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Perioperative Management

The Enhanced Recovery After Surgery (ERAS) guidelines for pancreaticoduodenectomy (PD), also known as theWhipple procedure, are evidence-based recommendations designed to optimize perioperative care, reducecomplications, and accelerate recovery. The ERAS Society first published guidelines for PD in 2012, with anupdate in 2019, incorporating the latest evidence and expert consensus. Below is a summary of keyrecommendations from the 2019 ERAS guidelines for PD, based on the best available evidence:

 

Key ERAS Recommendations for Pancreaticoduodenectomy (2019)

The guidelines include 27 items covering preoperative, intraoperative, and postoperative care, graded by evidence level (high, moderate, low, very low) and recommendation strength (strong or weak). Here are the main components:

Preoperative Phase

  1. Preoperative Counseling: Patients should receive detailed education about the procedure, recovery expectations, and ERAS protocol to improve compliance and reduce anxiety (strong recommendation, low evidence).
  2. Nutritional Optimization: Screen for malnutrition and provide nutritional support, especially for patients with weight loss or pancreatic cancer-related cachexia. Immunonutrition (e.g., arginine, omega-3 fatty acids) may reduce infectious complications (strong recommendation, moderate evidence).
  3. Prehabilitation: Encourage physical activity and smoking/alcohol cessation to optimize fitness before surgery (strong recommendation, low evidence).
  4. Preoperative Biliary Drainage: Routine drainage is not recommended for jaundice unless indicated (e.g., cholangitis, severe symptoms, or delayed surgery). If needed, endoscopic drainage is preferred over percutaneous (weak recommendation, low evidence).
  5. Fasting and Carbohydrate Loading: Minimize fasting (clear fluids up to 2 hours, solids up to 6 hours before surgery). Carbohydrate drinks may be considered to reduce insulin resistance, though evidence is limited in PD (weak recommendation, low evidence).

Intraoperative Phase

  1. Minimally Invasive Techniques: Laparoscopic or robotic PD may be considered in high-volume centers, but no clear evidence supports reduced complications compared to open surgery (weak recommendation, low evidence).
  2. Anesthesia and Analgesia: Epidural analgesia is recommended for pain control, supplemented by multimodal analgesia to minimize opioids (strong recommendation, moderate evidence).
  3. Fluid Management: Goal-directed fluid therapy to avoid over- or under-hydration, maintaining euvolemia to reduce complications like delayed gastric emptying (DGE) (strong recommendation, moderate evidence).
  4. Surgical Technique: No significant difference in outcomes (e.g., DGE, pancreatic fistula) between pylorus-preserving PD vs. classic Whipple, or antecolic vs. transmesocolic reconstruction (weak recommendation, moderate evidence).

Postoperative Phase

  1. Early Mobilization: Encourage mobilization on postoperative day 1 (POD1) to reduce complications like pneumonia and improve recovery (strong recommendation, moderate evidence). Compliance with early mobilization significantly reduces morbidity (odds ratio: 0.414).
  2. Early Oral Feeding: Initiate oral diet within 24–48 hours if tolerated, as early enteral nutrition improves nutritional status and reduces length of stay (LOS) without increasing complications (strong recommendation, moderate evidence).
  3. Nasogastric Tube (NGT) Management: Routine NGT use is not recommended; if used, remove by POD 0–1. Avoiding NGT is safe and does not increase complications (strong recommendation, high evidence).
  4. Drain Management: Early removal of abdominal drains (by POD 3–5) if no evidence of pancreatic fistula or other complications (strong recommendation, moderate evidence).
  5. Glycemic Control: Maintain postoperative blood glucose levels to prevent infection and other complications (strong recommendation, high evidence).
  6. Prevention of Delayed Gastric Emptying (DGE): Use of prokinetics (e.g., erythromycin) may be considered, but evidence is weak. Surgical technique does not significantly impact DGE rates (weak recommendation, low evidence).
  7. Postoperative Pancreatic Fistula (POPF) Management: Risk assessment and tailored drain management to minimize POPF-related complications (strong recommendation, moderate evidence).

Outcomes and Compliance

  • High Compliance Improves Outcomes: Studies show that ≥70% adherence to ERAS protocols is associated with reduced complications (Clavien-Dindo ≥3a), shorter LOS (median 12 vs. 15 days), and lower 30-day mortality.
  • Challenges in Implementation: Adherence is lowest for early oral feeding and drain removal due to concerns about complications like POPF and DGE. Elderly patients (≥75 years) show high compliance with items like glycemic control and NGT removal but lower adherence to early feeding and drain removal.
  • Safety and Feasibility: ERAS is safe and effective, reducing LOS and morbidity without increasing readmissions or mortality. This holds true across diverse populations, including elderly patients and those in resource-limited settings.

Evidence and Methodology

  • The 2019 guidelines were developed using a systematic literature search (Embase, Medline, Cochrane) and the Delphi method for expert consensus. Evidence quality was assessed with the GRADE system, and randomized trials were evaluated using CONSORT criteria.
  • The guidelines emphasize multimodal strategies to reduce surgical stress, optimize pain control, and promote early recovery, drawing from colorectal surgery success but tailored to PD’s complexity.
 

Practical Considerations

  • Implementation: Successful ERAS adoption requires a multidisciplinary team (surgeons, anesthesiologists, nurses, dietitians) and institutional commitment. Challenges include varying compliance rates and the need for tailored protocols in low-volume centers.
  • Future Research: Large-scale, multicenter prospective studies are needed to strengthen evidence, particularly for minimally invasive techniques and immunonutrition. Laparoscopic PD and personalized ERAS protocols are areas of growing interest.
 

Sources

  • Melloul E, et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg. 2020.
  • Lassen K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012.
  • Recent meta-analyses and cohort studies on ERAS implementation in PD.
For further details, visit the ERAS Society website (erassociety.org) or access the full guidelines at https://link.springer.com/article/10.1007/s00268-020-05462-w
 

The Enhanced Recovery After Surgery (ERAS) guidelines for liver surgery, updated in 2022 by the ERASSociety, aim to standardize perioperative care to reduce complications, shorten hospital stays, and enhancerecovery. These guidelines were developed using a modified Delphi method with 15 international experts and asystematic review of 7,541 manuscripts, resulting in 240 articles included to support 25 recommendation items.All items achieved consensus (>80% agreement) and are based on the Grading of Recommendations,Assessment, Development and Evaluations (GRADE) system. Below is a concise summary of keyrecommendations, including updates from the 2016 guidelines:

Key ERAS Recommendations for Liver Surgery

 

Preoperative Phase

  • Prehabilitation: Recommended for high-risk patients (e.g., those with comorbidities or poor functional status) to optimize physical condition before surgery. New in 2022.
  • Preoperative Biliary Drainage: Advised for patients with cholestatic liver (bilirubin >50 mmol/L), preferably percutaneous for perihilar cholangiocarcinoma, with surgery delayed until bilirubin drops below 50 mmol/L. New in 2022.
  • Smoking and Alcohol Cessation: Cease at least 4 weeks before hepatectomy to reduce complications. New in 2022.
  • Nutritional Support: Screen for malnutrition and provide nutritional optimization, especially in patients with advanced chronic liver disease (ACLD).
  • Preoperative Counseling: Provide psychological support and education to reduce anxiety and improve compliance, though specific liver surgery trials are limited.
  • Carbohydrate Loading: Recommended to reduce preoperative fasting and improve metabolic state.
  • Fasting Guidelines: Limit to 4 hours for solids and 2 hours for clear liquids to minimize metabolic stress.

Intraoperative Phase

  • Minimally Invasive Surgery: Preferred when feasible, as it reduces bowel recovery time and hospital stay.
  • Goal-Directed Fluid Therapy: Maintain low intraoperative central venous pressure to minimize blood loss and enhance recovery.
  • Antibiotic Prophylaxis: Use preoperative and intraoperative antibiotics, avoiding postoperative prophylaxis unless indicated for specific patients.
  • Skin Preparation: Use alcohol-based antiseptics for infection prevention.
  • Avoid Routine Drainage: Prophylactic abdominal drainage should be omitted, as it does not reduce complications and may delay recovery.
  • No Prophylactic Nasogastric Tube: Avoid routine use to promote early oral intake and reduce complications.

Postoperative Phase

  • Early Oral Intake: Initiate early to enhance bowel recovery and reduce length of stay (LOS).
  • Early Mobilization: Encourage rapid postoperative mobilization to improve functional recovery and reduce complications like thromboembolism.
  • Multimodal Analgesia: Use opioid-sparing techniques (e.g., paracetamol, NSAIDs if not contraindicated) over thoracic epidural analgesia, which is no longer preferred due to equivalent alternatives.
  • Thromboprophylaxis: Chemical prophylaxis (e.g., enoxaparin started 48–72 hours post-surgery) reduces venous thromboembolism (VTE) risk, which is higher in liver surgery.
  • Glycemic Control: Maintain to prevent complications.
  • Postoperative Laxatives: Use to promote bowel function and quicker recovery.
  • Dual Antiemetic Therapy: Recommended for postoperative nausea and vomiting (PONV) prophylaxis.

General Recommendations

  • Audit Compliance: Regular auditing of adherence to ERAS protocols is critical, as higher compliance correlates with reduced complications and LOS.
  • Avoid Mercedes-Type Incision: Not recommended due to increased recovery time.
  • No Routine Long-Acting Anxiolytics: Use short-acting anxiolytics for specific patients to avoid prolonged sedation.

Evidence and Impact

  • Evidence Levels: Nine items (36%) have high-level evidence (Level 1 or 2), and 16 (64%) carry a strong recommendation grade.
  • Outcomes: ERAS protocols have reduced postoperative complications, LOS, and costs in liver surgery, with meta-analyses showing significant benefits.
  • Gaps: Limited data exist for hepatectomy in cirrhotic patients, and prospective studies are needed to validate the protocol in this group

Special Considerations

  • Cirrhotic Patients: Specific studies are lacking, and careful patient selection is needed due to higher risks of posthepatectomy liver failure (PHLF).
  • Minimally Invasive Liver Surgery (MILS): Associated with lower complications and faster recovery, enhancing ERAS benefits.
  • ACLD Patients: Multidisciplinary evaluation, including hepatologist input, is crucial. Tools like transient elastography (TE) and MELD/CTP scores assess liver dysfunction and surgical risk.
 

Implementation

  • The ERAS Interactive Audit System (EIAS) supports guideline implementation, improving compliance and outcomes.
  • A multidisciplinary team approach, including surgeons, anesthesiologists, and nurses, is essential for success.
 

For detailed guidelines, access the full text at the ERAS Society website (erassociety.org) or the 2022 publication in World Journal of Surgery. Prospective studies are still needed to confirm the protocol’s clinical impact, particularly in complex cases like cirrhosis.

 
 
Nutrition prior to pancreaticoduodenectomy (Whipple procedure) is critical to optimize patient outcomes, as this major surgery for pancreatic, bile duct, or duodenal cancer can be physically demanding. Malnutrition is common in these patients due to pancreatic insufficiency, obstructive jaundice, or cancer-related cachexia, which can impair recovery, increase complications, and prolong hospital stays. Here’s a concise overview based on current evidence:
Key Nutritional Considerations
  1. Preoperative Nutritional Assessment:
    • Screening: Use tools like the Malnutrition Universal Screening Tool (MUST) or Nutritional Risk Screening (NRS-2002) to identify malnutrition risk.
    • Common Issues: Weight loss, low BMI (<18.5 kg/m²), reduced oral intake, or serum albumin <3.5 g/dL indicate malnutrition.
    • Biomarkers: Check albumin, prealbumin, and transferrin levels, though these can be affected by inflammation or liver dysfunction.
  2. Preoperative Nutritional Optimization:
    • High-Protein, High-Calorie Diet: Aim for 25–35 kcal/kg/day and 1.2–2.0 g/kg/day of protein to counteract catabolism, especially in malnourished patients.
    • Pancreatic Enzyme Replacement Therapy (PERT): If exocrine pancreatic insufficiency is present (e.g., steatorrhea, diarrhea), prescribe pancreatic enzymes with meals to improve nutrient absorption.
    • Immunonutrition: Formulas enriched with arginine, omega-3 fatty acids, and nucleotides may reduce postoperative infections and complications. Start 5–7 days preoperatively (e.g., 750–1000 mL/day of oral immunonutrition supplements).
    • Vitamin and Mineral Supplementation: Correct deficiencies (e.g., fat-soluble vitamins A, D, E, K) due to malabsorption or obstructive jaundice. Vitamin D and calcium are often needed.
    • Glycemic Control: Optimize blood glucose levels, as diabetes or impaired glucose tolerance is common in pancreatic cancer patients.
  3. Route of Nutrition:
    • Oral Nutrition: Preferred if the patient can tolerate it. Small, frequent, nutrient-dense meals are better tolerated.
    • Enteral Nutrition: If oral intake is inadequate (e.g., dysphagia, severe anorexia), consider nasogastric or nasojejunal feeding tubes for short-term support.
    • Parenteral Nutrition: Reserved for patients with severe malabsorption or intestinal obstruction, but avoid overuse due to infection risks.
  4. Preoperative Fasting and Carbohydrate Loading:
    • Enhanced Recovery After Surgery (ERAS) Protocols: Minimize fasting. Clear liquids are allowed up to 2 hours before surgery, and solids up to 6 hours.
    • Carbohydrate Loading: Administer oral carbohydrate-rich drinks (e.g., 50 g maltodextrin in 400 mL) 2–3 hours before surgery to reduce insulin resistance and improve postoperative recovery.
  5. Special Considerations:
    • Obstructive Jaundice: Bile salt supplementation may improve fat absorption.
    • Cachexia: Address with a combination of nutritional support, physical therapy, and possibly appetite stimulants (e.g., megestrol acetate) if appropriate.
    • Timing: Start nutritional optimization 7–14 days before surgery in malnourished patients, as per ESPEN guidelines.
Practical Recommendations
  • Collaborate with a dietitian to tailor a nutrition plan.
  • Monitor weight and nutritional status weekly leading up to surgery.
  • Avoid prolonged fasting and prioritize early postoperative feeding (enteral preferred) to support recovery.
Evidence-Based Insights
  • Studies show preoperative immunonutrition reduces infectious complications by 30–40% (ASPEN guidelines, 2020).
  • Malnourished patients have a 2–3 times higher risk of postoperative complications (e.g., pancreatic fistula, delayed gastric emptying).
  • ERAS protocols with carbohydrate loading and early feeding improve hospital stay duration by 1–2 days.

Pancreatic enzyme supplementation is often necessary after a pancreatectomy (partial or total removal of the pancreas) to address pancreatic exocrine insufficiency (PEI), which occurs when the pancreas no longer produces sufficient digestive enzymes to break down food. Below is a concise overview based on current medical understanding:

Why Supplementation is Needed
  • Pancreatectomy Impact: Removal of part or all of the pancreas reduces or eliminates the production of digestive enzymes (lipase, amylase, protease) needed for fat, carbohydrate, and protein digestion.
  • Consequences of PEI: Without adequate enzymes, patients may experience malabsorption, leading to symptoms like steatorrhea (fatty stools), weight loss, diarrhea, bloating, and nutritional deficiencies (e.g., fat-soluble vitamins A, D, E, K).
  • Total vs. Partial Pancreatectomy: Total pancreatectomy guarantees lifelong enzyme supplementation. Partial pancreatectomy (e.g., Whipple procedure or distal pancreatectomy) may lead to varying degrees of PEI, depending on the remaining pancreatic tissue and its function.
Pancreatic Enzyme Replacement Therapy (PERT)
  • Purpose: PERT replaces the missing pancreatic enzymes to aid digestion and prevent malabsorption.
  • Form: Typically administered as oral pancreatic enzyme preparations (e.g., Creon, Zenpep, Pancrelipase) containing lipase, amylase, and protease in enteric-coated capsules or tablets to protect enzymes from stomach acid.
  • Dosage:
    • Individualized based on the extent of pancreatic resection, meal size, and fat content.
    • General starting dose: 40,000–50,000 units of lipase per meal, with half that for snacks. Adjustments are made based on symptoms and nutritional status.
    • Higher doses may be needed for total pancreatectomy or severe PEI.
  • Administration:
    • Taken with meals and snacks to synchronize with digestion.
    • Capsules should be swallowed whole or, if opened, mixed with non-acidic food (e.g., applesauce) to avoid enzyme degradation.
    • Timing is critical—enzymes must be taken at the start of or during meals for optimal efficacy.
Monitoring and Adjustments
  • Symptoms to Monitor: Persistent steatorrhea, weight loss, or diarrhea may indicate inadequate dosing. Conversely, excessive dosing can cause side effects like abdominal pain or constipation.
  • Nutritional Assessment: Regular follow-up with a dietitian or gastroenterologist to evaluate nutritional deficiencies (e.g., vitamin D, B12, or zinc) and adjust PERT.
  • Adjunct Therapies:
    • Proton pump inhibitors (PPIs) or H2 blockers may be used to reduce gastric acid, enhancing enzyme activity.
    • Dietary modifications (e.g., smaller, frequent meals, low-fat diet in some cases) can help manage symptoms.
Additional Considerations
  • Diabetes Management: Total pancreatectomy often results in insulin-dependent diabetes (“brittle diabetes”) due to loss of endocrine pancreatic function, requiring separate management.
  • Quality of Life: Proper PERT improves nutrient absorption, weight maintenance, and overall quality of life.
  • Patient Education: Patients need guidance on timing, dosing, and recognizing signs of malabsorption to optimize therapy.
Challenges and Side Effects
  • Challenges: Non-compliance, incorrect timing, or under-dosing can lead to persistent malabsorption. Cost of PERT can also be a barrier for some patients.
  • Side Effects: Rare but may include nausea, abdominal cramping, or, in high doses, fibrosing colonopathy (a rare intestinal complication).
Clinical Guidance
  • Consultation: A gastroenterologist or pancreatic specialist should guide PERT initiation and titration.
  • Follow-Up: Regular monitoring of symptoms, weight, and nutritional markers (e.g., serum albumin, vitamin levels) is essential.
  • Guidelines: Recommendations from organizations like the American Gastroenterological Association (AGA) or European Society for Medical Oncology (ESMO) emphasize individualized PERT for post-pancreatectomy patients.

📨🏠📝

Drainage Yes 🆚 No

  • In pancreatic head cancer, preoperative biliary drainage associated delay in surgery does not affect survival rate.
  • Routine drainage in patients with pancreatic head cancer is associated to ↗️ surgical complication.

Endoscopic 🆚 Percutaneous

  • One study prematurely ⛔️✋ for ↗️ mortality in percutaneous group.
  • Percutaneous biliary drainage ↘️ morbidities & ↘️ LoS.
  • In biliary cancer dissemination is ↗️ after Percutaneous drainage.

Plastic 🆚 Metal stent

  • No outcome difference.
  • Plastic stent ↗️ cost effective.
  • No superiority of uncovered self-expandable metal stent 🆚 plastic stent.
  • Stent dysfunction is ↘️ in fully covered self expandable metal stent.

Convered 🆚 Uncovered Metal Stent

  • Similar outcome but different mechanisms of stent dysfunction.
Biliary drainage prior to pancreaticoduodenectomy (Whipple procedure) is a clinical intervention used in some cases to manage obstructive jaundice in patients with pancreatic or periampullary tumors, such as pancreatic ductal adenocarcinoma or cholangiocarcinoma. Below is an overview of the role, indications, methods, benefits, and controversies surrounding preoperative biliary drainage (PBD), based on clinical evidence and guidelines up to my knowledge cutoff in October 2023.
 1. Indications for Preoperative Biliary Drainage
PBD is typically considered in patients with obstructive jaundice (elevated bilirubin levels due to bile duct obstruction) caused by tumors in the pancreatic head, duodenum, or distal bile duct. Common indications include:
  • Severe jaundice: Serum bilirubin levels >15–20 mg/dL, which may impair liver function or increase surgical risks.
  • Cholangitis: Infection of the bile duct requiring urgent decompression.
  • Delayed surgery: When surgery is delayed (e.g., due to neoadjuvant therapy or logistical reasons), drainage may prevent complications like liver dysfunction or coagulopathy.
  • Symptomatic relief: To alleviate severe pruritus, malnutrition, or other jaundice-related symptoms.
  • Renal dysfunction: Jaundice can impair kidney function, and drainage may stabilize renal status before surgery.
 2. Methods of Biliary Drainage
  • Endoscopic Retrograde Cholangiopancreatography (ERCP):
    • Involves stent placement (plastic or metal) in the bile duct to restore bile flow.
    • Preferred in many centers due to its minimally invasive nature.
    • Risks: Pancreatitis, cholangitis, stent occlusion, or bleeding.
  • Percutaneous Transhepatic Cholangiography (PTC):
    • External or internal-external drainage catheter placed via the liver.
    • Used when ERCP fails or is not feasible (e.g., altered anatomy).
    • Risks: Bleeding, bile leak, infection, or catheter dislodgement.
  • Surgical Drainage:
    • Rarely used preoperatively due to invasiveness; may involve a bypass (e.g., choledochojejunostomy).
    • Typically reserved for cases where other methods fail or during palliative surgery.
3. Benefits of Preoperative Biliary Drainage
  • Restores liver function: Reduces bilirubin levels, potentially improving liver synthetic function and reducing coagulopathy.
  • Improves patient condition: Alleviates symptoms like pruritus, fatigue, and anorexia, improving quality of life and nutritional status.
  • Facilitates neoadjuvant therapy: In patients receiving preoperative chemotherapy or radiation, drainage prevents jaundice-related complications during treatment.
  • Reduces surgical complications: Theoretical benefit of improved liver function reducing postoperative liver failure or bleeding risks.
4. Controversies and Risks
The routine use of PBD is debated due to mixed evidence on its impact on surgical outcomes. Key points include:
  • Lack of clear survival benefit: Studies, including a 2010 randomized controlled trial (NEJM, van der Gaag et al.), showed no significant improvement in overall morbidity or mortality with routine PBD compared to early surgery in resectable cases. In fact, PBD was associated with higher complication rates (e.g., infections, pancreatitis).
  • Procedure-related complications: ERCP and PTC carry risks like pancreatitis (3–10%), cholangitis (up to 20%), and stent occlusion, which may delay surgery or worsen outcomes.
  • Potential to increase surgical complications: Stent placement can cause inflammation or infection, complicating pancreaticoduodenectomy (e.g., increasing pancreatic fistula risk).
  • Selective use recommended: Guidelines (e.g., from the International Study Group of Pancreatic Surgery and National Comprehensive Cancer Network) suggest avoiding routine PBD in patients with bilirubin <15 mg/dL who can undergo early surgery (within 1–2 weeks). PBD is reserved for specific indications like cholangitis, severe jaundice, or delayed surgery.
5. Current Guidelines and Recommendations
  • Selective approach: PBD is not routinely recommended for patients with resectable pancreatic cancer and mild to moderate jaundice (bilirubin <15 mg/dL) if surgery can be performed promptly.
  • Preferred method: ERCP with plastic stents is generally favored over metal stents for short-term drainage in resectable cases, as metal stents may complicate surgery due to tissue ingrowth.
  • Neoadjuvant setting: PBD is often necessary for patients undergoing preoperative chemotherapy or chemoradiation, as treatment duration (often 2–4 months) increases the risk of jaundice-related complications.
  • Multidisciplinary decision: The decision to pursue PBD should involve a multidisciplinary team (surgeons, gastroenterologists, oncologists) considering tumor characteristics, patient condition, and surgical timing.
6. Practical Considerations
  • Stent choice: Plastic stents are preferred for short-term drainage (e.g., 4–6 weeks), while self-expanding metal stents (SEMS) may be considered for longer durations or borderline resectable cases.
  • Timing: Drainage should be performed 4–6 weeks before surgery to allow bilirubin normalization and minimize stent-related complications.
  • Antibiotic prophylaxis: Often used during ERCP/PTC to reduce infection risk.
  • Monitoring: Post-drainage, patients should be monitored for stent occlusion, cholangitis, or other complications that may require stent exchange or antibiotics.
7. Conclusion
Preoperative biliary drainage prior to pancreaticoduodenectomy is a valuable tool in specific scenarios but is not routinely recommended due to potential complications and lack of clear benefit in all cases. It is most appropriate for patients with severe jaundice, cholangitis, or those requiring delayed surgery or neoadjuvant therapy. ERCP with plastic stents is the preferred method in most cases, but decisions should be tailored to the patient’s clinical status and tumor characteristics, guided by a multidisciplinary team.
Disclaimer

This page is designed only for learning support purposes.
It is not dedicated for any medical use or patient care.
HBPSurG makes no claims of the accuracy of the information contained herein.​

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