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Huang EY, Broderick RC, Spurzem GJ, Li JZ, Blitzer RR, Cheverie JN, Sandler BJ, Horgan S, Jacobsen GR. Long-term outcomes of PGA-TMC absorbable synthetic scaffold in both clean and contaminated ventral hernia repairs. Surg Endosc 2024; 38:2231-2239. [PMID: 38498213 DOI: 10.1007/s00464-024-10777-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Biosynthetic meshes afford the cost advantages of being made from fully synthetic material, but are also biodegradable, making them a versatile option that can be used in both clean and contaminated cases. The aim of this study is to evaluate the safety profile and long-term outcomes of using GORE BIO-A (BIO-A) as an adjunct to abdominal wall reconstruction in all wound classes. METHODS A retrospective review identified patients undergoing abdominal hernia repair using BIO-A from October 2008 to June 2018. The primary outcome was hernia recurrence rate. Only patients with at least 6-month follow-up were included when looking at recurrence rates. Secondary outcomes included 30-day morbidity categorized according to CDC Surgical Site Infection Criteria, return to operating/procedure room (RTOR), 30-day readmission, length of stay (LOS), and mortality. RESULTS A total of 207 patients were identified, CDC Wound Classification breakdown was 127 (61.4%), 41 (19.8%), 14 (6.8%), and 25 (12.1%) for wound classes I, II, III, and IV, respectively. Median follow-up was 55.4 months (range 0.2-162.4). Overall recurrence rate was 17.4%. Contaminated cases experienced higher recurrence rates (28.8% versus 10.4%, p = 0.002) at a mean follow up of 46.9 and 60.8 months for contaminated and clean patients, respectively. Recurrent patients had higher BMI (32.4 versus 28.4 kg/m2, p = 0.0011), larger hernias (162.2 versus 106.7 cm2, p = 0.10), higher LOS (11.1 versus 5.6 days, p = 0.0051), and higher RTOR rates (16.7% versus 5.6%, p = 0.053). 51 (24.5%) patients experienced some morbidity, including 19 (9.2%) surgical site occurences, 7 (3.4%) superficial surgical site infections, 16 (7.7%) deep surgical site infections, and 1 (0.5%) organ space infection. CONCLUSION This study affirms the use of biosynthetic mesh as a cost-effective alternative in all wound classifications, yielding good outcomes, limited long-term complications, and low recurrence. rates.
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Affiliation(s)
- Estella Y Huang
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Graham J Spurzem
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA.
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Rachel R Blitzer
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Joslin N Cheverie
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
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Naraynsingh V, Cawich SO, Hassranah S. Alternative to mesh repair for ventral hernias: Modified rectus muscle repair. World J Surg Proced 2023; 13:14-21. [DOI: 10.5412/wjsp.v13.i3.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/18/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections, adhesions, seromas, fistula formation and significant postoperative pain. The modified rectus muscle repair (RMR) is as an option to repair midline ventral hernias without mesh.
AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.
METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias > 5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit. Patients were reviewed in an outpatient clinic at 3, 6 and 12 mo and evaluated for hernia recurrence on clinical examination. Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences. All data were examined with SPSS ver 18.0.
RESULTS Over the 5-year study period, there were 52 patients treated for ventral hernias at this institution. Four patients were excluded and there were 48 in the final study sample, at a mean age of 56 years (range 28-80). The mean maximal diameter of the hernia defect was 7 cm (range 5-12 cm). There were 5 (10.4%) seromas and 1 recurrence (2.1%) at a mean of 36 mo follow-up.
CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias. The seroma rate can be further reduced with routine use of drains. The modified RMR also has the benefit of eliminating all mesh-specific complications.
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Affiliation(s)
- Vijay Naraynsingh
- Department of Surgery, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
| | - Shamir O Cawich
- Department of Surgery, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Samara Hassranah
- Department of Surgery, Medical Associate Hospital, St. Joseph, Trinidad and Tobago
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Li J, Shao X, Cheng T. Comparison of Different Weight Meshes in Ventral/Incisional Hernia Repair, the Outcomes of Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:402-410. [PMID: 37311039 DOI: 10.1097/sle.0000000000001191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/04/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The use of mesh is not without complications. Decreasing the mesh weight with the light-weight (LW) mesh may improve tissue growth and diminish mesh-related complications, yet, clinically, there are conflicting results regarding the influence of different weight meshes in ventral/incisional hernia repair. The aim of the present study is to compare the outcomes of different weight meshes for ventral/incisional hernia repair. METHODS The major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies were published through January 1, 2022, using the keywords "heavy weight" "light weight" "mesh" "ventral hernia" "incisional hernia". All relevant articles and reference lists in these original studies were also obtained from the above databases. RESULTS Eight trials (4 randomized controlled trials, 3 prospective studies, and 1 retrospective study) containing 1844 patients were included in the present meta-analysis. The pooled results showed that there was a significantly more rate of foreign body perception in the heavy-weight mesh group compared with the LW mesh group (odds ratio = 5.02, 95% CI: 1.05, 24.06). There was no significant difference concerning hernia recurrence, seroma, hematoma, surgical site infection, reoperation rate, chronic pain, quality of life, and hospital stay among different weight mesh groups. CONCLUSION Different weight meshes showed similar clinical results in ventral/incisional hernia repair, except that, perception of foreign body was reported more frequently in the heavy-weight mesh group as compared with the LW mesh group. However, the long-term hernia recurrence with different weights of meshes needs to be reevaluated considering the relative short-term follow-up in these studies.
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Affiliation(s)
- Junsheng Li
- Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
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Gao X, Li RF, Sun LX, Liu ZJ, Tian GJ, Qi H, Li XB. Prophylactic Effect of Simultaneous Placement of Mesh on Incidence of Parastomal Hernia After Miles' Surgical Resection of Colorectal Cancer: A Prospective Study. J Surg Res 2022; 277:27-36. [PMID: 35453054 DOI: 10.1016/j.jss.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 02/15/2022] [Accepted: 03/19/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To assess the prophylactic effect of simultaneous placement of mesh and the incidence of parastomal hernia (PSH) after abdominoperineal resection of rectal cancer. METHODS This study included real-world data of 56 surgically resected patients with colorectal cancer who were consecutively assigned to two groups: control (no mesh, n = 32) and experimental (received mesh, n = 24). An artificial patch was placed under the tunica vaginalis of rectus abdominis for patients in the experimental group, whereas those in the control group received routine sigmoidostomy. The median follow-up time was >20 mo. The difference in hazards function was analyzed by cox regression analysis. The Kaplan-Meir analysis was used to determine the survival curves. A P value of <0.05 was considered as significant. RESULTS The postoperative incidence rate of PSH was lower in the experimental (41.7%) group than in the control group (71.9%; P = 0.045). The PSH postoperative time in the experimental group was significantly delayed compared to the control group (48 mo versus 10 mo; P < 0.001). The risk of progression from H1 to H2 was less in the experimental group compared to the control group (49.28% versus 60.86%; P = 0.14). CONCLUSIONS Prophylactic mesh placement significantly prolonged postoperative time for the recurrence of PSH. The incidence of recurrence of H2 (severe PSH) requiring secondary surgical repair was also reduced.
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Affiliation(s)
- Xu Gao
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Ruo-Fan Li
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Li-Xin Sun
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China.
| | - Zuo-Jun Liu
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Guang-Jian Tian
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Hui Qi
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiao-Bin Li
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Lima DL, Estrada A, Pereira X, Alcabes A, Sreeramoju P, Malcher F. VERSATILITY OF POLY-4-HYDROXYBUTYRATE (PHASIX™) MESH IN ABDOMINAL WALL SURGERY. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:226-230. [PMID: 35830033 DOI: 10.1590/s0004-2803.202202000-41] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/03/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. OBJECTIVE We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. METHODS This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. RESULTS A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. CONCLUSION P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.
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Affiliation(s)
- Diego L Lima
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Arturo Estrada
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Xavier Pereira
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Analena Alcabes
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Prashanth Sreeramoju
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Flavio Malcher
- Division of General Surgery, NYU Langone Health, New York, United States
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Sahebally SM, Lim TZ, Azmir AA, Lu CT, Doudle M, Naik A, Nolan G, Papen MV. Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis. Int J Colorectal Dis 2021; 36:2007-2016. [PMID: 33877438 DOI: 10.1007/s00384-021-03924-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.
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Affiliation(s)
- Shaheel M Sahebally
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia. .,Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Titus Z Lim
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Alisha A Azmir
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Cu Tai Lu
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Mark Doudle
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Arun Naik
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Gregory Nolan
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Michael Von Papen
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
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Haddad A, Yahia DBH, Chaker Y, Maghrebi H, Daghfous A, Kacem MJ. Intraperitoneal migrating mesh plug wrongfully taken for right colon cancer: A case report. Int J Surg Case Rep 2021; 84:106088. [PMID: 34186460 PMCID: PMC8254107 DOI: 10.1016/j.ijscr.2021.106088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The use of mesh has become nowadays a standard for hernia repairs. It allows a tension-free hernioplasty and has shown that it is an effective way to prevent recurrences. But complications have been described. Intraperitoneal migration of mesh plug is an uncommon complication. CASE REPORT In this paper we report a case of a 57 year old male who has been operated on 12 years ago, he had a mesh plug repair for a ventral incisional hernia. The mesh migrated into the abdominal cavity and it was wrongfully taken for a locally advanced right colon cancer. Colonoscopy was done and biopsies were taken, but the results were not conclusive. He was operated on. We found the mesh that had migrated and eroded the hepatic flexure. There was a granulation tissue that also included some of the small intestine. There was also an abscess in the abdominal wall. He had an en-bloc resection of a part of the abdominal wall, small intestine and right colon. CONCLUSION Mesh hernioplasty is a frequent, simple and effective procedure with a low recurrence rate but it can be associated to serious complications such as mesh migration.
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Affiliation(s)
- A Haddad
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - D Bel Haj Yahia
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Y Chaker
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - H Maghrebi
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A Daghfous
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M J Kacem
- Surgery department A, Rabta Hospital, Rue Jbel Lakhdar, La Rabta Jebbari 1007, Tunis, Tunisia; The Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Christopher AN, Patel V, Othman S, Jia H, Mellia JA, Broach RB, Fischer JP. Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes. J Surg Res 2021; 264:199-207. [PMID: 33838404 DOI: 10.1016/j.jss.2021.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Hanna Jia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joseph A Mellia
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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Gogna S, Latifi R, Policastro A, Prabhakaran K, Anderson P, Con J, Choi J, Samson DJ, Butler J. Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis. Hernia 2020; 24:495-502. [PMID: 31981009 PMCID: PMC7223233 DOI: 10.1007/s10029-019-02068-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/04/2019] [Indexed: 12/18/2022]
Abstract
Background Complex abdominal wall reconstruction (CAWR) has become a common surgical procedure both in non-elderly and elderly patients. Objective The aim of this study is to analyze the outcomes of the elderly compared to nonelderly undergoing CAWR using propensity score matching. Methods All patients who underwent CAWR using porcine-derived, non-crosslinked acellular dermal matrix (ADM) (Strattice™) between January 2014 and July 2017 were studied retrospectively. Propensity matched analysis was performed for risk adjustment in multivariable analysis and for one-to-one matching. The outcomes were analyzed for differences in postoperative complications, reoperations, mortality, hospital length of stay and adverse discharge disposition. Results One hundred-thirty-six patients were identified during the study period. Non-elderly (aged 18–64 years) constituted 70% (n = 95) and elderly (aged ≥ 65 years) comprised 30% of the overall patient population (n = 41). Seventy-three (56.7%) were females. After adjustment through the propensity score, which included 35 pairs, the surgical site infection (p = 1.000), wound necrosis (p = 1.000), the need for mechanical ventilation (p = 0.259), mortality (p = 0.083), reoperation rate (p = 0.141), hospital length of stay (p = 0.206), and discharge disposition (p = 0.795) were similar. Conclusion Elderly patients undergoing CAWR with biological mesh have comparable outcomes with non-elderly patients when using propensity matching score.
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Affiliation(s)
- S Gogna
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, E-348, Valhalla, NY, 10595, USA
| | - R Latifi
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY, 10595, USA.
| | - A Policastro
- Medical Director SICU, PCU, Trauma and Critical Care, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-136, Valhalla, NY, 10595, USA
| | - K Prabhakaran
- Division of Trauma, Acute Care Surgery and Burns, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-150, Valhalla, NY, 10595, USA
| | - P Anderson
- Trauma Intensive Care Unit, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-145, Valhalla, NY, 10595, USA
| | - J Con
- Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, E-131, Office #E145, Valhalla, NY, 10595, USA
| | - J Choi
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, E-348, Valhalla, NY, 10595, USA
| | - D J Samson
- Department of Surgery, Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
| | - J Butler
- Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
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Buell JF, Sigmon D, Ducoin C, Shapiro M, Teja N, Wynter E, Hanisee MK, Parker G, Kandil E, Darden M. Initial Experience With Biologic Polymer Scaffold (Poly-4-hydroxybuturate) in Complex Abdominal Wall Reconstruction. Ann Surg 2017; 266:185-188. [PMID: 28594679 DOI: 10.1097/sla.0000000000001916] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the use of the new absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) in complex abdominal wall reconstruction. BACKGROUND Complex abdominal wall reconstruction has witnessed tremendous success in the last decade after the introduction of cadaveric biologic scaffolds. However, the use of cadaveric biologic mesh has been expensive and plagued by complications such as seroma, infection, and recurrent hernia. Despite widespread application of cadaveric biologic mesh, little data exist on the superiority of these materials in the setting of high-risk wounds in patients. P4HB, an absorbable polymer scaffold, may present a new alternative to these cadaveric biologic grafts. METHODS A retrospective analysis of our initial experience with the absorbable polymer scaffold P4HB compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our analysis was performed using SAS 9.3 and Stata 12. RESULTS The P4HB group (n = 31) experienced shorter drain time (10.0 vs 14.3 d; P < 0.002), fewer complications (22.6% vs 40.5%; P < 0.046), and reherniation (6.5% vs 23.8%; P < 0.049) than the porcine cadaveric mesh group (n = 42). Multivariate analysis for infection identified: porcine cadaveric mesh odds ratio 2.82, length of stay odds ratio 1.11; complications: drinker odds ratio 6.52, porcine cadaveric mesh odds ratio 4.03, African American odds ratio 3.08, length of stay odds ratio 1.11; and hernia recurrence: porcine cadaveric mesh odds ratio 5.18, drinker odds ratio 3.62, African American odds ratio 0.24. Cost analysis identified that P4HB had a $7328.91 financial advantage in initial hospitalization and $2241.17 in the 90-day postdischarge global period resulting in $9570.07 per case advantage over porcine cadaveric mesh. CONCLUSIONS In our early clinical experience with the absorbable polymer matrix scaffold P4HB, it seemed to provide superior clinical performance and value-based benefit compared with porcine cadaveric biologic mesh.
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Affiliation(s)
- Joseph F Buell
- *Tulane Abdominal Transplant Institute, Tulane University School of Medicine, New Orleans, LA†Tulane University School of Medicine, New Orleans, LA‡Department of Surgery, Tulane University School of Medicine, New Orleans, LA§Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA¶A. B. Freeman School of Business, Tulane University, New Orleans, LA
- Department of Economics, Tulane University, New Orleans, LA
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11
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Abstract
With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.
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Rastegarpour A, Cheung M, Vardhan M, Ibrahim MM, Butler CE, Levinson H. Surgical mesh for ventral incisional hernia repairs: Understanding mesh design. Plast Surg (Oakv) 2016; 24:41-50. [PMID: 27054138 DOI: 10.4172/plastic-surgery.1000955] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Surgical mesh has become an indispensable tool in hernia repair to improve outcomes and reduce costs; however, efforts are constantly being undertaken in mesh development to overcome postoperative complications. Common complications include infection, pain, adhesions, mesh extrusion and hernia recurrence. Reducing the complications of mesh implantation is of utmost importance given that hernias occur in hundreds of thousands of patients per year in the United States. In the present review, the authors present the different types of hernia meshes, discuss the key properties of mesh design, and demonstrate how each design element affects performance and complications. The present article will provide a basis for surgeons to understand which mesh to choose for patient care and why, and will explain the important technological aspects that will continue to evolve over the ensuing years.
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Affiliation(s)
- Ali Rastegarpour
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center
| | - Michael Cheung
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center
| | - Madhurima Vardhan
- Department of Biomedical Engineering, Duke University, Pratt School of Engineering, Durham, North Carolina
| | - Mohamed M Ibrahim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center
| | - Charles E Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Howard Levinson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center
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13
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Rastegarpour A, Cheung M, Vardhan M, Ibrahim MM, Butler CE, Levinson H. Surgical mesh for ventral incisional hernia repairs: Understanding mesh design. Plast Surg (Oakv) 2016. [DOI: 10.1177/229255031602400110] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Surgical mesh has become an indispensable tool in hernia repair to improve outcomes and reduce costs; however, efforts are constantly being undertaken in mesh development to overcome postoperative complications. Common complications include infection, pain, adhesions, mesh extrusion and hernia recurrence. Reducing the complications of mesh implantation is of utmost importance given that hernias occur in hundreds of thousands of patients per year in the United States. In the present review, the authors present the different types of hernia meshes, discuss the key properties of mesh design, and demonstrate how each design element affects performance and complications. The present article will provide a basis for surgeons to understand which mesh to choose for patient care and why, and will explain the important technological aspects that will continue to evolve over the ensuing years.
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Affiliation(s)
- Ali Rastegarpour
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael Cheung
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Madhurima Vardhan
- Department of Biomedical Engineering, Duke University, Pratt School of Engineering, Durham, North Carolina
| | - Mohamed M Ibrahim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Charles E Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Howard Levinson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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14
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Montori G, Coccolini F, Manfredi R, Ceresoli M, Campanati L, Magnone S, Pisano M, Poiasina E, Nita G, Catena F, Ansaloni L. One year experience of swine dermal non-crosslinked collagen prostheses for abdominal wall repairs in elective and emergency surgery. World J Emerg Surg 2015; 10:28. [PMID: 26136817 PMCID: PMC4487506 DOI: 10.1186/s13017-015-0023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/22/2015] [Indexed: 02/08/2023] Open
Abstract
Introduction The approach to the abdominal wall surgical repair is dramatically changed in the last years. This study evaluates our institutional outcomes about the usage of biological meshes for abdominal wall repair in different setting: in elective surgery, in emergency surgery and in abdominal wall repair following open abdomen (OA) procedure. Methods A database was prospectively conducted (January–December 2014) and data were reviewed for patients who underwent to an abdominal wall reconstruction with swine dermal non-cross linked collagens prostheses either in elective or emergency setting, and following OA/laparostomy procedure. Demographic data, co-morbidities, indications for surgery, intra-operative details, post-operative complications and outcome (peri-operative, 3, 6, 9-months) were analyzed. Results A total of 30 cases were reported: 9 in elective surgery (Group 1), 4 in emergency surgery (Group 2) and 17 with abdominal wall closure following OA management (Group 3). Two meshes were removed: 1 in the Group 1 and 1 in the Group 3. During follow-up only one patient in the Group 3 had a recurrence of the incisional hernia. Mortality rate was 11.1 % at 3 months in Group 1, 0 % in the Group 2, and 29.4 % in peri-operative period in the Group 3. Conclusions The use of non-cross linked biological meshes can be safe and versatile in different situations from elective to emergency surgery, and also for the reconstruction of the abdominal wall after OA procedure, with an acceptable recurrence and mortality rate.
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Affiliation(s)
- Giulia Montori
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Federico Coccolini
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Roberto Manfredi
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Marco Ceresoli
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Luca Campanati
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Michele Pisano
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Elia Poiasina
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Gabriela Nita
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- General surgery department, Ospedale Maggiore, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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15
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Vranckx J, Stoel A, Segers K, Nanhekhan LL. Dynamic reconstruction of complex abdominal wall defects with the pedicled innervated vastus lateralis and anterolateral thigh PIVA flap. J Plast Reconstr Aesthet Surg 2015; 68:837-45. [DOI: 10.1016/j.bjps.2015.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/19/2015] [Accepted: 03/05/2015] [Indexed: 11/27/2022]
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16
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Caso Maestro O, Abradelo de Usera M, Justo Alonso I, Calvo Pulido J, Manrique Municio A, Cambra Molero F, García Sesma A, Loinaz Segurola C, Moreno González E, Jiménez Romero C. Porcine acellular dermal matrix for delayed abdominal wall closure after pediatric liver transplantation. Pediatr Transplant 2014; 18:594-8. [PMID: 25039398 DOI: 10.1111/petr.12319] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2014] [Indexed: 01/11/2023]
Abstract
Children are one of the groups with the highest mortality rate on the waiting list for LT. Primary closure of the abdominal wall is often impossible in the pediatric population, due to a size mismatch between a large graft and a small recipient. We present a retrospective cohort study of six pediatric patients, who underwent delayed abdominal wall closure with a biological mesh after LT, and in whom early closure was impossible. A non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) Reconstructive Tissue Matrix; LifeCell Corp, Bridgewater, NJ, USA) was used in all of the cases of the series. After a mean follow-up of 26 months (21-32 months), all patients were asymptomatic, with a functional abdominal wall after physical examination. Non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) ) is a good alternative for delayed abdominal wall closure after pediatric LT. Randomized controlled trials are necessary to determine the best moment and the best technique for abdominal wall closure.
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Affiliation(s)
- O Caso Maestro
- Department and Institution, General Surgery and Abdominal Organ Transplantation, Hospital 12 de Octubre, Madrid, Spain
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17
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Wink JD, Wes AM, Fischer JP, Nelson JA, Stranksy C, Kovach SJ. Risk factors associated with early failure in complex abdominal wall reconstruction: a 5 year single surgeon experience. J Plast Surg Hand Surg 2014; 49:77-82. [PMID: 24693869 DOI: 10.3109/2000656x.2014.903195] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Complex abdominal wall reconstruction (AWR) is commonly performed, but with a significant rate of surgical complications and hernia recurrence. The aim of this experiential review is to assess risk factors for hernia recurrence after complex AWR. A retrospective review of AWR patients from 2007-2012 was performed. Rates of hernia recurrence were assessed. Univariate analyses and subsequent multivariate logistic regression analysis was used to assess independent predictors of early hernia recurrence. One hundred and thirty-four consecutive cases of AWR were performed over a 5-year period. Hernia recurrence developed in 14 (10.4%) patients. Hernias derived from trauma (OR = 19.76, p = 0.011) and those who experienced postoperative wound infections (OR = 18.81, p = 0.004) were at increased risk for hernia recurrence. In conclusion, increased vigilance must be paid to patients presenting after trauma with massive loss of domain and those who experience postoperative infection, as these cohorts are at added risk for failed reconstruction.
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Affiliation(s)
- Jason D Wink
- Division of Plastic Surgery, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
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18
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Fischer JP, Wink JD, Nelson JA, Kovach SJ. Among 1,706 cases of abdominal wall reconstruction, what factors influence the occurrence of major operative complications? Surgery 2014; 155:311-9. [DOI: 10.1016/j.surg.2013.08.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 08/12/2013] [Indexed: 01/22/2023]
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Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, Liu J, Butler CE. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 2013; 217:999-1009. [PMID: 24083910 DOI: 10.1016/j.jamcollsurg.2013.08.015] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation. STUDY DESIGN We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications. RESULTS We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p < 0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p < 0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p < 0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width > 15 cm to be independent predictors of hernia recurrence (HR 7.3; p < 0.001 and HR 2.5; p = 0.028, respectively). CONCLUSIONS Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.
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Affiliation(s)
- Justin H Booth
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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20
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Michel SAAX, Vogels RRM, Bouvy ND, Knetsch MLW, van den Akker NMS, Gijbels MJJ, van der Marel C, Vermeersch J, Molin DGM, Koole LH. Utilization of flax fibers for biomedical applications. J Biomed Mater Res B Appl Biomater 2013; 102:477-87. [DOI: 10.1002/jbm.b.33025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/19/2013] [Accepted: 08/01/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Sophie A. A. X. Michel
- Department of Biomedical Engineering, Faculty of Health, Medicine & Life Sciences; Maastricht University; Maastricht The Netherlands
| | - Ruben R. M. Vogels
- Department of Surgery; Maastricht University Medical Center; Maastricht The Netherlands
| | - Nicole D. Bouvy
- Department of Surgery; Maastricht University Medical Center; Maastricht The Netherlands
| | - Menno L. W. Knetsch
- Department of Biomedical Engineering, Faculty of Health, Medicine & Life Sciences; Maastricht University; Maastricht The Netherlands
| | - Nynke M. S. van den Akker
- Department of Physiology, Faculty of Health, Medicine & Life Sciences; Maastricht University; Maastricht The Netherlands
| | - Marion J. J. Gijbels
- Department of Pathology within the; Cardiovascular Research Institute Maastricht (CARIM); Maastricht The Netherlands
- Department of Molecular Genetics within the; Cardiovascular Research Institute Maastricht (CARIM); Maastricht The Netherlands
- Department of Medical Biochemistry, Academic Medical Center (AMC); University of Amsterdam; The Netherlands
| | | | | | - Daniel G. M. Molin
- Department of Physiology, Faculty of Health, Medicine & Life Sciences; Maastricht University; Maastricht The Netherlands
| | - Leo H. Koole
- Department of Biomedical Engineering, Faculty of Health, Medicine & Life Sciences; Maastricht University; Maastricht The Netherlands
- Department of Biomedical Engineering, Faculty of Engineering; University of Malaya; Kuala Lumpur Malaysia
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