Manipal Manual of Surgery PDF
Preview Manipal Manual of Surgery
Contents Forewords vii Preftaotc heFe o uErdtiht ion ix Preftaotc heFe i Erdsitt ion xi SECTIIOG:NE NERSAULR GERY 1.WounKde,l oHiydep,r troSpchaiarcn d •Deepp almaabrs cess MetaboRleiscp otnosI en jury 3 •Tenosynovitis •Mycetopmead is •Typoefsw oundCsl:a ssification Ingrotwoinena gi l •Generparli ncoifpm laensa gemeonfot p en wounds 5.ChronIincf ecDtiisoeuass e 51 •Componeonfwt osu nhde aling •Actinomycosis •Factaofrfse cwtoiunnghd e aling •Leprosy •Compartmseynntd romes •Deformiinlt eiperso sy •Hypertrsocpaahrni dck eloid •Syphilis •Classifoifsc uartgiiwoconau lnd s •AIDS •Healoifns gp eciatliissseude s •Metaborleiscp otnois nej ury 6.DifferDeinatginaoolfsL iesUg l caenrd PressSuorree 59 2.AcutIen fectSiionnuFssi,,s taunlda SurgiSciaItlne f ection 15 •Clineixcaamli nation •Management •Cellulitis •Wounddr essings •Ludwiagn'gsi na •Traumautlicce r •Lymphangitis •Venouulsc er •Abscess •Tropuhlicce r •Cervitcuable rcluylmopuhsa denitis •Tropiuclacle r •Boicla.r buncle •Post-throumlbcoetric •Erysipelas •Raruel cers •Chronaibcs cess •Diabeutliccfe oro t •Necrotfiassicnigi tis •VAC •Acutpey omyositis •Maggotth erapy •Surgisciiatnlef ections •Pressure sore •Asepasnidsa ntisepsis •Sinaunsdf istula 7.LoweLri mlbs chaeamnidPa o pliteal 3.TetaannudsG asG angrene 33 Aneurysm 76 •Tetanus •Lowelri mibs chaemia •Gasg angrene •Collactierrcaull ation •Typoefsg asi nfections •Clinfiecaatlu res •A casree poorfnt e crki gidity •Clineixcaamli nation •Management 4.Hanadn dF ooItn fections 41 •Differdeinatginaols is •Paronychia •Acutaer teorcicallu sion •Acutley mphangitis •Critliicmiabsl c haemia •Subcutanienofuesc tions •Popliatneeaulr ysm •Terminpaulls pp acien fections •Ainhum •Apicsaulb ungiunafle ction •Frostbite •Webs pacien fections •Reperfuisnijounr ies xvi ManiMpaanlu oafSl u rgery 12H.aemorrShhaogcaekn, dB lood •Faetm bolism •Aierm bolism Transfusion 17( •Fontacilnaes sification •ICgUa ngrene •Haemorrhage -Classification -Pathophysiology 8.UppeLmrib l schaeamnidGa a ngrene98 -Management •Shock •Raynauddi'sse ase -Classification •Thoraocuitcsl yentd rome -Pathophysiology •Axilvleaitrnhy r ombosis -Management •Vasculitis syndrome •Acutaed reinnaslu fficiency •Gangrene •Hyperboaxryigce n •Cancrourmi s •Centvreanlo purse ssure Acrocyanosis •Pulmonary wceadpgpierl elsasruyr e •Druagb usaen dg angrene •Blotorda nsfusion •Iatrodgreungi-ci ngdauncgerde ne •Blopordo ducts •Subclasvtiesaaynln drome •Plassmuab stitutes •Bleeding disorders 9.LymphaLtyimcpVshe, ssaenlds 13B.urSnksi,Gn r afatinndFg l aps 185 Lymphoma 110 •Burns •Lymphoedema-aannadpt hoymsyi ology •Fresek girna fting •Lymphcaitriccu lation •Flaps •Primlayrmyp hoedema •Electbruircnasl •Secondlayrmyp hoedema •Chemibcuarln s •Lymphangiography •Hydrotherapy •Hodgkliynm'psh oma 14A.cid-BBaaslea nFcleua,in ddE lectro1l9y4tes •Non-Hodgkin's lymphoma •Burkliytmtp'hso ma •Basdiecf initions •Sezasryyn'dsr ome •Henderson-Haesqsuealtbiaolnch •Chyluria •Regulaotfai coind -bbaaslea nce •lmmunohistochemistry •Acid-bdaisseo rders •Bonmea rraonwdp eripbhleorsoatdle m •Rapiindt erproefat naA tBiGro enp ort cetlrla nsplants •Normpahly siology •Watreerg ulation 10V.aricVoesiaenn sdD eeVpe iTnh rombo1s2i7s •Disturboafvn ocleusm e •Primary vveairniscose •Regulaotfsi oodnic uomn centration •Secondvaarryi cvoesien s •Disturbiancn ocnecse ntration •Surgaincaatlo mvye noofsu yss toeflm e gs •Disturbiancn ocmepso soift ibofonld uyi ds •Anatoomfty h leo nsga phenvoeuisn •Clinnioctaels •Clineixcaamli nation •Periopefrlauttihidev rea py •Treatment •Specpiuarlp ossoel utions •Complications •Nutrition •Shosratp henvoaursi cosity 15T.umoaunrdsS oTfits Ssaurec oma 213 •Deevpe itnh rombosis •Recurvraernitc voesien s •Benitgunm ours •Pelcvoincg esstyinodnr ome -Papilloma •Pulmontahrryo mboembolism -Fibroma 11S.kiTnu mours 144 -Lipoma •Neurtaulm ours •Classification -Neuroma •Premalilgensainotn s -Neurofibroma •Bascaelcl alr cinoma -Neurilemmoma •Squamocuecsla lr cinoma -Chordoma •Melanoctyumtoiucr s •Maligtnuamnotu rs •Maligmnealnatn oma -Paraneopslyansdtriocm es •Othmearl igsnkatinuntm ours •Softti sssaurec omas •Othsekrli ens ions -Differdeinatginoaofsls o itfsit s ssaurec oma Contents xvii -Liposarcoma •Thyfruonicdtt eisotns -Maligfniabhnritos utsi ocytoma •Clineixcaamli nation -Synovial sarcoma •Goitre -Angiosarcoma •Multinodular goitre -Rhabdomyosarcoma •Retrosgtoeirtnrael -Kapossair'cso ma •Gravdeiss'e ase -Dermatofibprroostaurbceormaan s •Maligtnuamnotu rs •Anaplcaasrtciicn oma ,S olniotdaurlye 16C.ystSiwce llNiencgSksw ,e llainndgs •Thyroiditis MetastLaysmipNsho dNee ck 232 •Lintghuyarlo id •Cysstwiecl lings •Ectotphiycr oid •Necskw ellings 20P.arathaynrdAo dirde nals 361 •Diffedrieangtonifmoa isldi lssiw neel lings •Sweliltnih nsegu sb mandtirbiualnagrl e •Surgaincaatlo my •Sweliltnih ncega sr ottriida ngle •Congeanniotmaall y ,S weliltnih npego ss tterriiaonrg le •Physiologayn-adcc atolifPco TinHu m •AVf istula •Tetany •Secondiatnrh nieee csk •Hyperparathyroidism •Diffteyrpoeefnns te cdki ssections •Acuhtyep ercaclrciaseimsic •Pancotausmto'usr •Adregnlaaln ds-apnhaytsoimoyl,o gy •Disoorfad derrescn oarlt ex 17.OraCla viOtdyo,n tomLeiaspn, dP alat2e72 •Neuroblastoma •Phaeochromocytoma •Orcaaln cer •lncidentaloma •Premalciognndaintti ons •Geneprrailn ciples 21B.r east 377 •Carcionfbo umcacm aulc osa •Carcionfto omnag ue •Congeanniotmaall ies •Ulcoeftr osn gue •Surgaincaatlo my •Carcionlfoi mpa •Cysstwiecl olfbi rnegass t-classification •Carcimnaoxmiaal nltarruym •Acubtaec tmearsitailt is •Nasopharynx-cancer •Antibioma •Benliegsnii tnoh noesr c aalv ity Retromaambmsacreys s •Odontomes •Phylltouimdoeusr •Epulis •lntraccayrsctioinfcbo rmeaa st •Medimaenn stianlu s •Aberroafnt oiromdnaeslv eloapnmdent •Vincaenngti'nsa involution •Clelfiatpnc dl peaflta te •Ectospailcig vlaatrnuydm our •Fibroadenoma Mucocuyss ts ,D ucetc tasiac-epmllalas stmiat is •idiopgartahniucl ommaasttoiutsi s 18S.aliGvlaarnyd s 302 •Macrocysts •Galactocoele •Surgaincaatlo my Galactorrhoea •Acuptaer otitis Dupcatp illoma •Submandibular sialoadenitis •Carcionfto hmbear east •Saligvlaatrnuydm ours Effoeflc ytmsp hoabtsitcrf urcoctmai rocni noma •Summoafmr ayl igtnuamnotu rs breast •Fresyy'nsd rome •Breraescto nstruction •Sjogsryennd'rso me •Carcionfmo amlabe r east •Mikudliisceza se •Prophymlaasctteicct omy •Parfoitsitdu la •Mondodri'sse ase •Surgfeofrray cn iearlpva el sy •Angiosarcoma breast •Peripnheerrrveaepl aa nitdrr ansfers •Disoorfad uegrmse nmtaamtmioopnl asty •Rarber ecaasntc ers 19T.hyrGoliadn d 319 •Ac asoefc arcibnroemaas t •Surgaincaatlo my •Rececnhta nigtneh ste r eatomfent •Physiology carcinoma breast xviii ManipMaaln uoaflS u rgery SECTIIOIGN:A STROINTESSUTRIGNEARLY 22O.esophaangdDu isa phragm 429 25G.alBll adadnedPr a ncreas 55( •Surgiacnaatlo my •Surgaincaatlo my •Physiology •Physiology •Congenaintoamla lies GORD •Galslt ondeiss ease •Motidliistoyr ders •Acutceh olecystitis •Achalacsairad ia •Chroncihco lecystitis Nutcraocekseorp hagus •Obstrujcatuinvdei ce •Carcinoma •StricCtBuDre •Stricture •Sclerocshionlga ngitis Perforations •Choledoccyhsatl •Diverticulum •Carodliis'esa se •Dysphagia •Chronpiacn creatitis •Surgiacnaalt oomfty h dei aphragm •Cholangiocarcinoma •Diaphraghmeartniica •Congenbiitlaialat rrye sia •Trachea-oesofpihsatguelaal •Carcinoofmg aa bllla dder •Carcinoofmp aa ncreas 23S.tomaacnhdD uodenum 460 •Endocrtiunmeo urs •Surgiacnaalt omy •Acutpea ncreatitis •Gastprhiycs iology •Pseudocyst •H.p ylionrfie ction •Annulpaarn creas •Gastritis •Ectoppaincc reas •Peptuilcc deirs ease •Cystfiicb rosis •Acutceo mplicaotfpi eopntusil cc er •Pancredaitviics um •Chronciocm plicaotfpi eopntusil cc er •Pancrefaitsitcu la •Carcinsotmoam ach •Whibtiel e •Gastroinsttersottmiuanmlao lu rs (GISTs) •Pancreaastciict es •Gastlryimcp homa 26S.pleen 617 •Complicaotfgi aosntsr ectomy •Acifdu ncttieosnt s •Introduction •Acutdei latoaftt ihsoetn o mach •Surgaincaatlo my •Volvuolftu hsse t omach •Functoifot nhssep leen •Bezoars •Congenaibtnaolr malities •Idiopathic hypertrophic pyloric stenosis •Rupture •Chrondiuco denialle us •Complicaotfsi polnesn ectomy •Duodenaanla toamnydo bstruction •ITP •Gastsruircg feormryo rboibde sity •Heredistpahreyr ocytosis •Acquiaruetdo immhuaneem olayntaiecm ia 24L.iver 516 •Thalassaemia •Sicckelalenl a emia Surgaincaatlo my •Splenecftooormt yh ceorn ditions Physiology •Spleanritcea rnye urysm Pyogeanbiscc ess •Haicreyll elu kaemia Amoebaibcs cess •OPSI Hydactyisdt •Intere'smtoicsnotgm mon' •Othecry stdiics eases •Benitgunm ours 27P.eritoneum, PeMreisteonnteearly Cavity, •Hepatoma anRde troperitoneum 634 •Secondairnti helesi ver •Porthaylp ertension •Peritoneum •Portgaals tropathy •Acutpee ritonitis •Porbtlailo pathy •Laparostomy •Asciitnpe osr thaylp ertension •Abdomicnoamlp artmseynntd rome •Budd-Cshyinadrrio me •Subphraebnsicce ss •Roloefo ctreoitnsi udreg ery •Spectiyaploe fsp eritonitis •Livterra nsplantation •Omentum •Haemobilia •Mesentery Contents xix •Mismteys entery •Prolraepcsteu m •Mesenctyesrtic •Surgaincaatloo afmn yca aln al •Retroperitoneum •Haemorrhoids •Retropecryisattbo,sn ceteauslms o,u r •Anoreacbtsacle ss •Fisitanun loa 28S.maIlnlt estine 666 •.Fi sisnau nroe •Anatomy VAAFT •Physiology •Pilosniinduasl •Abdomtiunbaelr culosis •Sacrocotcecryagteoamla •Tuberpceurliotuosn itis •Maligtnuamnootuaf rn sca aln al •Glandtuulbaerr culosis •Striocfat nuacralen a anlrd e ctum •Intetsutbienraclu losis •Anailn continence •Inflambmoawtdeoilrs ye ases •lleostomy 32L.owGears tinrtoesBtlieneadli ng 812 •Surgciocmapll iocfea nttieforenivsce r •Causes •Inteasmtoienbaila sis •Clineixcaamli nation •Radieanttieorno pathy •Peutz-Jegher syndrome •Investigations •GIST •Explolraaptaorroyt omy •Carcitnuomiodu r •Haemobilia •Shogrustty ndrome •Angiodysplasia •Diverticula 33T.hAep pendix 824 •Intefsitsitnualla •Develoapnmaden notm alies 29L.arIgnet estine 700 •Surgaincaatlo my •Surgaincaatlo my •Acuatpep endicitis •Function •Diffedrieangtnioasli s •Appendmiacsuslar •Tumours •Complications •Famiploilayclpo olsiis •Neoplasm •Heredniotnaproyl yposis •Mucocoele •Colorceacntcaelr •Faefciaslt ula •Carcinoma •Valeanptpiennod ix •Colsocnr eening Post-appensdeipcseicsrt-eocpmaoysr et •Diverdtiisceualsaer 34H.ernia 842 •Faefciaslt ula •Colosntirci cture •Anatomy •Indirect hernia 3.0IntesOtbisntarlu ction 729 •Direct hernia •Sigmoid volvulus •Clineixcaamli nation •Complications •Meckdeilv'esr ticulum •Recurhreernnti a •Adhesainobdna sn ds •Spechiearln ias •Gasltlo inlee us •Giahnetr nia •lntussusception •Sporthsemrenni a •Mesenvtaesrciouccl calru sion •Slihdeirnngi a •Hirschdsipsreuansge's •Femohrearln ia •Atraenssdit ae nosis •Rartey poeffs e mohrearln ia •Arrersotteawdti ibtoahnn ds •Umbihleircnaila •Volvnuelounsa torum •lncihseironniaal •Meconiiluemu s •Epigahsetrnriiac •lmperfaonruaste •lnterphaerrineitaal •Foobdo loubss truction •Spigheelrinaina •Paraillyetuisc •Lumbhaerr nia •Marlo taatnimdoi nd gvuotl vulus •Obturhaetronri a •Perihneeran!i a 31R.ectaunmdA naCla nal 772 35U.mbilaincdAu bsd ominal Wall877 •Surgaincaatlo my •Carcirneocmtau m •Classiofufi mcbaitdliiioscnea als es xx ManipMaaln uoaflS urgery •Umbiliincfalla mmation •Pancreiantjiucr ies •Umbilfiicsatlu loe •Renianlj uries •Umbilniecoapll asms •Retroperhiateomnaetoolm a •Abdomidneahli scence •Blaisntj uries •Divariocfor etcitoin •Warfianrjeu ries •Rectsuhse ahtahe matoma •Misswiolueno dfsa bdomen •Melengeayn'gsr ene •Triage •Desmotiudm our •Endometriosis 37A.bdomiMnaasls 900 36B.luAnbtd omiTnraalu Wmaara, n dB last •Clineixcaamli noafta ibodno mimnoasls InjuarnidTe rsi age 885 •Mosisnt hrei gihltif aocs so •Firtmoh arndo dumloasris tn h uem bilriecgailo n •Livienrj uries •Smablolw eiln juries •Thcey smtoiscis nt haeb domen •Coloinnijcu ries •Mosisnt heep igostrium •Duodeinnajlu ries •Mosistn h rei ghhytp ochondrium SECTI1O1UN1R :O LOGY 38I.nvestiogfta htUeir oinnTsar rayc t 923 •Surgaincaatlo omfuy r ethra •Urine •Ruptuurreet hra •Blood •Stricutruerteh ra •Intravuernoogurso m •Hypospodios •Retrogpryaedleo grophy •Retenotfi ounr ine •Renoarlt eriogrophy •Posteurrieotrvh arlavle •Cystourethrogrophy 41P.rosatnadSt eem iVneasli cles 972 •Urethrogrophy •Ultrosonogrophy •Surgaincaatlo my •Computetroimsoegdr aphy •Strucatnuartaolm y •Radioissoctaonpnei ng •Benipgrno sthoytpiecr p(lBaPsHi)a •Endoscopy •Carcinoofmt ah ep rostate 39K.idnaenydU reter 932 •Gleasosnc'osr e •Prostotitis •Surgaincaatlo my •Polyckyisdtniecy s 42P.enTiess,at nidSs c rotum 981 •Horseskhioden ey •Rensatlo nes •Surgiacnaalt oomfyp enis •Uretsetroince •Phimosis •Hydronephrosis •Parophimosis •Rentaulb erculosis •Carcinoofmp ae nis •Wilmtsu'm our •Peyrondiies'esa se •Pyonephrosis •Anatoomfyt het estis •Perinephric abscess •Hydrocoele •Dialysis •Undescentdeesdt is •Rentarla nsplantation •Ectotpeisct is •Varicocoele 40T.hUer inBalrayd adnedUr r ethra 954 •Spermotocoele •Epididcyymsotl •Surgical anatomy •Torstieosnt is •Vesiccaollc ulus •Testitcuumloaurr s •Carcinoofbm laa dder •Fourngiaenrg'rse ne •Ectovpeisoi coe •Fractpuernei s •Acutcey stitis •Diverticulo 43.DifferDeinatginoaofHls a iesm aturi1a002 •Urinfairsyt uloe •Causes •Intercsytsittiitails •Histaonrdey x amination •Schisthooseommoot obium •Investigations •Urindairvye rsion •Hoemoturio •Ruptbulraed der •History Contents xxi SECTIIOVSN:P ECIALITIES 1009 •Sourcaensdm ethods 44.CheTsrta uCmaar diothSourragceircy •Chesttr auma •Measurement •Clinuisceasl •Blutnrta uma •Curattirveea tment •Pulmonianrjyu ries •Pallitarteiavtem ent •Tracheobroinncjhuiraiels •Radiothreeraacptyi ons •Myocarcdoinatlu sion •Advancienrs a diatthieorna py •Surgiecmaplh ysema •Mediasetmipnhayls ema 48. 1071 PrincoifAp nlaeess thesiology •Mediastmiansasle s •Preoperaastsievses ment •Pulmonaasrpye rgilloma •Generaanla esthaegteinct s •Congenhietaarldt i seases •Muscrleel axants •Patednutc taurst eriosus •Endotraicnhteuabla tion •Coarctaotfia oonr ta •Monitoring •Coronaarryt ebryyp agsrsa ft •Locaanla esthetics •Offpu mpc oronaarrtye bryyp assusr gery •Regioannaale sthesia •Abdomianoarlt aince ury(sAmAsA ) •Pairne lief •Complicaotfai noaness thesia 1035 45.Neurosurgery •Cardiopulrmeosnuasrcyi tation •Whaitns e w/?R eceandtv ances Classifoifhc eaatidin ojnu ries •Primlaersyi ons 49. 1108 OrgaTnr ansplantation •Secondlaersyi ons •Extraduralh/aeepmiadtuormaal PRINCOIFTP RLAENSS PLANTATION •Chronsiucb duhraaelm atoma •Introduction •Donosre lection •Raisiendt racprraensisaulr e •Recipeiveanltu ation •Fractsukruel l •Rejection CSFr hinorrhoea •lmmunosuppression •Potptu'fstf uym our TRANSPLANTATION LIVER •Hydrocephalus •Indications •Bratiunm ours •Contraindications •Braindsetaetmh •Selecctriiotne ria •MELsDc ore 1047 46.PrincoifRp aldeiso logy •Types •Barisuwma llow •Techniques •Barimuema l •Complications •Barimuema flo llow through •Roloefc ellturlaanrs plantation •Barieunme ma SMABLOLW TERLA NSPLANT •Enteroclysis •Indications •Angiography •Contraindications •Pre-trarnescpilpaeinvetan ltu ation •Splenoportography •Evaluaatnidmo ann agement •Sialography •Typeasn do peratpirvoec edure •Computteodm ography •Detaoiftl hse techniques •Ultrasonography •Complications Magnerteisco nainmcaeg ing ISCLEELTTLR A NSPLANTATION •Periphveernaolg raphy •Indications •Myelography •Contraindications •lntervernatdiioonlaolg y •Pre-trarnescpilpaeinvetan ltu ation •PEsTc an •Evaluaatnidmo ann agement •Virtcuoallo noscopy •Typeasn do peratpirvoec edure 47. 1061 •Detaoiftl hste e chniques PrincoifCp lliensRi acdaila Otnicoonl ogy •Complications •Radiation •Indications •Dosfer actionation •Contraindications xxii ManiMpaanlu oafSl u rgery SECTIVO:VN I VVAO CEE XAMINATION 50X.-raaynsdI mages 1119 •Carcipneonmias •PlaXi-nr ays •Semintoemsat is •Barsiwuaml low •Cholecystectomy •Barmieuaml •Hydactyisdt •Bareinuemm a •Carcisntoommaa ch •ERCP •Lipoma •T-tcuhboel angiography •Maligmnealnatn oma •Splenoport(oSvPeVno)graphy •Thyroidectomy •CTscan •Wideex ciosfsi koinn •PEsTc an 53O.peratSiuvreg eLrayp,a roscopic Surgery 51I.nstruments 1129 andA ccessories 1151 •Appendicectomy Forceps •HernioBrarshsaipnhiy: •Retractors •Surgfeohrryy d rocoele •Occlucsliaomnp s •Inciasndidro ani (n&IaD g)e •Dilators •Inciosfdi roani onfba rgeeaa bsstc ess •Trachetousbteomy •Circumcision •Rubber tubes •Veneseocrct uditoo wnn •Catheters •Vasectomy •Sengsttuabkeen •Tracheostomy 52S.pecimens 1142 •Suprapubic cystostomy (SPC) •Thyroidectomy •TlBy mphadenitis •Amputations •Hodglkyimnp'hso ma •Amputaitlnie ogns •Carcitnoonmgau e •Uppleiram mbp utations •Chrognaiscut lrciecr •Opecnh olecystectomy •Linpiltaisst ica •Vagotomy gas(tGrJo)jejunostomy •lntussusception •Exciossfiw oenl lings •Carcinoma rectum •Colosnuircg ery •Gangreanpopuesn dicitis •Laparossucrogpeircy •Carcicnoolmoan •Hifgrhe qu(eHFne)cl ye ctrosurgery •Meckdeilv'esr ticulum •Cryosurgery •Polyckyisdtniecy •Lasiesnru sr gery •Rencaelcl alr cinoma •Stapilsneu rrsg ery •Hydronephrosis Index 1183 Section GeneSruarlg ery 1.WoundK,e loHiydp,e rtrSocpaharin cdM etaboRleiscp otnosI en jury 2.AcutIen fectSiionnuFssi,,s taunldSa u rgiSciatIlen fection 3.TetanaunsdG asG angrene 4.Hanadn dF ooItn fections 5.ChronIincf ectDiiosuesa se 6.DifferDeinatginaoolfs L iesgU lcaenrd P ressSuorree 7.LoweLri mlbs chaeamnidPa o pliteal Aneurysm 8.UppeLri mlbs chaeamnidGa a ngrene 9.Lymphatics, LyamnpdLh y mVpehsosmeals 10.VaricVoesiean nsd D eeVpe iTnh rombosis 11.SkiTnu mours 12.HaemorrhSahgoeca,kn dB looTdr ansfusion 13.BurnSsk,iG nr aftainndFg l aps 14.Acid-BBaaslea nFcleu,ai nddE lectrolytes 15.TumouarnsdS ofTti ssSuaer coma 16.CystSiwce lliNnegcsSk,w ellainndMg est astLaysmipsNh o dNee ck 17.OraCla viOtdyo,n tomLeisap,n dP alate 18.SalivGalrayn ds 19.ThyroGilda nd 20.ParathyanrdoA iddr enals 21.Breast
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