|Abstract:||Surgical smoke is produced when tissues are dissected or cauterised by heat generating devices. Perioperative personnel and patients are routinely exposed to this smoke, and the use of smoke evacuation devices in operating theatres is not mandatory. This review will examine the most recent literature relating to surgical smoke in an attempt to discover guidelines for best practice and thereby provide recommendations for future practice.|
Smoke (Health aspects)
Surgery (Health aspects)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: April, 2012 Source Volume: 22 Source Issue: 4|
|Topic:||Event Code: 310 Science & research|
|Product:||Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Surgical smoke is the gaseous by-product produced when tissue is dissected or cauterised by heat generating devices such as lasers, electrosurgical units, ultrasonic devices and high speed burrs, drills and saws (Ulmer 2008). Perioperative personnel and patients are routinely exposed to this smoke. The aim of this literature review is to examine the most recent evidence pertaining to surgical smoke, whether it poses a risk to human health and what, if any, protective precautions are necessary. This review will focus on the smoke produced by electrosurgical units and lasers.
The use of smoke evacuation units in operating theatres is not mandatory. While these units are available, their use is inconsistent, being utilised more in some specialties than others. Furthermore some surgeons refuse to use smoke detectors indicating that the units impede dexterity due to the smoke evacuation hand pieces. It was felt that more information was needed relating to surgical smoke, the possible health implications, and whether there is a need for smoke evacuation units to be used routinely and consistently. By examining the latest evidence on this topic, we hoped to find specific guidelines and thereby to empower perioperative personnel with the knowledge and evidence to change practice if necessary.
Nurses have a responsibility to provide care which is based on the best evidence available (NMC 2008). Evidence based practice aims to deliver the best care based on current evidence and validated research, while recognising professional knowledge and patients' views as important contributory factors (Hek & Moule 2006).
This literature review will begin by identifying the search strategies that were applied. The anatomy, physiology and pathophysiology relating to the creation and inhalation of smoke plume will be examined. Findings from the literature will then be presented by the themes identified, and conclusions and recommendations for future practice will be made.
The Biomed Central Journals, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Health Management Information Consortium (HMIC), PubMed, Web of Knowledge and Wiley Interscience databases were searched for articles relating to surgical smoke and health. The keywords used were 'surgical', 'surg*', 'smoke' and 'health' in different combinations. A total of 195 articles were identified, which was reduced to 31 by applying parameters of articles published in English and within the last 5 years. Further articles were identified from reference lists. Articles by Baggish et al (1991), Barrett and Garber (2003), Gatti et al (1992) and Wenig et al (1993) were sought out as these were common citations in the work of others. After reviewing, using the Critical Appraisal Skills Programme (CASP 2006) for qualitative and quantitative research, a total of 23 articles were considered appropriate for this literature review. Three main themes were identified namely: the contents of surgical smoke, the effects on human health, and the protection of perioperative personnel and patients.
Anatomy, physiology and pathophysiology of smoke inhalation
Surgical smoke is produced when tissues are dissected or cauterised by heat generating devices such as electrosurgical units and laser. Electrosurgery utilises high frequency current. Resistance in the tissues to this current generates heat (McCormick 2008). Lasers produce extremely high temperatures in the form of a concentrated monochromatic light beam (Ulmer 2008). When applied to tissue the heat produced by these methods causes cells to rupture and disperse their contents into the air (Alp et al 2006).
Cells have different structures and functions, but are composed of the same common characteristics, namely a nucleus containing DNA surrounded by the cytoplasm and encased within the cell membrane. The cytoplasm is the fluid component of the cell, while the cell membrane mostly contains proteins, cholesterol and phospholipids (Seeley et al 2003). When cells are subjected to the high temperatures of electrosurgery and laser, intracellular fluid boils and the cell membrane ruptures. This allows cellular fluid to be released as steam, and cell contents to be expelled into the environment (AfPP 2009). The British Occupational Hygiene Society (2006) comments that some cellular elements which have been found to be present in surgical smoke are blood fragments and viruses.
As well as cellular elements, a number of chemicals have been found in surgical smoke (Barrett & Garber 2003). The irritant effect of these chemicals, particularly on the respiratory system, is a cause for debate in the literature. There is particular concern over the small size of some of the particles found in surgical smoke (Alp et al 2006, Bruske-Hohlfeld et al 2008). Electrosurgical units and lasers produce different sized particles. The mean aerodynamic size of electrosurgical particles is 0.07 micrometers, while laser particles have a larger mean aerodynamic size of 0.31 micrometers (Ulmer 2008). It is important to consider particle sizes in relation to the induced effects when inhaled. Particles less than 10 micrometers in diameter are able to be inhaled and deposited along the respiratory tract (Bruske-Hohlfeld et al 2008).
There are several protective mechanisms to expel foreign particles when they are inhaled into the respiratory system. The nasal cavity, nasopharynx and trachea are lined with a mucous membrane of pseudostratified ciliated columnar epithelium. This contains goblet cells that are responsible for producing mucous. The mucous traps debris in the air and the cilia propel it towards the pharynx, where it can be swallowed and eliminated in the digestive system. This mechanism is also found in the lower regions of the respiratory system. In the airways between the trachea and the terminal bronchioles it is referred to as the mucociliary escalator (Seeley et al 2003).
At the end of the bronchioles are the alveoli where gaseous exchange takes place. In this region of the respiratory system the epithelium is not ciliated. The alveoli consist of simple squamous epithelium. Debris which succeeds in reaching the alveoli must be removed by macrophages. Dust cells are the macrophages specific to this region (Seeley et al 2003).
Alp et al (2006) point out that both large and small particles can be irritating to the airways, however smaller particles, those between 0.5 micrometers and 5 micrometers are able to penetrate the deepest areas of the lung. Particles of this size are referred to as lung-damaging dust. Bruske-Hohlfeld et al (2008) comment that insoluble particles of less than 2.5 micrometers in size are most concerning. These particles are not expelled by mucociliary clearance, but will precipitate in the alveoli where they initiate a phagocytic response by the dust cells. These fine particles may induce an inflammatory and pro-thrombotic response.
When an inflammatory response is initiated by irritants entering the respiratory system, swelling of the mucous membranes occurs and mucous production is increased. When this inflammation is chronic the number of immune cells in the bronchi increases. These cells release chemical mediators which promote inflammation, increase mucous secretion and attract further immune cells to the bronchi. Constant irritation of the trachea may result in tracheal epithelium becoming stratified squamous epithelium lacking cilia and goblet cells. Consequently the normal protective function of the tracheal epithelium is lost (Seeley et al 2003).
Repeated or prolonged exposure to respiratory irritants may cause a variety of chronic pulmonary conditions such as pulmonary fibrosis, bronchitis and emphysema. Pulmonary fibrosis is most commonly caused by exposure to irritants such as coal dust. The normal lung tissue is replaced by fibrous connective tissue which reduces the elasticity of the lungs, therefore making breathing difficult (Seeley et al 2003).
Bronchitis is inflammation of the bronchi. The mucous membranes become inflamed, mucous production is increased and mucous removal by the cilia is compromised. This condition can lead to emphysema. Due to inflammation the bronchioles become obstructed and damaged. Narrowing of the bronchioles reduces air movement in and out of the lungs. This factor, combined with coughing to remove mucous, results in increased pressure in the alveoli causing them to rupture which leads to decreased surface area for gaseous exchange. Alp et al (2006) list bronchitis and emphysema among conditions linked to the risks of surgical smoke, while Fan et al (2009) add pulmonary fibrosis also.
The NMC (2008) dictates that a high standard of practice and care must be provided at all times. The AfPP (2009) considers that surgical smoke is a part of the patient care environment. Therefore it is important to consider the evidence regarding surgical smoke to ensure that the perioperative environment is safe for personnel and patients.
Content of surgical smoke
The literature suggests that surgical smoke contains harmful chemicals as well as cellular components that include blood and viral cells. The composition of surgical smoke is believed to be 95% water and 5% chemicals and cellular debris (Spearman et al 2007, Ulmer 2008). Jones et al (2006) describes surgical smoke as a mixture of biological and chemical agents. While the mechanisms are different, the smoke produced by electrosurgery and laser has very similar particle content (McCormick 2008). The chemical composition of surgical smoke has been well documented. Hydrocarbons, nitriles, phenols and fatty acids are the main chemicals present (Alp et al 2006, Spearman et al 2007, Fan et al 2009, Lin et al 2010). Barrett and Garber (2003) produced a list of 38 chemicals found in surgical smoke (Appendix 1). Acrylonitrile, hydrogen cyanide, carbon monoxide and benzene are a major concern.
Acrylonitrile is a colourless, volatile chemical that is able to be absorbed through the skin and lungs (Ulmer 2008, AfPP 2009). The Health Protection Agency (2007) describe acrylonitrile as a hazardous, volatile chemical normally found in the production of plastics. This chemical is not normally found in high enough concentrations in the environment to cause harm. It is classed however as toxic by inhalation, swallowing or skin contact. It is also irritating to the respiratory system and skin, and a possible carcinogenic to humans (HPA 2007). Acrylonitrile is able to liberate hydrogen cyanide which can also be absorbed through the skin, lungs and gastrointestinal tract (Ulmer 2008, AFPP 2009). This produces toxic effects due to the formation of cyanide with short term exposure causing reactions such as sneezing, eye irritation and nausea, while long term exposure has been shown to be carcinogenic in laboratory animals (Alp et al 2006).
Hydrogen cyanide is a colourless gas or liquid which occurs naturally in small amounts in the enviroment, but is found mainly in industrial manufacturing of other chemicals. It is classed by the Health Protection Agency as very toxic by inhalation. Excessive exposure can cause cardiac arrhythmias, coma and death, while chronic low level exposure could have neurological effects (HPA 2011c).
Carbon monoxide is well known to be toxic by inhalation, with cumulative effects. It is most commonly found in the burning of fossil fuels. The Health Protection Agency class carbon monoxide as a colourless, odourless, poisoness gas which by prolonged exposure can cause serious damage to health and also to the unborn child (HPA 2011b).
Benzene is a colourless, volatile, organic compound that occurs naturally and also in man-made processes such as plastic and adhesive manufacture. It is a known human carcinogen (Gates et al 2007, Spearman et al 2007, HPA 2011a) and exposure to benzene has been linked to various blood disorders including anaemia and leukaemia (Alp et al 2006). Excessive exposure to benzene may also cause genetic damage, and therefore it is strictly regulated. The Health Protection Agency warns that prolonged exposure to benzene through inhalation, swallowing or skin contact can cause serious damage to health (HPA 2011a).
As well as chemical components, inert and live cellular material including blood particles and viral cells have been found in surgical smoke (BOHS 2006). Viable bacteria including bacillus subtilis and staphylococcus aureas, and viruses have been found to be present (McCormick 2008).
The human health risks
The evidence has shown that surgical smoke contains chemicals hazardous to health, and may pose an infection risk due to the transmission of viable cells. Barrett and Garber (2003) consider that the main risks to perioperative personnel are respiratory irritation and inflammation, transmission of infection and genotoxicity. The main risk to patients is the effect of surgical smoke in the peritoneal cavity during laparoscopic procedures (Alp et al 2006, Fan et al 2009, O'Riley 2010).
Irritation and inflammation
Alp et al (2006) believe that when inhaled, surgical smoke may induce acute and chronic inflammatory changes in the respiratory tract. They compiled a list of 21 potential health risks (Appendix 2) associated with surgical smoke ranging from hypoxia and dizziness to emphysema, asthma and chronic bronchitis. There are concerns over the small size of particles found in surgical smoke as when inhaled they are able to penetrate surgical masks and deposit in the alveolar region of the lungs (McCormick 2008). Alp et al (2006) suggest that this can cause alveolar congestion and emphysematous changes in the respiratory tract.
As long ago as 1993, Wenig et al (1993) carried out a quantitative study on the effects of laser and electrosurgery smoke on the respiratory system of laboratory rats. Control rats were housed separately to compare results. Their study found that exposure to smoke produced by cauterising pig skin caused behavioral changes in these animals, as well as changes in lung parenchyma. These included blood vessel hypertrophy, emphysematous changes and alveolar congestion. Wenig et al (1993) concluded that both laser and electrosurgical smoke produced pathologic changes in the lungs of rats, which increased proportionally with length of exposure. While they acknowledged that the rats were exposed to higher levels of smoke than normally found in operating theatres, they recommended that perioperative personnel and patients should be protected from such risks.
Ball (2010) agrees that there is cause for concern. In this descriptive, exploratory and explanatory study, Ball examined surveys completed by 777 perioperative nurses on compliance with surgical smoke evacuation recommendations in the United States. The survey found that, compared to the general population, perioperative nurses displayed twice the incidence of some respiratory problems including sinus problems, infections and bronchitis. While this study did not set out to discover a correlation between the inhalation of surgical smoke and respiratory problems, the author points out that these findings should be a reason for concern, as these conditions have been linked to inhaling surgical smoke.
As well as the health risks due to inhalation, surgical smoke is said to be irritating to the eyes and skin (Alp et al 2006, BOHS 2006, Spearman et al 2007). The chemicals it contains are also documented to be harmful to the central nervous system, and it is suggested that they may cause renal and hepatic toxicity (Spearman et al 2007).
There have been concerns raised over the belief that surgical smoke is carcinogenic due to the known carcinogenic effects of the chemicals present (Gatti et al 1992, Alp et al 2006, Bigony 2007). Gates et al (2007) carried out a study investigating the lung cancer risk of operating room nurses in the USA. They collected data from 86,747 women, between 1976 and 2000, in a nurses' health study. Married registered nurses aged between 30 and 55 who lived in the 11 most populous states at that time were asked to enroll.
The authors examined the association between the duration of employment as an operating room nurse (a proxy measure for exposure to surgical smoke), and the subsequent lung cancer risk. Their study found no increased risk of lung cancer associated with long term exposure to surgical smoke. Their results actually showed a lower incidence of lung cancer in this cohort of females.
While the authors did attempt to allow for many factors that could have influenced their results, they acknowledged that a number of limitations may have affected their findings. These included the general overall health of the individual, lifestyle factors and the possibility that occurrence of cancers may not have arisen until after the study ended. They did conclude however that surgical smoke exposure may increase the risk of developing chronic pulmonary conditions such as asthma, and recommended that, considering the inflammatory and mutagenic potential of surgical smoke, precautions should be taken to minimize the exposure of perioperative personnel and patients. They also added that additional research is needed in this field. The BOHS (2006) comments that, even though there is no evidence to show that surgical smoke is carcinogenic to humans, there are persistent concerns.
Surgical smoke has been shown to be mutagenic (Gatti et al 1992). A mutagen is an agent which can cause changes in a gene, usually involving the composition of the DNA (Seeley et al 2003).
It is believed that the mutagenic properties of surgical smoke are mainly due to the presence of benzene (Barrett & Garber 2003). Gatti et al (1992) carried out one of the first studies to determine the mutagenicity of surgical smoke. This study collected electrocautery smoke produced during the actual procedures of two reduction mammaplasties on different aged women. The samples were collected from approximately 2.5 to 3ft above the operating field. The authors then examined the effect the samples had on the DNA of a TA98 strain of salmonella. A control sample was obtained from a side-room free of any smoke, and this was used to compare results. The smoke particles collected were found to be mutagenic to the TA98 strain of salmonella, in that they were able to alter the genetic make-up of the bacteria. Gatti et al (1992) concluded that their results showed that mutagens were present in surgical smoke, although their results could not determine if this represents a serious health hazard to humans. They expressed that there should be greater awareness as to the potential health risks and exposure should be limited.
Concerns have been raised over the potential infection risk associated with live cell transmission in surgical smoke (Baggish et al 1991, Alp et al 2006, BOHS 2006,
Bigony 2007, Springer 2007, Ulmer 2008, Fan et al 2009, Rimmer 2009, Ball 2010). Baggish et al (1991) carried out one of the first studies to determine whether intact viral cells capable of infection could be carried in laser smoke. They vapourised tissue pellets infected with Human Immunodeficiency Virus (HIV) using a carbon dioxide laser and evacuated the smoke through sterile collection tubing. The findings of their study were that potentially infectious debris accumulated in the collection tubing and these remained viable for up to 14 days. The authors concluded that smoke should be evacuated before it is inhaled by perioperative personnel. The authors commented that further studies were needed to ascertain infectivity to humans. Springer (2007) comments that there are no documented cases of viral infection linked to inhalation of surgical smoke, and no evidence to show that infections can be transmitted to humans in this way.
The main risk to patients from surgical smoke is the effects of carbon monoxide during laparoscopic procedures (Alp et al 2006, Fan et al 2009, O'Riley 2010). When carbon monoxide combines with haemoglobin it forms carboxyhaemoglobin and methaemoglobin which reduces the oxygen-carrying capacity of the blood and can result in hypoxic stress (Alp et al 2006). Watson (2010) lists eleven symptoms (Appendix 3) associated with elevated carboxyhaemoglobin levels and carbon monoxide poisoning. These include headache, palpitations, nausea and vomiting. Barrett and Garber (2003) believe that the effects of carbon monoxide may contribute to post-operative nausea and headaches after laparoscopic surgery.
Protection of perioperative personnel and patients
All of the literature reviewed recommends that, even with limited evidence of harm to humans from surgical smoke, exposure should be minimized for operating room personnel and patients. There is some debate as to the level of protection that surgical masks offer, with concern expressed that standard surgical masks do not offer adequate protection to perioperative personnel (Barrett & Garber 2003, Alp et al 2006, Bruske-Hohlfeld et al 2008). Alp et al (2006) suggest that surgical masks are effective in capturing large particles, 5 micrometers and above, but are inadequate at filtering smoke. Barrett and Garber (2003) agree and add that high efficiency respirator masks may provide better protection, but no studies have shown their effectiveness in this field. Ulmer (2008) comments that these high filtration type masks can filter particles to approximately 0.1micrometers, but points out that viral particles can be much smaller than this, ranging from approximately 0.01 - 0.3 micrometers. Ulmer (2008) also adds that, to be effective, these masks need to fit snugly and be changed often. McCormick (2008) agrees and suggests that masks offer no protection from very fine particles, adding that both standard and high filtration masks reach a saturation point when air will then be drawn in from around the mask. Edwards and Reiman (2008) are of the opinion that the use of respirator masks is only preferable when smoke evacuation systems are not available.
Theatres normally have high general ventilation systems, but these systems alone are not effective in protecting perioperative personnel from surgical smoke (Springer 2007, AORN 2008).
The majority of the literature reviewed concludes that the best protection is offered by smoke evacuation devices placed near the source of production (Alp et al 2006, BOHS 2006, Bigony 2007, Edwards & Reiman 2008, McCormick 2008, Ulmer 2008, Ogg & Denholm 2009). This type of device is sometimes referred to as a local exhaust ventilation (LEV) device (BOHS 2006). Comprehensive guidance on appropriate smoke evacuation measures has been produced by BOHS (2006) and is intended to be utilised by National Health Service managers. Ulmer (2008) recommends smoke evacuation systems that are triple filtered, comprising a pre-filter to capture large particles, an ultra-low particulate air (ULPA) filter, and a third charcoal filter to capture toxic chemicals. Ogg & Denholm (2009) agree that ULPA filtration is a necessity and that surgical smoke should be evacuated during all procedures.
The primary concern in relation to patients and surgical smoke is exposure during laparoscopic procedures. To protect patients from this risk it is recommended that filters be attached to the valves on the cannulas used (Barrett & Garber 2003, Alp et al 2006, Bruske-Hohlfeld et al 2008, Ulmer 2008, Watson 2010). These filters remove most of the harmful chemicals and biological matter, allowing continuous ventilation and filtration of the pneumoperitoneum (Alp et al 2006). Barrett and Garber (2003) advocate the use of such techniques to reduce intra-abdominal levels of carbon monoxide and other toxins.
The aim of this literature review was to examine the most current evidence relating to surgical smoke created by electrosurgical units and lasers, and to try to ascertain whether there is a risk to health and what, if any, protective precautions should be in place. The literature was examined to see if any reliable evidence-based guidelines were available which could be utilised to aid a change of practice if necessary, and thereby improve the perioperative care environment.
Surgical smoke is a mixture of biological and chemical components (Jones et al 2006). The literature shows that the chemical content can have serious health implications. Acrylonitrile, hydrogen cyanide, carbon monoxide and benzene are a major cause for concern. All four of these chemicals are classed as harmful to human health (HPA 2007, 2011a, 2011b, 2011c). There are concerns that some of the chemicals in surgical smoke are carcinogenic (Alp et al 2006, Gates et al 2007, Spearman et al 2007), and mutagenic (Gatti et al 1992, HPA 2011a).
Live and inert cellular material has been found in surgical smoke (BOHS 2006) and viable viruses and bacteria have also been shown to be present (Baggish et al 1991, McCormick 2008).
The main risks to the health of patients from surgical smoke is believed to be from the accumulation of carbon monoxide in the pneumoperitoneum during laparoscopic procedures (Alp et al 2006, Fan et al 2009, O'Riley 2010). It is thought that this may produce hypoxic effects, and could also contribute to symptoms such as nausea and headache post-operatively (Barrett & Garber 2003, Watson 2010). It is recommended that specialised filters be placed on the cannulas during laparoscopic procedures where smoke is produced to protect patients from these risks (Barrett & Garber 2003, Alp et al 2006, Bruske-Hohlfeld et al 2008, Ulmer 2008, Watson 2010).
The main risks to the health of perioperative personnel from surgical smoke are acute and chronic respiratory irritation and inflammation, irritation of the eyes and skin, transmission of infection, and genotoxicity by its mutagenic properties (Barrett & Garber 2003, Alp et al 2006). The very small size of the particles found in surgical smoke is concerning due to their potential to be inhaled deep into the respiratory system (Alp et al 2006, McCormick 2008).
The literature reviewed suggests that standard surgical masks do not provide adequate protection from the inhalation of surgical smoke due to the very small particle sizes, and the fact that a snug fit is not possible (Barrett & Garber 2003, Alp et al 2006, Bruske-Hohlfeld et al 2008). High filtration masks are thought to offer better protection, but the majority of the literature considers that the most effective protection is provided by smoke evacuation devices placed near the point of smoke production. The BOHS (2006) has produced comprehensive guidelines on the recommended specifications of smoke evacuation units that should be utilised whenever smoke is produced.
Due to the nature of this topic there is no definite proven link between surgical smoke and the effect it has on human health, but neither is there any firm evidence that shows it is safe to be exposed to surgical smoke. Therefore it would seem that until such time as evidence shows that surgical smoke poses no risks to health, a preventative approach would be the sensible option.
*Smoke evacuation systems should be used routinely and consistently whenever surgical smoke is produced.
*Smoke evacuation systems should incorporate a local exhaust ventilation device placed as near to the point of smoke production as possible (within 5cm).
*Smoke evacuation units should be triple filtered consisting of a pre filter, ULPA filter, and a third charcoal filter.
*Specialised filters should be fitted to the cannulas used during laparoscopic procedures where smoke is produced, to protect patients from the toxic effects of carbon monoxide in surgical smoke.
*Further research into this subject should be undertaken. In the meantime perioperative personnel should be made aware of the potential risks and what they should be doing to protect themselves and their patients.
This literature review was undertaken as part of the perioperative practice module run by Swansea University at The College of Human and Health Sciences, St. Davids Park, Carmarthen.
Chemicals identified within surgical smoke (Barrett & Garber 2003)
2,3-Dihydro indene (hydrocarbon) Ethane
Ethylene Ethyl Benzene Formaldehyde
Indole (amine) Isobutene
3-Methyl butenal (aldehyde)
6-Methyl Indole (amine)
2-Methyl propanol (aldehyde) Methyl pyrazine
Risks of surgical smoke (Alp et al 2006)
Acute and chronic inflammatory
changes in respiratory tract
(emphysema, asthma, chronic
Human Immunodeficiency Virus
Symptoms associated with elevated carboxyhaemoglobin levels and carbon monoxide poisoning (Watson 2010)
Shortness of breath
Lower extremity weakness
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About the author
RNA, BN (Hons)
Staff Nurse, Theatres, Glangwili General Hospital, Carmarthen
No competing interests declared
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by Cara Sanderson
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