|Year : 2012 | Volume
| Issue : 5 | Page : 99-115
Comparative study of laparoscopic versus open appendicectomy
Manit K Gundavda, Ajay H Bhandarwar
Department of Surgery, Sir J.J. Group of Hospitals, Mumbai, Maharastra, India
|Date of Web Publication||28-Jun-2013|
Manit K Gundavda
B/204, Hilton, Shastrinagar, Andheri (West), Mumbai - 400 053, Maharastra
Source of Support: None, Conflict of Interest: None
Comparative Study of Laparoscopic (LA) versus Open Appendicectomy (OA) as a Cross sectional hospital based study for evaluation of:
Postoperative quality of life
- Postoperative pain
- Amount of Narcotics/Analgesics used
- Hospital stay
- Time to full recovery
Background: This underdeveloped residuum of the caecum has no known function and is commonly termed as a 'vestigial' organ, yet diseases of the appendix loom large in surgical practice; and appendicitis continues to be the most common acute abdominal condition that requires immediate surgical treatment. Study Design: Study to be carried out over a period of two months included patient diagnosed with appendicitis and admitted to surgery ward at Sir J.J. Group of Hospitals, Mumbai, India and St. George Hospital, Mumbai, India and willing to be enrolled in the study.Demographic data, clinical features, investigations, Technique, reintroduction of diet, postoperative pain, use of analgesia, hospital stay were documented and outcome recorded in a predesigned case record form. Return to normal activity and work was determined by questioning during postoperative clinic. Results: Proved that laparoscopic procedures cause less post-operative pain than their conventional counterpartsAnalgesic requirement for post operative analgesia was significantly less in LA (mean 4 inj. doses) compared to the OA (mean 5.9 inj. doses) Hospital stay was less for LA (2.23 days) than OA (3.4 days) Full recovery on the basis of return to normal activity was earlier in LA (6.53 days) as compared to OA (8.7 days). Conclusion: LA holds a promising prospect and may replace OA in the near future as the method of choice for effective and qualitative clinical management of appendicitis in emergency and in elective set up.
Keywords: Appendicectomy, comparative, laparoscopy
|How to cite this article:|
Gundavda MK, Bhandarwar AH. Comparative study of laparoscopic versus open appendicectomy. Indian J Med Sci 2012;66:99-115
| ¤ Introduction|| |
'Appendix: Forgettable, yet not so forgotten'
This underdeveloped residuum of the caecum has no known function and is commonly termed as a 'vestigial' organ, yet diseases of the appendix loom large in surgical practice; and appendicitis continues to be the most common acute abdominal condition that requires immediate surgical treatment. 
Appendicitis is one of the best known medical entities and yet may be one of the most difficult diagnostic problems; to confront in an emergency, often requiring removal of the inflamed appendix. ,
Appendicectomy has been one of the commonest emergency procedures in surgery. Appendicectomy may be performed as a laparoscopic or as an open operation.
Open appendicectomy (OA) through laparotomy has been the gold standard for more than a century as far as surgical removal of appendix is concerned. 
Minimal invasive surgery has rapidly evolved as a major specialty in the past decade. Laparoscopic surgery has thoroughly changed the concept of general surgery over the last 15 years and surgeons have rapidly progressed from the diagnostic to the advanced procedures.
Recently several authors proposed that laparoscopic appendicectomy (LA) should be preferred for the treatment of acute appendicitis. Advantages of LA like less pain, faster recovery, fewer wound infections, improved cosmesis and less post-operative morbidity are obvious from the various randomized trial conducted worldwide comparing OA and LA. Review of the world literature suggests that definitely the trend is moving from open to LA. 
Even though modern diagnostic facilities, surgical skills, fluids and antibiotics therapy has brought down the mortality from 50% (before 1925) to less than 1/10,000 people, still the morbidity is more than 5-8%.
Reginald Fitz coined the term "Appendectomy" in 1886. Mc Burney popularized the concept of early surgery and the muscle splitting incision technique. LA has been well established by Semm. 
De Kok performed a laparoscopic assisted appendicectomy in 1977. In 1983, Kurt Semm performed first LA.  Schreiber in 1987 performed LA for acute appendicitis. Today there are different clinical trials with varied result. 
Laparoscopic appendectomy may be feasible, but whether it confers any advantage to patients with appendicitis is not known. In this project, I have sincerely attempted to compare OA against LA.
| ¤ Terminology|| |
Acute appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. While mild cases may resolve without treatment, most require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock. And it has been recognized as one of the most common causes of acute abdomen pain worldwide. 
History of appendicitis and appendicectomy
Appendicitis has been recognized as one of the most common causes of acute abdomen pain worldwide. Appendicectomy has been the treatment of choice for acute appendicitis.
Heuristic Books of Thoth and the Books of the Dead contain statements which probably refer to appendix. The appendix is crudely represented attached to the bowel in Greek Votive Jar's from Cos and Gnidos. 
Berengar Da Carpi gave the first full account of the condition, while Goldbeck in 1830 introduced the term "perityphilitis", which delayed the progress and understanding of the disease. 
Appendicitis was first recognized as a disease entity in 16 th century and was called perityphlitis. Reginald Fitz, professor of medicine at Harvard first described acute appendicitis in 1886. He was also the first to use the term "appendicitis". ,
OA is used since last century. Claudius Amyand, surgeon to Westminster and Sergeant Surgeon to George II performed the first appendicectomy in 1736.  In 1889 Charles McBurney, in New York published the first several papers that standardized the diagnosis and treatment of appendicectomy. Since its introduction by McBurney in 1894, appendicectomy has been the treatment of choice for acute appendicitis.  General surgeons were very slow to adopt laparoscopy. ,
In 1983 Kurt Semm, a gynaecologist from Germany reported first case of LA.  In 1987, first LA for acute appendicitis was described by Schreiber. 
In 1993, only after report of 625 patients of LA with superb results by Pier and associates, the role of laparoscopy for appendicectomy became popular. 
In the 100 year's since the first successful removal of the appendix for acute appendicitis, appendicectomy has become the commonest emergency surgical procedure. The high incidence of appendicitis in the population at large and increasing demands towards reduction in hospital stay, cosmetic scar and post-operative discomforts has promoted surgeons today to adapt to the ingenious mixture of surgery and laparoscopy for the removal of the pathological appendix. 
I had the unique opportunity to present randomized clinical trial of 60 patients who underwent this trial and discuss the comparison between LA and OA in terms of post-operative pain, amount of narcotic/analgesic used, hospital stay, time to full recovery.
Development of appendix
At an early embryonic stage, it has the same caliber as the caecum and is in line with it. It is formed by excessive growth of the right wall of the caecum which pushes the appendix to the inner side. 
Gross anatomy of the appendix
The average length of the appendix is 7.5 to 10 cm. The appendix is averagely 0.5 cm longer in males than in the females. In the analysis of 10,000 cases of postmortem examination gave the location of the appendix as follows: 
The anatomic location of the appendix determines the symptoms and the signs when the appendix is inflamed.
- Retrocaecal: 74%
- Pelvic: 21%
- Subcaecal: 1.5%
- Perileal: 1%
- Postileal: 5%.
The mesoappendix, which springs from the lower surface of the mesentery, is subject to great variations. The appendicular artery, a branch of the division of ileocolic artery, passes behind the terminal ileum to enter the mesoappendix a short distance from the base. The artery is an end - artery. Sometimes an accessory appendicular artery can be seen which is a branch of the posterior caecal artery and is also called the Artery of Seshachalan.
The lumen is irregular, being encroached upon by multiple longitudinal folds of mucosal membrane lined by columnar cells of intestinal mucosa of colonic type. 
Crypts are present but few in number and in the base of the crypts lay argentaffin cells.
The sub mucosa contains numerous lymphatic aggregation nodules.
Pathology of appendicitis
Obstruction of the lumen seems to be essential for the development gangrene and perforation. Continuous mucus secretion and inflammatory exudation increases intra luminal pressure, obstructing lymphatic drainage. Edema and mucosal ulceration develops with bacterial translocation to the sub mucosa. Further distention of appendix may cause venous obstruction and ischemia of appendix wall leading to gangrene and perforation [Figure 1].
Clinical features of appendix: 
Clinical features: 
- Catarrhal (non-obstructive)
- Acute obstructive.
Clinical signs: 
- Periumbilical pain
- Pain shifts to rt. Iliac fossa
Signs to elicit appendicitis and investigations: 
- Local tenderness
- Muscle guarding
- Rebound tenderness.
- Tenderness in right iliac fossa
- Rebound tenderness
- Rovsing's sign
- Pointing sign
- Obturator test
- Psoas test.
The diagnosis of acute appendicitis is mainly clinical. Several methods have been suggested to diminish the diagnostic error that occurs if diagnosis is based solely on the clinical picture of suspected appendicitis. The symptoms of appendicitis can initially be difficult to differentiate from gastroenteritis. Early symptoms may include vague bloating, indigestion and mild pain which generally is perceived as being in the area of the umbilicus.
As the infection worsens, the pain becomes more prominent in the right lower quadrant. There is usually nausea, vomiting and loss of appetite. The pain is generally constant and progressive. There may be diarrhea, fever, and chills. These symptoms progress over several hours to several days. However, many patients may not report the sequence of symptoms outlined above. Therefore, an accurate diagnosis of appendicitis can often be challenging. Many other conditions can mimic appendicitis such as gastroenteritis, kidney stones, urinary infections, ulcerative colitis and Crohn's disease. In women, problems such as ovarian cysts and pelvic infections can mimic appendicitis. In fact appendicitis is a disease which can mimic most of the causes of abdominal pain as well as some chest pathology. 
Despite new X-ray techniques [Figure 2]a and b, computerized tomography (CT) scans and ultrasounds, the diagnosis of appendicitis can be challenging. So far the most accurate non-invasive method of diagnosis is ultrasonography or a CT scan but this is not totally reliable. The history and physical examination generally lead to the correct diagnosis. Indications for the surgical treatment of appendicitis:
| ¤ Oa|| |
The placement of the operative incision is partly decided on the location of maximal tenderness detected on physical examination [Figure 3]a and b.
In general, the classical grid-iron incision over the McBurney's point is made. Alternatively, a right lower quadrant incision placed in the transverse (Robert-Davis) or in the direction of the sick lines (Lanz) is used. 
Exploration and mobilization of the appendix
If there is difficulty in locating the appendix, it can be found by tracing the teania coli along the caecum to their junction.
Removal of the appendix
After the delivery of the appendix, it should be held up by a Babcock's forceps. The vessels in the mesoappendix are dealt with simple transfixation and ligated with thread. The appendix is divided close to the artery forceps and the stump invaginated by the purse string [Figure 4]a and b.
Occasionally, the appendix in retrocaecal position is firmly bound down along the length of the ascending colon. Under such a condition a retrograde appendicectomy has to be performed.
- Clinically suspected acute appendicitis especially in obese patients and young females.
- Recurrent appendicitis.
- Clinically suspected acute complicated (perforated) appendicitis.
- When diagnosis is in doubt.
- Diagnosis of appendicitis at unusual position.
- Normal looking appendix on laparoscopy.
- Incidental appendicectomy along with other laparoscopic procedures.
- Incidental BaMFT radiograph showing presence of faecolith in right iliac fossa. 
- Perforated appendicitis and appendicular abscess.
- Septic peritonitis.
- Severe bleeding disorders.
- Prior abdominal surgeries
- Minor bleeding disorders
- Known abdominal anomalies
- Inability to tolerate general anesthesia
- Pelvic inflammatory disease and endometriosis
- Severe co-morbid illness
- Inexperience with technique.
Technique [Figure 5]a-f
- Patient position and room set up.
- Port position.
- Division of mesoappendix.
- Ligation and division of appendix.
- Extraction of the appendix.
Potential advantages of LA
- Retrograde removal of appendix.
- Sub mucosal appendicectomy.
- Two hand technique of LA. 
Steps of laparoscopic appendectomy
- Allows thorough exploration of cavity.
- Allows definitive treatment for non- appendiceal lesions.
- Reduced hospital stay.
- Avoids negative or unnecessary laparotomy.
- No need for extension of incision for abdominal location of appendix.
- No post-operative discomfort and narcotic requirement.
- Early resumption of routine work.
- Reduced incidence of complications - wound infections, post-operative adhesions, incisional hernias, infertility.
- Improved cosmetic result.
- Allows thorough peritoneal toilet in case of appendicular perforation.
- Laparoscopy is particularly useful in obese and overweight patients. 
At the end of procedure the base of the appendix is inspected for homeostasis. The appendix is pulled into the right upper trocar. Both the appendix and trocar are removed in such a fashion that the appendix should
not touch the abdominal wall. Trocar is replaced; abdomen washed with saline and a drain is placed in right lower quadrant [Figure 5]. ,,
| ¤ Aims|| |
The aim of this study was to compare the effectiveness of laparoscopic and conventional "open" appendicectomy in the treatment of acute appendicitis. The following parameters were evaluated for both laparoscopic and open procedures.
- Post-operative pain.
- Amount of analgesic used (post-operative analgesic requirement).
- Hospital stay.
- Time to full recovery.
| ¤ Objectives|| |
To achieve the above aims, project was conducted at tertiary teaching institute, Mumbai over a period of 2 years in patients with clinical diagnosis of appendicitis.
| ¤ Materials and Methods|| |
60 patients presenting with clinical diagnosis of appendicitis. In order to compare the two techniques, patients undergoing LA were compared to patients undergoing OA over a period of 2 months. Those patients were excluded who had perforated appendicitis.
Study to be carried out over a period of 2 months includes patient diagnosed with appendicitis and admitted to surgery ward at Sir J. J. Group of Hospitals, Mumbai, India and Grant Medical College, Mumbai, India and willing to be enrolled in the study after obtaining the valid written informed consent.
Factors and variables recorded include:
Demographic data, clinical features, investigations, technique, post-operative pain, post-operative use of analgesia, complications, scar size, return of bowel movements, starting of oral liquids, hospital stay, functional index, time to subjective full recovery and days of sick leave have been documented.
And outcome has been recorded in a predesigned case record form.
Return to normal activity and work was determined by questioning during post- operative clinic.
Following the calculation of the sample size, this study was conducted in which 60 patients were equally distributed in equally in two treatment groups - OA and LA group.
All observations were analyzed statistically.
Multiple linear and logistic regression analyses were used to assess the endpoints.
All values are expressed as the mean value. The significance of differences between the groups was tested using Students t test and standard error of difference between two means was calculated (P < 0.05) was considered significance.
The observation and inference are drawn from only those cases that were evaluated, investigated, and followed-up.
- Patients with acute pain in right iliac fossa.
- Patients proven to have acute appendicitis on clinical examination followed by USG.
- Patients proven to have recurrent appendicitis in BaMFT.
- Age more than 12 years.
- Patient willing to be enrolled in study and have signed the consent form.
- Patient with no other systemic illness.
- Patients medically unfit for pneumoperitoneum.
- Previous abdominal surgery.
- Age less than 12 years.
- Patient not willing to be enrolled in study.
- Pregnant females.
- Patient with systemic illness.
Sixty patients with similar characteristics of appendicitis were recruited to either open (50%) or laparoscopic (50%) appendicectomy.
Present study was performed with the help of the following proforma
For all the patients following parameters were evaluated
1. Post-operative pain [Figure 6]
Post-operative pain is evaluated in terms of post-operative analgesic requirement. Post-operative pain at rest was estimated after 24 h using a visual analogue scale (VAS.) graded from 0.0 to 10.0. VAS measurements were made before administration of the analgesic. VAS was measured weekly for 4 weeks after the discharge.
2. Analgesics used
Analgesics were used as per patients demand and we used diclofenac or tramadol most commonly. Early ambulation was encouraged in both the groups.
3. Functional index
Was measured at 7 th day post-operatively by a functional index test comprising of three parts: (a) climbing stairs, (b) mounting a bed, (c) squatting. Each test was graded from 1 to 3 on basis of difficulty.
4. Hospital stay
Measured in days of admission.
5. Sick leave
Application of leave/absence from duty.
6. Return of bowel peristalsis and starting of oral liquids
From time of surgery to time of passing of flatus a presence of bowel sounds and reintroduction of liquid diet.
7. Subjective full recovery (return of normal activities)
Defined as return of usual activity of domestic and social life of the patients.
8. Rate of wound infection
Wound related complications, infection, abscess formation, seroma, cellulites etc.
9. Cosmetic benefit
Defined in terms of scar size (cm) and external appearance.
In the present randomized clinical trial study conducted, 60 patients were studied and their hospital and follow-up status was meticulously recorded to bring into light the following data. The distribution into the age group shows that the procedure can be applied to any patient. Maximum numbers of patients were in younger age groups and male to female ratio shows that females outnumbered males.
In the present study, the evaluated results are the following:
The maximum number of cases was observed in the age group of 25-36 years with a female (32) to male (28) ratio of 1.14:1. The average age of patients undergoing LA was 25.5 years while it was 25.63 years for those undergoing OA [Table 1].
Post-operative pain. ( P < 0.05 upto 7 days) [Table 2], [Figure 3] It has been shown that those patients who underwent successful laparoscopic appendectomy have a better post-operative recovery. The reduced trauma to the abdominal wall is a very significant factor in post-surgical discomfort. The better mobility of the abdominal musculature and the earlier ambulation, reduce the risk of the early post-operative complications of pneumonia and embolism. Patients had less post-operative pain with LA than OA during 1 st week post-operatively. Patients subjected to OA had more post-operative pain at 28 days after operation. This was measured by VAS. 24 h after surgery pain scores were 3.73 in LA and 4.26 in OA. After 3 days average VAS scores were 1.76 for LA and 1.96 for OA. After 1 week, in LA group VAS was 1.07 and 1.23 in OA group. Thereafter it was not significant. Patients undergoing OA had low but persistent post-operative pain 4 weeks post-operatively but this may well be of no clinical significance given the values are low.
Analgesic requirement for post-operative pain [Table 3] relief in LA was about 4 inj. doses compared to 5.9 inj. doses in OA group ( P < 0.05).
Functional index [Table 2] measured at 1 week was 1.16 in LA and 1.23 in OA which was quite insignificant.
Return of bowel peristalsis ( P < 0.05) [Table 4] in LA group was 0.71 days while 1.7 days in OA group.
Staring of oral liquids ( P < 0.05) [Table 4] was earlier in LA group than in the OA group. Oral fluids were started in 0.71 days in LA and in 1.7 days in OA patients.
Wound related complications ( P < 0.001) [Table 4], were seen more in the OA group. Wound infection regarding skin was almost negligible in LA, as the appendix was pulled into the trocar before removing. This maneuver minimizes the chances of wound infection to the skin. The risk of wound infection is less in laparoscopic appendectomy compared to the open procedure. Incidence of 6.67% in the LA group as compared to 16.67% in OA group. Complications commonly seen were wound gaping, seroma, cellulites and fat necrosis.
Scar size ( P < 0.001) [Table 4], [Figure 7]a and b was more in patients who underwent OA as compared to LA. Regarding cosmetic benefit, most patients in the LA group were highly satisfied by their scar size (almost hidden) as compared to the OA group.
Hospital stay ( P < 0.05) [Table 5] was 2.23 days in LA group while it was 3.4 in the OA group. Thus increase in length of hospital stay in OA was reduced significantly in LA.
Time to full recovery ( P < 0.05) [Table 5] was 6.53 days in LA group while 8.7 days in OA. Thereby recovery in LA was earlier than OA group.
Sick leave (P < 0.05) [Table 5] taken by patients in LA group was 6.54 days and 8.23 days for patients in OA group.
Wound related complications
Tabulation of Observations and Results
LA has gained lot of attention around the world. However, the role of laparoscopy for appendicectomy, one of the commonest indications, remains controversial. Several controlled trials have been conducted, some are in favour of laparoscopy, others not. 
The goal of this project was to ascertain that if the LA is superior to conventional, and if so what are the benefits and how it could it be instituted more widely. There is also diversity in the quality of the randomized controlled trials. The main variable in these trials are following parameters:
- Post-operative pain
- Amount of narcotic/analgesic used (post- operatively).
- Hospital stay (days).
- Time to full recovery (days).
It is proved that laparoscopic procedures cause less post-operative pain than their conventional counterparts. Scores were significantly less in patients undergoing LA as compared to patients undergoing OA. Though different studies have not demonstrated such effect on post-operative pain, or the measure of pain was on the basis of the requirement of analgesics, a general opinion of less post-operative pain in LA as compared to OA was noted. ,
Another interesting observation has been the patient's perception of pain after appendectomy. Those who underwent laparoscopic appendectomy were more vocal of pain although it was of a lower intensity. However, after 48 h they had a better sense of wellbeing. This could have arisen from the expectation that laparoscopic procedures are painless or a lower level of endorphins released or the peritoneal injury from the pneumoperitoneum. It is likely that laparoscopic technique causes less pain due to multiple (usually three) but ultimately smaller skin lesion.
Analgesic administered as per demand of the patient showed that requirement of post-operative analgesia was significantly less in LA group (mean 4 inj. doses) compared to the OA group (mean 5.9 inj. doses).
The reduced trauma to the abdominal wall is a very significant factor in post-surgical discomfort. The better mobility of the abdominal musculature and the earlier ambulation, reduce the requirement of analgesics and the risk of the early post-operative complications of pneumonia and embolism; probably due to smaller wound and lesser retraction and handling of tissues.
LA has significant advantages over open appendectomy with respect to length of hospital stay, rate of routine discharge, and post-operative in-hospital morbidity. In the present study hospital stay was less for LA group (2.23 days) than OA (3.4 days) and this result is well matched when compared to other series.
Longer hospital stay in OA is because of late return of bowel activities and delay in starting of oral liquids. Also greater chances of wound related complications in OA may prolong the hospital stay. Thus hospital stay has decreased significantly in patients who underwent LA than open surgery.
Time to full recovery (days)
In the present study, full recovery on the basis of return to normal activity was seen earlier in LA group (6.53 days) as compared to OA group (8.7 days).
| ¤ Summary|| |
The present study of randomized clinical trial of LA versus OA is summarized below:
Future prospects of laparoscopic appendectomy
- The clinical outcome in LA does not differ from that of patients subjected to OA.
- LA is associated with less post-operative pain and reduced analgesic requirement as compared to OA group.
- LA is associated with faster recovery and early restart of oral intake than OA.
- Significantly low wound related complications and infections are reported in LA than OA.
- LA patients showed better post-operative comfort, convalescence and less morbidity when compared to OA.
- There is an early return to normal activities and work in patients with LA in contrast to OA.
- Wounds of LA had better cosmetic benefit than OA wounds.
- LA is associated with a shorter hospital stay and sick leave than OA group.
- LA has been shown to be useful in overweight and obese patients.
In the future, remote handling technology will overcome some of the manipulative restriction of current instruments. There is no doubt that 20 years from now some surgeons will be operating exclusively via a computer interface controlling a master-slave manipulator. But the future of any new technology depends upon applications and training. 
Appendicectomy has been the treatment of choice for acute appendicitis. Though OA is considered as the gold standard, LA has gained lot of attention around the world. 
However, the role of laparoscopy for appendicectomy, one of the commonest indications, remains controversial. Several controlled trials have been conducted, some are in favour of laparoscopy, others not.
Laparoscopic appendectomy is equally safe, and can provide less post-operative morbidity in experienced hands, as open appendectomy. Most cases of appendicitis can be treated laparoscopically. Laparoscopic appendectomy is a useful method for reducing hospital stay, complications and return to normal activity. Since quality of life of the patients was an important aim of this study, monitoring the postoperative pain, postoperative requirement of analgesics showed laparoscopic procedures to have more advantage and give superior results.
With better training in minimal access surgery now available, the time has arrived for it to take its place in the surgeon's repertoire.
Laparoscopic procedures hold promise by decreasing the loss of earning days by an early return of normal activity and shorter hospital stay. Hence it is beneficial in a developing country like ours where majority of the patients are daily wage workers.
Hence LA holds a promising prospect and may replace OA in the near future as the method of choice for effective and qualitative clinical management of appendicitis in emergency and in elective set up. 
| ¤ Acknowledgments|| |
I am greatly indebted to my guide and teacher Dr. A. H. Bhandarwar, Associate Professor, Sir J.J. Group of Hospitals and Grant Medical College, Mumbai. Not only for allowing me to do this project under him, but also for his invaluable guidance and encouragement throughout my study. I am Thankful to the Department of Surgery, Sir J.J. Group of Hospitals and Grant Medical College, for permitting me to conduct this study in this institution.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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