Research progress in posthepatectomy acute pancreatitis after liver resection_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

KANG Linwei , LI Jiankang ,  YANG Jihong

Department of Hepatobiliary Surgery, Affiliated Hospital of Hebei University, Baoding, Hebei 071000, P. R. China;

Corresponding author：

YANG Jihong, Email: doctoryangjh@sina.com

Keywords：

acute pancreatitis; posthepatectomy; diagnosis; treatment

DOI：

10.7507/1007-9424.202305047

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To understand the incidence and mechanism of posthepatectomy acute pancreatitis (PHAP) after liver resection, and to explore diagnosis, treatment, and preventive strategies to enhance prognosis for the patients with PHAP. Method The literature on studies relevant PHAP both domestically and internationally was retrieved and reviewed. Results The incidence rate of PHAP was approximately 0.7% by the literature. The exact etiology was still unclear. According to the existing research results, it was speculated that the pathogenesis might be related to the portal vein congestion, reactive oxygen species, surgical trauma, and other factors. At present, there were no comprehensive guidelines for the diagnosis and treatment of PHAP after liver resection both domestically and internationally. The diagnosis was mainly based on the clinical manifestations, early signs and symptoms, biochemical examination and imaging evaluation. The treatment principle of the PHAP was similar to that of common acute pancreatitis. The symptomatic supportive treatment was performed for the patients with mild to moderate PHAP, while the surgical treatment and minimally invasive surgery were chosen for the severe PHAP. The best way prevented for PHAP was the preoperative comprehensive evaluation of patients, and quit smoking and drinking, and so on. The careful operation should be performed during the surgical process to minimize portal vein congestion and reduce reactive oxygen species in blood vessels.The blood biochemistry, hematuric amylase, pancreatic function, and relevant infection indicators should be closely monitored after surgery, and abdominal ultrasound should be repeated several times to achieve early identification and timely treatment. Conclusions Although the incidence rate of PHAP is not high, it is a serious surgical complication. The prevention, early detection, and early treatment should be strengthened for PHAP, and we should focuse on earlier and more accurate prediction model in future.

Citation： KANG Linwei, LI Jiankang, YANG Jihong. Research progress in posthepatectomy acute pancreatitis after liver resection. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2023, 30(11): 1389-1394. doi: 10.7507/1007-9424.202305047 Copy

1.	Torres OJM, Coelho FF, Kalil AN, et al. Surgical resection for non-Asian intrahepatic lithiasis: The Brazilian experience. Asian J Surg, 2021, 44(3): 553-559.
2.	Petrov MS, Yadav D. Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastroenterol Hepatol, 2019, 16(3): 175-184.
3.	Iannuzzi JP, King JA, Leong JH, et al. Global incidence of acute pancreatitis is increasing over time: a systematic review and meta-analysis. Gastroenterology, 2022, 162(1): 122-134.
4.	Lorio E, Patel P, Rosenkranz L, et al. Management of hepatolithiasis: review of the literature. Curr Gastroenterol Rep, 2020, 22(6): 30.
5.	Baskiran A, Kement M, Barut B, et al. Acute pancreatitis: a rare but serious complication for living liver donors; risk factors and outcomes. Exp Clin Transplant, 2022, 20(4): 413-419.
6.	Chopinet S, Bollon E, Hak JF, et al. The white test for intraoperative screening of bile leakage: a potential trigger factor for acute pancreatitis after liver resection—a case series. BMC Surg, 2021, 21(1): 356.
7.	Hayashi K, Abe Y, Shinoda M, et al. Clinical impact of intraoperative bile leakage during laparoscopic liver resection. Surg Endosc, 2021, 35(8): 4134-4142.
8.	Bang JY, Wilcox CM, Arnoletti JP, et al. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc, 2020, 32(3): 298-308.
9.	Schepers NJ, Bakker OJ, Besselink MG, et al. Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis. Gut, 2019, 68(6): 1044-1051.
10.	Miyagawa S, Makuuchi M, Kawasaki S, et al. Changes in serum amylase level following hepatic resection in chronic liver disease. Arch Surg, 1994, 129(6): 634-638.
11.	Lee PJ, Papachristou GI. New insights into acute pancreatitis. Nat Rev Gastroenterol Hepatol, 2019, 16(8): 479-496.
12.	Loos M, Strobel O, Mehrabi A, et al. Postoperative acute pancreatitis is a serious but rare complication after distal pancreatectomy. HPB (Oxford), 2021, 23(9): 1339-1348.
13.	Petersen OH, Gerasimenko JV, Gerasimenko OV, et al. The roles of calcium and ATP in the physiology and pathology of the exocrine pancreas. Physiol Rev, 2021, 101(4): 1691-1744.
14.	De Pretis N, De Marchi G, Frulloni L. Hypertriglyceridemic pancreatitis. Minerva Gastroenterol Dietol, 2020, 66(3): 238-245.
15.	Miyagawa S, Makuuchi M, Kawasaki S, et al. Serum amylase elevation following hepatic resection in patients with chronic liver disease. Am J Surg, 1996, 171(2): 235-238.
16.	Hashimoto N, Haji S, Nomura H, et al. Hyperamylasemia after hepatic resection. Hepatogastroenterology, 2003, 50(53): 1472-1473.
17.	Tocchi A, Mazzoni G, Liotta G, et al. Increased blood amylase levels in the postoperative period after liver resection. G Chir, 1998, 19(6-7): 262-264.
18.	Otsubo T. Control of the inflow and outflow system during liver resection. J Hepatobiliary Pancreat Sci, 2012, 19(1): 15-18.
19.	Kubota K, Makuuchi M, Noie T, et al. Risk factors for hyperamylasemia after hepatectomy using the Pringle maneuver: randomized analysis of surgical parameters. Arch Surg, 1998, 133(3): 303-308.
20.	Arkadopoulos N, Nastos C, Defterevos G, et al. Pancreatic injury after major hepatectomy: a study in a porcine model. Surg Today, 2012, 42(4): 368-375.
21.	Varsos P, Nastos C, Papoutsidakis N, et al. Desferrioxamine attenuates pancreatic injury after major hepatectomy under vascular control of the liver: experimental study in pigs. HPB Surg, 2012, 2012: 714672.
22.	Bläuer M, Laaninen M, Sand J, et al. Wnt/β-catenin signalling plays diverse functions during the process of fibrotic remodelling in the exocrine pancreas. Pancreatology, 2019, 19(2): 252-257.
23.	Ratti F, Fiorentini G, Cipriani F, et al. Perioperative and long-term outcomes of laparoscopic versus open lymphadenectomy for biliary tumors: a propensity-score-based, case-matched analysis. Ann Surg Oncol, 2019, 26(2): 564-575.
24.	Kaneko J, Ishiwatari H, Asakura K, et al. Biliary obstruction and pancreatitis after duodenal stent placement in the descending duodenum: a retrospective study. BMC Gastroenterol, 2022, 22(1): 257.
25.	Teterin YS, Kulikov YD, Rogal ML, et al. Endoscopic transluminal drainage for infected pancreatic necrosis. Khirurgiia (Mosk), 2022, (2): 17-23.
26.	Antila A, Siiki A, Sand J, et al. Perioperative hydrocortisone treatment reduces postoperative pancreatic fistula rate after open distal pancreatectomy. A randomized placebo-controlled trial. Pancreatology, 2019, 19(5): 786-792.
27.	Rhu J, Choi GS, Kim JM, et al. Intraoperative ultrasonography as a guidance for dividing bile duct during laparoscopic living donor hepatectomy. Ann Transplant, 2019, 24: 115-122.
28.	Wei L, Zhang ZT, Zhu ZJ, et al. A new approach to accomplish intraoperative cholangiography in left lateral segmentectomy of living liver donation. Ann Transplant, 2019, 24: 155-161.
29.	Tuysuz U, Aktas H, Batı IB, et al. The role of intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy. Asian J Surg, 2021, 44(1): 147-152.
30.	Reddy MS, Narasimhan G, Cherian PT, et al. Death of a living liver donor: opening Pandora’s box. Liver Transpl, 2013, 19(11): 1279-1284.
31.	Gardner TB. Acute pancreatitis. Ann Intern Med, 2021, 174(2): ITC17-ITC32.
32.	Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut, 2013, 62(1): 102-111.
33.	Fung C, Svystun O, Fouladi DF, et al. CT imaging, classification, and complications of acute pancreatitis. Abdom Radiol (NY), 2020, 45(5): 1243-1252.
34.	马进坡, 徐德全, 赵加斌, 等. 降钙素原在急性胰腺炎及胰腺感染中的价值. 中国普外基础与临床杂志, 2021, 28(1): 130-134.
35.	陈梦婷, 余清萍, 李雨, 等. 血清PCT、NLR及CRP水平与急性胰腺炎严重程度的相关性. 西部医学, 2021, 33(12): 1849-1853.
36.	Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. JAMA, 2021, 325(4): 382-390.
37.	Pereira R, Eslick G, Cox M. Endoscopic ultrasound for routine assessment in idiopathic acute pancreatitis. J Gastrointest Surg, 2019, 23(8): 1694-1700.
38.	Wan J, Ouyang Y, Yu C, et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc, 2018, 87(5): 1180-1188.
39.	Umans DS, Timmerhuis HC, Hallensleben ND, et al. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open, 2020, 10(8): e035504.
40.	Buxbaum JL, Quezada M, Da B, et al. Early aggressive hydration hastens clinical improvement in mild acute pancreatitis. Am J Gastroenterol, 2017, 112(5): 797-803.
41.	Iqbal U, Anwar H, Scribani M. Ringer’s lactate versus normal saline in acute pancreatitis: a systematic review and meta-analysis. J Dig Dis, 2018, 19(6): 335-341.
42.	Choosakul S, Harinwan K, Chirapongsathorn S, et al. Comparison of normal saline versus Lactated Ringer’s solution for fluid resuscitation in patients with mild acute pancreatitis. A randomized controlled trial. Pancreatology, 2018, 18(5): 507-512.
43.	Calamo-Guzman B, De Vinatea-Serrano L, Piscoya A. In response to fluid resuscitation with lactated Ringer’s solution vs. normal saline in acute pancreatitis: a triple-blind, randomized, controlled trial. United European Gastroenterol J, 2018, 6(3): 480-481.
44.	Boxhoorn L, Voermans RP, Bouwense SA, et al. Acute pancreatitis. Lancet, 2020, 396(10252): 726-734.
45.	van Grinsven J, van Brunschot S, van Baal MC, et al. Natural history of gas configurations and encapsulation in necrotic collections during necrotizing pancreatitis. J Gastrointest Surg, 2018, 22(9): 1557-1564.
46.	James TW, Crockett SD. Management of acute pancreatitis in the first 72 hours. Curr Opin Gastroenterol, 2018, 34(5): 330-335.
47.	Vege SS, DiMagno MJ, Forsmark CE, et al. Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology, 2018, 154(4): 1103-1139.
48.	Wolbrink DRJ, Kolwijck E, Ten Oever J, et al. Management of infected pancreatic necrosis in the intensive care unit: a narrative review. Clin Microbiol Infect, 2020, 26(1): 18-25.
49.	García-Rayado G, Cárdenas-Jaén K, de-Madaria E. Towards evidence-based and personalised care of acute pancreatitis. United European Gastroenterol J, 2020, 8(4): 403-409.
50.	Jenkins A, Shapiro J. Clinical guideline highlights for the hospitalist: initial management of acute pancreatitis in the hospitalized adult. J Hosp Med, 2019, 14(12): 764-765.
51.	Singh RR, Mitchell W, David Y, et al. Pancreatic fungal infection in patients with necrotizing pancreatitis: a systematic review and meta-analysis. J Clin Gastroenterol, 2021, 55(3): 218-226.
52.	Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology, 2018, 154(4): 1096-1101.
53.	Baron TH, DiMaio CJ, Wang AY, et al. American Gastroenterological Association clinical practice update: management of pancreatic necrosis. Gastroenterology, 2020, 158(1): 67-75.
54.	Jabaudon M, Belhadj-Tahar N, Rimmelé T, et al. Thoracic epidural analgesia and mortality in acute pancreatitis: a multicenter propensity analysis. Crit Care Med, 2018, 46(3): e198-e205.
55.	Guyot A, Lequeu JB, Dransart-Rayé O, et al. Management of acute pancreatitis. A literature review. Rev Med Interne, 2021, 42(9): 625-632.

1. Torres OJM, Coelho FF, Kalil AN, et al. Surgical resection for non-Asian intrahepatic lithiasis: The Brazilian experience. Asian J Surg, 2021, 44(3): 553-559.
2. Petrov MS, Yadav D. Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastroenterol Hepatol, 2019, 16(3): 175-184.
3. Iannuzzi JP, King JA, Leong JH, et al. Global incidence of acute pancreatitis is increasing over time: a systematic review and meta-analysis. Gastroenterology, 2022, 162(1): 122-134.
4. Lorio E, Patel P, Rosenkranz L, et al. Management of hepatolithiasis: review of the literature. Curr Gastroenterol Rep, 2020, 22(6): 30.
5. Baskiran A, Kement M, Barut B, et al. Acute pancreatitis: a rare but serious complication for living liver donors; risk factors and outcomes. Exp Clin Transplant, 2022, 20(4): 413-419.
6. Chopinet S, Bollon E, Hak JF, et al. The white test for intraoperative screening of bile leakage: a potential trigger factor for acute pancreatitis after liver resection—a case series. BMC Surg, 2021, 21(1): 356.
7. Hayashi K, Abe Y, Shinoda M, et al. Clinical impact of intraoperative bile leakage during laparoscopic liver resection. Surg Endosc, 2021, 35(8): 4134-4142.
8. Bang JY, Wilcox CM, Arnoletti JP, et al. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc, 2020, 32(3): 298-308.
9. Schepers NJ, Bakker OJ, Besselink MG, et al. Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis. Gut, 2019, 68(6): 1044-1051.
10. Miyagawa S, Makuuchi M, Kawasaki S, et al. Changes in serum amylase level following hepatic resection in chronic liver disease. Arch Surg, 1994, 129(6): 634-638.
11. Lee PJ, Papachristou GI. New insights into acute pancreatitis. Nat Rev Gastroenterol Hepatol, 2019, 16(8): 479-496.
12. Loos M, Strobel O, Mehrabi A, et al. Postoperative acute pancreatitis is a serious but rare complication after distal pancreatectomy. HPB (Oxford), 2021, 23(9): 1339-1348.
13. Petersen OH, Gerasimenko JV, Gerasimenko OV, et al. The roles of calcium and ATP in the physiology and pathology of the exocrine pancreas. Physiol Rev, 2021, 101(4): 1691-1744.
14. De Pretis N, De Marchi G, Frulloni L. Hypertriglyceridemic pancreatitis. Minerva Gastroenterol Dietol, 2020, 66(3): 238-245.
15. Miyagawa S, Makuuchi M, Kawasaki S, et al. Serum amylase elevation following hepatic resection in patients with chronic liver disease. Am J Surg, 1996, 171(2): 235-238.
16. Hashimoto N, Haji S, Nomura H, et al. Hyperamylasemia after hepatic resection. Hepatogastroenterology, 2003, 50(53): 1472-1473.
17. Tocchi A, Mazzoni G, Liotta G, et al. Increased blood amylase levels in the postoperative period after liver resection. G Chir, 1998, 19(6-7): 262-264.
18. Otsubo T. Control of the inflow and outflow system during liver resection. J Hepatobiliary Pancreat Sci, 2012, 19(1): 15-18.
19. Kubota K, Makuuchi M, Noie T, et al. Risk factors for hyperamylasemia after hepatectomy using the Pringle maneuver: randomized analysis of surgical parameters. Arch Surg, 1998, 133(3): 303-308.
20. Arkadopoulos N, Nastos C, Defterevos G, et al. Pancreatic injury after major hepatectomy: a study in a porcine model. Surg Today, 2012, 42(4): 368-375.
21. Varsos P, Nastos C, Papoutsidakis N, et al. Desferrioxamine attenuates pancreatic injury after major hepatectomy under vascular control of the liver: experimental study in pigs. HPB Surg, 2012, 2012: 714672.
22. Bläuer M, Laaninen M, Sand J, et al. Wnt/β-catenin signalling plays diverse functions during the process of fibrotic remodelling in the exocrine pancreas. Pancreatology, 2019, 19(2): 252-257.
23. Ratti F, Fiorentini G, Cipriani F, et al. Perioperative and long-term outcomes of laparoscopic versus open lymphadenectomy for biliary tumors: a propensity-score-based, case-matched analysis. Ann Surg Oncol, 2019, 26(2): 564-575.
24. Kaneko J, Ishiwatari H, Asakura K, et al. Biliary obstruction and pancreatitis after duodenal stent placement in the descending duodenum: a retrospective study. BMC Gastroenterol, 2022, 22(1): 257.
25. Teterin YS, Kulikov YD, Rogal ML, et al. Endoscopic transluminal drainage for infected pancreatic necrosis. Khirurgiia (Mosk), 2022, (2): 17-23.
26. Antila A, Siiki A, Sand J, et al. Perioperative hydrocortisone treatment reduces postoperative pancreatic fistula rate after open distal pancreatectomy. A randomized placebo-controlled trial. Pancreatology, 2019, 19(5): 786-792.
27. Rhu J, Choi GS, Kim JM, et al. Intraoperative ultrasonography as a guidance for dividing bile duct during laparoscopic living donor hepatectomy. Ann Transplant, 2019, 24: 115-122.
28. Wei L, Zhang ZT, Zhu ZJ, et al. A new approach to accomplish intraoperative cholangiography in left lateral segmentectomy of living liver donation. Ann Transplant, 2019, 24: 155-161.
29. Tuysuz U, Aktas H, Batı IB, et al. The role of intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy. Asian J Surg, 2021, 44(1): 147-152.
30. Reddy MS, Narasimhan G, Cherian PT, et al. Death of a living liver donor: opening Pandora’s box. Liver Transpl, 2013, 19(11): 1279-1284.
31. Gardner TB. Acute pancreatitis. Ann Intern Med, 2021, 174(2): ITC17-ITC32.
32. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut, 2013, 62(1): 102-111.
33. Fung C, Svystun O, Fouladi DF, et al. CT imaging, classification, and complications of acute pancreatitis. Abdom Radiol (NY), 2020, 45(5): 1243-1252.
34. 马进坡, 徐德全, 赵加斌, 等. 降钙素原在急性胰腺炎及胰腺感染中的价值. 中国普外基础与临床杂志, 2021, 28(1): 130-134.
35. 陈梦婷, 余清萍, 李雨, 等. 血清PCT、NLR及CRP水平与急性胰腺炎严重程度的相关性. 西部医学, 2021, 33(12): 1849-1853.
36. Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. JAMA, 2021, 325(4): 382-390.
37. Pereira R, Eslick G, Cox M. Endoscopic ultrasound for routine assessment in idiopathic acute pancreatitis. J Gastrointest Surg, 2019, 23(8): 1694-1700.
38. Wan J, Ouyang Y, Yu C, et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc, 2018, 87(5): 1180-1188.
39. Umans DS, Timmerhuis HC, Hallensleben ND, et al. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open, 2020, 10(8): e035504.
40. Buxbaum JL, Quezada M, Da B, et al. Early aggressive hydration hastens clinical improvement in mild acute pancreatitis. Am J Gastroenterol, 2017, 112(5): 797-803.
41. Iqbal U, Anwar H, Scribani M. Ringer’s lactate versus normal saline in acute pancreatitis: a systematic review and meta-analysis. J Dig Dis, 2018, 19(6): 335-341.
42. Choosakul S, Harinwan K, Chirapongsathorn S, et al. Comparison of normal saline versus Lactated Ringer’s solution for fluid resuscitation in patients with mild acute pancreatitis. A randomized controlled trial. Pancreatology, 2018, 18(5): 507-512.
43. Calamo-Guzman B, De Vinatea-Serrano L, Piscoya A. In response to fluid resuscitation with lactated Ringer’s solution vs. normal saline in acute pancreatitis: a triple-blind, randomized, controlled trial. United European Gastroenterol J, 2018, 6(3): 480-481.
44. Boxhoorn L, Voermans RP, Bouwense SA, et al. Acute pancreatitis. Lancet, 2020, 396(10252): 726-734.
45. van Grinsven J, van Brunschot S, van Baal MC, et al. Natural history of gas configurations and encapsulation in necrotic collections during necrotizing pancreatitis. J Gastrointest Surg, 2018, 22(9): 1557-1564.
46. James TW, Crockett SD. Management of acute pancreatitis in the first 72 hours. Curr Opin Gastroenterol, 2018, 34(5): 330-335.
47. Vege SS, DiMagno MJ, Forsmark CE, et al. Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology, 2018, 154(4): 1103-1139.
48. Wolbrink DRJ, Kolwijck E, Ten Oever J, et al. Management of infected pancreatic necrosis in the intensive care unit: a narrative review. Clin Microbiol Infect, 2020, 26(1): 18-25.
49. García-Rayado G, Cárdenas-Jaén K, de-Madaria E. Towards evidence-based and personalised care of acute pancreatitis. United European Gastroenterol J, 2020, 8(4): 403-409.
50. Jenkins A, Shapiro J. Clinical guideline highlights for the hospitalist: initial management of acute pancreatitis in the hospitalized adult. J Hosp Med, 2019, 14(12): 764-765.
51. Singh RR, Mitchell W, David Y, et al. Pancreatic fungal infection in patients with necrotizing pancreatitis: a systematic review and meta-analysis. J Clin Gastroenterol, 2021, 55(3): 218-226.
52. Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology, 2018, 154(4): 1096-1101.
53. Baron TH, DiMaio CJ, Wang AY, et al. American Gastroenterological Association clinical practice update: management of pancreatic necrosis. Gastroenterology, 2020, 158(1): 67-75.
54. Jabaudon M, Belhadj-Tahar N, Rimmelé T, et al. Thoracic epidural analgesia and mortality in acute pancreatitis: a multicenter propensity analysis. Crit Care Med, 2018, 46(3): e198-e205.
55. Guyot A, Lequeu JB, Dransart-Rayé O, et al. Management of acute pancreatitis. A literature review. Rev Med Interne, 2021, 42(9): 625-632.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Research progress in posthepatectomy acute pancreatitis after liver resection

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content