Early Leakage Research Articles

Drain fluid amylase as a biomarker for the detection of anastomotic leakage after rectal resection without a diverting ileostomy.

Anastomotic leak (AL) is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary diverting ileostomy (TDI) does not prevent an AL and presents inherent complications of its own. Numerous drain fluid biomarkers (BM) have been studied in colorectal surgery and extravasated intraluminal substances (EILS) such as amylase have shown promise. The aim of this study was to assess drain fluid amylase (DFA) as a BM of AL after minimally invasive rectal resection without a TDI. A single centre prospective cohort study performed from 2018 to 2021. The primary outcome was DFA measured daily whilst the drain was in situ. Rectal tube amylase was also measured for the first two post-operative days to quantitate the intra-luminal levels of the enzyme. DFA was compared between patients who experienced AL and those who did not. Of the 62 patients studied, six (9.7%) experienced AL. There was a statistically significant difference in DFA between patients who experienced AL (Median:1373.5U/L; IQR: 306-7953) and patients who did not experience an AL (Median: 27.0U/L; IQR: 16-38); p< 0.0001. The measurement of drain fluid amylase is a highly sensitive BM of early clinical anastomotic leak in patients undergoing a rectal resection with an extraperitoneal anastomosis and when a TDI is not incorporated. This simple, inexpensive and non-invasive test should be considered in all patients as an adjunct to the clinical diagnosis and differentiation of AL from other postoperative complications.

Leakage Detection Based on CEEMDAN Analysis for Hydraulic Cylinder Using Acoustic Emission Technique

The early internal leakage fault characteristics in hydraulic cylinder are very weak and vulnerable to environmental noise, which makes the early internal leakage fault detection very difficult. In comparison with internal leakage detection by the pressure signal, internal leakage by Acoustic emission (AE) signal has higher sensitivity and accuracy. So this paper adapts the algorithms combining complete ensemble empirical mode decomposition with adaptive noise (CEEMDAN) and auto regressive (AR) spectrum. Comparing with the mean value of first intrinsic mode function (IMF1) instantaneous amplitude based on EEMD, The experimental results verify the proposed algorithms based on CEEMDAN distinguish different internal leakage levels obviously and has better performance.

LAPAROSCOPIC PERITONEAL DIALYSIS CATHETER PLACEMENT WITH RECTUS SHEATH TUNNELING: A ONE-PORT SIMPLIFIED TECHNIQUE.

ABSTRACT - BACKGROUND:The success of peritoneal dialysis depends on the proper placement and functional longevity of the dialysis catheter. Laparoscopic implantation of a catheter through a rectus sheath tunneling can minimize the risks of catheter failure.AIMS: This study aims to describe one-port simplified technique for laparoscopic placement of a peritoneal dialysis catheter with rectus sheath tunneling.METHODS: The simplified laparoscopic insertion of a Tenckhoff catheter with rectus sheath tunneling was performed in 16 patients with chronic renal failure.RESULTS: During the follow-up period, no major complications occurred. Three patients were excluded. One was referred to the renal transplant some weeks after implantation, and one died for other reasons during the follow-up. Another patient needed adhesiolysis due to previous surgery, so an additional port was necessary. The other 13 catheters worked properly, and no postoperative hemorrhage, early leaks, hernia, or catheter migration occurred. One patient had a tunnel infection 11 months after the implant. No peritonitis was observed during the follow-up.CONCLUSIONS: The technique is simple, reproducible, and safe, with good results in catheter function, few complications, and a high catheter survival rate. It does not require a special device or trocar and avoids excessive port sites.

Endoluminal vacuum therapy for rectal anastomosis is safe and does not increase risk of strictures in a swine model

Endoluminal vacuum therapy has been experimentally used in patients with esophageal, rectal, and Roux-en-Y bypass surgery. Yorkshire pigs are good animal models for studying the safety and efficacy of endoluminal vacuum therapy and prior studies have employed these devices in rectal anastomotic defects, as rescue therapy for early anastomotic leaks, as well as prophylactic therapy as a means of protecting high risk anastomosis. The objective of this study is to assess the effects of a prophylactic vacuum assist device on bowel tissue surrounding an intact anastomosis at 30 days post device removal. A total of seven pigs underwent a rectal resection with primary anastomosis: five experimental pigs with a prophylactic endoluminal vacuum device in place for 5 days post-surgery and two control pigs with no device. All animals were euthanized on the 35th post-operative day and subjected to a necropsy with a histopathological evaluation of the rectal anastomosis. No significant difference in inflammation or strictures was observed between the anastomosis of animals with the endoluminal vacuum devices and controls. We, therefore, conclude that endoluminal vacuum therapy is safe for prophylactic use in pigs undergoing low anterior resection and does not cause significant strictures. Anastomotic leak is a feared complication resulting in increased costs, length of stay, and emotional distress. Endoluminal negative pressure vacuum therapy is a new technology that has been used in experimental models in both animals and humans for prevention and treatment of anastomotic leak. In this series we demonstrate endoluminal vacuum therapy is safe in a porcine model and does not result in stricture or increased adhesion formation. We expect endoluminal vacuum therapy to become more widely used in the future in both prevention and treatment of anastomotic leaks.

Bleb Management Following Trabeculectomy and Glaucoma Drainage Device Implantation

While treatment options available to patients with glaucoma are expanding, trabeculectomy and glaucoma drainage device implantation (GDI) remain a mainstay in glaucoma surgical care. This article reviews key aspects of bleb management following trabeculectomy and GDI surgery. Basics of postoperative management of trabeculectomy and GDIs are reviewed, as well as how to manage complications such as early and late bleb leaks, fibrosis, bleb dysesthesia and the hypertensive phase. In general, careful surgical technique, close postoperative monitoring and appropriate intervention can help patients achieve safe outcomes and long-term control of intraocular pressure.

Advanced monitoring and simulation for underground gas storage risk management

It is crucial to ensure the safety and integrity of underground gas storage (UGS) infrastructure for energy reliability in California, and many other places around the world. To address the risk management need in UGS industry, we take advantage of recent advances in downhole fiber optic monitoring and coupled well-reservoir simulation to provide unprecedented understanding of gas flow in wells at UGS sites. We have combined advanced monitoring and simulation of UGS operations into a decision-support system called the Integrated Risk Management and Decision Support System (IRMDSS). The IRMDSS framework includes three components: (i) mechanistic models, (ii) continuous and frequent monitoring data, and (iii) a supervisory interface for performing analyses using the models and monitoring data. The goal of the IRMDSS is to equip UGS operators with real-time monitoring data and simulation tools that can alert them to potential failures, detect early leakage, and support mitigation decision-making to prevent otherwise larger failures. We demonstrate an application of the IRMDSS by analyzing the temperature and pressure response to a hypothetical leak. Through a review of distributed temperature sensing (DTS) data collected at an operating UGS facility we show that DTS can uniquely and precisely identify the depth of the gas-water-contact in the well annulus, and that DTS can provide an early warning signal of upward gas flow as would occur in a well blowout scenario. When combined with modeling analysis, a rough leak rate can be roughly estimated to understand the severity of the leakage conditions and to support the mitigation decision needed. • Mechanistic models simulate system responses to UGS facility operations. • Advanced monitoring technologies provide continuous update status for UGS facilities. • DTS data can provide real-time well leakage detection and identify leaky location. • Combination of models and advanced monitoring benefits UGS risk management.

The Association of Vitamin D3 With Early Anastomotic Leakage in Patients Undergoing Hemicolectomy Surgery.

Anastomotic leak (AL) is one of the most important postoperative complications after hemicolectomy with stapled anastomosis. This study aimed to evaluate the association of preoperative vitamin D3 with early anastomotic leakage after right colon cancer surgery with stapled anastomosis. In this prospective cohort study, 535 patients who underwent right colon cancer surgery (right hemicolectomy) with stapled anastomosis were enrolled. A subset of 315 patients was included in the study after meeting the inclusion criteria. Preoperative vitamin D level was measured and analyzed for association with early AL using univariable and multivariable logistic regression analyses. This study included 315 cases; among them, 18 (5.71%) patients developed early AL. Vitamin D3 was significantly higher among patients without early AL (P < .001). Low vitamin D3 status was reported among 111 patients (35.2%) and 204 (64.8%) of patients did not have low vitamin D3 status (sufficient level = 30-100ng/mL). Sufficient vitamin D3 levels before right colon cancer surgery with stapled anastomosis was associated inversely with early AL (crude OR = .89, 95% CI = .85-.94, P < .001 and adjusted OR = .89, 95% CI = .82-.98, P = .02). The vitamin D3 level has a protective association with early AL. As a result, low vitamin D3 status may be a risk factor for early AL development, suggesting that it can be one of the predictors of early AL occurrence.

Early leakage of peritoneal effluent to subcutaneous tissue after a sneeze

Norovirus is the common cause of gastroenteritis in humans. There is no report of liver dysfunction in children caused by norovirus infection. Baclofen has been used mainly to treat spasticity in children with cerebral palsy. Hepatotoxicity of baclofen has not been previously described in children. This report describes the case of acute liver dysfunction in the course of norovirus gastroenteritis in a child with cerebral palsy (CP) on baclofen. A 7-year 7month-old child who diagnosed spastic quadriplegic cerebral palsy showed mild fever and diarrhea. He started taking baclofen a week before the symptom started. His illness was diagnosed as norovirus gastroenteritis, but liver dysfunction accompanied this gastroenteritis (AST/ALT 589/401 (IU/L)). He recovered completely within 2 weeks without any damage left. When a child with cerebral palsy gets norovirus enteritis while taking baclofen, it would be necessary to close monitoring for liver failure.

Outcomes of surgical bleb revision at a tertiary Singapore eye hospital.

To describe the outcomes of surgical bleb revisions from a tertiary glaucoma service in Singapore. One hundred and thirty-one eyes of 129 patients who underwent surgical bleb revisions at the Singapore National Eye Centre between 2007 and 2014 were included in the study. The indications for bleb revision were: bleb-related infection (BRI), early and late bleb leak, early and late overfiltration, and bleb dysesthesia. Regression analysis was applied to elucidate risk factors. The mean age of the patients was 66years, 62.6% were male, and 88.5% were Chinese. The majority of the eyes had primary glaucoma (79.4%). The mean interval from the initial trabeculectomy or phaco-trabeculectomy to the bleb revision was 58.8months. The overall success rate was 69.5%. By Kaplan-Meier survival analysis, the overall cumulative success range fell from 78.6% to 49.1% over 10years. Eyes with early bleb leak had lower surgical success compared to eyes with late bleb leak, early overfiltration and late overfiltration (P = 0.026, log-rank test). The IOP improved significantly post-operatively for eyes with BRI, early bleb leak, late bleb leak, early overfiltration and overfiltration (P < 0.05). Vision improved significantly in eyes with early overfiltration, but deteriorated in eyes with BRI (P < 0.05). The overall success rate for surgical bleb revisions was good with complete resolution of the primary problem in the majority of cases. However, eyes with early bleb leak were less likely to have successful outcomes and should be monitored more closely post-operatively.

The effects of preoperative intestinal dysbacteriosis on postoperative recovery in colorectal cancer surgery: a prospective cohort study

BackgroundAccumulating evidence suggests a critical role of intestinal dysbacteriosis in surgical site infections and anastomotic leakage after abdominal surgery. However, a direct correlation between pre-existing dysbacteriosis and postoperative infectious complications has not yet been established clinically.MethodsA total of 353 consecutive patients who underwent colorectal cancer (CRC) surgery were enrolled. Gram-stained faecal smears were tested at admission and the first defecation after surgery. Intestinal dysbacteriosis was graded into three groups: normal or slightly decreased intestinal microflora (grade 1), moderate dysbacteriosis (grade 2), and severe dysbacteriosis (grade 3). Clinical outcomes were postoperative infections and anastomotic leakage within 30 days after surgery.ResultsAt the preoperative assessment, 268 (75.9%) patients had normal or slightly decreased intestinal microflora, 58 (16.4%) patients had moderate dysbacteriosis, and 27 (7.6%) patients had severe dysbacteriosis. The patients with preoperative dysbacteriosis had a higher rate of early postoperative diarrhoea (grade 2: OR = 4.53, 95% CI 2.28–9.00, grade 3: OR = 4.52, 95% CI 1.81–11.31), total complications (grade 3 40.7% vs. grade 2 25.9% vs. grade 1 12.7%, P < 0.001), and anastomotic leakage (grade 3 11.1% vs. grade 2 5.2% vs. grade 1 1.5%, P = 0.002). An interaction effect among preoperative dysbacteriosis and early postoperative diarrhoea on total complications was observed in rectal cancer patients (P for interaction = 0.007).ConclusionsAn imbalance of the intestinal microbiome exists in a considerable proportion of CRC patients before surgery. Preoperative dysbacteriosis is associated with higher rates of early postoperative diarrhoea, which further correlates with infectious complications and anastomotic leakage. However, the contribution of preoperative dysbacteriosis to the occurrence of anastomotic leakage needs to be clarified in further studies.Trial registration ChiCTR, ChiCTR1800018755. Registered 8 October 2018—Retrospectively registered, http://www.chictr.org.cn/ChiCTR1800018755.

Effect of geometry and upstream stagnation thermodynamic parameters on CO2 choked flow through orifices

Small breaks may occur in the early equipment cracks or seal failures. A comprehensive understanding of small breaks leakage is essential for early leakage detection technology development. This paper describes carbon dioxide (CO2) choked flow experiments through orifices under quasi-steady-state conditions with a nozzle 1.0 mm in diameter, covering upstream pressure range of 8.1–10.71 MPa and upstream temperature range of 310–369 K. Effect of orifice length-to-diameter ratio (L/D), upstream stagnation pressure, and upstream stagnation temperature on choked flow rate were investigated. As L/D increases, choked flow rate decreases. HRM simulated the trend of choked mass flow rate vs. L/D more reasonably. Thermal non-equilibrium phenomenon occurs in the test section. Thermal non-equilibrium degree inside orifice decreases with L/D increase. As stagnation pressure increases and stagnation temperature decrease, choked flowrate increases due to larger density. Experimental data of choked flow rate are useful in understanding small break leakage process, and verifying models or develop new models.

Early Detection

A length-unlimited flexible printed circuit technology is enabling a robust, precise and early oil leak detection system.

Early biliary complications after pancreatoduodenectomy

This study aimed to review latest investigations concerning early biliary complications following major pancreatic surgery. 127 original articles in English language were found via PubMed literature search using key words over the last 5 years. After application of exclusion criteria (full-text in English not available, duplicating paper, age of paper over 5 years) a total of 29 articles were included in this study. Herein we review epidemiology and classification of early biliary complications after pancreatoduodenectomy, current views on pathogenesis, prophylaxis, diagnostics and treatment of early biliary complications. In early postoperative course of pancreatoduodenectomy patients may develop transient jaundice, cholangitis, early biliary strictures and post-procedural bile leak. Frequency of these conditions range from 3 to 24% and depends on epidemiological features of population, statistics and combined conditions. A number of patient- and surgery-dependent risk factors have been described. Modern interventional radiology offers a wide range of procedures for diagnostics and treatment of early biliary complications after pancreatoduodenectomy which showed to be safe and effective when endoscopic manipulations are contraindicated due to high risk. Well-timed diagnosis and treatment allow to avoid severe early biliary complications, re-interventions and reoperations which provides a good prognosis and lowers medical and financial burden.

Importance of Corneal Angiography in Subclinical Limbitis in a Case of Atopic Keratoconjunctivitis

The aim of this study was to report corneal angiography features in subclinical limbitis in a patient with atopic keratoconjunctivitis. This is a case report. A 22-year-old woman with a medical history of atopic keratoconjunctivitis was referred for bilateral corneal neovascularization with scarring. On examination, no signs of active disease were noticed at the slit lamp. Ocular surface angiography detected active corneal limbitis, showing as limbal leakage at fluorescein angiography in the early phase and leakage after indocyanine green angiography in the late phase. The patient was treated with topical corticosteroid. At follow-up, the fluorescein angiography and indocyanine green angiography no longer showed limbal leakage, whereas the slit lamp examination was unchanged. Active allergic corneal limbitis may present as subclinical inflammation, with no signs of activity at the slit lamp examination. Therefore, its diagnosis can be challenging without the use of corneal angiography.

Safety of transanal ileal pouch-anal anastomosis for ulcerative colitis: a retrospective observational cohort study

BackgroundColectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. The objective of this study was to determine anastomotic leakage rates and treatment after taIPAA as well as short- and long-term pouch function.MethodsWe conducted a retrospective analysis of a prospective database of all patients undergoing taIPAA at an academic tertiary referral center in Germany, between 01/03/2015 and 31/08/2019. Patients with indications other than ulcerative colitis or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded for short- and long-term follow up due to diverging postoperative care yet considered for evaluation of anastomotic leakage.ResultsA total of 22 patients undergoing taIPAA during the study time-window were included in analysis. Median age at the time of surgery was 32 ± 12.5 (14–54) years. Two patients developed an anastomotic leakage at 11 days (early anastomotic leakage) and 9 months (late anastomotic leakage) after surgery, respectively. In both patients, pouches could be preserved with a multimodal approach. Twenty patients out of 22 met the inclusion criteria for short and long term follow-up. Data on short-term pouch function could be obtained in 14 patients and showed satisfactory pouch function with only four patients reporting intermittent incontinence at a median stool frequency of 9–10 times per day. In the long-term we observed an inflammation or “pouchitis” in 11 patients and a pouch failure in one patient.ConclusionPostoperative complication rates in patients with benign colorectal disease remain an area of concern for surgical patient safety. In this pilot study on 22 selected patients, taIPAA was associated with two patients developing anastomotic leakage. Future large-scale validation studies are required to determine the safety and feasibility of taIPAA in patients with ulcerative colitis.

Comparison of multicolor scanning laser ophthalmoscopy and optical coherence tomography angiography for detection of microaneurysms\xa0in diabetic retinopathy

This study aimed to evaluate the usefulness of multicolor (MC) scanning laser ophthalmoscopy (MC-SLO) in detecting microaneurysm (MA) in eyes with diabetic retinopathy (DR). This was a retrospective cross-sectional study. Eyes with DR underwent fluorescein angiography (FA), MC-SLO, optical coherence tomography angiography (OCTA), and color fundus photography (CFP) were analyzed. The foveal region was cut in an 6 × 6 mm image and the number of MA in each image was counted by retina specialists to determine the sensitivity and positive predictive value. FA results were used as the ground standard. MAs were classified as those with early, late, or no dye leakage based on FA images. Fifty-four eyes of 35 patients with an average age of 64.5 ± 1.24 years were included. The sensitivity of MA detection was 37.3%, 15.3%, and 4.12% in MC-SLO, OCTA, and CFP, respectively (P < 0.01 in each pair).The positive predictive value was 66.4%, 46.4%, and 27.6% in MC, OCTA, and CFP, respectively (P < 0.01 in each pair). Sensitivity for MAs with early leakage was 36.4% in MC-SLO, which was significantly higher than 4.02% in OCTA. MC-SLO was more useful in detecting MA in eyes with DR than OCTA.

Minimally invasive peritoneal dialysis catheter insertions with concomitant cholecystectomy or hernioplasty: Surgical technique and our experiences.

Peritoneal dialysis is a well-accepted replacement therapy in patients with end-stage renal disease. There are many different options adopted on how to insert a peritoneal dialysis catheter. In our institution, a laparoscopic insertion has become the method of choice for providing peritoneal dialysis access in adult patients. The aim of this study was to analyze surgical outcomes of patients after laparoscopically assisted placement of a PD catheter some of them after concomitant cholecystectomy or hernioplasty. We have evaluated 70 consecutive patients from 1st of October 2015 to 30th of April 2020 who underwent laparoscopic insertion of a peritoneal dialysis catheter. Demographic data, details about surgery and about peri- and postoperative complications were gathered. Out of 70 enrolled patients, 15 had gallstones (21%) and underwent concomitant laparoscopic cholecystectomy. Three patients (4%) had abdominal wall hernia and underwent concomitant hernioplasty. We observed no perioperative complications connected with any of the performed procedures. There was one early postoperative complication: an early leak of dialysate fluid. Late complications were observed in nine patients (13%): mechanical catheter problems (two patients), peritonitis (three patients), skin exit-site infections (two patients), peri-catheter leak (one patient), and port-site hernia (one patient). For all patients with concomitant gallbladder disease or abdominal wall hernias we suggest to perform synchronous surgeries, due to finding no more complications after concomitant procedures in comparison to patients in whom only a PD catheter was inserted. Concomitant procedures are done to spare patients two separate procedures and to avoid possible complications. We also suggest using the cholecystectomy first, PD catheter insertion second approach for having excellent peri- and postoperative results.

Prediction of early vascular cement leakage following percutaneous vertebroplasty in spine metastases: the Peking University First Hospital Score (PUFHS)

BackgroundCement leakage into venous blood posed significant challenge to surgeons. The aim of the study was to create a Peking University First Hospital Score (PUFHS) which could evaluate the probability of vascular cement leakage among spine metastases patients following percutaneous vertebroplasty.MethodsThe study retrospectively enrolled 272 spine metastases patients treated with percutaneous vertebroplasty. We randomly extracted all enrolled patients as the training or validation group and baseline characteristic comparison was assessed between the two groups. Creation of the PUFHS was performed in the training group and validation of the PUFHS was performed in the validation group.ResultsOf all the 272 patients, the total number of included vertebrae was 632 and the median treated levels were 2 per patient. Vascular cement leakage occurred in 26.47% (72/272) of patients. The baseline characteristics were comparable between the two groups (P > 0.05). Three risk predictors (primary cancer types, number of treated vertebrae levels, and vertebrae collapse) were included in the PUFHS. The area under the receiver operating characteristic curve (AUROC) of the PUFHS was 0.71 in the training group and 0.69 in the validation group. The corresponding correct classification rates were 73.0 and 70.1%, respectively. The calibration slope was 0.78 (95% confidence interval[CI]: 0.45–1.10) in the training group and 1.10 (95% CI: 0.73–1.46) in the validation group. The corresponding intercepts were 0.06 (95% CI: − 0.04–0.17) and − 0.0079 (95% CI: − 0.11–0.092), respectively.ConclusionsVascular cement leakage is common among spine metastases after percutaneous vertebroplasty. The PUFHS can calculate the probability of vascular cement leakage, which can be a useful tool to inform surgeons about vascular cement leakage risk in advance.

Imaging and leaks in peritoneal dialysis

Dialysate leaks are non-rare mechanical but dreaded complications in peritoneal dialysis (PD). They usually occur at the beginning of PD, with various clinical events depending on their location. Use of imaging tests such as computed tomography (CT) peritoneography, or magnetic resonance imaging (MRI) peritoneography, or scintigraphic peritoneography, can confirm the diagnosis and guide surgical intervention if needed. These simple, non-invasive, and accessible tests can be done in collaboration between the radiological et peritoneal teams. Depending on the leakage site, PD can be pursued with small volumes with a cycler. In other cases, it must be interrupted and the patient transferred to hemodialysis, in order to permit the peritoneal cavity to regain its integrity by cicatrization or with surgical intervention. Imaging can help to make sure peritoneal cavity has regained its integrity after this period of transition. Early leaks can be avoided by delaying PD start with by 14 days. Intraperitoneal pressure does not seem to contribute significantly. Prevention of PD leaks essentially depends on individual risk factors such as obesity or anterior abdominal surgeries. This article reviews the characteristics of dialysate leaks in PD and the imagery tests to limit transfer to hemodialysis.

Determination and analysis of leak estimation parameters in two-phase flow pipelines using OLGA multiphase software

Pipeline leakage incidents have led to serious environmental concerns, prompting the development of various methods to detect leakage in pipelines. Hence, there is a justified need for early leakage detection as well as leakage prediction system. Many of the leak detection techniques are based on computational intelligence techniques such as artificial neural networks, support vector machine, and fuzzy systems. This paper focuses on determining leak detection parameters such as mass flow rate, temperature, and pressure with and without a leak in pipelines evaluated using OLGA multiphase software. An OLGA-based computerized model is used in leak simulation for analyzing inlet and outlet parameters such as mass flow rate, temperature, and pressure over the flow inside the pipeline. The leak sizes were varied from 0% to 50 % leak opening and the inlet and outlet parameters were measured and studied. The pressure and mass flow rates are observed to decrease with increasing leak size, while temperature decreases with leak size until 25 % and later increases. Mass flow rate is observed to be the most important parameter in detecting a leak and localizing it. The maximum percentage of variation in mass flow rate was observed to be 33.6 % for 50 % leak openings, for a single leak, and 32.4 % for multi-leak scenario.