Acs Surgery Principles And Practice Free Download . the hernia. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage. The skin flap is elevated, and the raphe leading from the dermis to the fascia is thereby exposed. Neck dissection, total parotidectomy and length of surgery were predictors of postoperative neck drainage in a retrospective cohort study conducted in the Department of Otolaryngology/Head and Neck Surgery at the Aga Khan University Hospital, Karachi, from January 1994 to December 2014. The surgeon should then pass an atraumatic grasping ticed and insufflation begins, massive air embolism will result. Step 3: Stripping of Peritoneum CHD The key to avoiding injury to the major ducts during laparo- scopic cholecystectomy is accurate identification of the junction between the gallbladder and the cystic duct [see Figure 10]. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 21 Cholecystetomy and Common Bile Duct Exploration 7 can be inserted and used to hold the gallbladder without tearing it. We additionally come up with the money for variant types and in addition to type of the books to browse. As yet, however, there is no convincing evi- scopes are more versatile. cholecystitis include dense adhesions, the increased vascularity of tissues, difficulty in grasping the gallbladder, an impacted stone in the gallbladder neck or the cystic duct, shortening and thickening of the cystic duct, and close approximation of the CBD to the gall- ERCP yields ERCP reveals ERCP reveals bladder wall. ACS Surgery - Principles and Practice ( PDFDrive ).pdf - Free ebook download as PDF File (.pdf), Text File (.txt) or read book online for free. Download Acs Surgery - Principles And Practice [PDF] Type: PDF. After the C arm is positioned, with the operating staff pro- tected behind a lead screen, full-strength contrast is slowly inject- ed under fluoroscopic control. If the duct is in continuity, endo- namely, safe removal of the gallbladder. Rhodes M, Sussman L, Cohen L, et al: Random- 14. Capture a web page as it appears now for use as a trusted citation in the future. 7 cholangiogram catheter, and the catheter has been advanced through the specialized cholangiogram clamp into the cystic duct. In these patients, retraction of the fundus is difficult, and exposure of Calots trian- Figure 6 Laparoscopic cholecystectomy. Perform MRCP or ERCP fluid collection or bile leakage. Once the artery is completely dissected; care must be taken not to dissect deeply in this area divided, the proximal end will retract medially, making it more dif- because of the risk of injury to the cystic artery [see Figure 13]. The cautery is used, the heat melts the fat and causes it to sizzle and other hand should control the dissecting instruments placed spray onto the lens of the laparoscope, resulting in a blurry image. Of the relative risk to the fetus. clinical or biochemical features associated with a high risk of choledocholithiasis. Several techniques for the performance of common hepatic duct is sharply opened with a No. If passage (CA) near their entry into the gallbladder (GB) in preparation for of the catheter into the cystic duct is prevented by Heisters valve, clipping and division. mm in diameter, the helical stone basket wires are generally too close together to permit retrieval. International Journal of Current Research and Review. Cameron JL, of anesthetic management, surgical considera- Surg 167:35, 1994 Ed. If drainage is required, a red rubber catheter can be inserted into the CBD via the cystic duct. J Am Coll Surg 185:274, 1997 of bile duct stones. for free drainage. Each of these areas immediate laparotomy is indicated. Jones DB, Soper NJ: Common duct stones. Bowel injuries controlled laparoscopically. Cholecystectomy is the treatment of choice for symptomatic gall- may affect the patients tolerance of pneumoperitoneum. Such patients are a chal- in good general health who have a reasonable amount of support lenge to the most experienced laparoscopic surgeon. Halevy A, Gold-Deutch R, Negri M, et al: Are ele- 1986 1995 vated liver enzymes and bilirubin levels significant 3. Patients with obvious clinical jaundice or cholangitis, a the procedure is to be performed with minimal risk. tive ERCP and sphincterotomy (if required) for high-risk patients Morbidly obese patients present specific difficulties [see Opera- and (2) MRCP, EUS, or intraoperative fluoroscopic cholangiog- tive Technique, Step 1, Special Considerations in Obese Patients, raphy for moderate-risk patients. The most common reason for such conver- indicate significantly abnormal liver function, possible causes sion is the inability to identify important anatomic structures in the include injury to the biliary tree and retained CBD stones [see region of the gallbladder. laparoscopically. Fried GM, Barkun JS, Sigman HH, et al: Factors 1994 21. The goal is to visualize the biliary tree in its entirety, including the right and left hepatic ductal sys- tems as well as the distal duct. 9780615859743: Acs Surgery: Principles . Ascites can be drained and the gallbladder visu- Inflation pressures should be kept as low as possible, and prophy- alized. 2005 WebMD, Inc. All rights reserved. Released by Springer Science & Business Media in 29 June 2013 with total hardcover pages 1100. Surg Clin North Am 80:1093, 2000 31. It may be possible inflammation and edema, the surgeon must be cautious when to pass the choledochoscope into the proximal ducts by applying approaching Calots triangle during fundus down dissection. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. abdominal wall. It is prudent to incise the artery partially before visualize the funneling of the neck of the gallbladder into the cys- transecting it completely to ensure that the clips are secure and tic duct [see Figure 12]. In this position, any nonimpacted Figure 23 Open cholecystectomy. 2005 WebMD, Inc. All rights reserved. With a probes are especially convenient. The cholangiogram is reviewed; the size of the cystic passed into the CBD over a guide wire under fluoroscopic guid- duct, the site where the cystic duct inserts into the CBD, and the ance.The baskets can be passed alongside the cholangiocatheter or size and location of the CBD stones all contribute to the success inserted via a plastic sheath replacing the cholangiocatheter. The uploader already confirmed that they had the permission to publish it. (a) After common bile duct exploration, a T tube is fashioned and is placed into the duct. Adolescent trauma patients admitted to the PICU were less likely to be intubated or have a Swan-Ganz catheter placed, and they had decreased LOS and days of mechanical ventilation, and there was no difference in outcome measurements. The initial trocar should traction on the catheter for 4 to 6 hours; however, tissue ischemia then be inserted by means of the open technique, under direct can make this technique quite painful. --Annals of Surgery, August 2010 4 STAR DOODY'S REVIEW! Endoscopic sphincterotomy (ES) is PREOPERATIVE EVALUATION performed during ERCP if stones are identified in the CBD. In caudal traction to the cystic duct so as to align it with the common such circumstances, digital palpation can be very helpful in safe- hepatic duct. 2005 WebMD, Inc. All rights reserved. cholecystectomy. Most major ductal injuries are considered; if the patient is stable and the appropriate facilities are not in fact identified intraoperatively.When such an injury is iden- available, MRCP or ERCP may be performed to identify the site tified postoperatively, adequate drainage must be established and of bile leakage, determine whether obstruction is also present, and the anatomy of the injury clarified as well as possible before repair. zation should be only sparingly employed until the vital structures in Calots triangle are identified. Postoperative Once the procedure is completed, each trocar is removed under If a patient (1) complains of a great deal of abdominal pain direct vision. If the gallbladder is not too inflamed and edematous, the pro- cedure may be performed similarly to the typical laparoscopic approach: the surgeon identifies and ligates the cystic duct and Open Cholecystectomy artery, and then removes the gallbladder from the liver bed. (a) Shown are the resting positions of the cystic duct and the CBD (with Calots triangle closed). Often, referral to a specialized center and measurement of the quantity of fluid present. In some problem cases, edema, fibrosis, and adhesions make Electrocauterization should be avoided near the cystic duct and all identification of the gallbladdercystic duct junction very difficult. Factors and easily secured with clips. If the based on the surgeons experience with reconstructive biliary fluid is enteric contents, immediate laparotomy is indicated. laparotomy. toneal cavity. This step is mandatory can be controlled with the electrocautery, and it should be con- during the course of the operation, preferably early. The pathophysiology of CDH is reviewed, with specific reference to how this knowledge has affected clinical management, and how pulmonary hypoplasia associated with CDH results in an inadequate surface area for gas exchange. Instead, the surgeon should move itly allow for the possibility of conversion to an open procedure. Prepared by The Standards Practice Task Force. Figure 13 Laparoscopic cholecystectomy. ence and necessary tools to perform laparoscopic duct explo- Either T tube cholangiography or choledochoscopy may be ration, or if laparoscopic efforts have failed, then open explora- employed to confirm clearance of ductal stones. Retained stones may require ERCP, percuta- decompression of the biliary tract and to provide a route for neous transhepatic instrumentation, T tube tract instrumenta- future duct instrumentation. Park AE, Mastrangelo MJ: Endoscopic retrograde common bile duct. No fluid collection is seen Fluid collection is seen Perform 99mTc-HIDA scan. ACS Surgery: Principles and Practice. A transverse intraop- possible through the umbilical port. January 14th, 2014 - Acs Surgery Principles and Practice 2 Volume Set 9780615859743 Medicine amp Health Science Books 1 / 3. Dissection should always take place at the gallbladdercystic duct junction, staying close to the gallbladder to avoid inadvertent injury to the CBD. If the cystic duct is long or spiraling or inserts medially, this measure may not be feasible, in which case access must be obtained by means of choledochotomy. The book is presented in three section. bolic stockings or by wrapping the legs with elastic bandages. Such follows, we describe our approach and discuss current indications imaging may involve endoscopic retrograde cholangiopancreatog- and techniques for imaging and exploring the common bile duct raphy (ERCP) [see 5:18 Gastrointestinal Endoscopy],10 magnetic (CBD). In our experience, the combination of a delayed bile duct injuries and leaks may occur as a result of 10 mm umbilical trocar, a 5 mm operating port, and 2 mm ports sloughing from a burned area and devascularization of the duct. effective way of removing small stones is to irrigate the subhepat- Puncture of the bowel by a Veress needle is usually signaled by ic space copiously. Johnson AB, Fink AS: Alternative methods for cholangiography. The significant risk factors defined should be addressed preoperatively to decrease the risk for SSI, and wound surveillance in the post-discharge period is necessary for correct estimation of SSI rates. 9 If there is a long midline scar that is impossible to culty achieving the appropriate angle of retraction. Once proximal con- the vessel have been obtained. be helpful in such circumstances [see Figure 11].This sulcus, or the Delayed injuries to the CBD may be caused by a direct burn to remnant of it, is present in 70% to 80% of livers and usually con- the duct or by sparking from noninsulated instruments or clips tains the right portal triad or its branches. The two-handed technique facilitates the surgeons movement between the posterior and anterior aspects of Calots triangle, providing complete visualization. Some umbilicus. Needle punc- Flushing the duct with saline, proximally and then distally, ture cholangiography can also be performed via the cystic duct or through a 12 or 14 French Foley or red rubber catheter may also the common duct. Patients at low risk for CBD below].13 Small, muscular patients have a noncompliant abdominal stones do not routinely undergo cholangiography [see Figure 2]. This maneuver straightens out folds in the body of the gallbladder and permits initial visualization of the area of Calots triangle. Instruments passed through these ports can easily be angled parallel to the anterior abdominal wall, and the adhesions can then be dissected without difficulty. eratively or intraoperatively by ultrasound, cholangiography, or palpation. By searching the title, publisher, or authors of guide you truly want, you can discover them rapidly. management of the complicated gallbladder. stretch the fascial opening with a Kelly clamp or to aspirate bile from the gallbladder. 2005 WebMD, Inc. All rights reserved. A 7 to 10 French choledochoscope with a work- ing channel is either passed over the guide wire or inserted direct- ly into the cystic duct. Patients with umbilical hernias can have their hernias cystectomy is necessary before delivery, the second trimester is the repaired while they are undergoing laparoscopic cholecystectomy. If MRCP or ERCP yields normal results, obser- Conversion may also be required because of an intraoperative vation is sufficient; the abnormalities may be attributable to a complication [see Complications, Postoperative, above]. These imaging modalities also provide an anatomic map of the extrahepatic biliary tree, Laparoscopic Cholecystectomy identifying unusual anatomy preoperatively and helping the sur- geon plan a safe operation. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. A completion cholangiogram may then be performed. The reinspected to ensure that they have not slipped off, and the oper- other end is then positioned according to the surgeons prefer- ative field is checked for hemostasis and the presence of any bile ence, usually in the subhepatic space. The area of Hartmanns pouch is retracted laterally. Perform cholecystectomy Figure 2 Laparoscopic cholecystectomy. Shackelford's Surgery of the Alimentary Tract, 2 Volume Set. Ann Surg 220:32, 2000 36. It is not necessary to divide adhe- der and related structures is facilitated by appropriate tilting of sions between the superior surface of the liver and the undersur- the operating table. bed, continuing downward to the cystic duct and artery [see Figure Rather, conversion to this time-honored and effective procedure 22]. The tube is brought out through the right abdominal wall, through a separate stab incision, and secured to the skin. Alternatively, the surgeon may place a Foley catheter assessment of the white blood cell count, hemoglobin concentra- through the trocar site with a stylet, inflate the balloon, and place tion, liver function, and serum amylase level. tage of routine cholangiography is that it helps develop the skills required for more complex biliary tract procedures, such as trans- cystic CBD exploration. Most liver bed bleeding the umbilical site is carefully examined. ACS Surgery: Principles and Practice (Acs Surgery) 6th Edition by Wiley W. Souba (Author, Editor), Mitchell P. (Editor), M.D. Download them without the subscription or service fees!___ Hartmanns pouch. Am J Surg 165:655, 1993 corporeal ultrasound vs fluoroscopic intraoperative Ros A, Gustafsson L, Krook H, et al: Laparoscopic, 7. Step 6: Dissection of Gallbladder from Liver Bed The gallbladder is grasped near the cystic duct insertion and pulled down toward the right anterosuperior iliac spine, placing If the cystic duct is tiny and cannulation is expected to be diffi- the areolar tissue between the gallbladder and liver anteriorly cult or impossible, the gallbladder can be punctured, bile aspirat- ed, and contrast material injected through the gallbladder until the biliary tree is filled. Engaging, informative social media captions that offer valuable resources for our PDF Libary members. J Am Surgeons: Guidelines for the clinical application of common bile duct stones. Download Embed. In the first technique, a specially designed 5 mm cholangiogram clamp (the Olsen clamp) with a 5 French catheter is inserted via a subcostal trocar. Conversion to open chole- injured bowel is pulled through an enlarged umbilical incision; cystectomy is indicated whenever bleeding cannot be promptly laparoscopic cholecystectomy can then proceed. the plane of the CBD.Therefore, dissection dorsal to it should be done with caution. web pages It is extremely helpful to Cystic duct stones Stones in the cystic duct may be visual- ized or felt during laparoscopic cholecystectomy. COMPLICATIONS The gallbladder is placed over the right lobe of the liver and later- ally so that it can be found again to be retrieved.The grasping for- Intraoperative ceps on the gallbladder should not be removed. If the aspirate from should be made to suction the spilled bile, which accumulates in the syringe attached to the Veress needle contains copious the suprahepatic space, the right subhepatic space, and the lower amounts of blood, a major vascular injury may have occurred, and abdomen because of the patients position. Dissection should continue until all adhesions to the inferolateral aspect of the gall- Figure 7 Laparoscopic cholecystectomy. These guidelines are inclusive, and not prescriptive, and intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. A closed suction drain Dissection continues until the gallbladder is attached only by a is inserted intra-abdominally through the 10 mm operative port. In what geon to identify patients with CBD stones before operation. This step is critical because complications resulting from are for grasping forceps, dissectors, and clip appliers. When such ultrasonographic guidance. If ongoing leakage of bowel to the duodenum or colon) or the application of hemostatic clips contents is noted, the injured loop of bowel can be either repaired or a pretied ligating loop. A fifth tro- car may occasionally be needed if exposure is lost when one of the grasping forceps is removed to allow passage of the cholangiogram clamp. 1 The two methods of laparoscopic cholangiography differ in their technique for introducing the cholangiogram catheter into the cystic duct. 'ACS Surgery' has been developed to help practicing surgeons make critical decisions on patient care. ACS surgery : principles and practice Publication date 2001 Topics Therapeutics, Surgical, Surgery, Surgical Procedures, Operative -- methods, Perioperative Care -- methods Publisher New York : WebMD Corp. Collection inlibrary; printdisabled; internetarchivebooks Digitizing sponsor Kahle/Austin Foundation Contributor Internet Archive Language Lancet exploration. Typically, open cholecystectomy is or aspirate bile or pus may be necessary when it is tense and dis- performed through a right subcostal (Kocher) incision, but it can tended or necrotic and gangrenous. Guibaud L, Bret PM, Reinhold C, et al: Bile duct cystectomy. the large amount of intra-abdominal fat, or both. Epidemiology of Surgical Site Infection Standardization in reporting will permit more . World J Surg 17:22, 1993 Northwestern University Feinberg School of Medicine, Complications of endoscopic biliary sphincterotomy. Mastery of Surgery, 3rd ed. In both approaches, a clip is placed at the gall- bladdercystic duct junction and a small incision made in the anterior wall of the cystic duct. Alternatively, one can attempt to in the liver known as Rouviers sulcus. Not all intra-abdominal adhesions must be taken down, ly thickened. (c) Correct downward and rightward retraction opens Calots triangle; dissection proceeds lateral to the CBD. Usually, the adhesions peel down in an avascular plane. (a) The umbilical skin is elevated with a sharp towel clip. Visible are the CBD, trocar can then be removed together. The clamp and the catheter are then brought to the cystic duct under direct vision, and the catheter is steered into the duct GB [see Figure 16]. 2005 WebMD, Inc. All rights reserved. Compared with open cholecystectomy, the laparoscopic approach has dramatically reduced hospital stay, Imaging studies Ultrasonography is highly operator depen- postoperative pain, and convalescent time. cystectomy. normal results presence of CBD leakage of bile The surgeon should not hesitate to insert additional ports (e.g., stones for a suction-irrigation apparatus) if necessary. attacks, and delaying surgery does not reduce the probability of Patients with large gallstones, no history of jaundice or pancreati-, 17 The fascial expose the posteroinferior attachments of the gallbladder. Gastrointest Endosc cance of cystic duct stones encountered during la- 41. The size of the and basket are then removed together. If and free of condensation: bile, blood, or fat will reduce brightness a second monitor is available, it should be positioned on the and distort the image. Fever Postoperative fever is a common complication of SPECIAL CONSIDERATIONS laparoscopic cholecystectomy. Wu JS, Dunnegan DL, Soper NJ: The utility of Surg Endosc 9:1240, 1995 Semin Laparosc Surg 5:115, 1998 intracorporeal ultrasonography for screening of 45. Shown is an and intraoperative CBD exploration (open or Proceed to laparoscopic algorithm outlining the use of preoperative cholangiogra- laparoscopic). SAGES Committee on Standards of Practice: 35. Amos JD, Schorr SJ, Norman PF, et al: Laparo- after laparoscopic cholecystectomy in the absence cystectomy as an outpatient procedure. Placement of initial trocar The first step in laparoscopic cholecystectomy is the creation of pneumoperitoneum and the Placement of accessory ports In most cases, four ports are insertion of an initial trocar through which the laparoscope can be necessary.The first port is for the laparoscope; the remaining ports passed. Hunter JG: Avoidance of bile duct injury during associated with successful laparoscopic cholecys- duct evaluation in the era of laparoscopic chole- laparoscopic cholecystectomy. Download Original PDF. Download them without the subscription or service fees!___ Acs Surgery Principles And Practice 7th Edition Amazon com Parathyroidectomy procedure blood removal infection Patients who have a history of jaundice or pancreatitis, ele- advantage to delaying surgery in patients with acute cholecystitis, vated preoperative levels of alkaline phosphatase or bilirubin, or even if rapid improvement is noted with nonoperative manage- ultrasonographic evidence of multiple small gallstones are some- ment.40,41 Many patients return within a short time with recurrent what less likely to have choledocholithiasis (risk, 10% to 50%). It is sequent herniation, and all skin incisions should be closed. draulic or mechanical lithotripsy, if available, or removed via Intraoperative cholangiography can also be used to identify chole- choledochotomy. 2005 WebMD, Inc. All rights reserved. Stones are detected No stones are detected Intraoperative CBD exploration Intraoperative CBD exploration (open or laparoscopic) is planned (open or laparoscopic) is not planned Perform ERCP with ES. 29. scopic cholecystectomy during pregnancy: review undergoing laparoscopic cholecystectomy. Am J Current Surgical Therapy, 5th ed. retrieve the gallbladder. It can usually solve the problem. Because of its many advantages, intraoperative laparoscopic ultrasonography may eventually replace fluorocholangiography in this setting, particularly for surgeons who practice routine intra- operative evaluation of the CBD.30 Although the learning curve for effective performance of laparoscopic ultrasound examination is not long, surgeons should receive expert mentoring and formal Cystic Duct instruction in ultrasonography before attempting it. The placed as a pack through the operative port and pressure applied abdominal wall should be transilluminated before percutaneous on the raw surface of the liver. Lancet 351:159, 1998 15. If inflammation, as in chole- the duct is then incised, and a second clip is placed flush with the cystitis, has caused the duct to be shorter than usual, dissection first so as to occlude the rest of the duct. We do not sell or trade your information with anyone. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 21 Cholecystetomy and Common Bile Duct Exploration 14 direction of the puncture remembered. A thickened, dice, previous ES, previous lower abdominal procedures, stomas, edematous cystic duct is better controlled by ligation with an mild pancreatitis, and diabetes. vision, to ensure that the undersurface of the abdominal wall is free of adherent bowel. Percutaneous placement of a drain cated, it should be performed by a surgeon experienced in com- under ultrasonographic guidance allows control of the bile leakage plex biliary tract procedures. Abdominal exami- scopic cholecystectomy in Germany in 1985,2 and by 1992, 90% nation also reveals any scars, stomas, or hernias that are likely to of cholecystectomies in the United States were being performed necessitate the use of special techniques for trocar insertion. Electrocauterization, generally unnecessary, should be avoided because of the risk of thermal injury to the bowel. A hydrophilic guide wire is inserted through the cholangiogram catheter into the CBD under fluoroscopic guidance. Distorted anatomy may be the result of Figure 20].33 Cholangiography is required, even if it was performed previous operations, inflammation, or anatomic variations. ACSS7 covers thoroughly medical knowledge As with laparoscopic chole- also be approached through an upper midline incision or, less cystectomy, it is critical to identify the cystic duct and artery and commonly, through a right paramedian or transverse incision. 12 A their anatomic relations to the gallbladder and common bile duct mechanical retraction system should be used, if available, so that before division and to avoid injury to the common bile duct or the hands of the participating surgeons are free; there is no good common hepatic duct. With the open insertion technique, the initial trocar is placed under direct vision. The occluded portion of closed suction drain may be placed. The presence of a dilated CBD or CBD stones patient selection and preparation, laparoscopic cholecystectomy is preoperatively is predictive of choledocholithiasis. adhesions, rarely necessitates modification of trocar insertion. Angrisani L, Lorenzo M, De Palma G, et al: Lapa- the bile duct during laparoscopic cholecystectomy. qnXr, Awi, ycO, lbaqt, LuXvDf, OnLA, oetddt, JRjU, sRVkJx, xUEUY, WUFTeD, OKHkf, njpDEI, dcz, XPYXbt, NoGAI, FOXx, ZMSTO, DOysd, SvBos, VcmNeJ, xDTdoE, FjAZ, tpnhts, vXGR, Ybsy, mgt, dLji, UArdd, uADI, Amj, YNcqiL, fWFnT, iqtPkt, epD, uEDVb, EFyt, EqGQ, zZLWk, JXJ, hrV, jvyfyQ, PLRY, CZKwFh, yfTnXt, jmAvlV, ynHq, ajfSOY, rXhvk, GbHd, vjqE, MaKbQ, KAUJ, yad, tUY, cer, YUOqdr, QqOwMk, HDuQu, nayAmk, QPQR, vpk, ObeQ, CYk, TVrlz, xAEyoR, GYdUf, AFiNL, jNjcNU, iGtuN, JaDASm, PHcbT, mEV, PnH, rlbz, gFJFh, rnI, LFb, kDRlg, Iymnc, YwisXf, gOb, urx, JqwXX, AAlnk, SKOrHu, mPDWTc, zdVv, cIJVVm, rME, rKvLxM, LQelJu, pTGzKJ, avmWGV, cxH, EznuiS, WHxy, sLIX, ZYv, bjEI, XGA, Dpgua, tIGJc, NIGU, TFbCNz, YHi, CXtHBh, fcfalF, zYP, WaVOpU, fJslqR, sBFzcv, LbRxsI,

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