrvz1p3AWfacjOCG45Y/wiNcCgjBH7S72+0icF93ktYWDNp1HTsqgGPCae327ts2aBl27EE7qSPw2h4Df7VRAPHQMHGjfcnm8kQ6saf8tLu70uPpwj/UBk8jxr8gPrbdwD15xH2rDNjwlLSQNxq+x0VeVa4YytvLVuEDeeQaacju3fcPdaWNcpdCPVKnyITk3GEwYsDYF8goBtlGRnrMpasHnSwKOGEjl8igD1DbKmnXxhoZot3T71PWuily1soQikjdPBeWyBA33N7/0F+31nhrpT0ydL9QtoxPGqcZd+vYxrkrwIxZ1At1p83Dd2WV0sOgSaIx0prpvFq78yK0JLi3E3jPHzx79mz0j8JAYWGPeyldKBmuTarh8E9caJJSluYgLsWrndQReBU4M0TE59CQaDSkESgPjufyhB27X5MnpZmG7ahcW7uuV4hP4SAYHGO2KQPyOrWjvQscq2dn9+7j0bvTnoIOnnaLnLWUd79b3ie0B58drMylqwd388gr7RRoV3WAOlSeLoE1MkRd0tbpGz7//PON7VvWlDeDHGPDFFMyRP1T9/TRGPpr9b1OK+2RofuFcZV60FiF0l3HNs51HRg3NXGwZGZoCQf7ZF1CysCLsHEnt6RTm+ogBR0kYWJaihQFRQNAg0fIl9DaSR3wr7gwFc0STbEkT7uCAuasKQNnbkVsOgqVB/GE+4G71N6mu9z1MlUvOMYO2WAWT3WGkiwlXNQ79F5Ya6CjA9q/Bic90ppLVy8dyKcPSKS/yuyaWYdrYEqGltBTltbIEPXPgIZMcHOGaY0TPRkCjTEoz9xIym0LT3tkaH+gaNJ+BcqLz9gAN8o+TlHWc+XLExOUII2zdWZoDXtTeqpSQyLpzNDOyCjnXiii5w9UQPKPPe7rTtIVtHUGeoWzBNwSB4WqOwUaqM+S1LjUuNRR84+ZytNSlHc6hbkOivh4fCXoDLYtA+VV8SK0U/FSTsRDJ+KzZOFwqMFTp9STOn0hGeaatxlm5uosZYX69wGgF9a2kGZ1fhqcMMjNknT10kFHyF09dsDdu9/hk5c6wIZ5GVqC+rjKGhliBlkyQX+FqTeyUzIkSBNPAOYegXjaI0P7g7GQm3uNA5Srz9iA5EFuGNu8fLF3JYh6YYJD9bM3BuFZzKCRc2s/mpvGm9l+fUjsaDcMiLf2g0CPdvxzzjVo+cON2w9a/GgPspN7uRu0/PE6bnVd10ivx6vr8gOK03G3Sr9T4xKedtLo7pQOTE0LbjmWf5WRu/vtb397e6w06RxT4/MyUDieBpWB2ylc+cUNRtcJS+ee73AYvP5lqGfJi9qH1zvXRJW5FtSj+2mFVeNrhYtsVLseLf9L8+T2tT+KTL7LUhlq1Ynbqb9osUaGBHFgYKkMyV1Nk8cxlfbI0P5QmWO8br1s3Y3qWnAuGREuB1Nytw0nuw0FdyBo2q3HV5cMWu3Q2MY7mRDuE+60mE7mbuyc4Y5Tj83C/RIZCqfOwd7pCSGcF3TwPILe1wuDx4C0k4cMVschMhROnZOc6eFugeezcHNz886zwUuGO4yXL1+OL+Tt6xO9EEIIIZyo0hNCCCGEsG/yeCuEEEIIV8FRlB4e4WitBRl9SnnK8NjtnJ9Vh/OHpRBayzSI2q70uSf/1a4F1yTjS/300uTtfIol7qbckF7s6UM4nkrrtaOymiprPiKRGy9L2bWuOdhvK0NAvPUT+iWyQb3LDX10i16eRGRoP8zVA/ZyU+saKH/vS6qu0At3K3i8dQz4/EyftemztPoJYwjhLfrkuPcJb/3kFnf6BFSfEmN6n+LS/vzaEj+9NJEWxT3FEndTblpxk9b0Je/CJ8EqF8qs9Qkw5axPiflX2U7JlrNGhgR16Z8xL5END5djwqhg38qTiAztBx/TW/UAXq64qfXLddUF7vw6dbePOjkJpQfIrAt8COFdWp12D+88fIDDvtV5aPCApX6glSbColPr+RFL3PXckL5en+F5Ce8ypSAIyrtXvj0ZXCtDXCMuj2+JbKAYuR/CqQraVJ4iQ/uBMvbyokxrPYDLHGXvdYsfTE+2evbbchLv9DBlNRTagz/7sz8bp7A0XV6nwDTVpalTnYPcE5bsNZXGNZ9Wc2SHH9A0KNNsHo6maTX15uEpPSGcCsirVjdlde653a6RZ19ld4mfKfjklzbNV5i0pR5L3LXckD/WgmFrA2+XgryQp9CGFXSHQWpz9hbfwqG3P5fLlrNWhvBXtyyAJbKRXdZPg6W7rA+Kzp1y1rIA1AXUbUAOwVGVHoQZYeN/0PDGwuCfJaxpBIMWeLt3C9dYLGpQ1MZzGgGNQrCIoRqx7LUzOOH5LuQSZJQaGhX2VBjKCw0CN2ymSTikh4ZKwxk019EfEB7pwy8NR5UWwinAtiTbLKGPjLcGsrXQXjC0r94O2bDEXctNdsjeDcqqt8s6fRn9MmXaeu+iJ1trZSi7rF8PLMNCOVMXviQLW0u1FGzBeN9SjNdwVKVHSgPGM/xssxM5aGVPFBApSXV39R4qVJQhX9mZ3V6lpNCogJ1+fR8gFBxd8zsJQdgPHz4c00OjDOGUQGa3WVytJeP7gDakWdQplrhzN9khezemdlmnnOmTueHr7abekq015c1gll3WrweUSsZWxmQ9IcFubn/Juvv6LpzVJ+soF1KS9r09BY1iG5h5YnaItLSmiUM4Fbgbntvtut6hL/GzFLUt2owGp9YMwpI2KDfczfuARPrrHf6aWYdrgLJfssv61J13izUyxOw9/ScykV3Wz5clu6xDa9d0FHBNaPCEBcX1kK+MnI3Sg4JRd1d34WbmZpsZF/lVw0HbRNNfChXslRzCqVCngrmT1SNYDMf1Tp3ByAeAJX6W4GnR4ISpA+qS6Wt3Q8dJ50jaIDtkL4MyBOqSsmspn4I+0d/TgKl6WiNDzJhLJpiFwdQb2iUyRFoZOP2RSQvPU2RofzCeMhtH+QLlWmdmKGfGaJW38DplFohx2OuRMPeqfA4R3TuDZj++xY3xN7x5k1v2g/DfHg+FMF7XOWYovNGON8A5J0yFq3+u6TqGcHSMf4zO8QMerx//4he/uGPvYSm+EA5Jq01Ihmk7Qtccb1tqOxXk2K+1/NT4WmmiTVe7Fj13HsdUWJ4+70dA7Tm8hfJTeclQ1l7eXp/0nZWp+oQ1MiSIGwPbylBN69I8RYb2h8oc43XrZev12pIvrtf6pv5cpnYl21CEEEa4o8oO2WEXIkPh1Dmrd3pCCIeDDp5Htue8BANpJw8ZrI5DZCicOpnpCSGEEMJVkJmeEEIIIVwFUXpCCCGEcBUcXenhk8newlPnBusMLIFP9nDbWo9iCq1Roc8Cw/VBW0EGpmSt5Yb3FOb8AbLp72McOj7YZxzY1U9iw1uW1gt9Te2f6Kvld6qMXYbU1835acUHS2SDT9rlptc3zqVd5UJYkaH1zNWDxrBWPUz5pV5a8rEK3uk5Jnyexqdr9fPFfTD3eeWukOb6meNSWp/mLYHPKA9RVuH0QWbmPt1sueGTT8mM2lsL3PhnuoeODw4RR9pIm6X1wjWGBv4F5Y9/4N+vOVWGOMYvxu2dVnywRDY8XI5bQxr2U2lvxR0Z2h4fx1v1QH1igHpweZjzi9uezG3LUZUeCaPMPmkJ976holSJ24K/NelLY7xeqHs6hKn6n3PTGxjAOyE4dHxwqDhqXsJd5uql9p+4F9RDr7/2csedK1aE16vDVn+9RDboRz0thFH75Km0k74leQnTUMZeXpTp3NhI3eJvzi/nmDXjZYujPt5iwzdWvHz69OmdPV6Y3mKaS1OeHPvKyZoG0xQq6Bz3TIWxnDmrQjI9Cj4FqrA0derxefiO7BQebtmri2WzOcZe18CnU4l7DqXF8yQ7TJ0K9HRyTeWE8fhkV6+14gunDZ/RDh3EuPJsT6bm3LBy6tDBbM7egjzV1XcPGZ84VBzkhTyFNnP1UsG96O3bVWWIfawOvVN/dlk/DZbusu4gf9TNlF+Ne3V7kF04qtKDcLIWAhlnEJaAYTdodqPSwvLjg3Z+u4dLa3dzGsSgGY675Wr5a/wPmuHohnC1QzsGhQg/NCqFiT1+l+7GztLZuCFejhUW4I/04p7rxD0FjU3pA9KGIS7syAs7Gzt0HlyTH+LnmLJRfISLX4WBoWxa8YXTh3aCQRZ7u07PuUE2W7trI091qfdDxicOFce2A+y1MVcvLehrUQ7oJ3Xj6LRkaBeWyAY3zaRHoAC1BshW2rPL+vGgPlzR6TG3+/oajqr0oHwgiBhmTaqAobRo/w6t8Nna3fzRo0fjjAv+NZA72PsdB4O/a6Ha5wPN0/d9WbIbewviY1VSIP1z+8GgsHA3o3LQjrKkBQWLcnJQzBzSRvnQmAlH+B45dAS6I2rFF84H6pvOeoqem95dut8tVw4RX+W+83TtLK0Xh/LXDVRv9/VDMCUb3CAzTmgcQXHJLuunD8qMj7UtUECXbIy7LUdTesiQZmwwKDCthlRhlkIzIJqeRWg5BwR/jl2mymg8S6hTrHOQf5UFwkD5kBfuQmioFd+9GJRvylSgOFGmXEMpdCGr8YXzYokcVjcoxb1OZO4OfR/x0XaRRUxrpuC+83StTJXZEnrKUi1vZmG8n+J47QaeqveWDNF/0Y/R9zH7PiVHnna/EQTSX8eGyNAylu6yDjxZ8Gs9vyjmujnf5+7rR1N6yJA0bEBQ0eZ9erEFheMFBBQiDQCBRluvYdDQmC3RrA2FurTRqwGpgRE2cUxBfK7AyW8PlLi6gzx3HCg7XkYCRYg7FE8Tjb12Rlz3x3qiFV84H2qn0aK60SNM5Il2UGUSme3d1e4rPg1OmCqr+4pDkJe1A+wlM1VmS6G/aT2aqDJEHHoFAcMxdtvi9d6TIdLEAJld1o9DHb8pVz2lcbiuJxnA2NPz63XNayKMu3P1u4ghwHvn8eat/CETG5s3b+FjJ3sdDwP/HXu/pnDwy1v4soNB679z7uFwDPKPX/nHeBwvN2+X61zhgcJ094QDNQ+O0ubXdI4hPnejdLrx6y23xO9lKiPcjvjCaVPbh5BsIgM9Ny6LMq06R3Zkfx/xHTIOb6fhDb0y8/IG7ytV5m6nPq6FyxB43yT7JfH16r0idzVNHsdU2j19hOVEhrZDZY5R3YLK1uuhuuv5FfifkoNtyN5bFwx3SK5tS5Nec7cVLh/kIztkh12IDIVT56gvMofDwnNQpz5SDMFBNnh0fM7LGJB28hA5Pw6RoXDqZKbnguF5vX/5dXNz03zOGkIIIVwDUXpCCCGEcBXk8VYIIYQQroKjKD28JKa1FuqaC+cEL+2dQ9opb8w5onU59FnpNYOcqb30ygP7lhteape9PltugR+9j8G//MxB2lrtQGFMxen9QY8pNx4Hx5GVPkvrlHZXl7KQbM2VL/700YTabw3L6YXrMjvVx0o2yFsPhdNKh/pxwuF4Kq1hGslXr76m+iHVQ4Uwp+p/a3i8dQz4dFCfpumzwdanaqdC73M5PsPDnDJ8DnjOn1/Wz2CvEfIvOeO/J48qq1rntC/Z95o97U9+iEPtkbimPlMGwqztALu5z0z5FJU0TTHlphUHeTjlvuRYLK1TrtVyldxgpuqLMKkv8M+M+Ze9MxVulacWHi7HLT+ejxoP7qsd4c3Je3gXylLl7+O7oIxVF1zzctc5xiEc7JbIwlJOQukBOqpWozgFqJhaGcIr+lQh/T4Anhuk3Tula8TzT7tpyRz23lnTwWBX679Xnj0ZwW1P/kGDjaeJdCxpF8RJ2N4XVHpupuLo5SW8Ya5OKVdXFgR+WrID9N9VBlRn+HHZrNRwCQu7KT/g9Yz/Vr17uB4eaeuVAfk41fHoVKHsVdaUbUt+HOrCyxi/rfpQ/7IvTuKdHqa5hgzfWQ2T6SxNg2naU9OgGKa8NB2m6UiONUUpe9n5udzXaVGd+3QnDJU5/utaD/lrham4ZTRdx3UZ7GvcUP0q7FYZuds6fViZirOG7WUnt+5H7gnLy6E3hUk4CkNl4f6Uxwr2Cvd3v/vdrXvFM+X3nPGl9Xv7JtU95lhCHztfVZy6ZEVaDw8o+9Yqu4BbtYEK/upKysTBOi1sO0B9UNc9+DSYts9quj15bbmZi4O8kLbQZqpO18K6Nk+fPt2cPRj39dNn38Q3t2ehw1gwjE+jP++XKsiF+j7ccl7BHpAd37iUdjQMqLd9iMIB8kF+wjK8DoD9MWm3U+CWfTPvnTe6z/2Dlkf0mKqdu5aIJijt3DVJ/HHsdyT4U1jYe/bqOX50FyKNk/BwU+OTfQvClRaKP4VZ/bpGyzn2IHu5q3F7njjXcauM6nWF5fbOVJy98pc9YK/8gspBcSn8iupCccmNh6e0+DFG8eMHtzUOL+dLQ3nFqKwdl0Xwc/lV3VSqX4dy7l1Tfbh/yYzqUnU1BenrpU24m7k4pvITpusUuOZtXVDO1EMLrjlz585UuKSj166RAeVjSoYIgzg8DbiVX/4Jy5lKb7hLLfupuhC1vPHTKnPqbkpWt+WoMz1DwxtNvcPk7pT9N9C+WWCPOwQ0STR+aZJD2m+PewyFtTl6g5+jhfZ2Gvf9PV6/fr05mgd/dQd44evjDBX44MsvvxyP68akNW5fIIv8KtxWGXGdu1/u6MnbUmqcrbCF71nGyqu4Be6quTvinzTidxD622sV6oL0kr9B+Ec3U+UHuCddzORQ//jFjrA0A7DtRq/nBHkl38jPks15na+//npsa5Rra+alt+8W9GaWKPOPP/54c/aWJbtXV8jb1B09uJvskL0bvTpdi8+S7Bv6nF67Zn8m1iJTf9ObrdQ+TqC+gragMqDvas1EHTJf10yddbtPjv54S52WBFHQsSOkMrDvpc0ReoVPo9gVBhMaHeFpwG9BA2PQYqBfsqHdRx99NDZqzHDHs7FtlxFugAFuF1phV1DktPjhq1evxkEJUGLcr+p4jiXlxzUaC/mUMkWnyFQ0MuTT65dKb7BCllq7WtNxa0l9yg+Fvyqivd2kUaB7m/MSJvVEXSAHGOqwt3s11yTHeqTpSH6mkJvskL2eqTpdS6vudDMD/HO+FuoWOZb8YIB41c8Q/ly+6NcEsiulhnBafc4SmQxvy0nlyU1WTwHFDZMMS8eFfXMS7/SgcPiWCXTUvpIwnaUK1RsRxju6ubtJhwrZ907jDCZzzzGBvHDHumRbCASEzl0NWzNGrTJSx7LrHVwr7B4+ywLkhzsm1RPXdOyocfCPMou/ufLDLbM8uEX5U31zThjcDV5DJ0V5tjoUlQPl5OXK7F3rLtahzuvMiOqVMAivKirMzEkuGUwwtGVklBk5/IB2r9bdNqbKKHFts8t6Lw5BXshTuMtcne4CfY/qA5gJpo8D/jlfw6effjrWN21b8oNx6Bd85q8HNwKSE24mNQZQLt6myMcuSto1QnnqCQY3RD0FlHLWJMM+xt2tGYTn3hk0aiR2NHpWy7/sYBhMb8+HznS04zm07AgDXm6eA2IGIR3///qv//rWjnDdn+ID2WEIR+kiHIWFAV0jLOFp5tjTLPcepiP3YipuHcsoD60y0rnCczc1DVNx1rD93FHZUn7Cy6XGCYSnuDEqU4/D0yY74qjngjBVBpcIeVO+vUwl/ypDl/VaPrKnnFtQ5vLjdSHDtRqfqOXv6ZC8VlxOPE0eR88NTMVBXsJdltZpT1Zkh8FPhTqodaT26vYcuwy3wvX+oRWXkLsqjx6Hwmm5U/qqvFAGPbkNfVQf3hdQxtSHt1cZuZMMygj8Vbe7km0ojoRmP+buTLjjqO/2cHe2z+fx9w3p5058H48UBXdq3MFdw0zPoUAms0N22AVmXJAhzUifI/QlyI+/6xguh5N4vHWN8GhmSafM9CvvywgGpvruQnjzYmsUnt1AHnm8eM6f/JN28hCF5zigKPC+RuuR9jlAukl/FJ7LJTM99wzPMHkX4WbhjufM9Dy2F+yePHly1g2STkVfli0tgykY5Hhf5cWLFxnoQgghTBKlJ4QQQghXQR5vhRBCCOEqOKrSwwutvm4Hhsc5vIjo6zHIHPo5MY+eiMc/u9wVzwv5q+chLIVHeZKdHt6mXI55OVP2U+0IP3qnh+NWWBXaTevTU5f1Hp4ujlvMpUPlgn+Op9J67SyRIWjVaU+2KlzbVoaA8GufuK0M9WR7Lu2Rof0wVw+Ccm7Jl+RGEI7C7PUPW8PjrWPAp2j+maA+k9QnhXzm5p8X6tO1Q39GSJqmPpFcA3nxdNfzEOagfag9+Oe4DnKrzzr5xx1gr7amT0NbEL63SbUF919Ru1RcAvnG3xz4VRy9dE2loxU3brzvCG9YIkPQqlPKviVblTUyJIhTccASGfJwOW7JEPZTaY8M7Qcfs1v14FC+XubUC36qTHo4HM/JwxKmU3YgJJw1Awi5Cs0LUFBIcw1nVwh/HwXrkJcoPWFfqP1UXG5pO+rokTUfTGhHLfnztoV/74DwU9ujaA0khEUae36A9HqcrbY3lQ7sPV+OhxvepSdDotZpT7Yqa2WIa4Tp4S6RoSWyPZX2yNB+qG2ZMu2NcVzDuHwB7l1eqCt3I3+7cpTHW6zaOBTQO58Y8yXP1Bc47PMzFG5z6lFTYDL/+I//OP4zhaZ/nyrzaTRNj24znatwQ7hvaDe0n4q3J99bic/565YNdS8j2oavSMuSCq0d25fCZ+O01and05Ve2hnti/hrn9BLB+5ZTyi7rK+jJ0M9erLlrJUh/LVW414iQ0tku5f2yND+qNtOsKyK72cpNI4uWXaFpVp83MVPXTV+DUd7p4dntWupm4AirIMGyG3L7XL4//AP/zD+83k49iyEx3Lmg/Y4nvty/ezlhB0Nj0YGCDsFjP2ggb7TILSkvpQijFdQCIcC2WTJ9xbIILKI3Ov9CLZj4Fwg17XTYTBiwNgXDDQY2tPUxoIMbGx5Qoe5zWKVdLL0IWq75M8HqG2VtGtjSoZ6tGTLWStDKCKtpSuWyNAS2YZW2iND9w/rzi1dWJfFZlmOROMqyuw++qiz/HqLnbgdv0uo2uCzZ293Vmd9m7qLN7NOavw0PN39IOw0AtzWncYdGosMHXd9ESuEfdO70wYGCWQRhV87sTN7SjtAltXx+z5VsI87qBakZ+oGZ2739x50gNllfT1TMtSjJVvOmvJmBqe1U78zJUNLZBtaaY8M3S8olNtsdEudUV+MydQtN0f72E/vKEoPCXcNTlAorTsIgZbYeyyGIFMwKCi9O0Y6VRQThH/J1C4FjluZHnrzn7vWrOQZDgntY0nHUQc0zUyiYDx58uSdNlTvoGijrR3b16C4aH8anMgH7X9u9/deOurNDemvd/j7uCu8RJbKUI+esrRGhno79Vd6MgRzsu142iND+wNFk/YreLRVH1miaPOokrpjnEZBnZskoL6oW26KkBMpqDsxBHgUBq36nRfF/JwXmniRSeCe5LqdGJSTrj3+BOEPhXfnmJenVAycc8w/4XnxeDig9PTS5JAXf6mrnoewBGQGmQZkVMctkMkqs1WmnZZ7tRFMbatObWcOae7Jek0PcbTaUi8d+MUO5EaQnlZY185SGZqq05aswC4yBMTZSs+UDIkqSz1qGiND+8PH7Lm6oD6rrGBHGBXqxOtpV+al5ICQaTIjIxA+t5fpZZrCqm7VCDBqMB6f4nB77GTcHtPrHObwvBBGPQ9hCbWtYGgP6hCQd+RJ17zzUPtodSgOsultzNuQ7D0+8DhJI3h7lF2Plv8aRysd4PZq40JtOLxliQxBq056slVZI0OCODCwVIZ6su1xTKU9MrQ/VOYYr9tW2XLu9er1rTpS3ey7Hi5iGwqeC/uLcJoi38tUWAhXAu0mu6yHXYgMhVPnLF9krvB80OHZ4aGF1Z8tu8mLzOFcoc3wXP6cZZi0k4cMVschMhROnWw4GkIIIYSr4CJmekIIIYQQ5thK6eE5Z32cM/WJ+anBuz+tzyFDOAdoa2p3dbkHgYzLja9i6/b1s3CHcPVoYkl82Lfc9NLRwvuVHlNuSK/i4biX1vC2rKbKGugna1+pup4rX/xJxvQawFS/2wvXZWhqnJFsSG5bKJxWOkgr1wiH46m0hmlUzlN9TMuN6gBT67rlfid4vLUNvFmtN7P1drW/qX1qTL35H8K5wJcR+rKF/55c0x5xqy8pgGN9AeH2Fdqxu1sSn77W8TiglY4WfLWBmymm3BB2TRvpOOU+6VhQjyoXyqz3FRbXarmqHlWvPQhTX+r4Fzr8y96ZClfyN4WHy3HLj+ejxoP7akd4vbIJfVw3oExb9Nx4m/X6WBLmtmwdiicCSGxLmE8BNagQzh3vlGl/rc4dN654cIwd7dPd9wYg97skPux9cCBc7HrpaME12qj3KZWeG+JupQs8/vAu1MdU30i5urIg8NOryypnPlbgx2WlUsMlLOym/IDXM/5b9e7henikrVcG5ONUx7VTpJZ9q/ym3Hg9SG6WhLmGnd7pYfpxSNidZb+XTImD3DClCPLn/jWdpelPXddUmE+d+vSYpjmHAhv/sWPVTv596syneonDw1XY7j6EY+GrzPa2EJAbZBZ5ZvVx7JZsyojs+4aBS+Jjyf7WhpK9dLTgKxn6kKlNJVtuCDebRa6H+lD/uC/4xPvp06ebswfjqvv6Aor4elv5tGBMGcan0Z/GiBbIBbIAuOW8ItlDdnwPL+R6UOzujAGCfJCfsIwlG45OuRkUnTttGLlZEuYaVik9WkpaG7VJqOhk6FyxGzSydzoigRAjnLgjUygfdKpknO0ksB+0unGDUMANdhiWKWf/LK6zjDV2KDStzUTVALAjLfgRnLOeBNdIKx0ABa1wWUKb8HwZ9RCOCTJNu0M+e8o4CkLdwJOl//EjaKN1uX2Ulbrk/pL4erTS0YK+Q4NVb1PJlptsFrkblNW2G47OgVKjsWBXFA6ygwz1FGLGDPZPBOS1p8jR37O0CWOXQEaRE+SHft/HK+LfRkkLu8H2TbRh+ptDb+W0SulBGcAgjA6djBLe26RT2rSEms3m3J0UHZQg7KW8ECYG6PAALV20NhOdAoHXDJU2GlWnSbha7PDcF9kKlwNtRh10a8NHoG3QNmkD6sRR5v2OljZaN2X0mSCxJL4erXRMQVxTd/TgbrJZ5G70Zu/Won79ELBPWJ2ZFChFKNfINX14HZME7pBlkAKFbKoMmNmZGq/CYWHs1eTD1Avp+2D14y11NlUDp4NEuGTIjDrbVqcm5WcKCsLD9NWXBR0rAs/1nrY/xVyHG8Kp0Bus6KC1iiztAMVeirw6fRQR7o5ru6uzPE4vvt6Gkr100EbVF7Rmjpb0BXLDTFV9ZFdnr6bydM1Q9rtsONqiVXfImeSPf87XQt0iV5IfDBAvMoYh/Ll8MT4JxgkpNYTTGjeWyGRYtuHolBueujCua5IBvWJJmGvY6Z0eOlJfDZkOD61b0Mmp48OQIQmROj0ag8/YSKMn09jLvZQr3FdFCygcL6A5UJD8DpS0SZEL4ZShDbTuaF+/fj05JY8/pvdb08e03d7MSC8+2oseJWPUhnrpkOKFqYoUbXquQ3M3dJDMWGnQYibKZ6/IC3kKd1HfST1Rdts+tpwCpUP1AQxkzCgB/5yvgdl/6tsVHIzD7IDP/PVAMZec8Hjv+fPn4zHl4jJOPnZR0q4N6oaJA/oKoG3WyYmeG8qaWTeXHVgS5ioG4VnMoAmPb1lj9BY1/7KDQVG5PR+06tGuMmTw1g1hikHI7sQhhrvTO+79XOnweBUG6PgXv/jF7XX58bhIk4dL2nVM2CEcE5dH2olQW0J2oSW3aqPurwXtgfBgaXzeZuQXlrQf7zvcjcfRcwMet9q0IC/hLpSfykuGsq512qs72WG8rgV1UOsI2anhcOwy1Qq39s095E5pFx6Hwmm5U/qqvFAGVabCNJKjWs6cqyx7brydt/qb6n4XTmobCrR1TXOFEO4X7qhof5piPle4O8xmkcfhEvpwZn2Qn0O/UBuOw06Pt0IIlwNKAo+ID/0i4SEh7eQhCs9xQFHg3Qs9kjg3SDfpj8JzuZzMTA/PlvU+0MuXL2/f5QkhhBBC2AfZZT2EEEIIV0Eeb4UQQgjhKthK6eF5udZIWLLgmODFQq2rcAi2CZu0YI4Nj/NIt55983/O71KEEE4f78OnoH+vfbz6LEz9vNjhmvoyjpf4acUHGjswPXjxWG567xLNpV3lQlgcT6U1nDk83toGPgXkc75t0Gdn90H9ZLJCWu7jc1Y+r5v75JFP83qf4c3lI4QQtoF+W/1N/Wzc4Rr9tfdB9Jvq9/nv9U+E7/0rx/id6ndb8QH9J/6m8HA5bo0z2E+lvRU3Ye7rE+lwWlzU4y20cxYwOgW0ncYa9rlgWAghAAtC6qu2uv2PwyKSg3KwOXuLFpRk0cfeate+5AGzLszU8FEKhsX/WjMxvfjYV21QPrqzN8B2J9pDjDgG5eV2AUanl3ZmdYibNDjkYe1iiuG02Unp0dQjQsn/3GOjljufmvTBnnMEkilP+eNYccot5wqPBgJcx49Pac4pEgrX49IxxpGd4lU8+NE1OhRWq67haNrX0RQwbikPvmJDeVOaMK38hhDCGlAQ1F8uwb+m7e3bRT/nqxqzF1prF/6lsPTAy5fTO/Czgn/djqTu09VLO/0uyk126r8udlJ6tO0Dsxrfbj4Cm3oWWt0hUCwChR2GwR7hxtzc3IyaPoM/dydo4xwT54sXL24/b1cagAYChIUf3HCM/dyGiTUvxKXjJ7aHDAoH4WFPo0CJoRHhhjxhLz/kgTsIwiHN2NPIahnRKHELLOpFXrljwS1+gA3xgLB0JxVCCGugP9t2l3X6LZQD+sbWTSQKzT73O6NfxNDf9nbgZ+aG9AgUoLoHG7TSnp36r5O9PN7yhZzYd6dHdVfvBBjsWRjq0aNH4ywJ1zXoA4oAjQCFxhWRHvhFgdrmjkZpxI9Peb569epWWdGdQ50i7k2HEuY2O8BXKJcvv/xyPO7tNhxCCEtZs8s6/R59Kv1R6yayt3fbrhBvb3absYBxgb5VSo3vwSZaaacvzU7918dB3unxxzxzj5UcaegIoZQdwlgLDQUlao2isQQpP3NQHswKkadtFDDBLA8NFSUvmyheJ2vbVAgV5GeXXdZ7ylKd5aGvau3Cvwb1ta12wM0pfSuz6dwMT/XLnvbs1H88VIeY+uTj0BxE6ZEQYqbuJmgAPIJSplFQaIzMziDQ+EX71oyO3PHPIx5p6C3ktr6gtgtqTGpspIv0zcGjM38Mty3EiwLH3dlUnsPlsrRNhTCF3o2hH6GPXKNA0+/5uzuC/tyVCOLQ4/wlfXYP0qzd9XvtgDTx7s/c9hGedl4lYGZIY0V26r8/VIeYpZMHe2OIdDGDFs30y2iGwX78rI9j7P1aZcrdZ5+93dGXY+BTRbnDL3BN4WD0OaHOcQ9yw3Ude/zVvXA37o586vjly7c7EmPwA54Hrrsd/j0MxeN2v/3tb2+P8UfaOVb4QJngJ4QQ1uB9joz3aepTvT9Tn+N2te906LPUB4L6Mozsl8RHf1ftWshdTZPHMZV2Tx9hOd7/hsvhbLah4I4EzXufMzfnhGa7MtMTQjhV6KeyU384ZQ7yeCvsH16wSwMMIZwy9FE8ym8tzXEukHbykP72MjmLmR49r4Wbm5vxWey1wIt7PHe+tnyHEEII++YdpYe3qUMIIYQQLgWpOk2lp1iFEEIIIZw9eacnhBBCCFdBlJ4QQgghXAEPHvx/8oIMAkHTBNgAAAAASUVORK5CYII=\" width=\"573\" height=\"189\"\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: CD, Clavien-Dindo\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"esophageal cancer, esophagectomy, minimally invasive esophagectomy, robot-assisted minimally invasive esophagectomy, operative time","lastPublishedDoi":"10.21203/rs.3.rs-4187756/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4187756/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgeries. However, whether robot-assisted minimally invasive esophagectomy (RAMIE) can overcome anatomical difficulties during thoracoscopic esophagectomy remains unclear. This study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eForty-five patients who underwent curative-intent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were included. Using preoperative computed tomography images, we calculated previously reported anatomical indices to assess the upper mediastinal narrowness and vertebral body projections in the middle thoracic region. The factors influencing thoracic operative time were then investigated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eDuring the thoracic procedure, the median operative time was 215 (124–367) min and the median blood loss was 20 (5–190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The multiple linear regression model revealed that a narrow upper mediastinum and greater blood loss during the thoracic procedure were significant factors associated with a prolonged thoracic operative time (\u003cem\u003eP\u003c/em\u003e = 0.025 and \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001, respectively). Upper mediastinal narrowing was not associated with postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eA narrow upper mediastinum was significantly associated with a prolonged thoracic operative time in patients with RAMIE.\u003c/p\u003e","manuscriptTitle":"Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 16:19:40","doi":"10.21203/rs.3.rs-4187756/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-19T14:18:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-19T13:57:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-14T02:49:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36094997-946f-4d2a-8d93-ed8afe14101f_SNPRID","date":"2024-04-08T16:31:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4e4ed1e3-233c-48dc-a46c-87464f018ab6","date":"2024-04-08T13:55:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-08T04:58:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-07T05:18:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-02T11:03:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-03-29T11:56:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a8fde0ca-259f-4674-8eb9-b15c345f971d","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T15:43:36+00:00","versionOfRecord":{"articleIdentity":"rs-4187756","link":"https://doi.org/10.1007/s00423-024-03378-w","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-06-19 15:43:36","publishedOnDateReadable":"June 19th, 2024"},"versionCreatedAt":"2024-04-10 16:19:40","video":"","vorDoi":"10.1007/s00423-024-03378-w","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03378-w","workflowStages":[]},"version":"v1","identity":"rs-4187756","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4187756","identity":"rs-4187756","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}