Esophageal Perforation and Rupture

Esophageal Perforation and Rupture 

Key Points

  • Esophageal perforation or rupture is a life-threatening condition in which the cervical, thoracic, or intra-abdominal esophageal sections are perforated or ruptured iatrogenically, traumatically, spontaneously, or through the ingestion of foreign bodies
  • Often results in the dissection of air along the subcutaneous planes or into the mediastinum, presenting with chest pain, dyspnea, fever, and neck pain
  • Diagnosed clinically based on patient history, signs, and symptoms, and confirmed through visualization; chest radiograph (with water-soluble contrast if needed) is obtained in all patients, with CT scan obtained if needed, and esophagram (chest fluoroscopy with a water-soluble contrast medium) performed if other imaging is inconclusive
  • Patients with esophageal perforation or rupture are considered critically ill and require immediate treatment and management in an ICU
  • Treatment is dependent on degree of containment of esophageal contents and extent of mediastinal contamination; it may be surgical or nonsurgical
  • Patients with esophageal perforation or rupture have decreased morbidity and mortality rates if treated within the first 24 hours

Pitfalls

  • Lack of physician experience with this condition (owing to its rarity) along with the diversity of clinical symptoms may delay diagnosis, increasing the risk of morbidity and mortality 2

Terminology

Clinical Clarification

  • Esophageal perforation or rupture is a life-threatening condition in which the cervical, thoracic, or intra-abdominal esophageal sections are perforated or ruptured iatrogenically, during trauma, spontaneously, or through the ingestion of foreign bodies 3
  • May result in the esophageal contents passing into the mediastinum, pleural cavity, and peritoneum
  • A hallmark symptom is the dissection of air along the subcutaneous planes or into the mediastinum as identified by radiography in up to 90% of cases 3

Classification

  • Classified by cause of perforation or rupture
    • Iatrogenic 4
      • Most common (up to 70% of all cases 5)
      • Most common sites of iatrogenic esophageal perforation are at anatomically narrowing zones, such as the cricopharyngeal region of the cervical esophagus and the lower esophageal sphincter
    • Spontaneous 3
      • Commonly affects the left posterolateral wall of the lower third of the esophagus 2 to 3 cm proximal to the gastroesophageal junction
      • Usually associated with intense retching and vomiting
      • Represents 15% of cases 6
    • Foreign bodies 1
      • Can partially or completely lacerate the anatomic narrowing of the esophagus
    • Trauma
      • Such as blunt trauma or gunshot wound

Diagnosis

Clinical Presentation

History

  • Cervical perforation 7
    • Cervical pain (90%)
    • Classically associated with dysphagia and/or odynophagia that worsens with neck flexion and swallowing; dysphonia may also be noted
  • Thoracic perforation 7
    • Thoracic pain (79%); usually lateralizes to side of perforation
    • Vomiting (84%)
    • Dyspnea (53%)
    • Epigastric pain (47%)
    • Dysphagia (21%)
      • Mackler triad (thoracic pain, vomiting, subcutaneous emphysema) is highly suggestive of the condition but is present in fewer than one-third of cases
  • Abdominal perforation 7
    • Dorsal pain (worsened by lying on the back) or epigastric pain radiating to the back or scapula (due to diaphragmatic irritation)
  • Other reported associated symptoms include:
    • Hematemesis (8%) 8
    • Fever (44%) 8

Physical examination 3

  • Patients are typically in distress 1
  • Emphysematous crepitus is evident in 60% and 30% of patients with cervical and thoracic esophageal perforations, respectively 1
    • Systolic crunching sound (Hamman sign) may be detectable over the cardiac apex
  • Systemic inflammatory response may develop depending on length of time since perforation and the degree of contamination, with signs including the following:
    • Fever (over 38.5 °C); detected in approximately 51% of cases
    • Tachycardia is common
    • Tachypnea
    • Hemodynamic instability
  • Left-sided pleural effusion may be present with distal thoracic esophageal perforation/rupture causing dullness to percussion over the involved area 9
    • Right-sided pleural effusion is associated with more proximal perforation/rupture

Causes and Risk Factors

Causes

  • Iatrogenic esophageal perforation/rupture accounts for up to 70% of cases and results from: 10 11
    • Endoscopic procedures
      • Occurs at a rate of approximately 0.03% of cases using a flexible endoscope and 0.11% with a rigid scope
      • 1% to 6% risk for endoscopic variceal sclerotherapy
    • Esophageal dilation for strictures and achalasia
      • Risk of 0.5% for esophageal dilation, increasing to 1.7% for dilation for achalasia
    • Surgery on tissue in close proximity to the esophagus
      • Increased risk with certain procedures (eg, mediastinal surgery, cervical spine surgery, thyroidectomy)
    • Transesophageal echocardiography
      • 0.1% to 0.3% risk
  • Spontaneous rupture, also known as Boerhaave syndrome, occurs in the absence of preexisting pathology (15% of cases) 1
    • Typically results from intense vomiting or severe retching
  • Foreign objects or trauma 1
    • Perforation tends to occur where there is anatomic esophageal narrowing:
      • Cricopharyngeus muscle (level of C5-C6)
      • Left main-stem bronchus
      • Aortic arch
      • Lower esophageal sphincter
    • Swallowed foreign bodies account for 80% of cervical perforations 7
      • Materials that were inappropriately ingested (eg, metal safety pins)
      • Ingestion of caustic liquids
    • Blunt trauma 12
    • External air-blast 4
    • Gunshot wounds
  • Rarely, esophageal rupture is due to the following:
    • Parturition
    • Weight lifting
    • Status epilepticus
    • Use of Heimlich maneuver

Risk factors and/or associations

Sex
  • Esophageal rupture affects men more often than women (55% versus 45%, respectively) 10

Diagnostic Procedures

Primary diagnostic tools

  • Initial diagnosis is clinical and is based on symptoms, signs, and patient history 3
  • Lack of physician experience with this condition (owing to its rarity), along with the diversity of clinical symptoms, may delay diagnosis, increasing risk of morbidity and mortality 2
  • Begin diagnostic work-up immediately upon clinical suspicion of esophageal rupture 1
    • Definitive diagnosis is based on radiographic evidence 1
      • Posteroanterior and lateral plain chest radiography may help diagnose esophageal rupture; it can be done first if diagnosis is uncertain and often is performed first in practice 1
        • Sufficient for identifying indirect signs of esophageal rupture
        • If patient can swallow, consider using an oral water-soluble contrast medium such as diatrizoate meglumine (Gastrografin)
        • If radiographic evidence is negative and clinical symptoms persist, obtain a CT scan or repeat after 4 to 6 hours
      • CT of the chest and upper abdomen with oral contrast medium is a first line diagnostic tool used to provide both esophageal and extraesophageal information and may be chosen instead of chest radiography 1
        • Indicated for all patients but especially for those with external trauma, caustic injuries, or critical illness
        • Key examination in patients with suspected perforation or other foreign body–related complications 13
      • Esophagram is the second line imaging modality, indicated if CT scan with contrast enhancement is inconclusive 8
    • Flexible upper endoscopy is used only when there is a high clinical suspicion of a perforation but radiographic imaging result appears negative/equivocal, or when swallowing contrast media is not an option 1

Imaging

  • Plain chest radiography 9
    • May obtain in all patients; add water-soluble contrast medium if needed
    • May show indirect signs of esophageal rupture that include the following:
      • Pneumomediastinum diagnosed as
        • Radiolucent outline around the heart and mediastinum
      • Subcutaneous emphysema diagnosed as
        • Radiolucent striation
      • Pneumothorax and lung collapse diagnosed as
        • Air in the pleural space
        • A shift of the mediastinum
      • Hemothorax diagnosed as
        • Partial or complete opacification of the hemithorax
      • Pleural effusion
  • CT of the chest and upper abdomen with oral contrast medium is best imaging procedure 1 13
    • May be used as first line instead of chest radiography or if chest radiography is inconclusive
    • Key examination in patients with suspected perforation or other foreign body–related complications 13
    • Diagnostic findings of esophageal rupture include the following:
      • Collection of fluid and/or air in the mediastinum
      • Esophageal thickening
  • Chest fluoroscopy with a water-soluble contrast medium (esophagram) 1
    • Second line imaging procedure if chest radiograph and/or CT scan is inconclusive
    • Diatrizoate meglumine (Gastrografin) will show contrast leak in most cases
    • Diagnostic findings of esophageal rupture include contrast medium extravasation accompanied by large pleural effusion
    • Avoid barium sulfate owing to extravasation into mediastinum leading to the following:
      • Fibrosing mediastinitis
      • Long-term presence may make interpretation of future mediastinal imaging difficult
    • 10% false-negative rate 9

Procedures

  • Insertion of a thin, flexible tube equipped with fiber optics and a camera into the upper gastrointestinal tract to visualize a suspected esophageal rupture
  • High suspicion of perforation and negative radiographic findings
  • Patient unable to swallow contrast agent
  • Esophageal perforation observed with radiographic study
  • Hemodynamic instability
  • Conversion of small tear to a larger perforation during air insufflation
  • Direct visualization of perforation site indicates its location and extent

Differential Diagnosis

Most common

  • Acute aortic dissection 14 (Related: Acute Aortic Syndrome)
    • Patients typically present with sudden, severe pain that may radiate from chest or abdomen to back or extremities; hypertension is present in approximately 75% of cases
    • Differentiate by presentation:
      • Sudden chest or back pain accompanied by at least 1 of the following symptoms:
        • Pulse deficit
        • Aortic regurgitation
        • Neurologic manifestations, including the following:
          • Stroke
          • Spinal cord ischemia
          • Ischemic neuropathy
          • Hypoxic encephalopathy
    • Diagnose radiographically
      • Contrast-enhanced CT of the chest and abdomen is commonly used to detect aortic dissection
      • Bedside transesophageal echocardiogram can be used to diagnose aortic dissection when managing a hemodynamically unstable patient
  • Acute pericarditis 15 (Related: Pericarditis)
    • Differentiate by presentation:
      • Typically sudden-onset, high-intensity pleuritic chest pain that worsens with deep inspiration radiating to the neck and upper limbs
      • Pain worsening in supine position and improving when sitting
      • Pericardial friction rub is useful to discern pericarditis when present (85% of cases at some time during the disease course)
    • Diagnose
      • ECG showing typical changes of diffuse upwardly concave ST-segment elevation with PR depression
      • CT showing the enlargement of the ascending or descending aorta
      • Chest radiograph showing excess fluid in the pericardium; appearance of an enlargement of the heart may occur in the presence of pericardial effusion of more than 200 mL
  • Mallory-Weiss tear 16
    • Longitudinal mucosal laceration (intramural dissection) at the gastroesophageal junction resulting from sudden increase in pressure within the stomach (eg, vomiting) accounts for up to 15% of upper gastrointestinal bleeding cases
    • Differentiate by presentation
      • Acute upper gastrointestinal bleeding accompanied by epigastric or back pain and weakness
    • Diagnose
      • Esophagogastroduodenoscopy facilitates visualizing site of mucosal tear at gastroesophageal junction and allows for treatment at the same time
  • Pneumonia (Related: Community-Acquired Pneumonia in Adults)
    • Differentiate clinically
      • Patient presents with fever, cough, pleuritic chest pain, dyspnea, and tachypnea
    • Diagnose
      • Chest radiography facilitates the visualization of airspace opacity, lobar consolidation, or interstitial opacities
      • Sputum and blood culture to identify organism causing the infection
  • Myocardial infarction (Related: Acute Coronary Syndromes)
    • Differentiate clinically
      • Initially causes substernal pressure or pain with radiation to neck, lower jaw, or arms; may be precipitated by exertion
        • Often associated with dyspnea, nausea, and diaphoresis
    • Diagnose
      • Typical ECG changes and positive cardiac biomarkers (eg, troponins) diagnose infarction
  • Spontaneous pneumothorax
    • Differentiate clinically
      • Sudden onset of pleuritic chest pain and dyspnea
      • Classically occurs in tall, thin males in their teens or twenties; also can occur in patients who smoke and have lung disease
      • Findings on examination may include absent tactile fremitus and decreased breath sounds over the involved area of lung
    • Diagnose
      • Plain chest radiograph shows radiolucent air and absence of lung markings in area of collapse

Treatment

Goals

  • Prevent further contamination of body cavities with adequate drainage and antibiotics
  • Eliminate any focus of infection and inflammation
  • Restore alimentary tract continuity
  • Establish nutritional support

Disposition

Admission criteria

Esophageal perforation rupture is a medical emergency; admit suspected cases to the hospital immediately

Criteria for ICU admission
  • Suspected or confirmed cases of esophageal perforation/rupture require ICU observation and management

Recommendations for specialist referral 3

  • Gastroenterology referral/consultation is recommended for all patients with esophageal perforation/rupture
  • Thoracic surgical consultation is recommended for all patients with esophageal perforation/rupture, even if nonoperative treatment is chosen
    • If thoracic surgery is not available, transport patient to a facility with available thoracic surgery as soon as possible 1

Treatment Options

Begin empiric broad-spectrum antibiotic coverage for anaerobes and both gram-negative and gram-positive aerobes when diagnosis is first suspected 5

Typically, cervical esophageal perforation is managed by placement of a drain alone; thoracic or abdominal perforation involves more contamination and is more difficult to contain, requiring surgical management 9

  • Endoscopy is sometimes used to repair a perforation if treated immediately

Surgical treatment

  • Gold standard of treatment for patients with early diagnosis (within 24 hours) of unconfined cervical, thoracic (especially when greater than 6 cm in length 18), and abdominal esophageal perforations 17
    • For rapid closure of the esophageal leak and drainage of the mediastinal or pleural collection
    • Immediate parenteral nutrition and broad-spectrum antibiotics are necessary to minimize mediastinitis
    • Necessary for the treatment of clinically unstable patients
    • Specific operative strategies are chosen based on location of injury, presence of underlying esophageal disease, and degree of tissue damage, combined with patient’s overall condition
      • Percutaneous drainage
        • Recommended for patients with cervical perforation or those who seek medical treatment after 48 hours from time of incident
      • Extensive surgical drainage and tube thoracostomy
        • Recommended for patients with thoracic or abdominal perforations to contain leakage into mediastinum; occasionally required for cervical esophageal perforation
        • As a general principle, all thoracic or abdominal esophageal perforations require wide mediastinal drainage by opening the parietal pleura in its entire length of the esophagus
        • Debridement with primary closure with or without inclusion of buttressing with adjacent tissue can be done at this time
      • Primary closure with or without autologous tissue
        • Perforations in cervical esophagus
        • Primary closure can be done with interrupted sutures
        • Feeding jejunostomy and draining gastrostomy for nutrition and to allow distal drainage
      • Esophagectomy is recommended as a secondary surgical procedure followed by immediate or delayed reconstruction 5
        • Indicated to close an esophageal rupture that was not closed during primary surgery owing to severe mediastinitis or underlying esophageal pathology
        • Immediate reconstruction is indicated when pathologic process is a localized resectable cancer or an undilatable or malignant stricture reconstruction
        • Delayed reconstruction is indicated when there is significant devitalized tissue that does not allow a primary repair (eg, caustic ingestion; when primary repair failed and there is ongoing mediastinal sepsis) 8
          • Involves source control by debridement, drainage, and cervical esophagostomy for proximal drainage, and gastrostomy for distal drainage with feeding jejunostomy for nutritional support
      • Esophageal T-tube 9
        • For patients with thoracic or abdominal perforations who are hemodynamically unstable
        • Indicated for patients whose perforation cannot be repaired with primary closure
        • Delayed presentation of thoracic or abdominal perforation

Endoscopic treatment

  • Use of endoscopic treatment is increasing for perforations recognized immediately, not associated with pleural or mediastinal contamination, in clinically stable patients with no signs of sepsis present 13 19
    • Increasingly used to treat intrathoracic esophageal perforation smaller than 6 cm with immediate placement of esophageal endoscopic clips or stent to close the defect 18
  • Emergent endoscopy (less than 6 hours) is recommended for sharp-pointed objects, batteries, and magnets 13
  • Endoscopy is not employed in clinically unstable patients

Nonoperative treatment (approximately 25% of cases) 9

  • Indicated for most patients with cervical esophageal perforation; appropriate for those with the following:
    • Well-contained perforation and minimal mediastinal soilage on imaging or endoscopic evaluation 17
    • Injury limited to the esophageal wall 17
    • No malignancy, stricture, or obstruction in area of perforation 8
    • No evidence of systemic infection 8
    • Hemodynamic stability 17
    • Late presentation (24 hours after incident) but good clinical condition 17
    • Contained cavity that drains back into esophagus 8
    • No perforation into abdominal cavity 8
    • No free extravasation of contrast medium into body cavities 8
    • Availability of advanced imaging modalities and thoracic surgery
  • Nonoperative treatments include the following: 9
    • Securing the airway and ordering NPO status
    • Nasogastric suction
    • Pain management with opioid analgesics as needed
    • Broad-spectrum IV antibiotics
    • Proton pump inhibitors
      • Indicated for patients with severe erosive esophagitis, esophageal stricture, or malignancies, and/or those who are experiencing dysphagia
    • Nutritional support
  • Patients treated nonoperatively remain NPO for 7 days, after which a meglumine diatrizoate (Gastrografin) swallow radiographic study is obtained 8

Drug therapy

  • Begin empiric broad-spectrum antibiotic coverage for anaerobes and both gram-negative and gram-positive aerobes when diagnosis is first suspected. 5
    • β-lactam antibiotics
      • Cefuroxime
        • Cefuroxime Sodium Solution for injection; Adults: 750 mg IV every 8 hours for 7 to 10 days.
      • Ampicillin
        • Ampicillin Sodium Solution for injection; Adults: 500 mg IV every 8 hours for 7 to 10 days.
    • Nitroimidazole antimicrobial 20
      • Metronidazole
        • Metronidazole Solution for injection; Adults: 500 mg IV every 8 hours for 7 to 10 days.
    • Oxazolidinone antibiotic
      • Linezolid 21
        • Linezolid solution for injection; Adults: 600 mg IV every 12 hours.
  • Proton pump inhibitors 5
    • Pantoprazole
      • Pantoprazole Sodium Solution for injection; Adults: 40 mg IV every 12 hours. Switch to oral therapy when feasible.

Nondrug and supportive care

Nonoperative treatment (approximately 25% of cases) 9

  • Indicated for most patients with cervical esophageal perforation; appropriate for those with the following:
    • Availability of advanced imaging modalities and thoracic surgery
    • Well-contained perforation and minimal mediastinal soilage 17
    • No perforation into abdominal cavity 8
    • Injury limited to the esophageal wall 17
    • No malignancy, stricture, or obstruction in area of perforation 8
    • No evidence of systemic infection 8
    • Uncompromised circulation 17
    • Late presentation (24 hours after incident) but good clinical condition 17
    • Contained cavity that drains back into esophagus 8
    • No free extravasation of contrast medium into body cavities 8
  • Supportive care 9
    • Securing the airway and ordering NPO status
    • Nasogastric suction
    • Pain management with opioid analgesics as needed
    • Broad-spectrum IV antibiotics
    • Proton pump inhibitors
      • Indicated for patients with severe erosive esophagitis, esophageal stricture, or malignancies, and/or those experiencing dysphagia
    • Nutritional support
  • Patients treated nonoperatively remain NPO for 7 days, after which a meglumine diatrizoate (Gastrografin) swallow radiographic study is obtained 8

Parenteral nutrition 5

  • To provide nutrition to patients with a dysfunctional gastrointestinal tract and those who are experiencing dysphagia
  • Total parenteral nutrition through a central catheter or indwelling IV line
    • May be customized to individual patient requirements, or a standardized solution may be used
  • Transition to oral feeding is varied among patients owing to multiple factors
Procedures
Primary closure with or without anchoring using autologous tissue 3

General explanation

  • Surgical closure of the rupture primarily using interrupted sutures
    • Repair can be further stabilized with vascularized autologous tissues (eg, pleural flap, diaphragmatic pedicle graft, omentum onlay graft, rhomboid and latissimus dorsi muscles, intercostal muscles, pericardial fat pad)

Indication

  • Perforations without extravasation of contrast medium into surrounding body cavities
  • Hemodynamic instability

Contraindications

  • Mediastinal sepsis
  • Underlying malignancy, stricture, or obstruction at site of perforation

Complications

  • Site leakage
Tube thoracostomy and surgical drainage (thoracotomy) 22

General explanation

  • A chest tube is inserted into the pleural space and placed to suction (tube thoracostomy)
  • In general, all thoracic or abdominal esophageal perforations require wide mediastinal drainage by opening the parietal pleura in its entire length of the esophagus
  • Tube placement and surgical drainage (thoracotomy) are typically carried out at the same time; in the absence of cancer or an irreversible distal obstruction, meticulous repair of an intrathoracic esophageal perforation is the preferred approach, regardless of the duration of the injury 23

Indication

  • Thoracic or abdominal perforations (to contain leakage into mediastinum)
  • Cervical perforation only if the patient’s pleural effusion becomes grossly contaminated and/or the perforation/rupture remains unconfined after initial percutaneous drainage and nonoperative treatments have been done

Contraindications

  • Cervical perforation in a stable patient

Complications

  • Bleeding or hemothorax
  • Perforation of internal organs
  • Intercostal neuralgia
  • Subcutaneous emphysema
  • Pneumonia
  • Empyema
Esophagectomy 5

General explanation

  • Partial or full surgical removal of the esophagus, with concurrent reconstruction from sections of the stomach or the large intestine

Indication

  • Thoracic or abdominal perforations that were not closed during primary surgery owing to severe mediastinitis or underlying esophageal pathology
  • Thoracic or abdominal perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple reflux strictures that cannot be dilated

Contraindications

  • Hemodynamic stability and perforation/rupture amenable to primary closure
  • Hemodynamic instability and perforation/rupture that can be repaired with esophageal T-tube

Complications

  • Pneumonia
  • Atrial fibrillation
  • Recurrent laryngeal nerve injury
  • Chyle leak/chylothorax
  • Anastomotic leak
  • Functional abnormalities (eg, dumping syndrome, reflux)
Esophageal T-tube 17

General explanation

  • The T-tube creates a controlled esophagocutaneous fistula, allowing drainage of the esophagus and time for tissues to heal

Indication

  • Hemodynamic instability
  • Esophageal injuries that cannot be repaired with primary closure
  • Delayed presentation of thoracic or abdominal esophageal perforation

Contraindications

  • Perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple undilatable reflux strictures
  • Severe mediastinitis or underlying esophageal pathology

Complications

  • Leakage
  • Atrial fibrillation
  • Empyema
  • Sepsis
  • Chronic fistula formation
Percutaneous drainage 9

General explanation

  • Recommended to stabilize or minimize leakage into surrounding tissues and mediastinum, and to contain pleural contamination
  • Use of fluoroscopy, CT, or ultrasonography to guide needle placement for drainage
  • A drainage tube may be inserted until no further drainage is produced

Indication

  • Cervical esophageal perforation for patients without sepsis who are hemodynamically stable
  • For patients with perforations confined to the mediastinum or who seek medical attention more than 48 hours after the injury

Contraindications

  • Gross mediastinum contamination
  • Perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple undilatable reflux strictures

Complications 24

  • Inadvertent catheterization of adjacent organs
  • Vascular fistula formation
  • Pseudoaneurysm formation
  • Infection

Monitoring

  • All patients hospitalized with esophageal perforation or rupture require close monitoring for hemodynamic instability and evidence of systemic infection, typically provided in an ICU 8
  • Before discharge, imaging is repeated (CT, chest radiograph, or esophagram) using oral meglumine diatrizoate (Gastrografin) to test the perforation site 5
    • Patients treated nonoperatively are imaged after 7 days without oral intake to determine closure of the perforation before initiating an oral diet 8

Complications and Prognosis

Complications

  • Complications are reported in approximately 14% of patients with cervical perforation, 39% with thoracic perforation, and 25% with abdominal perforation 3
    • Pneumonia
    • Empyema
    • Esophageal narrowing or stricture
    • Periesophageal abscess
    • Esophageal leakage
    • Mediastinitis
    • Peritonitis
    • Cardiopulmonary collapse
    • Multiorgan failure

Prognosis

  • Mortality of esophageal rupture or perforation ranges from 10% to 40% 25 8 and is improved with early recognition and treatment initiation within 24 hours; 3 treatment begun more than 48 hours after perforation is associated with 40% to 60% mortality 5
    • Iatrogenic perforation has lower mortality of 10%, whereas rupture after emesis is associated with mortality of 60% to 70%

Sources

1: Soreide JA et al: Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 19:66, 2011

Cross Reference 

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