Interactive Transcript
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Sven, uh, Sellinger is, uh, our friend who,
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uh, invented this technique,
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you know, with respect to the vascular system,
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but it is the exact same technique.
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So let's unpack this bad boy.
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Okay, so the first thing we do is we get a needle
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to essentially say, you know what, I got my
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little needle here, I got my imaging guidance.
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So, we'll use ultrasound for
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the sake of comparison here.
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And so, I know exactly, sort of,
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wherewhere the skin is, which is what I have
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to start as my origin, departure.
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Departure, destination.
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Destination being the abscess.
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And I gotta, I gotta get
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7.4 ccentimeters.
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So maybe I'm going to start with a little UE
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20 00:00:41,065 --> 00:00:42,755 Centesis Needle, okay, which has a little
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sharp stylet, kind of like a little bevel
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tip, and then it has a little outer catheter.
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It comes in often sort of
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7 centimeters and 10 centimeters.
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So I was like, alright,
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let me use the 10 centimeters one.
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That'll give me a little distance.
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So, got that marked out.
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So then I'm going to get
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in there, boom, I'm inside.
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And so then, once I'm inside, I do the
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exact same thing that we did in the trocar
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technique, where we say, oh, you know
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what, let's aspirate, alright, because,
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who knows what this is.
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This may be a hematoma, whatever.
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So let's go ahead and aspirate that fluid.
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We got the fluid out, sucked out.
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So now we're in.
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Looks yellow, smells like pus, it's pus, okay?
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So let's move on now.
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So now we're inside, we
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confirm, destination, pus.
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This is where we want to be
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with our life at this moment.
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So let's go ahead and send the
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wire in, and we call this wire in.
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So nice if we're using a Benson wire, which
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usually has about 7 centimeters of a floppy tip.
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So we get that 7 centimeters to coil, and then
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it kind of hits and stops at that nice sort
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of solid portion of the wire.
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And then we sort of maintain
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that as a little railroad, okay?
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So then we take out the access catheter,
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in this case perhaps a USES and TESIS
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needle, USES and TESIS catheter, and
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then we say, okay, well now we're in.
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And so the next step may be to say, alright,
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after we sort of place that guide
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wire, now we may want to dilate, right?31 00:00:58,405 --> 00:01:00,205 And so then, once I'm inside, I do the
1:00
exact same thing that we did in the trocar
1:02
technique, where we say, oh, you know
1:03
what, let's aspirate, alright, because,
1:05
who knows what this is.
1:07
This may be a hematoma, whatever.
1:08
So let's go ahead and aspirate that fluid.
1:10
We got the fluid out, sucked out.
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So now we're in.
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Looks yellow, smells like pus, it's pus, okay?
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So let's move on now.
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So now we're inside, we
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confirm, destination, pus.
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This is where we want to be
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with our life at this moment.
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So let's go ahead and send the
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wire in, and we call this wire in.
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So nice if we're using a Benson wire, which
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usually has about 7 centimeters of a floppy tip.
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So we get that 7 centimeters to coil, and then
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it kind of hits and stops at that nice sort
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of solid portion of the wire.
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And then we sort of maintain
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that as a little railroad, okay?
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So then we take out the access catheter,
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in this case perhaps a USES and TESIS
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needle, USES and TESIS catheter, and
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then we say, okay, well now we're in.
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And so the next step may be to say, alright,
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after we sort of place that guide
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wire, now we may want to dilate, right?
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Right?
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So we say, okay, we need to go from this five
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French catheter to an eight French,
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or what I prefer is to start with a ten French
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drainage catheter. Or if you're
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dealing with more viscous collections,
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like in the case of peripancreatitis,
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you might use a 14 or 16 French catheter.
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But then you need to dilate up to that, right?
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And so once you've dilated up, you're
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like, okay, the pump has been primed.
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So now we're ready to just melt that bad
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boy through the skin, the catheter into the
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collection, over the wire, nice little railroad.
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And then once we're in, the catheter takes the path
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of the wire, and then we pull the wire out.
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If we started with a nice blunt stiffener
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in the actual catheter, we then remove that.
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Here we see an image of the plastic
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stiffener that's typically in place,
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which is used usually for exchanges.
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And then the blunt metal stylet, which as you
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can see, the blunt tip is actually ending here.
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I kind of pulled it out a little bit
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just so you can see that the minute you
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pull it out, it kind of begins to form.
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And there's that string that Dr.
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Constance Cope sort of
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developed very, very ingeniously.
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So when this is pulled out, it naturally wants
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to form because of memory, a little pigtail.
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But then this little string, this
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little suture, allows you to, um, just kind
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of get it into position, so it kind of makes
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a nice little piggy pigtail loop.
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Okay?
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Gotta love the little piggy pigtail loop.
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So this is what it looks like.
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You know, in my hands, in your hands, it looks
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the same way, and once it's out, you know,
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you sort of get that nice pigtail to form.
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It's a nice little retention device.
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It forms with the shape of an abscess,
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which is typically round or spherical in nature.
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And then you have this sort of ring.
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In this case, this happens to be one of the
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manufacturers that makes this, and it
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has a little feature where you can kind
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of throw the string around this, and then, boom,
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just kind of lock it in place, cut the suture
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at this tip here, and then you're off to help
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the patient sort of move past this collection.
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Alright, so what are the advantages
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of the Sellinger Technique, and
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let's talk about the disadvantages.
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Well, you know, this technique can facilitate
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the drainage of a large, multi-loculated collection.
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It allows you to get that wire in,
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and send your catheter wherever you want it to be,
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dependently, or non-dependently. Although, you
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might not want to go non-dependently, because fluid usually
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falls and collects in the dependent areas.
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So, it’s better to drain it from the bottom up,
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or from the dependent area to the non-dependent area.
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It allows for more control; you
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know, I’m an expeditious person when it
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comes to getting things done.
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I think that safety is first, and
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so for me, I tend to use the Sellinger technique
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because I feel
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it gives me a little bit more control.
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I believe that planning, staging, and
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ratcheting as I move forward with the
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procedure while locking in safe, controlled,
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and intentional steps is really the way I
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like to care for my patients.
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But we’re discussing advantages here for
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the purpose of your appraisal as well.
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So that you can determine
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which technique is best for you.
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For me, I feel like in cases
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where there are difficult-to-access
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collections, the Sellinger technique works pretty well.
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Some people think it’s a little time-consuming,
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you know, and it just depends on how pressed
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for time you are to move from this patient
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to the next. But it's completely up to you
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in terms of your discretion, what
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you think is time-consuming versus what’s not.
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One of the things people talk about is,
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sometimes there can be kinking
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that occurs with the guide wire. If you’re
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advancing a catheter with a stiffener through
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the wire, you might not get that catheter to end
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up in the abscess if you kink the wire.
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My response to that is perhaps,
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you should use a technique where you watch the
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catheter as it advances over the wire.
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What I teach our residents is that once you hit the trough or the
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crest of the wire, depending on where
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the wire’s going, you stop.
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Stop at the apex or the point
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of the trough or crest with the stiffener, and then
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begin to feed the catheter off the stiffener.
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Guide it onto the wire and into the collection,
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which helps to bypass the kinking risk.
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