• <tr id="yyy80"></tr>
  • <sup id="yyy80"></sup>
  • <tfoot id="yyy80"><noscript id="yyy80"></noscript></tfoot>
  • 99热精品在线国产_美女午夜性视频免费_国产精品国产高清国产av_av欧美777_自拍偷自拍亚洲精品老妇_亚洲熟女精品中文字幕_www日本黄色视频网_国产精品野战在线观看 ?

    Clinical outcomes after major hepatectomy are acceptable in lowvolume centers in the Caribbean

    2019-03-21 11:34:34ShamirCawichRaviMaharajVijayNaraynsinghNeilPearceWesleyFrancisKimonBonadieDexterThomas
    World Journal of Hepatology 2019年2期

    Shamir O Cawich, Ravi Maharaj, Vijay Naraynsingh, Neil Pearce, Wesley Francis, Kimon O Bonadie,Dexter A Thomas

    Abstract BACKGROUND Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease. There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease.This is the situation in many Caribbean countries.AIM To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean.METHODS We prospectively studied all patients who underwent major liver resections over five years. The following data were extracted: patient demographics, diagnoses,ECOG status, operation performed, post-operative morbidity and mortality.Statistical analyses were performed using SPSS ver 16.0 RESULTS There were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year. Sixty-nine major hepatic resections were performed for: colorectal liver metastases 40 (58%), non-colorectal metastases 9(13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%) and hepatoblastoma 1 (1.5%). Twenty-one patients had at least one complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%)patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths.CONCLUSION There are unique geographic, political and financial limitations to healthcare delivery in the Caribbean. Nevertheless, clinical outcomes are acceptable in the established, low-volume hepatobiliary centers in the Eastern Caribbean.

    Key words: Liver; Surgery; Resection; Caribbean; Volume; Outcomes

    INTRODUCTION

    Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease[1]. They are accepted to be safe procedures when performed by trained hepatobiliary teams in specialized, high-volume centers[1-3].

    There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes[3,4,5]. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease. This is the situation in many Caribbean countries.

    While there are hepatobiliary units in the Caribbean, none meet the criteria to be defined as high-volume[3,4,5,6,7]. Additionally, hepatobiliary units in the Caribbean operate in challenging, resource-poor environments. In this study, we sought to determine whether the clinical outcomes were acceptable when major hepatectomies were performed in a low-volume, resource-poor hepatobiliary unit in the Eastern Caribbean.

    MATERIALS AND METHODS

    In 2011, an attempt was made to achieve service centralization in the Caribbean with the establishment of three hepatobiliary units in the Bahamas, Jamaica and Trinidad and Tobago. They were intended to serve as regional referral centers for patients requiring major hepatectomies across the English-speaking Caribbean[8]. This was supported by the Americas Hepatopancreatobiliary Association (AHPBA),culminating with the formation of a Caribbean Chapter of the AHPBA in 2015.

    The hepatobiliary unit in Trinidad and Tobago is the largest referral unit in the English-speaking Caribbean[8-9]. This unit is comprised of two hepatobiliary teams each headed by fellowship-trained hepatobiliary surgeons. All cases are discussed in a multidisciplinary team meeting where decisions are made for treatment of patients with hepatobiliary diseases.

    Ethics

    The local institutional review board granted permission to collect and examine data from all patients who underwent major hepatectomies in this setting.

    Study population

    We prospectively recorded data from all patients who underwent major hepatectomies with the hepatobiliary unit in Trinidad and Tobago over a five-year period from January 1, 2012 to December 30, 2016. We used the standardized definition of major hepatectomies as defined by Reddy et al[10]: resection of four or more liver segments.

    Data analysis

    The following data were recorded for all patients who underwent major hepatectomies during the study period: patient demographics, diagnoses, ECOG status, operation performed, operative details, therapeutic outcomes, post-operative morbidity and mortality. Complications were classified according to the modified Clavien-Dindo system[11]. Statistical analyses were performed using SPSS ver 16.0.

    RESULTS

    There were 69 major hepatectomies performed over the five-year study period.Therefore, the mean annual case volume was 13.8 major hepatectomies per annum.When examined chronologically, there was a steady increase in the number of hepatectomies performed each year, except in the year 2016 (Figure 1). During this time, the nation experienced an economic recession.

    Indications for operation

    All major hepatectomies were performed by one of two trained hepatobiliary surgeons for the following indications: colorectal liver metastases 40 (58%), noncolorectal metastases 9 (13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%)and hepatoblastoma 1 (1.5%).

    Patient demographics

    The patients in this series consisted of 40 men and 29 women, with a mean age of 63 years (Range 34-80; SD +/- 10.3; Median 65). Sixty-four (93%) patients had at least one co-morbidity. Overall, there were 40 (58%) patients with ASA scores ≥ III, as detailed in Table 1, and 39 (56.5%) patients with ECOG scores ≥ 2, as detailed in Table 2.

    After pre-operative multidisciplinary review, we anticipated that the hepatectomy procedure would be technically complex in 26 (37.7%) patients for: emergency hepatectomy for ruptured tumours or trauma (6), multiple intra-hepatic hepaticojejunostomies for hilar cholangiocarcinomas (4), IVC resection and reconstruction (4),borderline future liver remnants (4), synchronous colorectal operations (3),synchronous gastric resections (2), prior open hepatectomy scheduled for repeat laparoscopic resections (2) and synchronous nephrectomy (1).

    Operative details

    Fourteen (20.3%) hepatectomies were attempted using the laparoscopic approach,with 3 (21.4%) conversions for unclear anatomy (1), bleeding (1) and repair of IVC injury (1). The remaining 55 (79.7%) operations were planned using an open approach. No patients in this series underwent veno-venous bypass during major hepatectomies. The hanging maneuver with anterior parenchymal transection technique was used to complete hepatectomy in 18 (26.1%) patients and the conventional technique was used in the remaining 51 (73.9%) cases.

    Clinical outcomes

    Excluding patients who had synchronous resections performed, the mean operating time for a major hepatectomy alone was 380 min (Range 260-600; SD +/-75.8; Median 350). The operations in these patients were accompanied by a mean blood loss of 1405 mL (Range 600-4000; SD+/- 729; Median 1200) and mean transfusion requirements of 1.8 units of packed cells (Range 0-5; SD +/- 1.43; Median 2).

    Figure 1 Chronologic relationship of major liver resections performed.

    When we evaluated the subset of 26 patients in whom technically complex operations were anticipated, the mean operating time was 461.5 min (Range 300-650;SD+/-95.6; Median 455), mean estimated blood loss was 2009 mL (Range 800-3500;SD+/-667.4; Median 2000) and the mean transfusion requirement was 3.2 units of packed cells (Range 1-5; SD+/-1.05; Median 3).

    In the 43 cases where technical difficulty was not anticipated pre-operatively, the mean operating time was 367 min (Range 260-600; SD+/-69.4; Median 350), mean EBL of 1236.7 mL (Range 600-4000; SD+/-679.5; Median 1000) and mean transfusion requirements of 1.37 units (Range 0-4; SD+/-1.3; Median 1).

    In this setting, we maintained a policy of mandatory ICU admission after major hepatectomy because institutional limitations generally did not allow the expected level of supportive care outside of the ICU setting. Therefore, all patients were admitted to the ICU post-hepatectomy, with a mean ICU stay of 5.3 d (Range 1-40;SD+/-7.37; Median 3). Fifteen (21.7%) patients required a prolonged ICU stay beyond 72 h for invasive treatment, ventilator and/or inotropic support. Overall, the mean duration of hospitalization after major hepatectomy was 16 d (Range 9-103; SD+/-13.35; Median 12).

    Morbidity / mortality analysis

    There were 58 patients with no complications or minor morbidity. These patients had a mean ICU stay of 3.2 d (Range 1-8; SD+/-1.55; Median 3) and mean hospital stay of 13.2 d (Range 9-35; SD+/-6.85; Median 10). In comparison, the 11 patients with major morbidity had a mean ICU stay of 16.3 d (Range 5-40; SD+/-14.1; median 6) and mean overall hospital stay of 31.1 d (Range 13-103; SD+/-25.4; Median 23).

    Twenty-one patients experienced at least one complication in this series. Minor complications were recorded in 17 (24.6%) patients and major complications in 11(15.9%) patients. The individual complications are outlined in Table 3.

    There were 4 (5.8%) reported deaths within 30 d of operation in this series. These included: (1) a 69 year-old man who underwent an abdomino-perineal resection and synchronous major hepatectomy. He developed intra-abdominal sepsis after a leak from a bladder injury; (2) an 80-year old man who underwent an extended right hepatectomy for colorectal liver metastases. He developed a significant bile leak, with resultant collections and eventually succumbed to intra-abdominal sepsis; (3) a 69-year old woman who had extended right hepatectomy for hepatocellular carcinoma and developed post-hepatectomy liver failure despite a 40% functional liver remnant;and (4) a 79-year old man who had an extended right hepatectomy for hilar cholangiocarcinoma. He developed a small bowel anastomotic leak and eventually succumbed to intra-abdominal sepsis.

    DISCUSSION

    At the turn of the 21stcentury, we witnessed the era of service centralization wheresurgical treatment for complex diseases was concentrated in specific centers in order to support sub-specialty teams performing these operations at high volumes[7,12,13]. This trend was supported by accumulating data to suggest that there were better perioperative outcomes in high-volume referral hospitals[3,4,5,6,14,15,16,17].

    Table 1 ASA scores for patients undergoing major liver resections in a low volume Caribbean center

    Specifically for major hepatectomies, the data demonstrated that high-volume centers achieved significant reductions in overall morbidity[3,5,6,14,16], 30-day mortality[3,5,14,15,16,17], readmission rates[16], cost[14]and the duration of hospital stay[6,14,16].Lu et al[14]also reported that high-volume centers achieved longer 5-year survival rates. These data seem to lend strong support to the principle of centralization.

    However, a closer look at the existing data revealed that there is no standardized definition of “high volumes”, with researchers applying ad-hoc definitions that range from as low as 10 as cases per annum[16]to as high as 150 cases per annum[18]. Most papers in the literature quote numbers in excess of 20 cases per annum[3,19,20,21,22,23].Using these definitions, the hepatobiliary unit in Trinidad and Tobago does not qualify as high volume, with a mean case volume of 13.8 major hepatectomies per year.

    Furthermore, the high volume centers are often tertiary referral hospitals that serve large catchment populations and attract significant funding. They are usually located in major cities within developed countries. Unfortunately, many patients in lessdeveloped Caribbean countries cannot access care in these high volume centers because of travel restrictions, financial limitations, lack of health insurance coverage and/or a paucity of social support structures. Even within the United States,Eppsteiner et al[17]noted that there was socio-economic inequity for access to care at high volume centers.

    We observed that most current reports, even those supporting centralization,documented that the majority of major hepatectomies are being performed in lowvolume centers - even in developed countries in the 21stcentury. Fong et al[3]reported in 2005 that only 1% of the hospitals that offered major hepatectomies in the United States of America actually qualified as high-volume centers. In fact, Fong et al[3]reported that the 1272 low-volume centers in the United States performed an average of 1 major hepatectomy per annum - substantially below the “high-volume mark”.

    Similar findings were reported by other researchers: Choti et al[5]reported that only 2.7% (1) of the 37 facilities performing major liver resections in the state of Maryland qualified as high-volume. The low-volume facilities performed an average of 1.5 cases annually[5]. Similarly, Glasgow et al[6]reported that only 3% of 138 hospitals performing liver resections in the state of California qualified as high volume. The low-volume hospitals performed ≤ 3 hepatectomies per annum[6].

    It seems that there is still not universal buy in to the concept of centralization for major hepatectomies. One reason for this may be the lack of practicality. This is especially true in developing countries and it can be appreciated by examining the health care environment in the Anglophone Caribbean. Narayansingh et al[24]outlined the unique challenges to healthcare delivery in this setting: (1) many countries are island states that are geographically separated by the Caribbean Sea; (2) there are political barriers since each country is independent and separately governed; (3) each island has distinctly different cultures; and (4) many surgeons, even those with subspecialty training, are required to perform a wide repertoire of general surgical procedures at low volumes. In addition, most of these countries have underfunded health care systems[8], leadership deficiencies[25,26], cultural resistance to multidisciplinary collaboration[8]and limited access to specialists and subspecialists[9,24]. These factors were all obstacles to service centralization in the Anglophone Caribbean.

    Despite the obstacles, surgical leaders recognized the need and established a hepatobiliary unit in Trinidad and Tobago to serve patients in the Eastern Caribbean[8]. There has been some success in this regard, as measured by theconsistent increase in the annual number of major liver resections performed by this unit (Figure 1). The reduction in case volumes in the year 2016 correlated with the country experiencing a recession. This led to a lack of consumables in Governmentfunded hospitals and it highlights our point that these demanding operations require significant resources. Coupled with the fact that these hospitals face unique challenges(scarcity of specialized equipment, blood products, ICU space and operating lists),one can realize that the environment is not always conducive to observing best practice recommendations.

    Table 2 Performance scores for patients undergoing major liver resections in a low volume Caribbean center

    Nevertheless, the clinical outcomes in this established low-volume hepatobiliary unit were acceptable. The perioperative mortality rate was 5.8% in our setting.Although reported 30-d mortality in high-volume centers ranged widely from 1.5%[5]to 9.4%[6], most high volume centers reported 30-d mortality between 4% and 6.5%[3,5,16,19]. Our results compared favourably to these high-volume centers. In contrast, the reported 30-day mortality in low volume centers range from 5%-22.7%[3,5,6,17,22].

    Major complications occurred in 15.9% of our patients. This was comparable to reports in the existing medical literature, where major hepatectomies in high-volume centers resulted in major morbidity in 13.2%[22]to 27%[27]of cases. Similarly, minor morbidity (24.6%) rates were comparable to existing reports from high-volume centers, ranging from 9.3%[18]to 26.9%[22].

    Potential critics may suggest that therapeutic outcomes may appear reasonable because of “case selection”, where high-risk patients are referred onward to highvolume referral centers. Obviously, it could have skewed the results toward improved outcomes if only low-risk patients were selected for major hepatectomies in our setting. However, more than half of the major hepatectomies at our facility were performed in high-risk patients, with ASA scores ≥ III (58%), ECOG scores ≥ 2 (57%)and at least one co-morbidity (93%). Moreover, after pre-operative MDT assessment a further 38% of the major hepatectomies performed in this setting were technically difficult operations.

    We do acknowledge that high volume referral centers treat more patients,including high-risk cases with multiple co-morbidities and complicated surgical histories. However, in our setting in the Caribbean, we did not have the luxury of“case selection” because the patients treated at our facilities had no other options for care, for reasons already discussed. We believe, therefore, that referral practices/case selection could not account for the clinical outcomes in this setting. Furthermore, this was a resource-poor environment with limited support services and numerous institutional limitations. These results demonstrated that, despite multiple challenges,the outcomes are not solely dependent on numbers.

    We agree with Gasper et al[28]that modern hospitals are complex adaptive systems whose outputs are determined by interactions between internal agents. We also agree with Hashimoto et al[29]that annual volume only contributes a partial assessment and that there is also a substantial contribution by surgeon training and experience. In this regard, we attribute our outcomes to the unit staff (1) having appropriate training; (2)developing an intimate knowledge of the health care system in which they work; (3)fostering a spirit of collective teamwork; (4) maintaining due diligence in care administration; (5) continued audit; and (6) knowledge of population-based data[30,31,32].

    In conclusion, Caribbean hospitals do not, and possibly never will, qualify as highvolume centers due to unique geographic, political and financial limitations to healthcare delivery in the region. Nevertheless, there can be good short-term outcomes when major hepatectomies are performed in low-volume hepatobiliary units in the Eastern Caribbean, despite a high proportion of high-risk patients requiring technically complex operations. This demonstrates that case volume is not the only determinant of good outcomes after major hepatectomy. To achieve goodoutcomes, there is also the need for teamwork, appropriately trained staff, due diligence in care administration, continued audit and knowledge of population-based data.

    Table 3 Complications after major liver resections in patients undergoing major liver resections in a low volume Caribbean center

    ARTICLE HIGHLIGHTS

    Research background

    In the past two decades, there was a trend to concentrate major hepatectomies in specific centers in order to support sub-specialty teams performing these operations at high volumes. This trend was supported by accumulating data to suggest that there were better peri-operative outcomes in high-volume referral hospitals. However, this is not practical in the Caribbean and other resource-poor countries.

    Research motivation

    Clinicians in the Caribbean do not have the luxury of “case selection” because most patients treated at our facilities have no other options for care. Therefore, these patients must receive treatment at low-volume, resource-poor centers with limited support services and numerous institutional limitations. The motivation for our research was to determine if the clinical outcomes are acceptable despite the numerous limitations.

    Research objectives

    To determine the clinical outcomes after major hepatectomies in a low-volume, resource-poor center in the Caribbean.

    Research methods

    We prospectively studied post-operative morbidity and mortality in all patients undergoing major hepatectomies in a low-volume Caribbean hepatobiliary center over a five-year study period. Statistical analyses were performed using SPSS ver 16.0.

    Research results

    There were 69 major hepatectomies performed over the study period (mean case volume of 13.8 major resections/year). More than half of the major hepatectomies were performed in high-risk patients, with ASA scores ≥ III (58%), ECOG scores ≥ 2 (57%) or at least one co-morbidity (93%).A further 38% of the major hepatectomies performed in this setting were technically difficult operations. Twenty-one patients experienced at least 1 complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11(15.9%) patients and 4 (5.8%) deaths.

    Research conclusions

    Although Caribbean hospitals do not qualify as high-volume centers, there can be good shortterm outcomes after major hepatectomies are performed in established hepatobiliary units. This demonstrates that case volume is not the only determinant of good outcomes after major hepatectomy.

    Research perspectives

    To achieve good outcomes, there is the need for teamwork, appropriately trained staff, due diligence in care administration, continued audit and knowledge of population-based data. Case volume is not the only determinant of good outcomes after major hepatectomy.

    日韩三级视频一区二区三区| 无限看片的www在线观看| АⅤ资源中文在线天堂| 嫩草影视91久久| 久久精品人妻少妇| 2021天堂中文幕一二区在线观 | 久久香蕉国产精品| www.www免费av| 色综合站精品国产| 十八禁网站免费在线| 亚洲成av片中文字幕在线观看| 啦啦啦 在线观看视频| 黑丝袜美女国产一区| 日本a在线网址| 很黄的视频免费| 人妻丰满熟妇av一区二区三区| av免费在线观看网站| 91成人精品电影| 国产精品九九99| 日本黄色视频三级网站网址| 国产精品久久久av美女十八| 日韩欧美免费精品| 麻豆成人午夜福利视频| 夜夜躁狠狠躁天天躁| 精品不卡国产一区二区三区| 美女午夜性视频免费| 黄片小视频在线播放| 最近最新免费中文字幕在线| 精品久久久久久成人av| 国产乱人伦免费视频| 亚洲国产毛片av蜜桃av| 听说在线观看完整版免费高清| 99在线视频只有这里精品首页| 午夜久久久久精精品| 久久久久国产精品人妻aⅴ院| 99国产极品粉嫩在线观看| 国产午夜精品久久久久久| 青草久久国产| 免费观看精品视频网站| 国内少妇人妻偷人精品xxx网站 | 日韩 欧美 亚洲 中文字幕| 国产精品精品国产色婷婷| 在线观看免费午夜福利视频| 中文字幕高清在线视频| 18禁观看日本| 国产精品自产拍在线观看55亚洲| 桃色一区二区三区在线观看| 中文资源天堂在线| 巨乳人妻的诱惑在线观看| 久久人妻福利社区极品人妻图片| 成年女人毛片免费观看观看9| 亚洲国产欧美网| 国内少妇人妻偷人精品xxx网站 | 深夜精品福利| 欧美色视频一区免费| 九色国产91popny在线| 一二三四在线观看免费中文在| 国产真人三级小视频在线观看| 日韩欧美免费精品| 99久久综合精品五月天人人| 搡老熟女国产l中国老女人| 国产精品国产高清国产av| 亚洲专区国产一区二区| 国产99白浆流出| 国产高清视频在线播放一区| 国产一区在线观看成人免费| 精品国产美女av久久久久小说| 国产精品免费一区二区三区在线| 亚洲狠狠婷婷综合久久图片| 中亚洲国语对白在线视频| 青草久久国产| 熟女少妇亚洲综合色aaa.| 午夜久久久久精精品| 成人欧美大片| 黄色成人免费大全| 亚洲真实伦在线观看| 日本 av在线| 亚洲精品在线观看二区| 精品一区二区三区四区五区乱码| 99在线视频只有这里精品首页| 色综合欧美亚洲国产小说| 国产aⅴ精品一区二区三区波| 亚洲中文日韩欧美视频| 亚洲 欧美 日韩 在线 免费| 操出白浆在线播放| 久久性视频一级片| xxxwww97欧美| 亚洲欧美日韩高清在线视频| 无限看片的www在线观看| 99久久久亚洲精品蜜臀av| 美女免费视频网站| 中文字幕人妻丝袜一区二区| 91老司机精品| 又黄又粗又硬又大视频| 欧美三级亚洲精品| 在线视频色国产色| 欧美黑人欧美精品刺激| 黄频高清免费视频| 亚洲成av人片免费观看| 老司机午夜福利在线观看视频| 免费观看精品视频网站| 亚洲色图av天堂| 亚洲精品在线观看二区| 亚洲,欧美精品.| 成年人黄色毛片网站| 黄色a级毛片大全视频| 亚洲精品中文字幕在线视频| 日本 av在线| 亚洲成av片中文字幕在线观看| 制服人妻中文乱码| 中文字幕久久专区| 国产亚洲av高清不卡| 午夜福利一区二区在线看| 美女大奶头视频| 成人三级黄色视频| 国内揄拍国产精品人妻在线 | 亚洲成人精品中文字幕电影| 久久99热这里只有精品18| 俄罗斯特黄特色一大片| 一本一本综合久久| 婷婷丁香在线五月| 亚洲av中文字字幕乱码综合 | 精品人妻1区二区| 黄片小视频在线播放| 成人免费观看视频高清| 亚洲色图 男人天堂 中文字幕| 亚洲 欧美一区二区三区| 97碰自拍视频| 国产亚洲精品久久久久5区| 熟女少妇亚洲综合色aaa.| 亚洲人成网站在线播放欧美日韩| 久久久国产精品麻豆| 亚洲人成伊人成综合网2020| 国产黄片美女视频| 长腿黑丝高跟| 中出人妻视频一区二区| 国产一级毛片七仙女欲春2 | 亚洲欧美精品综合一区二区三区| 长腿黑丝高跟| 欧美另类亚洲清纯唯美| 欧美成人午夜精品| 欧美激情极品国产一区二区三区| 亚洲男人的天堂狠狠| 日本成人三级电影网站| АⅤ资源中文在线天堂| 十分钟在线观看高清视频www| 757午夜福利合集在线观看| 亚洲激情在线av| 国产亚洲av嫩草精品影院| 99国产精品99久久久久| 午夜福利一区二区在线看| 香蕉国产在线看| 99国产精品99久久久久| 国产精品久久久久久精品电影 | 亚洲av成人不卡在线观看播放网| 久久天躁狠狠躁夜夜2o2o| 夜夜躁狠狠躁天天躁| av中文乱码字幕在线| 欧美在线一区亚洲| 精品高清国产在线一区| 国产免费av片在线观看野外av| 一区二区三区精品91| 免费一级毛片在线播放高清视频| 丁香欧美五月| 操出白浆在线播放| 精品不卡国产一区二区三区| 中文字幕另类日韩欧美亚洲嫩草| 啦啦啦观看免费观看视频高清| 人人妻,人人澡人人爽秒播| 国产成人精品久久二区二区91| 国产区一区二久久| 亚洲精品中文字幕一二三四区| 男女做爰动态图高潮gif福利片| 中文字幕人妻丝袜一区二区| 99久久无色码亚洲精品果冻| 国内精品久久久久久久电影| 国产人伦9x9x在线观看| 欧美绝顶高潮抽搐喷水| 欧美一区二区精品小视频在线| 精品乱码久久久久久99久播| 两性夫妻黄色片| 两个人看的免费小视频| 麻豆成人av在线观看| 男人舔女人下体高潮全视频| 精品免费久久久久久久清纯| 久久久久久亚洲精品国产蜜桃av| 波多野结衣巨乳人妻| 亚洲欧美精品综合一区二区三区| 日本五十路高清| 日本精品一区二区三区蜜桃| 男人操女人黄网站| 91老司机精品| 国产精品免费视频内射| 国产精品影院久久| 色综合亚洲欧美另类图片| 十八禁人妻一区二区| 人人妻人人看人人澡| 亚洲国产看品久久| 欧美人与性动交α欧美精品济南到| 国产伦在线观看视频一区| 欧美午夜高清在线| 国产区一区二久久| 亚洲国产欧美日韩在线播放| 99久久无色码亚洲精品果冻| 女人爽到高潮嗷嗷叫在线视频| 在线永久观看黄色视频| 久久久久久亚洲精品国产蜜桃av| 一进一出抽搐gif免费好疼| 免费女性裸体啪啪无遮挡网站| 久久人妻av系列| 午夜影院日韩av| 一本久久中文字幕| 婷婷亚洲欧美| 欧美日韩亚洲综合一区二区三区_| 国内久久婷婷六月综合欲色啪| 大型黄色视频在线免费观看| 亚洲成av人片免费观看| 亚洲精品一卡2卡三卡4卡5卡| 黄色视频不卡| 午夜久久久久精精品| 女人高潮潮喷娇喘18禁视频| 精品欧美国产一区二区三| 中文字幕精品免费在线观看视频| 19禁男女啪啪无遮挡网站| 成人三级做爰电影| 少妇粗大呻吟视频| 在线观看午夜福利视频| 老司机深夜福利视频在线观看| 亚洲久久久国产精品| 少妇的丰满在线观看| 国产一级毛片七仙女欲春2 | 一本大道久久a久久精品| 亚洲成人国产一区在线观看| 亚洲国产中文字幕在线视频| 亚洲美女黄片视频| 午夜激情福利司机影院| 亚洲中文字幕一区二区三区有码在线看 | 777久久人妻少妇嫩草av网站| 亚洲精品国产精品久久久不卡| 国产成人啪精品午夜网站| 韩国精品一区二区三区| 欧美色视频一区免费| 欧美不卡视频在线免费观看 | x7x7x7水蜜桃| 中文亚洲av片在线观看爽| 丝袜美腿诱惑在线| 国产激情偷乱视频一区二区| 欧美激情 高清一区二区三区| 女人被狂操c到高潮| 每晚都被弄得嗷嗷叫到高潮| 丝袜人妻中文字幕| 色老头精品视频在线观看| 琪琪午夜伦伦电影理论片6080| svipshipincom国产片| 亚洲精品一区av在线观看| 桃红色精品国产亚洲av| 婷婷亚洲欧美| 黄频高清免费视频| 久久久久久久久免费视频了| 欧美精品亚洲一区二区| 国产精品电影一区二区三区| 国产99白浆流出| 久久久久久国产a免费观看| 国产色视频综合| 怎么达到女性高潮| 正在播放国产对白刺激| 丝袜在线中文字幕| 狠狠狠狠99中文字幕| 精品无人区乱码1区二区| 国产99久久九九免费精品| 天天躁夜夜躁狠狠躁躁| 男人的好看免费观看在线视频 | 黑人巨大精品欧美一区二区mp4| 久久人妻福利社区极品人妻图片| 亚洲av片天天在线观看| 亚洲精品粉嫩美女一区| 日本一本二区三区精品| 久久99热这里只有精品18| 在线av久久热| 日本五十路高清| 国产熟女午夜一区二区三区| 亚洲精品国产区一区二| 一边摸一边抽搐一进一小说| 国产成+人综合+亚洲专区| 黄色视频不卡| 看免费av毛片| 国产欧美日韩精品亚洲av| √禁漫天堂资源中文www| 女人高潮潮喷娇喘18禁视频| 精品无人区乱码1区二区| 精品国产超薄肉色丝袜足j| 久久中文字幕一级| 亚洲免费av在线视频| 美女国产高潮福利片在线看| 国产精品免费一区二区三区在线| a在线观看视频网站| netflix在线观看网站| www.999成人在线观看| 法律面前人人平等表现在哪些方面| 女人高潮潮喷娇喘18禁视频| 免费在线观看亚洲国产| 12—13女人毛片做爰片一| 18美女黄网站色大片免费观看| 免费在线观看视频国产中文字幕亚洲| 香蕉丝袜av| 男女那种视频在线观看| 精品人妻1区二区| 久久久国产成人免费| 国产亚洲精品久久久久久毛片| а√天堂www在线а√下载| 色播在线永久视频| 国产一区二区三区在线臀色熟女| 久久久久久久久中文| 国产欧美日韩精品亚洲av| 亚洲欧洲精品一区二区精品久久久| 搡老岳熟女国产| e午夜精品久久久久久久| 午夜福利高清视频| 一级作爱视频免费观看| 每晚都被弄得嗷嗷叫到高潮| 一级作爱视频免费观看| 妹子高潮喷水视频| tocl精华| 国产亚洲精品久久久久久毛片| 男女视频在线观看网站免费 | 国产精品久久久av美女十八| 久久久久国产一级毛片高清牌| av中文乱码字幕在线| 日本一区二区免费在线视频| 欧美+亚洲+日韩+国产| 在线观看日韩欧美| 国产精品综合久久久久久久免费| 91国产中文字幕| 亚洲国产精品合色在线| 欧美在线一区亚洲| 老司机在亚洲福利影院| 母亲3免费完整高清在线观看| 色婷婷久久久亚洲欧美| 亚洲七黄色美女视频| 美国免费a级毛片| 嫩草影院精品99| 丁香六月欧美| 久久久久久国产a免费观看| 亚洲 欧美一区二区三区| 亚洲久久久国产精品| 日本撒尿小便嘘嘘汇集6| 99久久综合精品五月天人人| 桃红色精品国产亚洲av| 亚洲 欧美一区二区三区| 人人妻,人人澡人人爽秒播| а√天堂www在线а√下载| 亚洲人成网站高清观看| 久久人人精品亚洲av| 久久久久国内视频| 精品久久久久久久人妻蜜臀av| 一级a爱片免费观看的视频| 成年人黄色毛片网站| 国产伦一二天堂av在线观看| 亚洲,欧美精品.| 首页视频小说图片口味搜索| 999精品在线视频| 51午夜福利影视在线观看| 人妻丰满熟妇av一区二区三区| 在线视频色国产色| 最近在线观看免费完整版| 国产精品国产高清国产av| 亚洲熟妇中文字幕五十中出| 婷婷丁香在线五月| 天天躁夜夜躁狠狠躁躁| 免费看十八禁软件| 精品少妇一区二区三区视频日本电影| 国产成人影院久久av| 麻豆成人av在线观看| 在线观看午夜福利视频| 妹子高潮喷水视频| 久99久视频精品免费| 老熟妇仑乱视频hdxx| 欧美日韩福利视频一区二区| 少妇粗大呻吟视频| 免费在线观看成人毛片| 国产野战对白在线观看| 老司机福利观看| 国产不卡一卡二| 一卡2卡三卡四卡精品乱码亚洲| 巨乳人妻的诱惑在线观看| 老司机福利观看| av欧美777| 亚洲avbb在线观看| 国产一卡二卡三卡精品| 欧美一级a爱片免费观看看 | 男女视频在线观看网站免费 | 91麻豆精品激情在线观看国产| 亚洲第一电影网av| 日本精品一区二区三区蜜桃| 久久国产亚洲av麻豆专区| 亚洲无线在线观看| 搞女人的毛片| 亚洲国产欧美一区二区综合| 国产亚洲av高清不卡| 在线观看免费日韩欧美大片| 欧美一区二区精品小视频在线| 18禁黄网站禁片午夜丰满| 欧美又色又爽又黄视频| 老司机午夜福利在线观看视频| 啦啦啦免费观看视频1| 国产激情久久老熟女| 草草在线视频免费看| 国产精品永久免费网站| 88av欧美| 亚洲中文日韩欧美视频| 18禁美女被吸乳视频| 手机成人av网站| 国产精品久久视频播放| 久久久久久免费高清国产稀缺| 成年人黄色毛片网站| 一进一出抽搐gif免费好疼| 黄色片一级片一级黄色片| 日韩欧美国产一区二区入口| 中出人妻视频一区二区| 久久亚洲精品不卡| 最近最新中文字幕大全电影3 | 欧美中文综合在线视频| 88av欧美| 99久久99久久久精品蜜桃| 国产亚洲精品久久久久5区| 成人国产综合亚洲| 美女高潮喷水抽搐中文字幕| 18禁美女被吸乳视频| 久久性视频一级片| 亚洲欧美日韩无卡精品| 亚洲va日本ⅴa欧美va伊人久久| 身体一侧抽搐| 视频区欧美日本亚洲| 亚洲人成伊人成综合网2020| 91在线观看av| 国产三级在线视频| av在线天堂中文字幕| 一卡2卡三卡四卡精品乱码亚洲| 久久久久国产精品人妻aⅴ院| avwww免费| 国产色视频综合| 啦啦啦韩国在线观看视频| 免费看a级黄色片| 亚洲av熟女| 成人18禁高潮啪啪吃奶动态图| 久久久久久免费高清国产稀缺| 亚洲精品粉嫩美女一区| 成年免费大片在线观看| 日韩国内少妇激情av| 一进一出好大好爽视频| 国产欧美日韩一区二区精品| 91九色精品人成在线观看| 日本精品一区二区三区蜜桃| 国内精品久久久久久久电影| 中文字幕精品免费在线观看视频| 国产精品香港三级国产av潘金莲| 久久精品91无色码中文字幕| 亚洲 欧美一区二区三区| 人人妻人人澡欧美一区二区| 欧美在线一区亚洲| 观看免费一级毛片| 午夜福利高清视频| 中文字幕另类日韩欧美亚洲嫩草| 午夜久久久在线观看| 老汉色∧v一级毛片| 极品教师在线免费播放| 国产亚洲欧美精品永久| 国产一级毛片七仙女欲春2 | 免费看日本二区| 高清在线国产一区| 黑人巨大精品欧美一区二区mp4| 国产精品久久久人人做人人爽| 久久亚洲真实| 成人亚洲精品av一区二区| 亚洲最大成人中文| 亚洲精品久久成人aⅴ小说| 少妇裸体淫交视频免费看高清 | 欧美日本视频| 国产熟女xx| avwww免费| 一本久久中文字幕| 亚洲av成人一区二区三| 午夜福利一区二区在线看| 国产真实乱freesex| 色婷婷久久久亚洲欧美| 99精品欧美一区二区三区四区| 日本撒尿小便嘘嘘汇集6| 欧美日韩精品网址| 国产三级黄色录像| 午夜久久久在线观看| 国产爱豆传媒在线观看 | 亚洲狠狠婷婷综合久久图片| 午夜久久久在线观看| 18禁观看日本| 免费搜索国产男女视频| 窝窝影院91人妻| 国产又色又爽无遮挡免费看| 亚洲色图 男人天堂 中文字幕| 好看av亚洲va欧美ⅴa在| 国产欧美日韩一区二区三| 国产日本99.免费观看| 亚洲欧美精品综合一区二区三区| 国产精品九九99| 国产久久久一区二区三区| 亚洲专区中文字幕在线| 久久亚洲真实| 国产亚洲精品av在线| 久久精品国产清高在天天线| 亚洲欧美激情综合另类| 精品少妇一区二区三区视频日本电影| 久久久久久久午夜电影| 午夜成年电影在线免费观看| 久久精品人妻少妇| 日韩高清综合在线| 欧美乱色亚洲激情| 变态另类丝袜制服| 在线播放国产精品三级| 男女午夜视频在线观看| 视频在线观看一区二区三区| 9191精品国产免费久久| 亚洲男人天堂网一区| 欧美一级毛片孕妇| 欧美一区二区精品小视频在线| 大型av网站在线播放| 我的亚洲天堂| 在线观看www视频免费| 精品国产美女av久久久久小说| 国产午夜精品久久久久久| 午夜亚洲福利在线播放| 国产亚洲精品综合一区在线观看 | 韩国av一区二区三区四区| 欧美乱码精品一区二区三区| 啦啦啦韩国在线观看视频| 欧美另类亚洲清纯唯美| bbb黄色大片| a在线观看视频网站| а√天堂www在线а√下载| 男女视频在线观看网站免费 | 19禁男女啪啪无遮挡网站| tocl精华| 国产激情偷乱视频一区二区| 一区二区三区高清视频在线| 亚洲久久久国产精品| 免费在线观看黄色视频的| 国产亚洲精品综合一区在线观看 | 中文在线观看免费www的网站 | 久久久国产成人免费| 国产成人av激情在线播放| 久久久久久人人人人人| 成人免费观看视频高清| 国产国语露脸激情在线看| 久久 成人 亚洲| 欧美又色又爽又黄视频| 欧美黑人巨大hd| 少妇的丰满在线观看| 女同久久另类99精品国产91| 狠狠狠狠99中文字幕| 久久 成人 亚洲| 国产黄a三级三级三级人| 观看免费一级毛片| 色综合亚洲欧美另类图片| 成人亚洲精品av一区二区| 欧美av亚洲av综合av国产av| 黄色片一级片一级黄色片| 国产高清视频在线播放一区| 成人手机av| 一边摸一边做爽爽视频免费| 99久久无色码亚洲精品果冻| 少妇熟女aⅴ在线视频| 亚洲七黄色美女视频| 好看av亚洲va欧美ⅴa在| 叶爱在线成人免费视频播放| 一区二区三区国产精品乱码| 啦啦啦 在线观看视频| 窝窝影院91人妻| 美女高潮到喷水免费观看| 一级毛片女人18水好多| 哪里可以看免费的av片| 看免费av毛片| 19禁男女啪啪无遮挡网站| 黄色毛片三级朝国网站| 国产一区二区在线av高清观看| 亚洲av中文字字幕乱码综合 | 丰满人妻熟妇乱又伦精品不卡| 亚洲片人在线观看| 欧美国产日韩亚洲一区| 久久精品国产亚洲av香蕉五月| 欧美另类亚洲清纯唯美| 亚洲片人在线观看| 国产片内射在线| 午夜福利一区二区在线看| 中文在线观看免费www的网站 | 亚洲精品久久成人aⅴ小说| 日韩欧美在线二视频| 午夜a级毛片| www.熟女人妻精品国产| 香蕉av资源在线| 国产在线精品亚洲第一网站| 91麻豆精品激情在线观看国产| 91大片在线观看| 日韩欧美三级三区| 高潮久久久久久久久久久不卡| АⅤ资源中文在线天堂| 久久 成人 亚洲| or卡值多少钱| 欧美绝顶高潮抽搐喷水| 亚洲avbb在线观看| 欧美黑人精品巨大| 最新美女视频免费是黄的| 亚洲精品色激情综合| 久久青草综合色| 久久久国产精品麻豆| 国产亚洲精品一区二区www| 亚洲精品中文字幕一二三四区| 岛国在线观看网站|