¹Department of General Surgery, Faculty of Medicine, Al Baha University, Saudi Arabia

²Department of General Surgery, Benha Faculty of Medicine, Benha University, Egypt

³Student, Faculty of Medicine, Benha University, Egypt

⁴Student, Faculty of Dentist, Al Ahram Canadian University, Egypt

*Corresponding author: Taher H Elwan, Department of General Surgery, Faculty of Medicine, Al Baha University, Saudi Arabia, and Department of General Surgery, Benha Faculty of Medicine, Benha University, Egypt, Phone: 00966507227851, E-mail: [email protected].

Received Date : February 27, 2024

Publication Date: April 12, 2024

Citation: Elwan TH, et al. (2024). Navigating Nutritional Wellness: A Comprehensive Review of Post-Sleeve Gastrectomy Nutrition. Nutraceutical Res. 3(1):5.

Copyright: Elwan TH, et al. © (2024).

ABSTRACT

Sleeve gastrectomy has emerged as a leading surgical intervention for obesity, offering profound metabolic and weight-loss benefits. However, the success of this procedure hinges upon comprehensive postoperative care, particularly in terms of nutrition. This review provides a thorough examination of the nutritional considerations essential for optimal outcomes. Central to this voyage is a nuanced understanding of postoperative nutrition, essential for maximizing outcomes and ensuring long-term success following sleeve gastrectomy.

Keywords: Nutrition, Sleeve Gastrectomy, Obesity, Food.

INTRODUCTION

Sleeve gastrectomy, also known as vertical sleeve gastrectomy (VSG), is a surgical procedure designed to assist individuals in achieving significant weight loss and improving obesity-related health conditions. Sleeve gastrectomy gained ever-increasing popularity among laparoscopic surgeons [1]. During sleeve gastrectomy, approximately 75-80% of the stomach is removed, leaving behind a smaller, sleeve-shaped stomach pouch. This reshaped stomach restricts the amount of food that can be consumed at one time, leading to reduced calorie intake and promoting weight loss.

The procedure is typically performed laparoscopically, involving small incisions and the use of a camera and specialized instruments. Sleeve gastrectomy is considered a restrictive procedure, as it limits the volume of food that can be eaten, but it does not involve rerouting the digestive tract or implanting foreign devices, other mechanisms of energy intake reduction, such as intestinal distension and satiety signals through gut hormones to be investigated [2].

Beyond weight loss, sleeve gastrectomy has been shown to improve or resolve obesity-related health conditions such as type 2 diabetes [3], hypertension, renal [4], sleep apnea, and high cholesterol. Additionally, the surgery may lead to improvements in overall quality of life and psychological well-being [5].

Like any surgical procedure, sleeve gastrectomy carries risks and potential complications, including bleeding, infection, leakage from the staple line, and nutritional deficiencies [5]. Therefore, candidates for sleeve gastrectomy undergo thorough preoperative evaluation, including medical, nutritional, and psychological assessments, to determine their suitability for the procedure and minimize risks.

Postoperatively, patients must adhere to dietary guidelines, engage in regular physical activity, and attend follow-up appointments with healthcare providers to monitor progress, address any complications, and receive ongoing support. With proper adherence to postoperative care and lifestyle modifications, sleeve gastrectomy can offer individuals a powerful tool for achieving significant and sustainable weight loss, improving overall health, and enhancing quality of life [6].

THE ANATOMICAL ALTERATIONS POST-SLEEVE GASTRECTOMY

Post-sleeve gastrectomy, significant anatomical alterations occur within the gastrointestinal tract, fundamentally reshaping its structure and function. This surgical procedure involves the removal of approximately 75-80% of the stomach, leaving behind a tubular or sleeve-shaped stomach pouch. The anatomical changes post-sleeve gastrectomy lead to several notable alterations:

Reduction in Stomach Size: The most obvious change is the reduction in stomach size, which restricts the amount of food that can be consumed at one time. This smaller stomach pouch, with a capacity of around 50-150 milliliters, promotes early satiety and limits food intake.

Altered Gastric Hormone Secretion: The removal of a portion of the stomach affects the secretion of various hormones involved in appetite regulation and glucose metabolism. For example, levels of ghrelin, a hormone that stimulates hunger, are typically reduced after sleeve gastrectomy, contributing to decreased appetite and improved weight loss [7].

Changes in Gastric Emptying: The surgery can alter the rate at which food empties from the stomach into the small intestine. While early gastric emptying may occur initially due to surgical manipulation, there can be subsequent delays in gastric emptying as the stomach adapts to its new structure [8].

Impact on Nutrient Absorption: While sleeve gastrectomy primarily restricts food intake, it can also affect nutrient absorption to some extent [9]. However, unlike procedures such as gastric bypass, which involve rerouting the digestive tract, sleeve gastrectomy typically maintains the normal flow of food through the gastrointestinal tract, minimizing the risk of malabsorption.

Potential for Reflux: Some patients may experience gastroesophageal reflux disease (GERD) symptoms post-surgery, as the reduction in stomach size can lead to increased pressure on the lower esophageal sphincter, potentially allowing stomach acid to reflux into the esophagus [10].

Overall, these anatomical alterations play a crucial role in the success of sleeve gastrectomy by promoting weight loss, reducing hunger, and improving metabolic health. However, it's important for patients to adhere to postoperative dietary and lifestyle recommendations to optimize outcomes and minimize potential complications. Regular follow-up with healthcare providers is essential to monitor progress, address any issues, and ensure long-term success after sleeve gastrectomy.

HOW THE RESHAPED STOMACH IMPACTS DIGESTION, ABSORPTION, AND NUTRIENT ASSIMILATION

The reshaped stomach resulting from sleeve gastrectomy significantly impacts digestion, absorption, and nutrient assimilation in several ways:

Reduced Stomach Capacity: The most immediate impact of sleeve gastrectomy is the reduction in stomach size, limiting the volume of food that can be consumed during a meal. This reduction in stomach capacity leads to earlier satiety, prompting individuals to consume smaller portion sizes. As a result, the overall caloric intake is reduced, contributing to weight loss.

Altered Gastric Hormone Secretion: Sleeve gastrectomy can affect the secretion of various hormones involved in appetite regulation and glucose metabolism. For example, the surgery typically leads to a decrease in ghrelin levels, the hormone responsible for stimulating hunger. Lower ghrelin levels contribute to decreased appetite and improved weight loss outcomes [7].

Changes in Gastric Emptying: The reshaped stomach may also influence the rate at which food empties from the stomach into the small intestine. While some patients may experience rapid gastric emptying initially, the stomach's adaptation to its new structure can lead to delayed gastric emptying over time. This altered gastric emptying rate affects the rate at which nutrients are delivered to the small intestine for absorption.

Impact on Nutrient Absorption: Although sleeve gastrectomy primarily restricts food intake rather than altering the digestive tracts anatomy, some changes in nutrient absorption may still occur. The reduced stomach size may affect the mixing and breakdown of food, potentially influencing the absorption of certain nutrients. However, significant malabsorption is less common after sleeve gastrectomy compared to procedures like gastric bypass, which involve rerouting the digestive tract.

Micronutrient Deficiencies: Despite efforts to maintain a balanced diet and adhere to nutritional guidelines, individuals who have undergone sleeve gastrectomy are at risk of developing micronutrient deficiencies. Reduced stomach size and changes in gastric acidity can impair the absorption of vitamins and minerals such as vitamin B12, iron, calcium, and vitamin D [11]. Therefore, routine monitoring of nutrient levels and appropriate supplementation are essential to prevent deficiencies and ensure optimal health outcomes. Overall, the reshaped stomach following sleeve gastrectomy alters the dynamics of digestion, absorption, and nutrient assimilation, contributing to weight loss and metabolic improvements. However, careful attention to dietary habits, nutrient intake, and supplementation is necessary to mitigate potential deficiencies and support long-term nutritional wellness. Regular follow-up with healthcare providers, including nutritionists and bariatric specialists, is crucial to monitor nutritional status and provide tailored guidance for individuals post-sleeve gastrectomy.

GUT MICROBIOME AND SLEEVE GASTRECTOMY

The gut microbiome, consisting of trillions of microorganisms residing in the gastrointestinal tract, plays a crucial role in human health, metabolism, and immune function [12]. Emerging research suggests that sleeve gastrectomy, a bariatric surgery that involves reshaping the stomach, can have significant effects on the composition and function of the gut microbiome [7]. Here's a closer look at the relationship between sleeve gastrectomy and the gut microbiome:

Alterations in Microbial Composition: Studies have shown that sleeve gastrectomy can lead to changes in the diversity and composition of the gut microbiome [13]. Following surgery, there may be a decrease in the abundance of certain bacterial taxa associated with obesity and metabolic dysfunction, such as Firmicutes, and an increase in facultative anaerobic bacteria, such as Bacteroidetes. This change might be explained by functional changes induced by the SG procedure [14].

Effects on Microbial Metabolism: Sleeve gastrectomy can also influence microbial metabolism, including changes in the production of short-chain fatty acids (SCFAs) and bile acids. SCFAs, produced through the fermentation of dietary fiber by gut bacteria, play a role in energy metabolism, satiety, and inflammation. Alterations in SCFA production post-surgery may contribute to metabolic improvements and weight loss [15].

Impact on Host Metabolism: Changes in the gut microbiome following sleeve gastrectomy have been linked to improvements in host metabolism, including enhanced glucose homeostasis, insulin sensitivity [16], and lipid metabolism. Improvements in immune homeostasis within the white adipose tissue are also observed. These metabolic changes may be mediated, in part, by interactions between gut bacteria and host tissues, hormones, and immune cells.

Potential Mechanisms: The exact mechanisms underlying the relationship between sleeve gastrectomy and the gut microbiome are still being elucidated. Factors such as altered nutrient delivery, changes in gastric acidity, and modifications in gut hormone signaling may contribute to microbial alterations post-surgery [17]. Additionally, shifts in dietary habits and nutrient absorption patterns can influence the gut microbial ecosystem.

Clinical Implications: Understanding the impact of sleeve gastrectomy on the gut microbiome has important clinical implications. Manipulating the gut microbiome through dietary interventions, prebiotics, probiotics, or fecal microbiota transplantation (FMT) may offer therapeutic potential for improving metabolic outcomes and enhancing the success of bariatric surgery [18].

In conclusion, sleeve gastrectomy can induce significant changes in the composition and function of the gut microbiome, which may contribute to metabolic improvements and weight loss observed post-surgery. Further research is needed to elucidate the mechanisms underlying these microbial alterations and explore potential therapeutic strategies targeting the gut microbiome to optimize outcomes in individuals undergoing sleeve gastrectomy.

Nutritional Requirements and Deficiencies: After undergoing sleeve gastrectomy, patients must adhere to specific nutritional requirements to support healing, promote weight loss, and prevent deficiencies. Additionally, they are at risk of certain nutrient deficiencies due to the altered gastrointestinal anatomy and reduced food intake. Addressing these nutritional requirements and deficiencies is crucial for ensuring optimal health outcomes post-surgery:

Protein Intake: Adequate protein intake is essential for preserving lean body mass, promoting wound healing, and supporting metabolic function. Patients should aim to consume lean sources of protein such as poultry, fish, lean meats, eggs, dairy products, and plant-based protein sources. Protein supplements may be recommended to meet daily protein goals, especially during the initial stages of recovery [19].

Vitamin and Mineral Supplementation: Due to reduced stomach size and potential alterations in nutrient absorption, patients are at risk of developing deficiencies in vitamins and minerals. Common deficiencies after sleeve gastrectomy include vitamin B12, iron, calcium, vitamin D, and folate. Therefore, routine supplementation with these nutrients is typically recommended to prevent deficiencies and support overall health [20].

Hydration: Adequate hydration is essential for maintaining overall health and supporting proper digestion and metabolism. Patients should aim to drink plenty of fluids throughout the day [21], (It is important that you maintain adequate hydration throughout each stage of your diet progression. Your fluid intake is IMPORTANT. Dehydration can leave you feeling weak and nauseous. You should attempt to consume 48 – 60 oz. of fluids) [22] daily focusing on water as the primary beverage. However, patients should avoid consuming liquids with meals to prevent overstretching the stomach pouch and promote satiety.

Fiber Intake: While fiber is important for digestive health and regular bowel movements, patients may need to be cautious about consuming high-fiber foods immediately after surgery, as they can be difficult to tolerate. Gradually increasing fiber intake over time [23], incorporating sources such as fruits, vegetables, whole grains, and legumes, can help prevent constipation and promote gastrointestinal health.

Regular Monitoring and Follow-Up: Routine monitoring of nutritional status through blood tests and regular follow-up appointments with healthcare providers, including nutritionists and bariatric specialists, are essential for identifying and addressing any deficiencies or dietary challenges [19]. Adjustments to supplementation regimens or dietary recommendations may be made based on individual needs and response to treatment.In summary, addressing nutritional requirements and preventing deficiencies are critical components of post-sleeve gastrectomy care. Patients should receive ongoing support and guidance from a multidisciplinary healthcare team to optimize their nutritional status, promote successful weight loss, and achieve long-term health and well-being.

Behavioral Strategies for Success: Behavioral strategies play a crucial role in achieving success and maintaining long-term outcomes after sleeve gastrectomy [24]. These strategies focus on fostering healthy eating habits, promoting mindful behavior around food, and supporting overall well-being. Here are several key behavioral strategies for success: Portion Control: Emphasize the importance of portion control, encouraging patients to eat small, frequent meals throughout the day. Using smaller plates, utensils, and portioning tools can help patients gauge appropriate serving sizes and prevent overeating [25]. Mindful Eating: Promote mindful eating practices, which involve paying attention to hunger and fullness cues, savoring each bite, and eating slowly [26]. Some recent studies say that A Higher Meal Frequency May be Associated with Diminished Weight Loss after Bariatric Surgery [27]. Encourage patients to minimize distractions during meals, such as television or electronic devices, and focus on the sensory experience of eating. Chewing Thoroughly: Encourage patients to chew their food thoroughly before swallowing, as this promotes digestion, enhances nutrient absorption, and prevents discomfort or complications such as dumping syndrome [28].

Meal Planning and Preparation: Support patients in planning and preparing balanced meals that align with their nutritional needs and dietary preferences. Provide guidance on meal prep techniques, recipe modification, and grocery shopping strategies to facilitate healthy eating habits.

Food Journaling: Encourage patients to keep a food journal to track their eating habits, identify triggers for overeating or unhealthy food choices, and monitor their progress toward achieving nutritional goals. Reviewing food journals with a healthcare provider or nutritionist can provide valuable insights and support accountability [29].

Stress Management: Recognize the role of stress in influencing eating behaviors and weight management. Encourage patients to develop stress management techniques such as mindfulness meditation, deep breathing exercises, physical activity, or hobbies to cope with stress in healthy ways without turning to food for comfort [30].

Behavioral Modification Techniques: Explore cognitive-behavioral strategies to address emotional eating, food cravings, and maladaptive eating behaviors. Techniques such as cognitive restructuring, problem-solving skills, and stress management training can help patients develop healthier coping mechanisms and responses to food-related triggers [31].

Support Groups and Counseling: Encourage participation in support groups or individual counseling sessions to provide emotional support, share experiences, and learn coping strategies from peers who have undergone similar experiences. These groups can also provide accountability and motivation for making sustainable lifestyle changes [32]. By implementing these behavioral strategies, patients can cultivate a positive relationship with food, develop sustainable eating habits, and navigate the challenges of post-sleeve gastrectomy life successfully. Ongoing support from healthcare providers, along with a multidisciplinary approach that addresses both nutritional and behavioral aspects, is essential for achieving long-term success and maintaining optimal health outcomes.

Macronutrient Balance and Metabolic Health: Achieving and maintaining a balanced macronutrient intake is critical for supporting metabolic health and optimizing outcomes after sleeve gastrectomy. Here's how macronutrient balance contributes to metabolic health post-surgery:

Protein: Protein plays a crucial role in preserving lean body mass, supporting muscle strength, and promoting satiety. After sleeve gastrectomy, which reduces stomach capacity and may limit food intake, prioritizing protein-rich foods is essential to meet daily protein requirements [33]. Adequate protein intake also supports metabolic function and contributes to weight loss by increasing energy expenditure through the thermic effect of food protein-rich foods is an effective and safe tool for weight reduction that can prevent obesity and obesity-related diseases [34].

Carbohydrates: While carbohydrates provide energy, not all carbohydrates are created equal. Emphasizing complex carbohydrates such as whole grains, fruits, vegetables, and legumes can help stabilize blood sugar levels, promote sustained energy, and provide essential nutrients and fiber. Patients should aim to include high-fiber carbohydrates in their diet to support digestive health and prevent fluctuations in blood glucose levels [35].

Fats: Healthy fats are essential for optimal health and play a role in hormone production, cell membrane integrity, and nutrient absorption. While fat intake should be moderated to avoid excess calorie consumption, incorporating sources of unsaturated fats such as avocados, nuts, seeds, and fatty fish can provide essential fatty acids and support cardiovascular health. Limiting saturated and trans fats is important to reduce the risk of cardiovascular complications post-surgery [36].

Caloric Balance: Achieving a balance between caloric intake and energy expenditure is crucial for weight management and metabolic health after sleeve gastrectomy. While the surgery restricts food intake, patients should still aim to consume an appropriate number of calories to meet their energy needs and support weight loss goals. Working with a healthcare provider or nutritionist to establish personalized calorie goals based on individual factors such as age, gender, activity level, and metabolic rate can help optimize outcomes [37].

Metabolic Adaptations: After sleeve gastrectomy, metabolic adaptations occur as the body adjusts to changes in food intake and body composition. These adaptations may include improvements in insulin sensitivity [35], metabolic rate, and hormonal balance. By prioritizing a balanced macronutrient intake and making lifestyle modifications such as regular physical activity, patients can further support metabolic health and enhance weight loss outcomes. Overall, achieving a balanced macronutrient intake post-sleeve gastrectomy is essential for supporting metabolic health, preserving lean body mass, and promoting sustainable weight loss. Emphasizing protein-rich foods, complex carbohydrates, and healthy fats while monitoring caloric intake can help patients achieve optimal nutritional status and long-term success after surgery. Regular follow-up with healthcare providers and nutritionists is important to assess dietary adequacy, monitor metabolic parameters, and make adjustments to dietary recommendations as needed.

Micronutrient Supplementation: Micronutrient supplementation is a crucial aspect of post-sleeve gastrectomy care to prevent deficiencies and support overall health. Due to the reduced stomach size and alterations in nutrient absorption, patients are at increased risk of developing deficiencies in essential vitamins and minerals. Here's an overview of micronutrient supplementation recommendations after sleeve gastrectomy:

Vitamin B12: Sleeve gastrectomy can impair the body's ability to absorb vitamin B12 from food, as the production of intrinsic factor, necessary for B12 absorption, may be reduced. Therefore, regular vitamin B12 supplementation is essential to prevent deficiency and support neurological function. Sublingual or intramuscular vitamin B12 supplements are often recommended, as they bypass the need for stomach acid and intrinsic factor for absorption [11].

Iron: Iron deficiency is common after sleeve gastrectomy due to decreased intake and impaired absorption [38]. Iron supplementation may be necessary to prevent or treat anemia. However, certain forms of iron supplements may cause gastrointestinal side effects. Therefore, healthcare providers may recommend iron supplements in the form of ferrous sulfate, ferrous gluconate, or chelated iron, along with strategies to enhance absorption, such as taking supplements with vitamin C-rich foods [39].

Calcium and Vitamin D: Reduced stomach acid production and alterations in gastrointestinal anatomy can impair calcium absorption, increasing the risk of bone health issues such as osteoporosis [40]. Additionally, vitamin D deficiency is prevalent in patients undergoing bariatric surgery, as vitamin D absorption occurs primarily in the small intestine. Therefore, calcium and vitamin D supplementation are often recommended to maintain bone health and prevent fractures.

Multivitamins and Mineral Supplements: In addition to targeted supplementation of specific vitamins and minerals, many patients benefit from taking a comprehensive multivitamin and mineral supplement to address potential deficiencies and support overall nutritional status. These supplements typically contain a combination of vitamins and minerals, including vitamin A, vitamin E, zinc, magnesium, and others, tailored to the needs of post-sleeve gastrectomy patients. Routine Monitoring: Regular monitoring of micronutrient levels through blood tests is essential to assess nutritional status and identify deficiencies early. Healthcare providers may adjust supplementation regimens based on individual needs and response to treatment. Patients should adhere to prescribed supplementation regimens and notify their healthcare provider if they experience symptoms suggestive of nutrient deficiencies, such as fatigue, weakness, or changes in mood or cognition [41]. In conclusion, micronutrient supplementation plays a crucial role in mitigating the risk of deficiencies and supporting overall health and well-being after sleeve gastrectomy. A tailored supplementation regimen, along with routine monitoring and follow-up with healthcare providers, is essential to optimize nutritional status and promote long-term success after surgery.

Individualized Dietary Plans: Individualized dietary plans are essential for patients post-sleeve gastrectomy to ensure they meet their nutritional needs, support recovery, and achieve long-term weight loss success. These plans are tailored to each patient's unique circumstances, including their medical history, lifestyle, preferences, and specific requirements following surgery. Here's how individualized dietary plans can be developed:

Assessment of Nutritional Needs: Healthcare providers, including nutritionists and dietitians, conduct a comprehensive assessment of the patient's nutritional needs. This assessment takes into account factors such as age, gender, weight, height, activity level, metabolic rate, medical history, and any pre-existing nutrient deficiencies. Caloric and Macronutrient Goals: Based on the patient's individual characteristics and weight loss goals, healthcare providers establish personalized caloric and macronutrient targets. These targets ensure that patients consume an appropriate amount of calories, protein, carbohydrates, and fats to support metabolic health, preserve lean body mass, and promote weight loss [37].

Meal Planning and Food Choices: Nutritionists work with patients to develop customized meal plans that align with their dietary preferences, cultural background, and lifestyle. These meal plans emphasize nutrient-dense foods, including lean protein sources, fruits, vegetables, whole grains, and healthy fats. Portion sizes and meal frequency are tailored to accommodate the patient's reduced stomach capacity and promote satiety [42]. Balanced Nutrition: Individualized dietary plans focus on achieving a balanced intake of essential nutrients, including vitamins, minerals, and fiber. Special attention is given to ensuring an adequate intake of micronutrients that may be at risk of deficiency post-surgery, such as vitamin B12, iron, calcium, and vitamin D. Supplement recommendations may be integrated into the dietary plan to address specific nutrient needs.

By providing patients with individualized dietary plans tailored to their unique needs and circumstances, healthcare providers can empower them to make informed choices, adopt healthy eating habits, and achieve sustainable weight loss and improved metabolic health after sleeve gastrectomy. Ongoing support and guidance from a multidisciplinary healthcare team are essential to optimize outcomes and promote long-term success.

The Role of Multidisciplinary Support: The role of multidisciplinary support is pivotal in providing comprehensive care and optimizing outcomes for patients post-sleeve gastrectomy. A multidisciplinary approach involves collaboration among various healthcare professionals, including surgeons, dietitians, psychologists, nurses, and exercise physiologists, to address the diverse needs of patients undergoing bariatric surgery. Here's how each member of the multidisciplinary team contributes to supporting patients after sleeve gastrectomy:Surgeons: Bariatric surgeons perform the sleeve gastrectomy procedure and play a key role in preoperative evaluation, surgical decision-making, and postoperative care. They monitor patients for surgical complications, provide guidance on dietary progression, and address any concerns related to the surgical procedure.

Dietitians/Nutritionists: Registered dietitians or nutritionists specialize in developing individualized dietary plans and providing nutritional counseling for patients post-surgery. They educate patients about dietary guidelines, micronutrient supplementation, portion control, and meal planning. Dietitians monitor nutritional status, assess dietary adherence, and make adjustments to dietary recommendations as needed [43].

Psychologists/Psychiatrists: Mental health professionals play a crucial role in addressing the psychological and emotional aspects of weight loss surgery. They provide preoperative psychological evaluations to assess patients' readiness for surgery and identify potential risk factors. Postoperatively, psychologists offer counseling and support to help patients navigate the emotional challenges, body image concerns, and lifestyle changes associated with bariatric surgery [44].

By integrating the expertise of various healthcare professionals within a multidisciplinary team, patients receive comprehensive care that addresses their physical, nutritional, psychological, and social needs throughout the bariatric surgery process. This holistic approach promotes successful outcomes, enhances patient satisfaction, and supports long-term success in weight management and overall health after sleeve gastrectomy.

CONCLUSION

As patients traverse the terrain of post-sleeve gastrectomy nutrition, armed with knowledge, guidance, and unwavering determination, they embark on a path toward renewed vitality, enhanced well-being, and a brighter, healthier future. By embracing the principles of mindful eating, balanced nutrition, and holistic support, individuals can realize the full potential of their surgical transformation and embark on a lifelong voyage of nutritional wellness.

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