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Bhoriwal SK, Kumar S, Deo S, Sharma J, Mishra A, Kumar N, Saikia J, Dhall K. Clinical outcomes and technical description of unstented end to side pancreaticogastrostomy by small posterior gastrotomy. Ann Hepatobiliary Pancreat Surg 2021; 25:251-258. [PMID: 34053928 PMCID: PMC8180407 DOI: 10.14701/ahbps.2021.25.2.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/09/2022] Open
Abstract
Backgrounds/Aims Morbidity following Whipple’s surgery largely depends upon the pancreatic stump anastomosis leak. Pancreaticogastrostomy is one of the techniques of pancreatic stump reconstruction and is described variously in the literature. Duct to mucosa pancreaticogastrostomy is described either by a large 3-4 cm posterior gastrotomy or by small gastrotomy of 2-3 mm with the use of internal stents along with. We describe clinical outcomes and technique of 2 layer end to side pancreatico-gastrostomy by a small posterior gastrotomy without the use of internal stents. Methods Hospital records of 35 patients where the technique of, small posterior gastrotomy end to side duct to mucosa pancreatico-gastrostomy without internal stents, was used for pancreatic stump reconstruction were studied retrospectively. The data were analyzed for demographic details, stage of the disease, and short term outcomes related to surgical procedure. Results The mean duration of surgery was 7.4 hours. Grade A, B, and C POPF were observed in 10 (28.5%), 3 (8.5%), and 1 (2.8%) of patients respectively. The mean time to remove pancreatic drain was 9 days, and the mean time to start oral feeds was 8.9 days. The mean hospital stay was 12.9 days (07-26). Thirty days mortality was 2.8%. Conclusions Unstented duct to mucosa end to side pancreatico-gastrostomy technique is comparable with other pancreatico-gastrostomy techniques in outcomes in terms of POPF, morbidity, mortality, and hospital stay. However, to establish the superiority or inferiority of this technique, a larger study is recommended.
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Affiliation(s)
- Sandeep Kumar Bhoriwal
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Sunil Kumar
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Svs Deo
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Jyoti Sharma
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Ashutosh Mishra
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Naveen Kumar
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Jyoutishman Saikia
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Kunal Dhall
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
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Bao L, Chen ZT, Huang JC, Li MX, Zhang LL, Wan DL, Lin SZ. Small bowel perforation caused by pancreaticojejunal anastomotic stent migration after pancreaticoduodenectomy: A case report. Medicine (Baltimore) 2020; 99:e21120. [PMID: 32791686 PMCID: PMC7386991 DOI: 10.1097/md.0000000000021120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pancreaticoduodenectomy (PD) has been widely applied as a standard surgical procedure to treat periampullary diseases. The placement of a pancreaticojejunal anastomotic stent is considered an effective and safe method for preventing pancreatic fistula after PD. Recently, the role of pancreaticojejunal anastomotic stents has been challenged, as gradually increasing complications have been observed. Stent-related small bowel perforation has only occurred in 2 cases as long-term complications but has not been reported to occur within 1 week after surgery. PATIENT CONCERNS Here, we report the case of a 71-year-old female patient complaining of painless jaundice who underwent PD with a pancreaticojejunal anastomotic stent for a duodenal papillary adenocarcinoma (T4N1M0). Four days after surgery, she had a sudden rise in temperature, high white blood cell count, significantly elevated C-reactive protein and 400 ml green-brown drainage fluid. Enhanced computed tomography showed hydrops abdominis. DIAGNOSIS Small bowel perforation caused by stent migration was considered first. INTERVENTIONS An emergency exploratory laparotomy was performed. We located the pancreaticojejunal anastomotic stent, which extended 2 cm from the small bowel, and sutured the jejunum hole after cutting away the protruding part of the stent. OUTCOMES The patient recovered smoothly and was discharged on the 7th day after the second surgery. After more than 12 months of follow-up, the patient is doing well and is free of any symptoms related to the procedure. CONCLUSION We caution that stent-related complications can occur when perioperative patients suffer from unexplained or sudden changes in vital signs after PD. In addition, the function of the pancreaticojejunal anastomotic stent needs to be reevaluated by future studies.
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Affiliation(s)
- Li Bao
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Zhi-Tao Chen
- Zhejiang University School of Medicine, Hangzhou, China
| | | | - Meng-Xia Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Le-Le Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Da-Long Wan
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
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Bakheet N, Park JH, Shin SH, Hong S, Park Y, Shim IK, Hwang C, Jeon JY, Lopera JE, Song HY, Kim SC. A Novel Biodegradable Tubular Stent Prevents Pancreaticojejunal Anastomotic Stricture. Sci Rep 2020; 10:1518. [PMID: 32001759 PMCID: PMC6992790 DOI: 10.1038/s41598-019-57271-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/24/2019] [Indexed: 02/06/2023] Open
Abstract
Stricture of pancreatic-enteric anastomoses is a major late complication of a pancreaticoduodenectomy for the treatment of a periampullary tumor and can lead to exocrine and endocrine insufficiency such as malnutrition and diabetes mellitus. We investigated the safety and efficacy of a biodegradable tubular stent (BTS) for preventing a pancreaticojejunostomy (PJ) anastomotic stricture in both a rat and porcine model. The BTS was manufactured using a terpolymer comprising poly p-dioxanone, trimethylene carbonate, and glycolide. A cohort of 42 rats was randomized into 7 groups of 6 animals each after BTS placement into the duodenum for the biodegradation assay. A total of 12 pigs were randomized equally into a control and BTS placement group. The effectiveness of the BTS was assessed by comparing radiologic images with histologic results. Surgical procedures and/or BTS placements were technically successful in all animals. The median mass losses of the removed BTS samples from the rat duodenum were 2.1, 6.8, 11.2, 19.4, 26.1, and 56.8% at 1, 2, 3, 4, 6, and 8 weeks, respectively. The BTS had completely degraded at 12 weeks in the rats. In the porcine PJ model, the mean luminal diameter and area of the pancreatic duct in the control group was significantly larger than in the BTS group (all p < 0.05). BTS placement thus appears to be safe and effective procedure for the prevention of PJ anastomotic stricture. These devices have the potential to be used as a temporary stent placement to treat pancreatic-enteric anastomoses, but further investigations are required for optimization in human.
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Affiliation(s)
- Nader Bakheet
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
- Gastrointestinal Endoscopy and Liver unit, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Hyun Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sarang Hong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yejong Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In Kyong Shim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Changmo Hwang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
- Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jae Yong Jeon
- Department of Rehabilitation, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jorge E Lopera
- Department of Radiology, UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Song Cheol Kim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Bhanthumkomol P, Hara K, Mizuno N, Hijioka S, Okuno N, Yoshida T, Tokuhisa J, Siramolpiwat S, Vilaichone RK, Pornthisarn B, Niwa Y, Tajika M, Tanaka T, Ishihara M, Hirayama Y, Yamao K. Feasibility of the unilateral-flange stent for the treatment of benign pancreatic duct stricture: a pilot study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2017; 79:453-458. [PMID: 29238101 PMCID: PMC5719204 DOI: 10.18999/nagjms.79.4.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endoscopic placement of the plastic stent has been adopted as an initial treatment for chronic pancreatitis with pancreatic duct stricture. Stent fracture while attempting removal is one of the complications of stent exchange. The use of the unilateral-flange stent in these patients has never been reported. We investigated the outcomes associated with the use of this stent with regard to stent exchange and stent-related adverse events. From 2011 to 2015, 9 patients with chronic pancreatitis and main pancreatic duct (MPD) stricture treated with the unilateral-flange stent were included. Eleven endoscopic treatment sessions, 53 endoscopic stent deployments or exchange procedures were analyzed. Technical success rate was 100%. Forty-eight stents were exchanged on a regular basis in 1 to 6-month intervals. Another 5 stent exchange procedures were urgently performed due to stent obstruction and caused pancreatitis (n=2), symptomatic external stent migration (n=2), and concurrent cholangitis (n=1). The rate of symptomatic migration was 3.7%. The mean duration for stent exchange was 29 minutes and no stent fracture occurred during the procedure. Of 11 endoscopic treatment sessions, 7 were successful, 3 were changed to the metallic stents, and 1 was lost to follow-up. According to this study, unilateral-flange stent placement for benign MPD stricture is technically feasible and effective. Stent removal during the exchange period is unchallenging and without stent fracture.
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Affiliation(s)
| | - Kazuo Hara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsukasa Yoshida
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Junya Tokuhisa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sith Siramolpiwat
- Gastroenterology Unit, Thammasat University Hospital, Pathumthani, Thailand
| | | | - Bubpha Pornthisarn
- Gastroenterology Unit, Thammasat University Hospital, Pathumthani, Thailand
| | - Yasumasa Niwa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yutaka Hirayama
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
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Successful removal of an internal pancreatic stent that migrated into the bile duct using double-balloon enteroscopy after pancreaticoduodenectomy. Surg Today 2017; 48:167-174. [PMID: 28689268 DOI: 10.1007/s00595-017-1563-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Internal stents used during pancreaticoduodenectomy (PD) are generally spontaneously passed through the rectum by defecation. However, we encountered six patients with internal stents that migrated into the bile duct after PD. We herein report the outcomes of these six patients and the usefulness of double-balloon enteroscopy (DBE) for removal of such stents from the bile duct. METHODS An internal stent was placed across pancreaticojejunostomy in 416 (68.8%) of 605 consecutive patients undergoing PD between 2005 and 2015. This study evaluated the characteristics and outcomes of the six patients whose internal stent migrated into the bile duct. RESULTS Migration of an internal stent into the bile duct was found during follow-up computed tomography (CT) in 6 (1.4%) of 416 patients who had an internal stent placed during PD. Three patients developed stent-induced cholangitis, and two had bile duct stones. Excluding one patient whose internal stent spontaneously slipped out and disappeared from the bile duct, all patients underwent successful removal of a stent from the bile duct by a single instance of biliary intervention involving DBE. CONCLUSIONS Removal of a stent from the bile duct using DBE is a feasible and useful procedure that should be considered if an internal stent is detected during follow-up CT after PD.
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The Evaluation of Internal Stent-Related Complications and Risk Factors of Stent Migration in Pancreaticoduodenectomy. Int Surg 2016. [DOI: 10.9738/intsurg-d-16-00146.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The placement of an internal stent through a pancreatic anastomosis is one of the surgical techniques to reduce the incidence of pancreatic fistula. However, the fate of the internal stent after placement remains unclear. The aim of this study was to evaluate stent-related complications and risk factors of stent migration through pancreaticojejunostomy in pancreaticoduodenectomy. We retrospectively analyzed 159 patients who underwent pancreaticoduodenectomy or subtotal stomach-preserving pancreaticoduodenectomy. Stent migration and stent defecation were confirmed by computed tomography. Risk factors of delayed detachment and migration of the stent were analyzed. The median stent defecation time was 5.6 months and the stent was not expelled after 1 year in 33 patients (20.7%). Stent migration was detected in 11 patients (6.9%); the destination was always the hepatic duct. Stent-related complications were observed in 2 cases (1.3%). There were no significant risk factors of delayed detachment of the stent. Stent length ≤25 mm was the only significant predictive risk factor of stent migration into the hepatic duct in multivariate analysis. The low rate of stent-related complications and the absence of serious adverse effects observed in this study justifies that the placement of the internal stent during pancreaticoduodenectomy. Cases with delayed defecation require close and long-term follow-up, especially if a short stent was used.
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Park SH, Kim JH, Noh SY, Byun JH, Lee SS, Kim HJ, Park SH, Lee SK, Hwang DW, Kim SC, Han DJ, Lee MG. Migration of Internal Pancreaticojejunostomy Stents into the Bile Ducts in Patients Undergoing Pancreatoduodenectomy. J Gastrointest Surg 2015; 19:1995-2002. [PMID: 26245635 DOI: 10.1007/s11605-015-2906-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/28/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate the incidence, complications, and risk factors of the migration of internal pancreaticojejunostomy (PJ) stents into the bile ducts in patients undergoing pancreatoduodenectomy. METHODS Postoperative computed tomography (CT) and clinical data of 802 patients with CT-detectable internal PJ stents were reviewed to assess the occurrence of stent migration into the bile ducts and stent-induced complications with their clinical significance. Risk factors for stent migration and stent-induced complications were determined. RESULTS Stent migration into the bile ducts occurred in 135 patients (16.8 %); 40 of these (29.6 %) showed stent-induced complications including bile duct stricture, stone, and liver abscess. Clinically significant complications were identified in only eight patients. Neither the stent length nor diameter was associated with stent migration. A small stent diameter, peripheral location of the stent, absence of stent remigration from the bile ducts to the intestine, and longer stent retention time in the bile ducts were risk factors of stent-induced complications. CONCLUSIONS The incidence of internal PJ stent migration into the bile ducts was 16.8 %. Migrated stents frequently caused complications, although they were mostly subclinical. Stent-induced complications were associated with stent diameter and location, stent remigration to the intestine, and stent retention time in the bile ducts.
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Affiliation(s)
- So Hyun Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea.
| | - Seung Yeon Noh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Dae Wook Hwang
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
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