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Tjust AE, Hellman U, Giannopoulos A, Winsnes A, Strigård K, Gunnarsson U. Evaluation of Extracellular Matrix Remodeling in Full-thickness Skin Grafts in Mice. J Histochem Cytochem 2024; 72:79-94. [PMID: 38264898 PMCID: PMC10851880 DOI: 10.1369/00221554231225995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
Abdominal hernia is a protruding weakness in the abdominal wall. It affects abdominal strength and life quality and can lead to complications due to intestinal entrapment. Autologous full-thickness skin graft (FTSG) has recently become an alternative material for reinforcement in the surgical repair of large abdominal hernias instead of synthetic mesh. FTSG eventually integrates with the abdominal wall, but the long-term fate of the graft itself is not fully understood. This has implications as to how these grafts should be optimally used and handled intraoperatively. This study investigates the remodeling of FTSG in either the onlay or the intraperitoneal position 8 weeks after FTSG transplantation in an experimental mouse model. There was a significant presence of fibroblasts, indicated by vimentin and S100A4 staining, but there were significant variations among animals as to how much of the graft had been remodeled into dense connective tissue. This correlated significantly with the proportion of vimentin-positive cells in the dense connective tissue. We also found that collagen hybridizing peptide staining intensity, a marker of active remodeling, was significantly associated with the proportion of S100A4-positive cells in the dense connective tissue of the FTSG.
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Affiliation(s)
- Anton Erik Tjust
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden, Umeå University, Umeå, Sweden
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Urban Hellman
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Antonios Giannopoulos
- Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Annika Winsnes
- Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Karin Strigård
- Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Ulf Gunnarsson
- Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Holmdahl V, Strigård K, Gunnarsson U. Autologous full-thickness skin in the repair of complex ventral hernias: an innovative step into the future of complex hernia repair? Front Surg 2023; 10:1301702. [PMID: 38162093 PMCID: PMC10754975 DOI: 10.3389/fsurg.2023.1301702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024] Open
Abstract
The repair of complex ventral hernias, such as giant incisional or parastomal hernia, is associated with a high risk for complications and recurrence. Some serious complications are related to implantation of synthetic mesh as reinforcement material. Autologous full-thickness skin graft (FTSG) as reinforcement material in the repair of these complex hernias may offer a safe alternative. This is a review of the history of FTSG use in hernia surgery and the experiences of our research group regarding its application over the last decade. The results of FTSG used in the repair of giant ventral hernias are promising, and this method may already be recommended in selected cases. We have also conducted a translational chain of preclinical studies, based on a murine model, to gain a greater understanding of the behaviour of FTSG implanted in various positions in the abdominal wall. The use of intraperitoneal FTSG as reinforcement material in parastomal hernia repair is currently being evaluated in a randomised, controlled, multicentre study.
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Winsnes A, Ivarsson ML, Falk P, Gunnarsson U, Strigård K. Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study. Hernia 2022; 26:1695-1705. [PMID: 36048398 DOI: 10.1007/s10029-022-02664-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Autologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response. METHODS ECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation. RESULTS At 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V. CONCLUSION This preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.
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Affiliation(s)
- A Winsnes
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 87, Umeå, Sweden
| | - M-L Ivarsson
- Department of Surgery, University of Gothenburg, Gothenburg, Sweden
| | - P Falk
- Department of Surgery, University of Gothenburg, Gothenburg, Sweden
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 87, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 87, Umeå, Sweden.
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Holmdahl V, Stark B, Clay L, Gunnarsson U, Strigård K. Could full thickness skin grafts in an onlay position be the new gold standard for incisional hernia repair? Author's reply. Hernia 2022; 26:665-666. [PMID: 35296930 PMCID: PMC9012709 DOI: 10.1007/s10029-022-02589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 12/03/2022]
Affiliation(s)
- V Holmdahl
- Department of Surgical and Perioperative Sciences, Surgery, Sunderby Research Unit, Umeå University, Daniel Naezéns väg, 90185, Umeå, Sweden.
| | - B Stark
- Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, MK1 Karolinska Institute, Stockholm, Sweden
| | - L Clay
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Winsnes A, Falk P, Gunnarsson U, Strigård K. Full-thickness skin grafts to reinforce the abdominal wall: a cross-sectional histological study comparing intra- and extraperitoneal onlay positions in mice. J Wound Care 2022; 31:48-55. [PMID: 35077208 DOI: 10.12968/jowc.2022.31.1.48] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In the repair of complex abdominal wall hernia, there can be a strong preference to avoid synthetic or biological implants as reinforcement material. Autologous full-thickness skin grafts (FTSG) have shown promising results. However, there are few clinical data on the use of FTSG in an intraperitoneal position and rudimentary knowledge about postoperative histological appearance of tissue remodelling and repair. OBJECTIVE To investigate the histological appearance of FTSG in the intraperitoneal onlay mesh (IPOM) position. METHODS Isogeneic FTSG was positioned in the IPOM (10 mice) and the onlay position (10 mice). After eight weeks, tissues were harvested for histological analysis. Tissue structure, inflammation and cell survival were investigated with histological and immunohistochemical staining. RESULTS Morphology was similar in both positions. Luciferase staining indicated both onlay and IPOM graft cell survival, with microvascular networks present. In both positions, FTSG showed ongoing tissue remodelling processes and cystic formations containing hair and epidermis. Low-grade acute phase and chronic inflammation were present. Integration was observed in 50% of the mice with similar appearances in IPOM and onlay grafts. CONCLUSION FTSG is tolerated, with comparable results either inside or outside the abdominal cavity, and in line with historic histological evaluations. The results suggest further research on FTSG as a potential future reinforcement material in selected cases of complex abdominal wall hernia repair.
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Affiliation(s)
- Annika Winsnes
- Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 85, Umeå, Sweden
| | - Peter Falk
- Fibrinolysis Lab/Tissue Center, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Ulf Gunnarsson
- Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 85, Umeå, Sweden
| | - Karin Strigård
- Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Daniel Naezéns väg, 901 85, Umeå, Sweden
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Holmdahl V, Stark B, Clay L, Gunnarsson U, Strigård K. Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial. Hernia 2021; 26:473-479. [PMID: 34905143 PMCID: PMC9012705 DOI: 10.1007/s10029-021-02544-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/25/2021] [Indexed: 11/12/2022]
Abstract
Purpose Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia. Methods Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL). Results Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups. Conclusion The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM. Trial Registration The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.
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Affiliation(s)
- V Holmdahl
- Department of Surgical and Perioperative Sciences, Surgery, Sunderby Research Unit, Umeå University, Sjukhusvägen 10, 95442, Södra Sunderbyn, Sweden.
| | - B Stark
- Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, MK1 Karolinska Institute, Stockholm, Sweden
| | - L Clay
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Holmdahl V, Gunnarsson U, Strigård K. Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a randomised controlled trial. Trials 2021; 22:891. [PMID: 34876195 PMCID: PMC8650734 DOI: 10.1186/s13063-021-05884-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 11/26/2021] [Indexed: 11/12/2022] Open
Abstract
Background Parastomal hernia is a common complication of an enterostomy and can have a significant impact on health-related quality of life. Currently used methods of repair have high recurrence rates and considerable risk for complications. We have developed a new technique for parastomal hernia repair that uses full-thickness skin graft as reinforcement. Methods This study protocol describes a multicentre randomised controlled trial on parastomal hernia repair comparing a new full-thickness skin graft technique with conventional synthetic composite mesh as reinforcement of the abdominal wall. Patients with a symptomatic parastomal hernia will be included and followed up at 3, 12 and 36 months, with surgical complication as the primary outcome. Secondary outcomes will be recurrence rate and health-related quality of life assessed with VHPQ, EORTC C30 and CR29. Tissue biology and collagen metabolism will be investigated pre- and postoperatively using biopsies of the abdominal wall fascia and blood samples. Discussion Parastomal hernia constitutes a major clinical problem where the prospects of a good result after hernia repair are presently poor. This new method of repair with full-thickness skin grafting could be a new alternative in our surgical toolbox, but before then, it must be evaluated properly. Trial registration ClinicalTrials.gov NCT03667287. Registered on September 12, 2018
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Affiliation(s)
- Viktor Holmdahl
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden. .,Sunderby Research Unit, Umeå University, Luleå, Sweden.
| | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Karin Strigård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Holmdahl V, Gunnarsson U, Strigård K. Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a feasibility study. Tech Coloproctol 2020; 25:131-136. [PMID: 33151386 PMCID: PMC7847461 DOI: 10.1007/s10151-020-02368-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/23/2020] [Indexed: 11/06/2022]
Abstract
Background Parastomal hernia is a common complication of stoma formation and the methods of repair available today are unsatisfactory with high recurrence and complication rates. To improve outcome after surgical repair of parastomal hernia, a surgical method using autologous full-thickness skin grafts as intraperitoneal reinforcement has been developed. The purpose of this study was to evaluate the feasibility of this novel surgical technique in the repair of parastomal hernia. Methods A pilot study was conducted between January 2018 and June 2019 on four patients with symptomatic parastomal hernia. They had a laparotomy with suture reduction of the hernia and reinforcement of the abdominal wall with autologous full-thickness skin. They were then monitored for at least 1 year postoperatively for technique-related complications and recurrence. Results No major technique-related complications were noted during the follow-up Two patients developed a recurrent parastomal hernia at the long term follow-up. The other two had no recurrence. Conclusions Autologous full-thickness skin graft as reinforcement in parastomal hernia repair is feasible and should be evaluated in a larger clinical trial.
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Affiliation(s)
- V Holmdahl
- Department of Surgical and Perioperative Sciences, Umeå University, Norrlands Universitetssjukhus, Daniel Naezéns väg, Västerbottens län, 90185, Umeå, Sweden.
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Norrlands Universitetssjukhus, Daniel Naezéns väg, Västerbottens län, 90185, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Umeå University, Norrlands Universitetssjukhus, Daniel Naezéns väg, Västerbottens län, 90185, Umeå, Sweden
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Holmdahl V, Backman O, Gunnarsson U, Strigård K. The Tensile Strength of Full-Thickness Skin: A Laboratory Study Prior to Its Use as Reinforcement in Parastomal Hernia Repair. Front Surg 2020; 6:69. [PMID: 31921883 PMCID: PMC6915078 DOI: 10.3389/fsurg.2019.00069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/19/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose: Parastomal hernia is a common complication of an enterostoma. Current methods of repair have high recurrence rates and are associated with severe complications. Autologous full-thickness skin as reinforcement may reduce the recurrence and complication rates. This study aims to investigates the tensile strength of full-thickness skin; information that is essential if we are to proceed with clinical trials on humans. Methods: Full-thickness skin samples from 12 donors were tested for tensile strength, as well as the load tolerated by a suture through the skin. Strips of skin were cut out and stretched until breaking point. Sutures were made through skin samples and traction applied until either the tissue or the suture gave way. All done while recording the forces applied using a dynamometer. Identical tests were carried out on commercially available synthetic and biologic graft material for comparison. Results: The full-thickness skin strips had a median tensile strength of 604 N/cm. This tensile strength was significantly higher than that of the compared materials evaluated in this study. In full-thickness skin, the suture, or tissue endured a median force of 67 N before giving way, which was as high as, or higher than similar sutures through the compared materials. Conclusions: The tensile strength of full-thickness skin vastly exceeds the physiological forces affecting the abdominal wall, and sutures through skin endure high loads before giving way. The tensile strength of a full-thickness skin graft and the strength of sutures through this material will not limit its use for reinforcement in parastomal hernia repair.
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Affiliation(s)
- Viktor Holmdahl
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.,Sunderby Research Unit, Department of Surgical and Perioperative Sciences, Umeå University, Luleå, Sweden
| | - Olof Backman
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Karin Strigård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Holmdahl V, Stark B, Clay L, Gunnarsson U, Strigård K. One-year outcome after repair of giant incisional hernia using synthetic mesh or full-thickness skin graft: a randomised controlled trial. Hernia 2019; 23:355-361. [PMID: 30737622 PMCID: PMC6456465 DOI: 10.1007/s10029-019-01900-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/22/2019] [Indexed: 12/04/2022]
Abstract
PURPOSE Repair of giant incisional hernia often requires complex surgery and the results of conventional methods using synthetic mesh as reinforcement are unsatisfactory, with high recurrence and complication rates. Our hypothesis was that full-thickness skin graft (FTSG) provides an alternative reinforcement material for giant incisional hernia repair and that outcome is improved. The aim of this study was to compare FTSG with conventional materials currently used as reinforcement in the repair of giant incisional hernia. METHODS A prospective randomised controlled trial was conducted, comparing FTSG with synthetic mesh as reinforcement in the repair of giant (> 10 cm minimum width) incisional hernia. One-year follow-up included a blinded clinical examination by a surgeon and objective measurements of abdominal muscle strength using the Biodex-4 system. RESULTS 52 patients were enrolled in the study: 24 received FTSG and 28 synthetic mesh. Four recurrences (7.7%) were found at 1-year follow-up, two in each group. There were no significant differences regarding pain, patient satisfaction or aesthetic outcome between the groups. Strength in the abdominal wall was not generally improved in the study population and there was no significant difference between the groups. CONCLUSION The outcome of repair of giant incisional hernia using FTSG as reinforcement is comparable with repair using synthetic mesh. This suggests that FTSG may have a future place in giant incisional hernia repair.
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Affiliation(s)
- V Holmdahl
- Department of Surgery and Perioperative Sciences, Umeå University, Daniel Naezéns väg, 90185, Umeå, Sweden.
| | - B Stark
- Department of Molecular Medicine and Surgery, Karolinska Institute, Solna, Sweden
| | - L Clay
- Department of Clinical Science and Education, Karolinska Institute, Solna, Sweden
| | - U Gunnarsson
- Department of Surgery and Perioperative Sciences, Umeå University, Daniel Naezéns väg, 90185, Umeå, Sweden
| | - K Strigård
- Department of Surgery and Perioperative Sciences, Umeå University, Daniel Naezéns väg, 90185, Umeå, Sweden
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