ResearchPad - how-i-do-it https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[How We Do It: Modified Residency Programming and Adoption of Remote Didactic Curriculum During the COVID-19 Pandemic]]> https://www.researchpad.co/article/elastic_article_13364 To describe the modified operational plan we implemented for residents and faculty in our orthopedic surgery department to allow continuation of resident education and other core activities during the novel coronavirus (COVID-19) pandemic.DESIGNDescription of educational augmentation and programming modifications.SETTINGThe Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, Baltimore, MD.PARTICIPANTSResidents and faculty, Department of Orthopaedic Surgery.METHODSIn response to the COVID-19 pandemic, we developed and implemented a modified operational schedule and remote curriculum in the orthopedic surgery department of our health system. Our plan was guided by the following principles: protecting the workforce while providing essential clinical care; maintaining continuity of education and research; and promoting social distancing while minimizing the impact on team psychosocial well-being.RESULTSThe operational schedule and remote curriculum have been implemented successfully and allow resident education and other core departmental functions to continue as our health care system responds to the pandemic.CONCLUSIONSWe have been proactive and deliberate in implementing these operational changes, without compromise of our workforce. This experience provides residents exposure to real-life systems-based practice. We hope that our early experience will provide a framework for other surgical residency programs facing this crisis. ]]> <![CDATA[Surgery in times of COVID-19—recommendations for hospital and patient management]]> https://www.researchpad.co/article/N978f4edc-99ef-4009-b6dd-bd4e4a4a23e6 The novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has escalated rapidly to a global pandemic stretching healthcare systems worldwide to their limits. Surgeons have had to immediately react to this unprecedented clinical challenge by systematically repurposing surgical wards.PurposeTo provide a detailed set of guidelines developed in a surgical ward at University Hospital Wuerzburg to safely accommodate the exponentially rising cases of SARS-CoV-2 infected patients without compromising the care of emergency surgery and oncological patients or jeopardizing the well-being of hospital staff.ConclusionsThe dynamic prioritization of SARS-CoV-2 infected and surgical patient groups is key to preserving life while maintaining high surgical standards. Strictly segregating patient groups in emergency rooms, non-intensive care wards and operating areas prevents viral spread while adequately training and carefully selecting hospital staff allow them to confidently and successfully undertake their respective clinical duties. ]]> <![CDATA[Single-incision laparoscopic surgery portal vein embolisation before extended hepatectomy]]> https://www.researchpad.co/article/Nee3a2cea-885f-4977-a644-81282a7d80f1

Objective:

Portal vein embolisation (PVE) represents the standard procedure for augmentation of the contralateral lobe before extended right hepatectomy. However, possible limitations for the percutaneous transhepatic approach exist, for example, large tumours of the right lobe. Here, we present our experiences with single-incision laparoscopic surgery-PVE (SILS-PVE) as an alternative approach for settings where percutaneous routes are technically not feasible.

Methods:

A small umbilical incision is performed, and a GelPOINT Mini Advanced Access Platform (Santa Margarida, CA, USA) is placed. Staging laparoscopy is performed routinely followed by identification of an appropriate ileal segment, which is subsequently exteriorized through the small umbilical incision. A peripheral mesenteric vein is encircled and cannulated to access right portal vein branches. After sufficient embolisation of the right lobe, the peripheral vein is ligated, the single port is extracted and the umbilical wound is closed.

Results:

SILS-PVE was successfully applied in 10 patients (median age 60.5 years) between 12/2015 and 03/2018. The technique was indicated due to extensive tumours in the right lobe (n = 8), extensive hydatid cyst (n = 1) and during SILS right hemicolectomy in Stage IV colon cancer (n = 1). Mean operative time was 184 min (range 116–315). Patients were discharged on post-operative day 4 (range 2–9). Augmentation of the future liver remnant volume was assessed by computed tomography-volumetry 3–4 weeks after SILS-PVE and showed a mean relative increase of 64.95%, future remnant liver function showed a mean increase of 120.77%.

Conclusion:

The proposed SILS-PVE represents a technically simple and safe alternative to standard percutaneous transhepatic approaches. Perioperative risks can be minimised by minimally-invasive surgery, which is of explicit importance in multimodal approaches before major hepatectomy.

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<![CDATA[Extracervical Endoscopic thyroid surgery via Bilateral Axillo- Breast approach (BABA)]]> https://www.researchpad.co/article/Nd2a80159-ef47-48b7-8d05-108abdeae388

Extracervical, scarless in-the-neck endoscopic thyroidectomy (SET) is a relatively new offshoot of minimal access neck surgery which is gaining popularity rapidly. Among all the approaches described, hybrid approaches such as axillary-breast and bilateral axillo-breast (BABA) are most practiced world over. We have performed more than 130 cases of SET using various approaches (ABA, BABA and transoral vestibular approach). We find BABA most suitable for patients who present with larger goitres (≥6cm), toxic glands or low-grade thyroid cancers and are desirous of SET. Here, we describe the surgical technique of BABA, its pros and pitfalls based on our experience.

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<![CDATA[Segment IV approach for difficult laparoscopic cholecystectomy]]> https://www.researchpad.co/article/N6e2b6aff-412f-40e5-be4e-3994456a4446

Abstract

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D‐line) as a feasible landmark for carrying out difficult LC. The D‐line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D‐line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty‐two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D‐line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D‐line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54‐290) min and 10 (range, 0‐100) mL, respectively. No intra‐ or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

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<![CDATA[Developing an in vivo porcine model of duct‐to‐mucosa pancreaticojejunostomy (Yonsei‐PJDTM)]]> https://www.researchpad.co/article/Nb056cf31-dcd0-4f36-9693-941dc4190908

Abstract

Laparoscopic pancreaticoduodenectomy (LPD) is technically feasible, but its safety is still controversial. Pancreas texture and the small size of the main pancreatic duct indicate laparoscopic pancreaticoduodenectomy (LPD) as a challenging procedure. Thus, LPD could be a risk factor for postoperative pancreatic fistula (POPF), longer hospital stay, and delayed adjuvant chemotherapy that affects long‐term oncologic outcome. So, it is important to promote education on LPD especially techniques for pancreaticojejunostomy. A porcine model for duct‐to‐mucosa pancreaticojejunostomy (PJ) (Yonsei‐PJDTM) was developed, and details of the model will be described in this report.

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<![CDATA[Two‐in‐one method: Novel pancreaticojejunostomy technique for the bifid pancreas]]> https://www.researchpad.co/article/Nad9287a0-5994-438e-b31d-7591c85ed05f

Abstract

The bifid pancreas is a rare anatomical variation of the pancreatic duct in which double main pancreatic ducts in the body and tail of the pancreas join at the pancreas head and drain through the major papilla. When pancreaticoduodenectomies are carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the ‘two‐in‐one’ method for double pancreatic duct to jejunum anastomosis. Using the two‐in‐one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection. This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

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<![CDATA[How I do it? Uniportal full endoscopic contralateral approach for lumbar foraminal stenosis with double crush syndrome]]> https://www.researchpad.co/article/N76763066-b1e2-4bc2-a74c-4d8ab3d957c5

Background

Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce.

Methods

The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size.

Conclusion

The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04157-z) contains supplementary material, which is available to authorized users.

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<![CDATA[Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy]]> https://www.researchpad.co/article/Nc311a363-dced-4588-9f8e-b624eac3daab

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

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<![CDATA[Endovascular Repair of Aortic Arch Aneurysm with Surgeon-Modified Fenestrated Stent Graft]]> https://www.researchpad.co/article/5c8015b2d5eed0c484a9f961

The authors describe a technique of treating patients with aortic arch aneurysm using surgeon-modified fenestrated stent graft (SMFSG). The technique is demonstrated in a 80-year-old patient whose aneurysm was successfully excluded with a SMFSG using Cook Alpha thoracic stent graft. The device was deployed, removed from its delivery system, and a fenestration created before being mounted back on the delivery system and constrained. It was transitioned through a series of sheaths before being introduced into its original sheath. The device was implanted via a common femoral artery access site; fenestration cannulated from the left brachial artery and bridged with a stent graft.

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<![CDATA[Laparoscopically assisted insertion of peritoneal dialysis catheter]]> https://www.researchpad.co/article/5c37bb8ad5eed0c48449a150

Peritoneal dialysis (PD) is a generally accepted method for treatment of patients with the end-stage renal disease. A larger proportion of PD patients transfer to haemodialysis every year than the converse. Many of the underlying causes of transfer to haemodialysis are preventable. Infectious complications still remain the most common reason for transfer of PD patients to haemodialysis, catheter-related problems are the second most common cause. For PD to be effective it is very important to provide a quality peritoneal access with the insertion of PD catheter with minimum complications. With the development of minimally invasive and laparoscopic surgery, laparoscopic insertion of PD catheter is becoming widely accepted method, which showed to be effective with minor complications. In our institution, laparoscopic insertion of PD catheter in adult patients is a standard method for providing peritoneal access for chronic peritoneal dialysis.

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<![CDATA[How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation]]> https://www.researchpad.co/article/5c22c467d5eed0c484a92767

Background

Percutaneous transforaminal endoscopic discectomy (PTED) has emerged as a less invasive technique to treat symptomatic lumbar disk herniation (LDH). PTED is performed under local anesthesia with the advantage of immediate intraoperative feedback of the patient. In this paper, the technique is described as conducted in our hospital.

Methods

PTED is performed under local anesthesia in prone position on thoracopelvic supports. The procedure is explained stepwise: e.g. marking, incision, introduction of the 18-gauge needle and guidewire to the superior articular process, introduction of the TomShidi needle and foraminotomy up to 9 mm, with subsequently removal of disk material through the endoscope. Scar size is around 8 mm.

Conclusion

PTED seems a promising alternative to conventional discectomy in patients with LDH and can be performed safely.

Electronic supplementary material

The online version of this article (10.1007/s00701-018-3723-5) contains supplementary material, which is available to authorized users.

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<![CDATA[Modified transesophageal echocardiography of the dissected thoracic aorta; a novel diagnostic approach]]> https://www.researchpad.co/article/5989db4bab0ee8fa60bda690

Background

Transesophageal echocardiography (TEE) is a key diagnostic modality in patients with acute aortic dissection, yet its sensitivity is limited by a “blind-spot” caused by air in the trachea. After placement of a fluid-filled balloon in the trachea visualization of the thoracic aorta becomes possible. This method, modified TEE, has been shown to be an accurate test for the diagnosis of upper aortic atherosclerosis. In this study we discuss how we use modified TEE for the diagnosis and management of patients with (suspected) acute aortic dissection.

Novel diagnostic approach of the dissected aorta

Modified TEE provides the possibility to obtain a complete echocardiographic overview of the thoracic aorta and its branching vessels with anatomical and functional information. It is a bedside test, and can thus be applied in hemodynamic instable patients who cannot undergo computed tomography. Visualization of the aortic arch allows differentiation between Stanford type A and B dissections and visualization of the proximal cerebral vessels enables a timely identification of impaired cerebral perfusion.

During surgery modified TEE can be applied to identify the true lumen for cannulation, and to assure that the true lumen is perfused. Also, the innominate- and carotid arteries can be assessed for structural integrity and adequate perfusion during multiple phases of the surgical repair.

Conclusions

Modified TEE can reveal the “blind-spot” of conventional TEE. In patients with (suspected) aortic dissection it is thus possible to obtain a complete echocardiographic overview of the thoracic aorta and its branches. This is of specific merit in hemodynamically unstable patients who cannot undergo CT. Modified TEE can guide also guide the surgical management and monitor perfusion of the cerebral arteries.

Electronic supplementary material

The online version of this article (doi:10.1186/s12947-016-0071-6) contains supplementary material, which is available to authorized users.

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<![CDATA[Modified teaching approach for an enhanced medical physics graduate education experience]]> https://www.researchpad.co/article/5ac03981463d7e2e53e00f72

Lecture-based teaching promotes a passive interaction with students. Opportunities to modify this format are available to enhance the overall learning experience for both students and instructors. The description for a discussion-based learning format is presented as it applies to a graduate curriculum with technical (formal mathematical derivation) topics. The presented hybrid method involves several techniques, including problem-based learning, modeling, and online lectures, eliminating didactic lectures. The results from an end-of-course evaluation show that the students appear to prefer the modified format over the more traditional methodology of “lecture only” contact time. These results are motivation for further refinement and continued implementation of the described methodology in the current course and potentially other courses within the department graduate curriculum.

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<![CDATA[Tympanoplasty—conchal cavum approach]]> https://www.researchpad.co/article/5989d9e8ab0ee8fa60b6bf2a

The three well recognized tympanoplasty approaches: permeatal, postaural, and endaural, each have advantages and disadvantages. The permeatal approach is suitable only for ears with adequate canal size. The postaural approach limits visualization of the posterior eardrum margin. The endaural approach limits the view of the eardrum's anterior margin.

This study describes a modified endaural approach, developed to overcome these limitations. A retrospective case series review and collection of a prospective cohort of patient reported outcome data were undertaken to assess the technique.

Method

Standard incisions as used in an endaural approach are placed within the ear canal. The novel incision extends from the superior canal incision into the conchal cavum. This allows a flap of the thick, hairbearing skin from both the bony and cartilaginous portions of the canal to be raised, and everted, to provide an excellent view of the entire drum. Perichondrium can be harvested for grafting from the conchal cavum.

The clinical charts of all patients operated on by the first author using this technique from 2010–2012 were retrospectively reviewed. The size and position of the perforation, size of the canal, whether primary or revision surgery, graft take rate, hearing results and the occurrence of chondritis/perichondritis were recorded.

To investigate the morbidities and the acceptance by the patients of the incision/scar in the conchal cavum, all patients undergoing the procedure in the 8 months up to the end of August 2013 were prospectively recruited to complete a self-assessment Likert scale questionnaire recording postoperative pain, and satisfaction with the cosmesis of the operative site. The clinician recorded if there was any evidence of chondritis/perichondritis.

Results

A 100 % graft take rate was achieved in the 75 adults treated by the first author from 2010 to 2012 regardless of the size and position of the perforation, configuration of the canal, primary or revision surgery.

Preoperative Pure Tone Audiometric (PTA) Air Bone Gap (ABG) averaged over 3 frequencies (0.5, 1 and 2 K Hz) was 19.4dB (standard deviation = 9.6, range 2 to 50). Postoperative PTA ABG average was 6.2 dB (standard deviation = 8.3, range -7 to 37), demonstrating a statistically significant post-surgery mean improvement of 13.2 dB (paired T-test, p < 0.001).

Twenty-one patients who underwent the procedure in 2013, reported minimal postoperative analgesic use, and scored the acceptability of the incision scar highly (4.8 out of a maximum of 5). There was no case of chondritis/perichondritis in the 96 cases.

Conclusion

Whilst it is the surgeon’s decision to use a permeatal, postaural or endaural approach, the endaural approach with the conchal cavum modification is an excellent alternative to the traditionally described approaches.

Trial Registration

Clinical trial number: NCT02000843 at ClinicalTrials.gov

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<![CDATA[The use of a modified abbé island flap to reconstruct primary lip defects of over 80 %]]> https://www.researchpad.co/article/5989da80ab0ee8fa60b9a6fe

Background

Lip reconstruction for defects greater than 80 % present a challenge in maintaining acceptable oral function and good aesthetic results. Abbé flaps offer an excellent reconstructive option but are limited to defects under 65 %.

Methods

We describe a two-stage “modified Abbé island flap” technique whereby a full-thickness myocutaneous flap is combined with a modified Karapandzic flap, allowing for reconstruction of total and near total lip defects.

Results

Six patients underwent successful two-stage lower and upper lip reconstruction with this technique. Oral competence and satisfactory aesthetic outcomes were achieved in all six cases. There were no complications. Although microstomia was noted to a certain extent, we argue this impact to be less than the morbidity of a free flap that lacks sphincteric function.

Conclusion

The “Modified Abbé Island Flap” can be used to reconstruct near-total lip defects using locally innervated, well-vascularized tissues that recreate the oral sphincter and restore oral competence. The combination of the conventional Abbé flap with a modified Karapandzic flap provides reliable results and significantly reduces operating time.

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<![CDATA[Tissue Doppler, Strain and Strain Rate in ischemic heart disease “How I do it”]]> https://www.researchpad.co/article/5989d9d9ab0ee8fa60b66dd7

Echocardiography is the standard method for assessing myocardial function in patients with ischemic heart disease. The acquisition and interpretation of echocardiographic images, however, remains a highly specialized task which often relies entirely on the subjective visual assessment of the reader and requires therefore, particular training and expertise. Myocardial deformation imaging allows quantifying myocardial function far beyond what can be done with sole visual assessment. It can improve the interpretation of regional dysfunction and offers sensitive markers of induced ischemia which can be used for stress tests. In the following, we recapitulate shortly the pathophysiological and technical basics and explain in a practical manner how we use this technique in investigating patients with ischemic heart disease.

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<![CDATA[Intima media thickness, pulse wave velocity, and flow mediated dilation]]> https://www.researchpad.co/article/5989d9deab0ee8fa60b68bfc

The identification of vascular alterations at the sub-clinical, asymptomatic stages are potentially useful for screening, prevention and improvement of cardiovascular risk stratification beyond classical risk factors.

Increased intima-media thickness of the common carotid artery is a well-known marker of early atherosclerosis, which significantly correlates with the development of cardiovascular diseases. More recently, other vascular parameters evaluating both structural and functional arterial proprieties of peripheral arteries have been introduced, for cardiovascular risk stratification and as surrogate endpoints in clinical trials. Increased arterial stiffness, which can be detected by applanation tonometry as carotid-femoral pulse wave velocity, has been shown to predict future cardiovascular events and to significantly improve risk stratification.

Finally, earlier vascular abnormalities such as endothelial dysfunction in the peripheral arteries, detected as reduced flow-mediated dilation of the brachial artery, are useful in the research setting and as surrogate endpoints in clinical trials and have also been suggested for their possible clinical use in the future.

This manuscript will briefly review clinical evidence supporting the use of these different vascular markers for cardiovascular risk stratification, focusing on the correct methodology, which is a crucial issue to address in order to promote their use in future for routine clinical practice.

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<![CDATA[Laparoscopic HIPEC: A bridge between open and closed-techniques]]> https://www.researchpad.co/article/5af90ce3463d7e12431d4a7d

Hyperthermic intraperitoneal chemotherapy (HIPEC) is currently delivered after cytoreductive surgery in patients with several kinds of peritoneal surface malignancies. Different methods for delivering HIPEC have been proposed all of them being variations between two modalities: the open technique and the closed technique. The open technique assures optimal distribution of heat and cytotoxic solution, with the disadvantage of heat loss and leakage of cytotoxic drugs. The closed technique prevents heat loss and drug spillage, increases drug penetration, but does not warrant homogeneous distribution of the perfusion fluid. A novel procedure that combines the advantages of the two techniques by means of laparoscopy is herein presented.

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<![CDATA[Two and three dimensional echocardiography for pre-operative assessment of mitral valve regurgitation]]> https://www.researchpad.co/article/5989d9d9ab0ee8fa60b66f82

Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.

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