Acute pancreatitis Case reports

Acute pancreatitisCase reports

Clinical problemsClinical problems

• Use of antibioticsUse of antibiotics? (? (P 1 & 2P 1 & 2))• Surgical treatment of AP Surgical treatment of AP ? (? (P 3 & 4P 3 & 4))

Clinical problemsClinical problems

• Use of antibioticsUse of antibiotics? (? (P 1 & 2P 1 & 2))• Surgical treatment of AP Surgical treatment of AP ? (? (P 3 & 4P 3 & 4))

Case 1Case 1Case 1Case 1

Acute pancreatitisCase 1 – Patient KDAcute pancreatitis

Case 1 – Patient KD

HistoryHistory

• M, M, 6363 y y• Obesity – BMI Obesity – BMI 30.330.3 kg/m kg/m22

• Gallbladder stones Gallbladder stones • No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 33.533.5 h h

HistoryHistory

• M, M, 6363 y y• Obesity – BMI Obesity – BMI 30.330.3 kg/m kg/m22

• Gallbladder stones Gallbladder stones • No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 33.533.5 h h

Lab data & prognostic assessmentLab data & prognostic assessment

• WBC (G/l)WBC (G/l) 13.6 13.6 -- 19.8 19.8 -- 14.414.4

• CRP (mg/l)CRP (mg/l) 5757 - - 167167 - ND - ND

• RNS (pts)RNS (pts) 55• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 99 - 8 - 8 - 8 - 8• KCE (pts)KCE (pts) 44

• WBC (G/l)WBC (G/l) 13.6 13.6 -- 19.8 19.8 -- 14.414.4

• CRP (mg/l)CRP (mg/l) 5757 - - 167167 - ND - ND

• RNS (pts)RNS (pts) 55• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 99 - 8 - 8 - 8 - 8• KCE (pts)KCE (pts) 44

ERCP & CTERCP & CT

• ERCP (day 0)ERCP (day 0)CBD 5 mm, no stonesCBD 5 mm, no stonesNo ESNo ES

• CT (day 1)CT (day 1)Mild inflammatory infiltration close to body and tail ofMild inflammatory infiltration close to body and tail ofthe pancreas and in the left prerenal space, the pancreas and in the left prerenal space, no pancreatic necrosisno pancreatic necrosis(BLT (BLT CC, CTSI , CTSI 22))

ERCP & CTERCP & CT

• ERCP (day 0)ERCP (day 0)CBD 5 mm, no stonesCBD 5 mm, no stonesNo ESNo ES

• CT (day 1)CT (day 1)Mild inflammatory infiltration close to body and tail ofMild inflammatory infiltration close to body and tail ofthe pancreas and in the left prerenal space, the pancreas and in the left prerenal space, no pancreatic necrosisno pancreatic necrosis(BLT (BLT CC, CTSI , CTSI 22))

Acute pancreatitisCase 2 – Patient MKAcute pancreatitis

Case 2 – Patient MK

HistoryHistory

• M,M, 2929 y y• Overweight – BMI Overweight – BMI 28.528.5 kg/m kg/m22

• Gallbladder stonesGallbladder stones• No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 46.546.5 h h

HistoryHistory

• M,M, 2929 y y• Overweight – BMI Overweight – BMI 28.528.5 kg/m kg/m22

• Gallbladder stonesGallbladder stones• No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 46.546.5 h h

• WBC (G/l)WBC (G/l) 20.9 20.9 -- 15.9 15.9 -- 15.015.0

• CRP (mg/l)CRP (mg/l) 7171 - - 9595 - - 166166

• RNS (pts)RNS (pts) 22• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 4 - 2 - 54 - 2 - 5• KCE (pts)KCE (pts) 2 2

• WBC (G/l)WBC (G/l) 20.9 20.9 -- 15.9 15.9 -- 15.015.0

• CRP (mg/l)CRP (mg/l) 7171 - - 9595 - - 166166

• RNS (pts)RNS (pts) 22• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 4 - 2 - 54 - 2 - 5• KCE (pts)KCE (pts) 2 2

ERCP & CTERCP & CT

• ERCP (day 0)ERCP (day 0)CBD 12 mm, CBD 12 mm, impacted stone impacted stone + 4 other stones+ 4 other stonesSE done, stones removedSE done, stones removed

• TK (day 1)TK (day 1)Moderate inflammatory infiltrations in both prerenalModerate inflammatory infiltrations in both prerenalspaces, spaces, no pancreatic necrosis, no pancreatic necrosis, small amount of fluid small amount of fluid around the liver and mild bilateral hydrothoraxaround the liver and mild bilateral hydrothorax(BLT (BLT CC, CTSI , CTSI 22))

ERCP & CTERCP & CT

• ERCP (day 0)ERCP (day 0)CBD 12 mm, CBD 12 mm, impacted stone impacted stone + 4 other stones+ 4 other stonesSE done, stones removedSE done, stones removed

• TK (day 1)TK (day 1)Moderate inflammatory infiltrations in both prerenalModerate inflammatory infiltrations in both prerenalspaces, spaces, no pancreatic necrosis, no pancreatic necrosis, small amount of fluid small amount of fluid around the liver and mild bilateral hydrothoraxaround the liver and mild bilateral hydrothorax(BLT (BLT CC, CTSI , CTSI 22))

TKTKTKTK

Acute pancreatitisCases 1 & 2

• SIRS (+)SIRS (+)• Mild overweight / obesityMild overweight / obesity• BLT C, BLT C, no necrosisno necrosis, CTSI 2, CTSI 2• WBC WBC > 15 > 15 G/lG/l• CRP CRP > 150 > 150 mg/lmg/l

Should antibiotics be administered?Should antibiotics be administered?

Case 2 - MKCase 2 - MK• Very good prognosisVery good prognosis

Case 1 - KDCase 1 - KD• Moderate prognosisModerate prognosis

QuestionQuestion

Who should receive antibiotics?Who should receive antibiotics?

1.1.BothBoth

2.2.Patient 1Patient 1

4.4.NoneNone

BacteriologyBacteriology

• Bile - Bile - positivepositiveEscherichia coliEscherichia coli(sensitive to Ciprofloxacin, Imipenem)(sensitive to Ciprofloxacin, Imipenem)

• Blood – Blood – negativenegative (1x) (1x)

• Bile - Bile - positivepositiveEscherichia coliEscherichia coli(sensitive to Ciprofloxacin, Imipenem)(sensitive to Ciprofloxacin, Imipenem)

• Blood – Blood – negativenegative (1x) (1x)

• Blood –Blood – 10 x negative 10 x negative

Acute pancreatitisCase 1 & 2

• Wide-spectrum antibiotics were used in both casesWide-spectrum antibiotics were used in both cases• No complications acc. to Atlanta criteriaNo complications acc. to Atlanta criteria• Probably mild necrosis of peripancreatic fatProbably mild necrosis of peripancreatic fat• Hospital stay 22 days in both casesHospital stay 22 days in both cases• Course mild / severe ?Course mild / severe ?

Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK

HistoryHistory

• M, M, 7979 y y• General condition severeGeneral condition severe

Hypertension 20 yHypertension 20 yParkinson’s disease?Parkinson’s disease?

• Suspicion of gallstonesSuspicion of gallstones• Probably 20 h from onset of abdominal painProbably 20 h from onset of abdominal pain• Very severe abdominal painVery severe abdominal pain

HistoryHistory

• M, M, 7979 y y• General condition severeGeneral condition severe

Hypertension 20 yHypertension 20 yParkinson’s disease?Parkinson’s disease?

• Suspicion of gallstonesSuspicion of gallstones• Probably 20 h from onset of abdominal painProbably 20 h from onset of abdominal pain• Very severe abdominal painVery severe abdominal pain

• DehydrationDehydration• HR HR 116116/min, RR /min, RR 3030/min/min• No peristalsisNo peristalsis• Rebound tenderness Rebound tenderness +-+-

Angio-CT (day 0)Angio-CT (day 0)

• No mesenteric ischemiaNo mesenteric ischemia• Extensive atheromatosisExtensive atheromatosis• EExtensive inflammatory infiltration xtensive inflammatory infiltration

of peripancreatic fat, non-enhancement areaof peripancreatic fat, non-enhancement area(up to 1/3) in (up to 1/3) in bodybody and tail and tail

• BLT BLT CC, necrosis, necrosis < 1/3 < 1/3?, CTSI ?, CTSI 44

Angio-CT (day 0)Angio-CT (day 0)

• No mesenteric ischemiaNo mesenteric ischemia• Extensive atheromatosisExtensive atheromatosis• EExtensive inflammatory infiltration xtensive inflammatory infiltration

of peripancreatic fat, non-enhancement areaof peripancreatic fat, non-enhancement area(up to 1/3) in (up to 1/3) in bodybody and tail and tail

• BLT BLT CC, necrosis, necrosis < 1/3 < 1/3?, CTSI ?, CTSI 44

Angio-CT (day 0)Angio-CT (day 0)Angio-CT (day 0)Angio-CT (day 0)

ERCP (day 1)ERCP (day 1)

• Extensive swelling of D2 of moderate severity,Extensive swelling of D2 of moderate severity,bluish discoloration of mucosa, severe duodenopathybluish discoloration of mucosa, severe duodenopathy

• Papilla very small and tightPapilla very small and tight• No deep CBD cannulation despite No deep CBD cannulation despite pre-cutpre-cut• CDB narrow (< 4 mm)CDB narrow (< 4 mm)

• Extensive swelling of D2 of moderate severity,Extensive swelling of D2 of moderate severity,bluish discoloration of mucosa, severe duodenopathybluish discoloration of mucosa, severe duodenopathy

• Papilla very small and tightPapilla very small and tight• No deep CBD cannulation despite No deep CBD cannulation despite pre-cutpre-cut• CDB narrow (< 4 mm)CDB narrow (< 4 mm)

Lab dataLab data

• WBC (G/l)WBC (G/l) 10.810.8 -- 20.1 20.1 -- 15.3 15.3• PLTS (G/l)PLTS (G/l) 151151 - - 8787 – – 7272• HCT (%)HCT (%) 5050 - - 5353 - 48 - 48• paO2 (mm Hg)paO2 (mm Hg) 101 - 101 - 6565 - - 5252

• Cre (mg/dl)Cre (mg/dl) 1.1 - 0.9 - 1.1 - 0.9 - 1.61.6• AT III (%)AT III (%) ND - ND – ND - ND – 4242• CRPCRP ND!ND!

Lab dataLab data

• WBC (G/l)WBC (G/l) 10.810.8 -- 20.1 20.1 -- 15.3 15.3• PLTS (G/l)PLTS (G/l) 151151 - - 8787 – – 7272• HCT (%)HCT (%) 5050 - - 5353 - 48 - 48• paO2 (mm Hg)paO2 (mm Hg) 101 - 101 - 6565 - - 5252

• Cre (mg/dl)Cre (mg/dl) 1.1 - 0.9 - 1.1 - 0.9 - 1.61.6• AT III (%)AT III (%) ND - ND – ND - ND – 4242• CRPCRP ND!ND!

Prognostic assessmentPrognostic assessment

• RNS (pts)RNS (pts) 66• AP-II (pts 0-1-2)AP-II (pts 0-1-2) 1717 - - 1818 - - 17 17 (death risk (death risk 8585%)%)• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 5050 - - 6565 - - 5757 (death risk (death risk 6767%)%)• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 1 - 1 - 6 6 (death risk (death risk 8585%)%)

CT (day 2)CT (day 2)• Mild progressionMild progression• BLT E, necrosis BLT E, necrosis < < 1/3, CTSI 61/3, CTSI 6

CT (day 2)CT (day 2)CT (day 2)CT (day 2)

Clinical courseClinical course

• No improvement within 48 hoursNo improvement within 48 hours• Rapidly evolving multiorgan failureRapidly evolving multiorgan failure• Patient transferred to ICUPatient transferred to ICU• Surgical consultationSurgical consultation

Clinical courseClinical course

• No improvement within 48 hoursNo improvement within 48 hours• Rapidly evolving multiorgan failureRapidly evolving multiorgan failure• Patient transferred to ICUPatient transferred to ICU• Surgical consultationSurgical consultation

Acute pancreatitisCase 4 – Patient MLAcute pancreatitis

Case 4 – Patient ML

HistoryHistory

• F, F, 50 y50 y• No concomitant diseasesNo concomitant diseases• Mild obesity, BMI Mild obesity, BMI 31.631.6 kg/m2 kg/m2• 10 months befor10 months beforee single episode of biliary colic single episode of biliary colic

No gallbladder stonesNo gallbladder stones• 1. episode of ABP1. episode of ABP• Time from onset 8 hTime from onset 8 h

HistoryHistory

• F, F, 50 y50 y• No concomitant diseasesNo concomitant diseases• Mild obesity, BMI Mild obesity, BMI 31.631.6 kg/m2 kg/m2• 10 months befor10 months beforee single episode of biliary colic single episode of biliary colic

No gallbladder stonesNo gallbladder stones• 1. episode of ABP1. episode of ABP• Time from onset 8 hTime from onset 8 h

• ObesityObesity• JaundiceJaundice• Epigastric tendernessEpigastric tenderness

• Duodenum and papilla normalDuodenum and papilla normalCDB 10 mm, no stonesCDB 10 mm, no stonesNo ESNo ESMicroscopic bile analysis: CMC+, CaBG+++Microscopic bile analysis: CMC+, CaBG+++

Lab dataLab data

• WBC (G/l)WBC (G/l) 17.1 17.1 -- 15.3 15.3 -- 13.7 13.7• HGB (g/dl)HGB (g/dl) 14.3 - ND - 14.7 14.3 - ND - 14.7 - - 8.08.0 (d7) (d7)• paO2 (mm Hg)paO2 (mm Hg) 7373• TP (mg/dl)TP (mg/dl) 7.1 - 7.1 - 6.26.2 - - 5.05.0• CRPCRP (mg/l) (mg/l) 1010 -- 68 68 -- 200 200 -- 298 298

(d7)(d7)

Lab dataLab data

• WBC (G/l)WBC (G/l) 17.1 17.1 -- 15.3 15.3 -- 13.7 13.7• HGB (g/dl)HGB (g/dl) 14.3 - ND - 14.7 14.3 - ND - 14.7 - - 8.08.0 (d7) (d7)• paO2 (mm Hg)paO2 (mm Hg) 7373• TP (mg/dl)TP (mg/dl) 7.1 - 7.1 - 6.26.2 - - 5.05.0• CRPCRP (mg/l) (mg/l) 1010 -- 68 68 -- 200 200 -- 298 298

(d7)(d7)

• RNS (pts)RNS (pts) 66• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 88 - - 99 - - 66• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 23 - 22 - 1923 - 22 - 19• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 0 - 10 - 1

CT (day 2)CT (day 2)

• Enlarged pancreatic head, homogenous enhancement,Enlarged pancreatic head, homogenous enhancement,no necrosisno necrosis

• Fluid collections at both prerenal spaces, in spleen hilum,Fluid collections at both prerenal spaces, in spleen hilum,between small bowel loopsbetween small bowel loops

• BLT E, CTSI 4BLT E, CTSI 4

CT (day 2)CT (day 2)

• Enlarged pancreatic head, homogenous enhancement,Enlarged pancreatic head, homogenous enhancement,no necrosisno necrosis

• Fluid collections at both prerenal spaces, in spleen hilum,Fluid collections at both prerenal spaces, in spleen hilum,between small bowel loopsbetween small bowel loops

• BLT E, CTSI 4BLT E, CTSI 4

Clinical courseClinical course• InteIntennsive conventional management, antibioticssive conventional management, antibiotics• SIRS symptoms between days 10 and 16SIRS symptoms between days 10 and 16• Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 • Control CT (d26) – Control CT (d26) – progression, no pancreatic necrosis,progression, no pancreatic necrosis,

but extensive necrosis of peripancreatic fatbut extensive necrosis of peripancreatic fat• Second period of fever from day 32, ↑ WBC i CRPSecond period of fever from day 32, ↑ WBC i CRP• US – fluid collection, bacteriology – US – fluid collection, bacteriology – Str. faecalisStr. faecalis• Surgical consultation (d43)Surgical consultation (d43)

Clinical courseClinical course• InteIntennsive conventional management, antibioticssive conventional management, antibiotics• SIRS symptoms between days 10 and 16SIRS symptoms between days 10 and 16• Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 • Control CT (d26) – Control CT (d26) – progression, no pancreatic necrosis,progression, no pancreatic necrosis,

but extensive necrosis of peripancreatic fatbut extensive necrosis of peripancreatic fat• Second period of fever from day 32, ↑ WBC i CRPSecond period of fever from day 32, ↑ WBC i CRP• US – fluid collection, bacteriology – US – fluid collection, bacteriology – Str. faecalisStr. faecalis• Surgical consultation (d43)Surgical consultation (d43)

CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)

Acute pancreatitisCases 3 & 4

Case 4 – MLCase 4 – ML

• Day 43Day 43• Infected necrosisInfected necrosis• No MOFNo MOF• Moderate prognosisModerate prognosis

Case 4 – MLCase 4 – ML

• Day 43Day 43• Infected necrosisInfected necrosis• No MOFNo MOF• Moderate prognosisModerate prognosis

Case 3 – AKCase 3 – AK

• Day 3Day 3• Sterile necrosisSterile necrosis• ↑ ↑ MOFMOF• Bad prognosisBad prognosis

Who should be operated on?Who should be operated on?

QuestionQuestion

Who should be operated on?Who should be operated on?

1.1.Both patientsBoth patients

4.4.NoneNone

SurgerySurgery• Day 2 of hospitalizationDay 2 of hospitalization• 2000 ml brown fluid in the abdominal cavity2000 ml brown fluid in the abdominal cavity• Extensive pancreatic necrosis (black pancreas)Extensive pancreatic necrosis (black pancreas)

Necrosectomy. Setonage. LaparostomyNecrosectomy. Setonage. Laparostomy• Cardiac arrest at the end of the procedure, deathCardiac arrest at the end of the procedure, death• Autopsy:Autopsy:

Necrosis haemorrhagica pancreatis et telae adiposae.Necrosis haemorrhagica pancreatis et telae adiposae.Inflammatio purulenta cum necrosi d. choledochi.Inflammatio purulenta cum necrosi d. choledochi.

SurgerySurgery• Day 2 of hospitalizationDay 2 of hospitalization• 2000 ml brown fluid in the abdominal cavity2000 ml brown fluid in the abdominal cavity• Extensive pancreatic necrosis (black pancreas)Extensive pancreatic necrosis (black pancreas)

Necrosectomy. Setonage. LaparostomyNecrosectomy. Setonage. Laparostomy• Cardiac arrest at the end of the procedure, deathCardiac arrest at the end of the procedure, death• Autopsy:Autopsy:

Necrosis haemorrhagica pancreatis et telae adiposae.Necrosis haemorrhagica pancreatis et telae adiposae.Inflammatio purulenta cum necrosi d. choledochi.Inflammatio purulenta cum necrosi d. choledochi.

SurgerySurgery

• DayDay 49 49 of hospitalization of hospitalization• Extensive fat necrosisExtensive fat necrosis• Abscess (500 ml) in lesser sacAbscess (500 ml) in lesser sac

• Fat necrosis from right iliac fossa to diaphragmatic hiatusFat necrosis from right iliac fossa to diaphragmatic hiatus• Necrosectomy, setonage, laparostomyNecrosectomy, setonage, laparostomy

SurgerySurgery

• DayDay 49 49 of hospitalization of hospitalization• Extensive fat necrosisExtensive fat necrosis• Abscess (500 ml) in lesser sacAbscess (500 ml) in lesser sac

• Fat necrosis from right iliac fossa to diaphragmatic hiatusFat necrosis from right iliac fossa to diaphragmatic hiatus• Necrosectomy, setonage, laparostomyNecrosectomy, setonage, laparostomy

Surgery (2)Surgery (2)

• MuMulltiple exchangetiple exchangess of setones ( of setones (1111))days 51 to 68days 51 to 68

• Wound abscess in the epigastriumWound abscess in the epigastrium6 drainage procedures from day 103 to 1316 drainage procedures from day 103 to 131

• Gradual improvementGradual improvement• Discharge on day Discharge on day 146146

Surgery (2)Surgery (2)

• MuMulltiple exchangetiple exchangess of setones ( of setones (1111))days 51 to 68days 51 to 68

• Wound abscess in the epigastriumWound abscess in the epigastrium6 drainage procedures from day 103 to 1316 drainage procedures from day 103 to 131

• Gradual improvementGradual improvement• Discharge on day Discharge on day 146146

Acute pancreatitisIndications for surgery

• Infected necrosisInfected necrosis• Local complications of pancreatitisLocal complications of pancreatitis

• Sterile necrosisSterile necrosis

• Infected necrosisInfected necrosis• Local complications of pancreatitisLocal complications of pancreatitis

• Sterile necrosisSterile necrosis

No swellingNo swelling Minor swelling,limited to peripapillaryarea

Minor swelling,limited to peripapillaryarea

Severe swellingwith extensiveinvolvementof D2, bluishdiscoloration

Moderateswelling withextensive involvementof D2

DGE MUSK 2000-2005DGE MUSK 2000-2005

Duodenal swellingDuodenal swelling

DGE MUSK 2000-2005DGE MUSK 2000-2005

Normal duodenumNormal duodenum Deformed duodenal loopD2 deformed and narrowed

Deformed duodenal loopD2 deformed and narrowed

DGE & DPATMUSK

2000-2005

DGE & DPATMUSK

2000-2005Mucosal hyperemiaMucosal hyperemia

Edema of submucosal layerEdema of submucosal layer

Normal duodenumNormal duodenum Marked thickening of D2 wallMarked thickening of D2 wall

DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005

20 mm20 mm

D2 swellinglimited toperipapillaryarea

D2 swellinglimited toantero-medialwall

Severe swellingwith circularD2 involvement;lumen barely visiblein the most severe cases

n (851)%

Age (y)Sex (% F)BMI (kg/m2)SE failure (%)

n (851)%

Age (y)Sex (% F)BMI (kg/m2)SE failure (%)

N69081%

57.273

N69081%

57.273

MLD405%

62.153

30.613

MLD405%

62.153

30.613

60.759

31.917

60.759

31.917

SEV334%

65.149

32.370

SEV334%

65.149

32.370

0.00770.00010.00000.0000

Duodenopathy gradeDuodenopathy grade

Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)

n (851)%

CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)

n (851)%

CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)

N69081%

12312010.5 9.6 1.7

N69081%

12312010.5 9.6 1.7

MLD405%

16314411.812.2 2.3

MLD405%

16314411.812.2 2.3

23226714.912.8 3.5

SEV334%

29925914.618.8 4.9

SEV334%

29925914.618.8 4.9

0.00000.00000.00000.00000.0000

n (851)%

% severe% surgery% mortality

SGS-10

n (851)%

% severe% surgery% mortality

SGS-10

N69081%

31 4 2

N69081%

31 4 2

MLD405%

48 5 3

MLD405%

48 5 3

7216 8

SEV334%

944236

SEV334%

944236

0.00000.00000.0000

0.0000

0.00000.00000.0000

0.0000

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