|Year : 2021 | Volume
| Issue : 4 | Page : 202-210
Ventral hernia repair with concomitant soft tissue excision improves satisfaction without increased costs
Jacob Christopher Hubbuch1, Margaret A Plymale2, Daniel L Davenport3, Trevor N Farmer1, Seth D Walsh-Blackmore1, Jordan Hess1, Crystal Totten2, John Scott Roth2
1 College of Medicine, Lexington, KY, USA
2 Division of General, Endocrine, and Metabolic Surgery, Department of Surgery, University of Kentucky, Lexington, KY, USA
3 Division of Health Outcomes and Optimal Patient Services, Department of Surgery, University of Kentucky, Lexington, KY, USA
|Date of Submission||15-Jul-2021|
|Date of Decision||01-Aug-2021|
|Date of Acceptance||20-Aug-2021|
|Date of Web Publication||31-Dec-2021|
Dr. John Scott Roth
Division of General, Endocrine, and Metabolic Surgery, University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY 40536.
Source of Support: None, Conflict of Interest: None
PURPOSE: Soft tissue management following ventral hernia repair (VHR) may impact wound complications and hernia recurrence. Rationales for soft tissue excision (STE) include ischemia, redundancy, potential space reduction, and cosmesis. This study evaluates outcomes among patients undergoing VHR with and without STE. MATERIALS AND METHODS: Institutional Review Board-approved review of VHR patients at a single institution from 2014 to 2018 was performed for 90-day wound complications, reoperations, and readmissions. Hernia recurrence, chronic pain, functional status, and satisfaction were assessed through telephone survey. Outcomes and costs between groups were analyzed. RESULTS: One hundred and forty-four patients underwent VHR alone; 52 patients underwent VHR/STE. Obesity, larger defects, severe chronic obstructive pulmonary disease, and higher wound classes were more prevalent among VHR/STE. Deep surgical site infection [SSI (1% vs. 8%, P = 0.018)], wound dehiscence (13% vs. 33%, P = 0.003), and return to operating room (1% vs. 12%, P = 0.005) occurred more commonly in VHR/STE. Total costs were more than 50% greater ($18,900 vs. $29,300, P = 0.001) in VHR/STE, but after multivariable analysis adjusting for risk factors, total costs of VHR/STE no longer remained significantly higher ($18,694 vs. $21,370, P = 0.095). Incidence of superficial SSI (6% vs. 6%), seroma formation (14% vs. 12%), non-wound complications (7% vs. 17%), median length of stay (4 vs. 5 days), readmissions (13% vs. 21%), hernia recurrence (38% vs. 13%), and functional status scores (71 vs. 80) did not differ significantly between groups. Overall patient satisfaction (8 vs. 10, P = 0.034) and cosmetic satisfaction (6 vs. 9, P = 0.012) among VHR/STE were greater than VHR alone. CONCLUSION: Soft tissue resection during VHR results in greater patient satisfaction without increased costs.
Keywords: Panniculectomy, patient satisfaction, quality of life, soft tissue excision, surgical outcomes, ventral hernia repair
|How to cite this article:|
Hubbuch JC, Plymale MA, Davenport DL, Farmer TN, Walsh-Blackmore SD, Hess J, Totten C, Roth JS. Ventral hernia repair with concomitant soft tissue excision improves satisfaction without increased costs. Int J Abdom Wall Hernia Surg 2021;4:202-10
|How to cite this URL:|
Hubbuch JC, Plymale MA, Davenport DL, Farmer TN, Walsh-Blackmore SD, Hess J, Totten C, Roth JS. Ventral hernia repair with concomitant soft tissue excision improves satisfaction without increased costs. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:202-10. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/202/334563
| Introduction|| |
Ventral hernia repair (VHR) is commonly performed by general surgeons and plastic surgeons and incurs a large cost to the U.S. healthcare system. The rate of hernia recurrence after VHR has been reported to range from 24% to 43%. Obesity is a risk factor for the development of incisional hernia and recurrence following repair., It is estimated that a 1% reduction in recurrence would result in a $32 million yearly savings in procedural costs alone. With the growing prevalence of obesity in the USA, strategies that reduce the risk of hernia recurrence are needed to not only enhance patient well-being but also reduce the financial burden placed on the healthcare system.
Not infrequently, patients with ventral and incisional hernias present with redundant soft tissue or panniculus as a result of either the hernia contents within the subcutaneous tissue or obesity. Panniculectomy (PAN), which involves resection of the abdominal panniculus, can be performed as a stand-alone procedure or concomitantly during open abdominal procedures, including VHR.,,,, Potential advantages of performing PAN at the time of VHR include wider exposure of the abdominal wall for reconstruction, improved cosmesis, improved hygiene for patients who are at an increased risk for chronic dermatitis, cellulitis, intertrigo, candidiasis, edema, lymphedema, and skin ulcerations, and enhanced cost-effectiveness compared with staged procedures. VHR with a concomitant PAN (VHR/PAN) is postulated to decrease the risk for long-term hernia recurrence; however, few studies have evaluated this hypothesis with variable reported outcomes.,, Quality of life and patient satisfaction are important surgical outcomes increasingly being studied. These patient-reported outcomes are largely unstudied in VHR/PAN, although one recent report indicated that VHR/PAN might result in a higher quality of life score. It has not been determined previously whether patients are more satisfied after a concomitant procedure relative to those who received VHR alone; however, patients generally experience a high level of satisfaction after a PAN.,
Prior studies evaluating soft tissue excision (STE) during hernia repair are scarce and focus solely on concomitant PAN. It is common for soft tissue (subcutaneous tissue and skin) to be excised during a VHR for several reasons: tissue ischemia; de-vitalized soft tissue; undermining hernia sac resulting in the creation of redundant skin flaps; attenuated soft tissue related to prior wound complications; redundancy of skin following fascia closure to allow for potential space reduction; and large panniculus or cosmesis. The STE in many cases is quite extensive and mimics what is being done during a PAN; therefore, STE may similarly impact recurrence rates and wound complications. Currently, no studies have reported the effects of performing STE during VHR. The purpose of this study was to evaluate and compare outcomes in terms of complications, hospital costs, hernia recurrence, patient satisfaction, and quality of life between patients who underwent VHR alone and those who had concomitant STE (VHR/STE), including patients with concomitant VHR/PAN.
| Materials and Methods|| |
With Institutional Review Board approval, consecutive VHR cases (Current Procedural Terminology (CPT) codes 49560, 49561, 49565, or 49566) performed at a single tertiary care referral center from January 1, 2014 to May 31, 2018 were identified by reviewing surgical databases. Among these cases, an additional search was performed to identify patients who received a concomitant PAN (CPT code 15830). Patient demographics, perioperative characteristics, and 30-day clinical outcomes data were extracted from the local American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Review of electronic medical records provided surgical details including incision location, hernia defect size, size of STE, evidence of previous hernia repair, 90-day postoperative incidence of reoperation, and hospital re-admission. Ninety-day postoperative wound events were also identified and included superficial surgical site infection (SSI), deep SSI, and organ/space SSI, evidence of spontaneous wound dehiscence, wound necrosis, seroma formation, hematoma formation, and abscess formation. Centers for Disease Control and Prevention classification was used to differentiate superficial, deep, and organ/space SSI.
After an electronic medical record review was completed, telephone surveys were conducted to assess for hernia recurrence, patient satisfaction, and patient functional status. The survey was composed of multiple parts. A previously developed survey highly predictive of hernia recurrence was administered telephonically. Patient satisfaction with the overall repair and cosmetic outcomes was assessed with a 10-point scale. Patients were also questioned as to whether or not their abdomen causes them chronic pain and if so were asked to rank the pain on a 10-point Likert scale. Functional status was assessed with the verified HerQLes survey. Patient phone numbers were identified from institutional electronic medical records. Attempts were made to contact patients up to three times, and participation was voluntary. Patients were allowed to stop participating at any time during the survey administration, as well as request that their retrospective data not be included in the study. All telephone calls were made from institutional landlines.
The hospital cost accounting system was queried to obtain total actual hospital costs stratified into meaningful cost centers [operating room (OR), medical/surgical supplies, floor, ICU, pharmacy, etc.]. Information obtained from the retrospective review of the medical record was combined with information obtained from the hospital accounting database to result in a clinical and cost representation of the identified cases.
Continuous variables are reported as mean (SD) except for the length of hospital stay, which is reported as median (25–75th percentiles) because of its non-normal distribution. Categorical variables are reported as count (%) per category. Patient, hernia, and operative categorical variables were compared between VHR alone and VHR/STE groups using χ2 or Fisher’s exact tests; continuous variables were compared using Student’s t-test. Multivariable linear regression was performed comparing groups vs. log-transformed costs with adjustment for variables that differed significantly between groups. Significance was set at P < 0.05 for all analyses. Statistics were calculated using SPSS® version 26 (IBM® Corp., Armonk, NY, USA).
| Results|| |
Two hundred twenty patients were identified: 123 males (56%) and 97 females (44%); 24 were excluded from further analysis due to several factors [flank, perineal, or traumatic hernia (n = 13), concomitant procedures including enterocutaneous fistula takedown (n = 3), removal of hardware (n = 2), ileostomy creation (n = 1), or insufficient data in operative and post-operative clinic notes (n = 5)]. The amount of STE among VHR/STE patients ranged from 250 to 1680 cm2. Patients were divided into two cohorts based on the amount of soft tissue removed during their procedure. The two cohorts compared were: (1) VHR alone who had either no or minimal STE (<250 cm2) and (2) VHR/STE who either had STE that was ≥ 250 cm2 or underwent a coded PAN. Of the 196 cases reviewed, 144 were identified as VHR alone, and 52 were identified as part of the VHR/STE cohort.
Across all cases included in the study analyses, the average patient age was 56 years old (SD=12.4), and 59% (n = 89) of the patients were male. Patients who underwent VHR/STE were more likely to be obese (58% vs. 75%, P = 0.03) and to have severe chronic obstructive pulmonary disease (COPD) (6% vs. 15%, P = 0.04) than patients that underwent VHR alone. Demographic information are found in [Table 1]. The American Society of Anesthesiologists (ASA) Physical Status Classification, history of diabetes and/or hypertension, smoking status, steroid/immunosuppressant use, or blood thinner use/bleeding disorders were similar between the two patient cohorts.
|Table 1: Patient and hernia characteristics in patients undergoing VHR alone vs. VHR/STE|
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On average, the VHR/STE cohort had larger hernias (194 vs. 314 cm2, P < 0.001) and longer procedures (187 vs. 243 min, P < 0.001) than the VHR alone group. There was also a difference in incision type (P = 0.001), wound class (P = 0.02), and mesh type (P = 0.02), with VHR/STE undergoing more transverse incisions and less vertical incisions, having more contaminated and dirty/infected wounds, and receiving more biologic mesh. No difference existed between cohorts in the number of patients who had preoperative open wounds, prior hernia repairs, hernia type, or use of the separation of components technique. Perioperative characteristics are found in [Table 2].
|Table 2: Hernia and perioperative characteristics in patients undergoing VHR alone vs. VHR/STE|
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Overall, 90-day wound complications were comparable between the groups (28% vs. 42%, P = 0.06); however, deep SSI was more common among VHR/STE vs. VHR alone (8% vs. 1%, P = 0.02). Wound dehiscence was nearly tripled in the VHR/STE group (33%) compared with the VHR alone group (13%) (P = 0.003). Other wound complications such as necrosis, seroma, abscess, and hematoma did not differ significantly between the cohorts. VHR/STE patients did not have a higher incidence of 30-day non-wound complications. While 90-day hospital readmission was similar between groups within the same period, VHR/STE was more likely to return to the OR for issues regarding their abdominal wall. No documentation of hernia recurrence in any patient at 90 days postoperatively was assessed from chart review. Postoperative complications care found in [Table 3].
The average hospital length of stay across all patients was 4 days (IQR = 3–6), with VHR/STE staying 1 day longer on average (4 vs. 5, P = 0.06). Mean Case Mix Indices were 1.6 (SD=0.7) for both cohorts (P = 0.690). Total hospital costs for VHR/STE were 55% higher when compared with VHR alone, from approximately $18,900 to $29,300 (P = 0.001). OR costs, floor costs, medical and surgical supply costs, imaging costs, pharmacy costs, and ancillary services costs were all increased among VHR/STE patients. With adjustment for COPD, dyspnea, wound class, and mesh type, a generalized linear model of log-transformed total costs resulted in an estimated mean of $20,461 (95% confidence interval (CI) 15,226–27,497) in VHR alone vs. $27,718 (95% CI 21,018–36,552) in VHR/STE (P = 0.001). Adding hernia defect size to this model reduced the estimated mean total costs to $18,694 (95% CI $14,732–$23,722) in VHR alone vs. $21,370 (95% CI $17,001–$26,862) in VHR/STE (P = 0.095). Cost data are found in [Table 4].
|Table 4: Index procedure hospitalization costs in patients undergoing VHR alone vs. VHR/STE|
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The average time from procedure date to telephone survey was 40 months (SD=17), with no difference between the groups (41 vs. 35, P = 0.29). The response rate was 38.5% (n = 75) with 60 patients (41.7%) in the VHR alone group and 15 patients (28.8%) in the VHR/STE group responding to the survey. Based on patient responses, the incidence of hernia recurrence was 33% (n = 25) for the entire study group, with no significant difference existing between the two cohorts. A quarter of patients reported chronic pain (n = 19) at the time of follow-up, with an average pain score of 2.5. Using a 10-point Likert scale, overall satisfaction of the hernia repair operation was 8.3 (SD=2.8), and average satisfaction with abdominal appearance was 6.7 (SD=3.6). VHR/STE rated their satisfaction with repair (8.0 vs. 9.7, P = 0.03) and abdominal appearance (6.2 vs. 8.7, P = 0.01) higher than VHR alone. No difference was noted between cohorts in HerQLes scores with the average score being 72.7 (SD=28.0).
| Discussion|| |
Patient-reported satisfaction is increasingly an essential component of clinical outcomes research. Decreased patient satisfaction following hernia repair is related to undesirable cosmesis, chronic pain, and hernia recurrence. Patient-reported satisfaction after PAN is high., Cooper et al. showed a majority of patients who received PAN were very satisfied with the outcome, despite a high rate of complications. Mazzocchi et al. looked at a series of 22 patients who underwent VHR with component separation and PAN, all of whom reported satisfaction with their procedure. It has been assumed that PAN increases patient satisfaction after VHR, but the current study is the first to compare patient-reported satisfaction, and specifically cosmetic satisfaction, between VHR alone and VHR/STE. VHR/STE patients reported increased satisfaction with the cosmetic appearance of their abdomen and overall satisfaction with the repair compared with VHR alone patients in this study. This is despite having larger defect sizes; increased incidence of obesity; and more deep SSI, wound dehiscence, and returns to the OR. This raises the question of why VHR/STE patients have greater overall satisfaction with their repair. Perhaps, the increased long-term cosmetic satisfaction offsets the short-term complications.
Postoperative pain is a common complication after VHR. Pain scores have not been independently reported in the literature surrounding VHR/PAN. On analysis of our telephone survey results [Table 5], the prevalence of chronic pain was not different between the two cohorts. Tsirline et al. reported preoperative pain to be the greatest risk factor for postoperative pain after VHR. The current study data do not include preoperative pain scores; therefore, we are unable to determine an association between preoperative and postoperative pain among VHR/STE. While it was hypothesized that VHR/STE would increase functional status, no association was identified in this study. Similarly, Hutchison et al. also compared HerQLes functional status scores among VHR and VHR/PAN patients and found no difference. The small number of PAN patients evaluated in both that publication and the current study may be a factor in not appreciating any differences. Large-scale multi-centered studies would likely be required to definitively answer this question.
|Table 5: Telephone survey results in patients undergoing VHR alone vs. VHR/STE|
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Several risk factors for incisional hernia recurrence have been identified and include previous hernia repair, hernia defect size, obesity, postoperative wound complications, and possibly smoking. PAN is hypothesized to reduce recurrence rates as it involves removing excess skin and soft tissue from the abdomen, thereby reducing strain on the abdominal wall. In the largest study evaluating PAN with the longest duration of follow-up, Shubinets et al. reported that 2-year hernia recurrence rate was 35% lower among patients who underwent PAN compared with patients who did not (7.9% vs. 11.3%, P = 0.001), whereas other recent studies,, have reported similar recurrence rates. The current study data showed no difference in hernia recurrence between patients who underwent VHR/STE vs. VHR alone, even with a similar length of follow-up between the two groups. No difference in previous hernia repairs existed between cohorts, which is a known risk factor for recurrence. This finding, along with no difference in pain scores and functional status, further suggests that the increase in patient satisfaction among the VHR/STE group is likely dependent upon cosmetic satisfaction.
Abdominal wall reconstruction is associated with a high rate of SSI that can predispose the patient to hernia recurrence. Additionally, PAN is associated with a high rate of wound complications, and several studies have reported VHR with a concomitant PAN to increase the risk of wound and non-wound complications such as venous thromboembolism, pulmonary failure, SSI, postoperative hemorrhage, sepsis, and reoperation.,,,,,, Of these complications, superficial SSI and sepsis are the most commonly reported., A study comparing patients receiving PAN alone and patients undergoing a concomitant VHR with PAN found no difference in complication rates, suggesting that those patients requiring PAN may safely undergo concomitant hernia repair without increased risk. Our study also showed no difference in overall wound and non-wound complications between the groups. Of the wound complications that were increased in the VHR/STE group, only deep SSI and wound dehiscence were significantly different. Obesity, COPD, contaminated wounds, and increased hernia defect size are associated with increased complications after VHR,,,, all of which were more prevalent in the VHR/STE patients and may have contributed to the increased incidence of deep SSI and dehiscence in the cohort. Additionally, vascular compromise of overlying skin is a common indication for STE, and it is possible that the resection was not extensive enough in some of the VHR/STE patients, leaving behind devitalized tissue that later increased the risk of infection and dehiscence. Nevertheless, it is the practice of our group to maximally excise redundant and devitalized tissue based on the clinical appearance of the skin. It has not been our practice to utilize fluorescence imaging when resecting redundant or devitalized soft tissue.
Other differences existed between the groups including duration of operation and incision type, with VHR/STE patients having longer operations and more transverse incisions. The increased procedure length is most likely due to these patients having larger defect sizes that required more time to repair in addition to the extra time needed to excise excess soft tissue [Figure 1]. The majority of VHR/STE patients had only vertical incisions (69%), and 23% of the cohort had only transverse incisions. Transverse incisions were preferred in almost all PAN cases and many non-PAN STE cases due to the nature of performing soft tissue resection. Four VHR/STE patients had both a vertical and transverse incision (8%). Only one of the four patients with both a vertical and transverse incision was described as having a fleur de lis incision in the operative report. Both groups had similar percentages of polypropylene/synthetic mesh and absorbable mesh, but VHR had more synthetic barrier mesh and VHR/STE had more biologic mesh placed. The rationale for mesh selection differences between the groups can only be speculated, but is likely related to the increased prevalence of contaminated and infected wounds in the VHR/STE cohort. The increased rate of returning to the OR among VHR/STE patients was also likely associated with increased wound classes.
|Figure 1: Both the patients on the left (A) and the right (B) have excess abdominal soft tissue that warrants resection during hernia repair to mitigate the risk of tissue ischemia and seroma formation, in addition to providing a more cosmetic outcome|
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Hernia repair confers a large expense to the US healthcare system and may be performed at an overall net financial loss to a healthcare system. A previous study showed that VHR/PAN reduced healthcare costs compared with performing the operations separately. However, there was an associated increase in emergency room costs with the combined operation due to an increased incidence of wound and medical complications. Shubinets et al. showed that performing the two operations together led to an increase in cost, compared with performing a VHR alone, which was attributed to the greater length of stay and incidence of adverse events. The current study data showed an increase in costs across almost all aspects of care, including OR, floor, imaging, supplies, pharmacy, and ancillary service costs in the VHR/STE cohort. Increased costs associated with VHR/STE are most likely the result of increased complications and preoperative wound class as these factors have previously been shown to significantly increase costs after ventral and incisional hernia repair. On multivariate analysis controlling for COPD, dyspnea, wound class, and mesh type, the difference in costs was still significant. But after additionally controlling for hernia defect size, no significant difference in overall mean costs existed between the cohorts. Similarly, Hutchison et al. reported among matched cohorts that costs were higher among VHR patients compared with VHR/PAN patients but after multivariate regression no difference in costs was noted, and larger defect sizes were found to be associated with higher costs. This suggests that performing concomitant STE during VHR may be done at no additional cost to the healthcare system while also resulting in increased patient satisfaction.
Limitations of this study include an apparent selection bias due to the study’s retrospective nature. Soft tissue is often removed because the surgeon considers it a necessity due to redundancy of skin, tissue ischemia, or potential space reduction to reduce the chance of seroma formation. On gathering information from operative reports for this study, the indication for STE was not consistently stated, nor always obvious if it was planned prior to the procedure or an intraoperative decision to mitigate wound complications. Therefore, the results of this study are limited by selection bias as the primary surgeon most likely considered the additional procedure to be necessary within the VHR/STE while not so in the VHR alone group. Being a single institution study at a large academic medical center may also introduce another inherent selection bias based on referral patterns. Hernia recurrence was assessed with a telephone survey and not a more objective test such as CT imaging. Nevertheless, the survey used has a sensitivity of 85% and specificity of 81%, which is comparable to a physical exam. However, included in the survey are questions designed to assess for potential false positives, none of which were identified in our patient population. Also, we did not observe whether patients received closed incision negative pressure, which has been shown to augment outcomes in VHR/PAN patients.,
The small sample size of the study also limited our ability to determine the significance of several dependent variables. However, we limited our study to a 4-year period to limit the impact of changing techniques and practices that could create additional biases. Perhaps with increased sample size, some of the differences in complication rates and long-term outcomes may have reached significance. Large multi-center trials may ultimately be required to definitively answer the question as to the clinical benefits and costs associated with STE during VHR. The overall survey response rate of 38.5%, with 41.7% VHR alone patients and 28.8% VHR/STE patients responding, also limited the ability to fully understand long-term outcomes. Obesity, feasibly our most confounding variable in this study, could have potentially been controlled by a larger sample size, in addition to other variables such as COPD, wound class, and defect size. The surface area of soft tissue resection cutoff of greater than or equal to 250 cm2 as the inclusion criteria for VHR/STE in this study is rather arbitrary but was designated based on surgeon’s experience. Of course, skin excision is not just two-dimensional, and it is possible for someone with a smaller area of tissue removed to have more volume or mass removed as we did not have information regarding volume or weight of tissue removed. It would be interesting to compare outcomes of open-VHR after STE with a larger sample size to determine at what amount of STE an increase in complications may become significant.
It is important to note that our study differs from the current literature on the topic in several ways. First, it follows wound complication for 90 days from clinical charts as opposed to 30 days from NSQIP. It is our experience that wound complications can still occur after 30 days postoperation. By extending the window, we believe we have captured a better picture of the complications these patients face. Secondly, we are the first to compare pain scores and satisfaction. Thirdly, and perhaps most unique, we have not only compared VHR to VHR/PAN, but we are the first to look at the effects significant STE has on patients also undergoing open-VHR. We feel a significant patient population has been left out of the analysis in the current literature by just comparing VHR alone with VHR/PAN, and we encourage further studies to include STE.
| Conclusions|| |
STE during VHR can be performed without significant differences in overall complications or costs while increasing patients’ satisfaction. This study is unique in its attempt to evaluate the effects of STE after VHR and its comparison of patient satisfaction between the VHR alone and VHR/PAN. A prospective study is warranted to control for confounding factors and to investigate the effects of STE on hernia repair, in addition to other open abdominal surgeries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]