Rectal Perforation Research Articles

Severe Postoperative Bleeding After Stapled Hemorrhoidopexy: Incidence and Causes

Severe postoperative bleeding (SPB) represents a major issue of stapled hemorrhoidopexy (SH). The aim of the study is to assess SPB events over last 6 years. This essay is a retrospective study of clinical records on SH patients over a 6-year period 2012–2018 in the First Affiliated Hospital of a university. SPB events and other serious complications are assessed. A total of 41 of 3350 SH patients experienced SPB events and 49 SPB episodes (98%, 49/50) occurred within 14 postoperative days. Of the 41 SPB patients, 37 were discharged, 28 were identified as anastomotic bleeding, and 34 had an average Hb decrease of 33.9 g/l (range, 5–90 g/l). Univariate and multivariate analyses show the statistical significance between the SPB events and variables of surgeon group (p = 0.017 < 0.05), constipation (p = 0.030 < 0.05) and incarcerated hemorrhoid (p = 0.015 < 0.05). No postoperative mortality, rectal perforation, extrarectal/abdominal hemorrhage, and severe pelvic infection have been reported. SPB’s incidence is 1.25% and usually occurs within 2 weeks after SH. Patients with incarcerated hemorrhoid or constipation are more prone to SPB events, and extensive surgical experience can significantly reduce SPB events.

Rectal perforation as a complication of cystolitholapaxy; a case report

Rectal perforation as a complication of cystolitholapaxy; a case report

Rectal perforation and necrosis associated with Fleet enema.

Rectal perforation and necrosis associated with Fleet enema.

S1577 What’s 7-cm Long, Has Poked Holes in the Small and Large Bowel, and Is Now Guilty of Causing Rectal Perforation? A Biliary Stent!

INTRODUCTION: Endoscopic biliary stenting plays a major role in the management of pancreaticobiliary disease. Unfortunately, even this novel idea comes with complications. Some of these risks include stent occlusion, cholangitis, and pancreatitis. Stent migration, although rare, has also been described, with more cases associated with plastic stents as compared to metal stents. More unlikely still is resultant perforation, as most dislodged stents remain in the bowel without causing clinical symptoms until ultimately excreted in the stool. This case report aims to discuss the first example of rectal perforation caused by a migrated biliary stent. CASE DESCRIPTION/METHODS: Our patient is a 77-year old female who presented to the emergency room for abdominal pain. She has a significant history of recurrent pancreatitis complicated by bile duct stricture requiring multiple visits for common bile duct stent placement. The patient was admitted two months prior for acute pancreatitis. At that time, an ERCP revealed rapid tapering of the bile duct at the level of the ampulla with subsequent intervention via placement of a 10-French 7-cm plastic stent. During this visit, a CT scan of the abdomen revealed migration of the previously placed stent to the rectosigmoid colon, along with diverticulosis. Specifically, the proximal portion was seen located in the wall of the left lateral sigmoid colon and distal portion of the stent had perforated the right aspect of the rectal vault. A flexible sigmoidoscopy was performed with successful extraction through the anus. DISCUSSION: The most common site of perforation by a biliary stent is the duodenum. The most likely reason for this is that the duodenum is largely retroperitoneal, and therefore fixed. Furthermore, anatomic proximity also plays a part as the major papilla is located in the second part of the duodenum. Bowel fixation in a hernial sac, presence of adhesions, and diverticular disease all seem to be associated with increasing risk of perforation due to the impedance of peristalsis. Our case is unique as the stent perforated the distal rectum, which is anatomically extra-peritoneal. Extra-peritoneal organs are embedded in connective tissue hence making them fixed-thus increasing risk of perforation. It was most probably her diverticular disease which predisposed her to the rectal wall perforation. The diverticulum acted as an anchor, essentially trapping the stent proximally. The distal end was free to poke and prod, eventually perforating the rectal wall.

The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis.

Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation. A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Endoscopic closure of a perforated rectum with an over-the-scope clip following diagnostic colonoscopy.

Our patient is a 77-year-old-woman who underwent colonoscopy for rectal bleeding which revealed hemorrhoids. A day after the colonoscopy, the patient attended our hospital’s emergency room with severe lower abdominal pain. Computed tomography (CT) with rectal contrast revealed free air and extravasation of the contrast material into the abdominal cavity ([Fig. 1]). As there was no abscess nor ascites, after discussion with general surgeons endoscopic closure of the perforation was decided upon.

Rectal perforation from a perianal drain repaired with transanal minimally invasive surgery.

Rectal perforation from a perianal drain repaired with transanal minimally invasive surgery.

Impact of rectal perforation on recurrence during rectal cancer surgery in a national population registry.

Incidental perforation in rectal cancer surgery is considered a risk factor for poorer oncological outcome. Most studies emanate from the era before total mesorectal excision when staging, neoadjuvant treatment and surgical technique were suboptimal. This study assessed the impact of incidental perforation on oncological outcome in a cohort of patients with optimized management. Data from the Swedish Colorectal Cancer Registry for patients undergoing R0 abdominal surgery for TNM stage I-III rectal cancer between 2007 and 2012, with 5-year follow-up, were analysed. Multivariable analysis was performed. In total, 6176 patients were analysed (208 with and 5968 without perforation). The local recurrence rate was increased after perforation (7·2 per cent (15 of 208) versus 3·2 per cent (188 of 5968); P = 0·001), but there were no differences in rates of distant metastasis (16·3 per cent (34 of 208) versus 19·8 per cent (1183 of 5968); P = 0·215) and overall recurrence (20·7 per cent (43 of 208) versus 21·0 per cent (1256 of 5968); P = 0·897). The 5-year overall survival rate was lower after perforation (66·4 versus 75·5 per cent; P = 0·002), but the 5-year relative survival rate was no different (79·9 versus 88·2 per cent; P = 0·083). In multivariable analysis, perforation was a risk factor for local recurrence (hazard ratio 2·10, 95 per cent c.i. 1·19 to 3·72; P = 0·011), but not for the other outcomes. Incidental perforation remains a significant risk factor for LR, even with optimized management of rectal cancer. This must be considered when discussing adjuvant treatment and follow-up.

Transfeminine Gender Confirmation Surgery with Penile Inversion Vaginoplasty: An Initial Experience.

Background:To detail the early experience with and results of a transfeminine (TF) genital reconstruction at an established plastic surgery practice in Western New York.Methods:Between June 2016 and June 2019, 30 patients underwent penile inversion vaginoplasty for TF gender reassignment. All patients fulfilled World Professional Association for Transgender Health and NY State criteria for reassignment surgery. All surgeries were carried out at a large, government-owned tertiary care center.Results:There were 30 patients in this retrospective study, with a mean age of 37 years (SD 5.4) and a mean body mass index of 27.3 kg/m2 (SD 3.2 kg/m2). Nineteen patients never smoked, 4 were former smokers, and 7 were current smokers. Primary surgery was an orchiectomy and modified single-stage penile inversion vaginoplasty. Mean operative time was 6.0 hours. Mean initial hospital stay was 8.2 days. Three of the 30 (10%) patients required transfusion. There were 6 (20%) complications. Three complications (10%) required reoperation: 1 patient for wound dehiscence on postoperative day 7, 1 for rectal perforation identified on postoperative day 10, and 1 for urethrovaginal fistula. All complications were addressed without sequalae. Twenty of the 30 (66%) patients have undergone revision surgery. Indications for revision were prolapse correction/deepening, labiaplasty, clitoral hood construction/revision, meatal asymmetry, urinary fistula repair, and posterior vaginal flap revision. Twenty-one of 28 (75%) revisions were outpatient surgeries. There were no complications from these procedures. Overall satisfaction via survey was 92% (24 respondents).Conclusions:TF gender reassignment is a novel, challenging set of procedures for the specialty of plastic surgery. With appropriate consideration and technique, penile inversion vaginoplasty is a safe, effective means of achieving this goal.

Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal cancer.

In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach. We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video. Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453min and median blood loss was 46g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation. The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.

Rectal perforation, a rare adverse event of ventriculoperitoneal shunt: Case report

Rectal perforation, a rare adverse event of ventriculoperitoneal shunt: Case report

Perineal Wound Outcomes after Extralevator Abdominoperineal Excision for Rectal Adenocarcinoma- A Tertiary Care Centre Experience

Abstract Extralevator Abdominoperineal excision (ELAPE) for low rectal cancer results in a large perineal defect, often requiring reconstruction by a biological or absorbable mesh or a flap as compared to conventional Abdominoperineal excision (CAPE). Although there are indications for oncological superiority with ELAPE, the incidence of wound-related complications is postulated to be higher when compared to CAPE due to the removal of more amount of tissue around the anorectum. On the other hand, the incidence of inadvertent rectal tube perforation during dissection is lesser in ELAPE and hence perineal wound breakdown and infection are postulated to be lesser in some other studies. We conducted a retrospective study in the department of colorectal surgery, Christian Medical College; Vellore from 2011 to 2017 to compare the perineal wound-related complications following CAPE and ELAPE. The data were retrieved from the prospectively maintained computerized inpatient and out-patient follow up records and comparisons were made in terms of incidence of perineal wound outcomes, need for reoperations and duration of hospital stay. A total of 138 patients underwent CAPE and 57 patients underwent ELAPE over a period of 7 years. There was no statistical difference in baseline characteristics and patients who underwent neo-adjuvant chemoradiation between the two groups. Perineal wound complications were seen in 63% (87) of the patients after CAPE compared to 64.9% (37) of the patients after ELAPE. There was no perineal herniation or wound dehiscence following ELAPE, whereas these complications occurred in 1 and 5 patients respectively after CAPE. Similarly, the incidence of reoperations was 8% in CAPE as compared to 5.4% in ELAPE although not statistically significant. There was no difference in the length of hospital stay. Hence, in our experience, perineal wound complications were similar in the Extralevator approach to APE (ELAPE) as compared to conventional APE (CAPE) for rectal adenocarcinoma.

Pitfalls in diagnosis and treatment of Hirschsprung's disease

Abstract Background and purpose Hirschsprung's disease (HD) presents itself by delayed passage of meconium, neonatal bowel obstruction and/or chronic constipation. In 80% of cases the disease is diagnosed in the first year of life. Difficulties or misdiagnosing HD are infrequently met. The aim of this case series is to highlight the pitfalls in diagnosis and treatment of HD. Case presentation: case 1&2 A 4 and 6 months old ♂ were diagnosed as rectal perforation in the neonatal period and colostomy was performed. At the age of 4 and 6 months respectively they developed fecal fistula after colostomy closure. Revision of stoma was done and biopsy proved that both had aganglionic rectal biopsy. Abdominal PT was performed for both after 3 and 4 months. Case 3 A 5 years ♀ came with recurrent attacks of intestinal obstruction since the age of 1 year. Both plain X ray and contrast studies were inconclusive. Finally was diagnosed after a second exploration and histopathological biopsies with total colonic aganglionosis. Case 4 A 1.5 years old presented with neonatal intestinal obstruction. His preoperative gastrografen enema were inconclusive. He underwent surgical exploration at the age of 2 weeks ended with right transverse colostomy and multiple colonic and rectal biopsies proved to be aganglionic. Case 5 A 3 months old ♂ came with caecostomy construction because of caecal perforation during neonatal period. Although there was no histopathological report earlier about the colon but his current rectal biopsy was devoid of ganglion cells. Conclusions:High degree of suspicion with physician care plan and routine biopsy are essential in all non NEC neonatal perforation during exploration to avoid missing of HD.

A case of iatrogenic immunodeficiency-associated colonic lymphoma complicating ulcerative colitis

BackgroundUlcerative colitis (UC) is one of the major types of inflammatory bowel diseases and is associated with a significantly increased risk of not only lymphoproliferative disorders but also lymphomas, of which most cases are related to the long-term usage of immunosuppressants. Here, we demonstrate a very rare case of other iatrogenic immunodeficiency-associated colonic diffuse large B-cell lymphoma (Oii-DLBCL) complicating UC and rectal perforation. In addition, we reviewed the clinicopathological features of previous cases of DLBCL related to UC.Case presentationA 68-year-old man was diagnosed with left-sided UC 26 months prior. Although he was followed by immunosuppressive therapy with azathioprine and infliximab, an emergency total proctocolectomy was performed due to rectal perforation. The resected specimen exhibited irregular wall thickening and elevated multinodular lesions extending from the mid-transverse colon to the rectum, measuring up to 52 cm in length. Histologically, the lesion was diagnosed as Oii-DLBCL and crypt abscess surrounded by mixed inflammatory cell was remained.ConclusionOii-DLBCL complicating UC with rectal perforation is extremely rare. Macro- and microscopic findings are important for early diagnosis of the lesion.

Epidemiological and pathological aspects of noninfectious diseases of the gastrointestinal tract in 114 horses in Southern Brazil

ABSTRACT: Equine colic is one of the most common cause of death in horses, but few studies have investigated specifically the conditions at the necropsy. This study aimed to describe the epidemiological and pathological features of noninfectious diseases of the gastrointestinal tract in horses. A retrospective study was conducted in search of cases of these diseases affecting horses from 2005 to 2017. During this period, 114 horses died of noninfectious diseases of the gastrointestinal tract, and the main causes were: primary gastric dilation (27/114), volvulus (27/114), enterolithiasis (20/114), rectal (colonic) perforation (15/114), gastric or cecocolonic impaction (10/114), incarcerations (6/114), intussusception (4/114), and others (5/114). Mixed breeds horses (56/114) and males (69/114) were mostly affected. The horses had a median and mean age of 10 and 10.9-years old, respectively. Primary gastric dilation was characterized by distension of the stomach by moderate to large amounts of content, which in 21 cases caused tearing of the stomach wall at the greater curvature (peritonitis), and the main predisposing factor was alimentary overload (17/27). Intestinal volvulus occurred within the small intestine (14 cases) and within the large intestines (13 cases). Grossly, there was intestinal ischemia with reddened to deep-black serosa and diffusely red mucosae. Enterolithiasis caused partial or complete obstruction of the right dorsal colon (9/20), transverse colon (4/20), small colon and right dorsal colon (3/20), rectum and right dorsal colon (2/20), and small colon (2/20). Viscera perforation and peritonitis occurred in 11 cases. Rectal (colonic) perforation involved the rectum (10/15), rectum/small colon (4/15), and the small colon (1/15). It was characterized by a focally extensive transmural tearing, associated with reddened borders, and retroperitoneal to diffuse peritonitis. Palpation related iatrogenic injuries (11/15) were the main cause. Impactions affected the large colon (7/10), the cecum (2/10), and the stomach (1/10). Incarcerations consisted of inguinoscrotal hernias (2/6), small intestine entrapment by a mesenteric failure (2/6), diaphragmatic hernia, and umbilical eventration. Grossly, the organs were constricted by a hernial ring, with intestinal ischemia and reddened to dark-red serosa. Predisposing factors included previous surgeries (2/6) and patent inguinal ring (1/6). Intussusception involved the small intestine (3/4) and ileocecum (1/4). Foals with lack of colostrum intake and concomitant pneumonia was a characteristic presentation (3/4). Grossly, the intussusceptum slipped into intussuscipiens, with diffuse deep black-red discoloration. Other causes included large colon displacement (2/5), extrinsic and intrinsic obstruction of the small intestine (2/5), and an intestinal adenocarcinoma. Noninfectious gastrointestinal diseases are major causes of death in horses. Epidemiological and gross features of the conditions should be accounted to obtain a final diagnosis of the cause of the colic.

Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications.

The aim of this study was to analyse local single-institution data and perform a systematic review of the literature to calculate precise risk estimates of rectal stump-related morbidity and mortality following subtotal colectomy in patients with inflammatory bowel disease (IBD), including Crohn's colitis, ulcerative colitis and indeterminate colitis. Institutional information systems were interrogated to obtain local patient data. A systematic review of MEDLINE and EMBASE was performed to identify relevant articles. Fixed-effects or random-effects meta-analysis of proportions was performed to calculate pooled incidence estimates, including local data. Sixty-one patients were included locally and all had their rectal stump closed intra-abdominally. Four patients (8.3%) had a rectal stump perforation and 30-day mortality was 0. Fourteen papers were included in our review alongside local data, with a total of 1330 patients included. Pooled mortality was 1.7% (95% confidence interval, CI 1.0-2.8), pooled incidence of pelvic abscess/sepsis, stump leak and wound infection was 5.7% (95% CI 4.4-7.3), 4.9% (95% CI 3.7-6.6) and 11.3% (95% CI 7.8-16), respectively. Subcutaneous placement of the stump was associated with the highest incidence of stump leak (12.6%, 95% CI 8.3-18.6), and closure of the stump with both staples and suture was associated with the highest incidence of pelvic abscess (11.1%, 95% CI 5.8-20.3). Mortality and the incidence of wound infection were similar across stump closure techniques. There was evidence suggesting considerable heterogeneity and publication bias among studies. This study provides estimates of morbidity associated with the rectal stump after subtotal colectomy for IBD. A closed intra-abdominal stump seems to be associated with the highest rate of pelvic abscess/sepsis. Further work in form of an international collaborative project would allow individual patient data analysis and identification of risk factors for complications.

Rectal perforation following endorectal prostate MRI: an unexpected complication

BackgroundProstate cancer is a common cancer among men in developed countries. Prostate magnetic resonance imaging (MRI) has been widely employed for early diagnosis of prostate cancer and recommending a treatment plan. The incidence of rectal perforation during endorectal prostate MRI is rare and has never been reported before. Herein, we present a case of rectal perforation after a prostate MRI examination that was subjected to emergency surgical intervention because of the acute presentation of generalized peritonitis. Patients with systemic comorbidities are reportedly at greater risks of encountering colonoscopic perforation. Endorectal prostate MRI is a safe diagnostic modality, but inadequate lubrication of the endorectal coil or over-insufflation of the balloon during the procedure may also lead to serious complications such as hollow organ perforation. Early surgery will be necessary should peritoneal symptoms persist.Case presentationIn 2015, a 56-year-old man came to our ER due to acute abdominal pain after he finished his MRI exam. The exam indicated diffuse tenderness over his abdomen and at the ER, his abdominal CT (computerized tomography) was checked. The images revealed extraluminal air in the perirectal fat and the pneumoperitoneum. In response, exploratory laparotomy, simple closure of rectal perforation, and loop-S colostomy were performed and the patient was discharged 1 month after operation.ConclusionsProstate MRI is a secure procedure with few complications. Clinicians must keep in mind the possibility of perforation when using ultrasound probe. Hollow organ perforation can result in serious morbidity or death. As a result, patients need to be informed of the complications of prostate MRI. When performing the procedure, clinicians must be cautioned about the potential problems for patients with high-anesthetic risk.

Early Metabolic and Inflammatory Intraperitoneal Changes After Rectum Perforation.

Purpose Anastomotic leakage (AL) is the most dreaded complication in rectal surgery. It has a great impact on postoperative morbidity and mortality. This animal model, in which we have studied postoperative metabolic and inflammatory changes, is designed to imitate an AL.Methods Twelve pigs were randomized into 2 groups. In the experimental group, an iatrogenic rectal perforation was performed, with the control group having a sham operation. The 2 groups were followed for 10 hours after operation with regard to vital parameters, arterial lactate, and cytokines interleukin (IL) 1, IL6, and IL10 in the blood and intraperitoneally. Intraperitoneal microdialysis analyses of glucose, lactate, glycerol, and pyruvate were performed and the lactate/pyruvate ratio was calculated.Results Glucose levels were lower in the experimental group after 4 hours. After 7 hours, lactate and lactate/pyruvate ratio was higher in the experimental group. At the same time intraperitoneal cytokines IL6 and IL10 were higher in the experimental group. Blood samples showed higher IL6 after 7 hours in the experimental group. Conclusion In this study, several significant differences between the groups in metabolic and inflammatory values were detected. Further clinical studies are recommended to evaluate the importance of intraperitoneal metabolic and inflammatory analyses as a diagnostic tool for early identification of an AL.

Rectal Perforation Caused by Accidental Ingestion of a Denture Adhesive

Rectal Perforation Caused by Accidental Ingestion of a Denture Adhesive

A comparative study of ultrasound-guided caudal block versus anatomical landmark-based caudal block in pediatric surgical cases

Background: Caudal block is a popular regional anesthesia technique in pediatrics for anesthesia and perioperative analgesia. Conventional landmark-based technique is a simple technique with good success rate but associated with complications such as dural puncture and venous injection. Ultrasound-guided caudal block is known to improve the success rate and reduce the complications noted with the landmark technique. We aimed to compare the success rates of caudal block in landmark- and ultrasound-guided techniques.Methods: One hundred and twenty-four children under 10 years admitted for infraumbilical surgeries were randomly allocated to Group L and Group U caudal block was administered based on landmarks in Group L and by using ultrasound in Group U. In both the groups, observations noted were success of caudal block, visibility and palpability of sacral cornu; identification of hiatus; first attempt success; number of attempts; block performance time; and complications. In Group U, ultrasound visualization of sacral hiatus, needle, and distension of sacral canal with injection was also noted.Results: Success rates were 81.8% and 92.1% in Group L and Group U, respectively (P = 0.045). Complications noted in Group L were blood tap (23.8%), subcutaneous swelling (15.2%), dural puncture (1.5%), and rectal perforation (1.5%). In Group U, only blood tap (3%) was the complication noted. Block performance was faster in Group L than Group U. There was no significant difference in the first attempt success rate and number of attempts.Conclusion: Ultrasound-guided caudal block improves the success rate, reduces complications, and ensures safety.