REINFORCEMENT SCAFFOLDS FOR MAINTAINING A REDUCED SIZE OF A STOMACH AND METHODS OF USE

Abstract

A method of performing bariatric surgery includes inserting a gastrectomy device into a stomach of a patient, positioning the gastrectomy device in a selected location in the stomach, transecting a portion of the stomach thereby reducing a size of the stomach, and applying a reinforcement scaffold to an outer surface of the stomach. The reinforcement scaffold is configured to maintain the reduced size of the stomach.

Claims

1-14. (canceled)

15. A method of performing bariatric surgery, comprising: transecting a portion of a stomach thereby reducing a size of the stomach; and wrapping at least one reinforcement scaffold about the stomach, wherein the at least one reinforcement scaffold includes a first longitudinal section that enshrouds a first semi-circumferential portion of the stomach, and a second longitudinal section that enshrouds a second semi-circumferential portion of the stomach.

16. The method according to claim 15, wherein the at least one reinforcement scaffold includes a first reinforcement scaffold and a second reinforcement scaffold, and wrapping the at least one reinforcement scaffold about the stomach includes: wrapping the first reinforcement scaffold semi-circumferentially about the stomach; and wrapping the second reinforcement scaffold semi-circumferentially about the stomach, such that the first and second reinforcement scaffolds together cover a circumference of the stomach.

17. The method according to claim 16, further comprising: attaching a first end of the second reinforcement scaffold to the transection line formed in the stomach; and attaching a second end of the second reinforcement scaffold to the portion of the stomach that is opposite to the transection line.

18. The method according to claim 16, wherein the first and second reinforcement scaffolds are configured to exhibit a different physical characteristic from one another.

19. The method according to claim 18, wherein the first reinforcement scaffold is more rigid than the second reinforcement scaffold.

20. The method according to claim 16, wherein the first reinforcement scaffold covers a posterior section of the stomach and the second reinforcement scaffold covers an anterior section of the stomach.

21. The method according to claim 15, wherein the first and second longitudinal sections are configured to exhibit a different physical characteristic from one another.

22. The method according to claim 15, wherein the first longitudinal section is more rigid than the second longitudinal section.

23. The method according to claim 15, wherein the first longitudinal section covers a posterior section of the stomach and the second longitudinal section covers an anterior section of the stomach.

24. The method according to claim 15, further comprising: attaching a first end of the at least one reinforcement scaffold to a transection line formed in the stomach; and attaching a second end of the at least one reinforcement scaffold to a portion of the stomach that is opposite to the transection line.

25. The method according to claim 15, further comprising at least one of suturing, gluing, or stapling the at least one reinforcement scaffold to the stomach.

26. The method according to claim 15, wherein the at least one reinforcement scaffold is fabricated from a material that substantially resists expansion.

27. The method according to claim 15, wherein transecting the portion of the stomach includes stapling the portion of the stomach.

28. The method according to claim 15, wherein reducing the size of the stomach includes forming the stomach into a tubular configuration.

29. The method according to claim 15, further comprising: inserting a gastrectomy device into a stomach of a patient; and positioning the gastrectomy device in a selected location in the stomach prior to transecting.

30. A method of performing bariatric surgery, comprising: transecting a portion of a stomach thereby reducing a size of the stomach; wrapping a first reinforcement scaffold about the stomach to cover a first semi-circumferential portion of the stomach; and wrapping a second reinforcement scaffold about the stomach to cover a second semi-circumferential portion of the stomach.

31. The method according to claim 30, wherein the first and second reinforcement scaffolds are configured to exhibit a different physical characteristic from one another.

32. The method according to claim 30, further comprising: attaching a first end of the first reinforcement scaffold to a transection line formed in the stomach; and attaching a second end of the first reinforcement scaffold to a portion of the stomach that is opposite to the transection line.

33. The method according to claim 31, further comprising: attaching a first end of the second reinforcement scaffold to the transection line formed in the stomach; and attaching a second end of the second reinforcement scaffold to the portion of the stomach that is opposite to the transection line.

34. The method according to claim 30, wherein the first and second reinforcement scaffolds are fabricated from a material that substantially resists expansion.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

[0022] The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the disclosure and, together with a general description of the disclosure given above, and the detailed description of the embodiment(s) given below, serve to explain the principles of the disclosure, wherein:

[0023] FIG. 1 is a front view of an illustrative embodiment of a surgical system including a reinforcement scaffold, and a gastrectomy device being navigated through an enteral pathway of a patient into a stomach of a patient in accordance with the principles of the present disclosure;

[0024] FIG. 2 is a cross sectional view of a transected stomach having the gastrectomy device of FIG. 1 disposed therein;

[0025] FIG. 3A is a perspective view of the reinforcement scaffold of FIG. 1 wrapped about a portion of a stomach after a sleeve gastrectomy procedure;

[0026] FIG. 3B is an end cross-sectional view, taken along line 3B-2B of FIG. 3A, of the reinforcement scaffold wrapped around the stomach;

[0027] FIG. 4A is a perspective view of a pair of reinforcement scaffolds wrapped about a portion of a stomach after a sleeve gastrectomy procedure; and

[0028] FIG. 4B is an end cross-sectional view, taken along line 4B-4B of FIG. 4A, of the reinforcement scaffolds wrapped around the stomach.

DETAILED DESCRIPTION

[0029] As used herein, the term clinician refers to a doctor, nurse, or other care provider and may include support personnel. The terms proximal or trailing each refer to the portion of a structure closer to a clinician, and the terms distal or leading each refer to a portion of a structure farther from the clinician.

[0030] With reference to FIG. 1, a system 1 for performing bariatric procedures is provided and generally includes a gastrectomy device 100 for reducing a size of a patient's stomach, and a reinforcement scaffold 200 (see also FIG. 3A) to maintain or substantially maintain the reduced size of the patient's stomach. Gastrectomy device 100 includes an elongate tube 110 and a movable component, such as, for example, a sail member 140 supported on or within elongate tube 110. In use, as described in further detail below, gastrectomy device 100 is inserted into an oral cavity (e.g., a mouth M) of a patient and is advanced distally (i.e., caudally) along an enteral pathway EP that includes a track that extends between oral cavity M and a stomach ST of the patient. Gastrectomy device 100 is positioned in a selected location within the stomach ST and a portion of the stomach ST is transected to reduce the size of the stomach ST. After the stomach ST is reduced in size, reinforcement scaffold 200 (FIG. 3A) is applied to stomach ST to maintain the reduced size of the patient's stomach ST, as will be described in detail below.

[0031] With continued reference to FIG. 1, elongate tube 110 of gastrectomy device 100 can be formed of any material with sufficient flexibility to enable elongate tube 110 to maneuver along the patient's track or enteral pathway EP between the oral cavity M and the stomach ST. Elongate tube 110 includes a trailing end or proximal end 110a and a leading end or distal end 110b. Elongate tube 110 extends between the proximal and distal ends 110a, 110b. It is contemplated that elongate tube 110 can be curved along its length, linear, or any shape suitable for a particular bariatric surgical procedure. Elongate tube 110 defines a channel 116 extending along and through the length of elongate tube 110. Elongate tube 110 further includes a series of openings or apertures 128 extending between an outer surface and an inner surface of elongate tube 110. Apertures 128 provide for fluid communication between channel 116 and an environment exterior to elongate tube 110. When suction is applied to elongate tube 110 from a vacuum source VS, elongate tube 110 can adhere to tissue, such as, for example, stomach tissue, due to the plurality of openings 128 directing suction towards stomach tissue.

[0032] Proximal end portion 110a of elongate tube 110 has an opening 117 configured for connection with vacuum source VS. Distal end 110b of elongate tube includes a distal tip 112. Distal tip 112 has a blunt, arcuate outer surface such that advancement of elongate tube 110 through internal body cavities of a patient allows the elongate tube 110 to follow the track of the body cavities while inhibiting penetration by the distal tip 112 (i.e., distal tip 112 is configured for atraumatic insertion). In some embodiments, distal tip 112 can be variously configured, such as, for example, oval, oblong, tapered, uniform, non-uniform, smooth, polished, and/or rounded.

[0033] Sail member 140 of gastrectomy device 100 is formed from a semi-rigid, resiliently flexible material, e.g., a suitable elastomer, and may be in the form of a rod. Sail member 140 defines a length greater than the length of elongate tube 110 such that sail member 140 can be accessed outside the patient and/or remotely of the surgical site. Sail member 140 is supported on elongate tube 110. Distal movement of sail member 140 causes a distal portion of sail member 140 to expand or bow outwardly relative to elongate tube 110.

[0034] Further details regarding gastrectomy device 100 and alternate embodiments thereof can be found in U.S. Pat. No. 9,801,748, filed on Oct. 23, 2014, U.S. Pat. No. 9,414,947, filed on May 13, 2014, and U.S. patent application Ser. No. Error! Unknown document property name., filed on May 13, 2014 (now U.S. Patent Application Publication No. 2015/0328031, the entire contents of each of which being incorporated by reference herein.

[0035] With reference to FIGS. 3A and 3B, as mentioned above, in addition to gastrectomy device 100, system 1 further includes a reinforcement scaffold 200 used to maintain a reduced size of a stomach, as will be described in detail below. Reinforcement scaffold 200 may be in the form of a surgical buttress, a mesh, or the like, and fabricated from a material that substantially resists stretching/expanding under applied tension. Reinforcement scaffold 200 may be made from any suitable biocompatible natural or synthetic material. The material from which reinforcement scaffold 200 is formed may be bioabsorbable or non-bioabsorbable. It should of course be understood that any combination of natural, synthetic, bioabsorbable, and non-bioabsorbable materials may be used to form reinforcement scaffold 200.

[0036] Some non-limiting examples of materials from which reinforcement scaffold 200 may be made include, but are not limited to, metals, poly(lactic acid), poly (glycolic acid), poly (hydroxybutyrate), poly (phosphazine), polyesters, polyethylene glycols, polyethylene oxides, polyacrylamides, polyhydroxyethylmethylacrylate, polyvinylpyrrolidone, polyvinyl alcohols, polyacrylic acid, polyacetate, polycaprolactone, polypropylene, aliphatic polyesters, glycerols, poly(amino acids), copoly (ether-esters), polyalkylene oxalates, polyamides, poly (iminocarbonates), polyalkylene oxalates, polyoxaesters, polyorthoesters, polyphosphazenes and copolymers, block copolymers, homopolymers, blends and combinations thereof.

[0037] In embodiments, natural biological polymers may be used in forming reinforcement scaffold 200. Suitable natural biological polymers include, but are not limited to, collagen, gelatin, fibrin, fibrinogen, elastin, keratin, albumin, hydroxyethyl cellulose, cellulose, hydroxypropyl cellulose, carboxyethyl cellulose, chitan, chitosan, and combinations thereof. In addition, the natural biological polymers may be combined with any of the other polymeric materials described herein to produce reinforcement scaffold 200.

[0038] Reinforcement scaffold 200 may be porous or non-porous, or combinations of porous and non-porous layers. Where reinforcement scaffold 200 is non-porous, reinforcement scaffold 200 may retard or prevent tissue ingrowth from surrounding tissues thereby acting as an adhesion barrier and preventing the formation of unwanted scar tissue. Thus, in embodiments, reinforcement scaffold 200 possesses anti-adhesion properties. Techniques for forming non-porous layers from such materials are within the purview of those skilled in the art and include, for example, casting, molding, and the like.

[0039] In embodiments, reinforcement scaffold 200 is porous and possesses hemostatic properties. Where reinforcement scaffold 200 is porous, it has openings or pores over at least a portion of a surface thereof. Suitable materials for forming the porous layer include, but are not limited to foams (e.g., open or closed cell foams). In embodiments, the pores may be in sufficient number and size so as to interconnect across the entire thickness of the porous layer. In other embodiments, the pores do not interconnect across the entire thickness of the porous layer. In yet other embodiments, the pores do not extend across the entire thickness of the porous layer, but rather are present at a portion of the surface thereof. In embodiments, the openings or pores are located on a portion of the surface of the porous layer, with other portions of the porous layer having a non-porous texture. Those skilled in the art reading the present disclosure will envision other pore distribution patterns and configurations for the porous layer.

[0040] Where reinforcement scaffold 200 is porous, the pores may be formed using any method suitable to forming a foam or sponge including, but not limited to the lyophilization or freeze-drying of a composition. Suitable techniques for making foams are within the purview of those skilled in the art. Porous reinforcement scaffold 200 can be at least 0.2 cm thick and is contemplated to be within a range of from about 0.3 to about 1.5 cm thick. Porous reinforcement scaffold 200 can have a density of not more than about 75 mg/cm.sup.2 and, in embodiments below about 20 mg/cm.sup.2. The size of the pores in the porous reinforcement scaffold 200 can be from about 20 m to about 300 m, in embodiments from about 100 m to about 200 m.

[0041] Reinforcement scaffold 200 may also include a reinforcement member (not explicitly shown). The reinforcement member may be associated with a porous or non-porous layer or may be positioned between a non-porous layer and a porous layer of reinforcement scaffold 200. Alternately, the reinforcement member may be positioned entirely within one or more of the individual layers (i.e., embedded within the porous layer, the non-porous layer, or both) of reinforcement scaffold 200. It is also envisioned that the reinforcement member may be positioned at the surface of one of the layers making up reinforcement scaffold 200 and, in embodiments, may be positioned at an exterior surface of reinforcement scaffold 200.

[0042] Some suitable non-limiting examples of reinforcement members include fabrics, meshes, monofilaments, multifilament braids, chopped fibers (sometimes referred to in the art as staple fibers) and combinations thereof. Where the reinforcement member is a mesh, it may be prepared using any technique known to those skilled in the art, such as knitting, weaving, tatting, knipling or the like. Where monofilaments or multifilament braids are used as the reinforcement member, the monofilaments or multifilament braids may be oriented in any desired manner. For example, the monofilaments or multifilament braids may be randomly positioned with respect to each other within reinforcement scaffold 200. As another example, the monofilaments or multifilament braids may be oriented in a common direction within reinforcement scaffold 200. Where chopped fibers are used as the reinforcement member, the chopped fibers may be oriented in any desired manner. For example, the chopped fibers may be randomly oriented or may be oriented in a common direction. The chopped fibers can thus form a non-woven material, such as a mat or a felt. The chopped fibers may be of any suitable length. For example, the chopped may be from 0.1 mm to 100 mm in length, in embodiments, 0.4 mm to 50 mm in length.

[0043] It is envisioned that the reinforcement member of reinforcement scaffold 200 may be formed from any bioabsorbable, non-bioabsorbable, natural, or synthetic material previously described herein and combinations thereof. Where monofilaments or multifilament braids are used as the reinforcement member, any commercially available suture material may advantageously be employed as the reinforcement member.

[0044] In embodiments, at least one bioactive agent may be combined with reinforcement scaffold 200 and/or any of the individual components (the porous layer, the non-porous layer and/or the reinforcement member) used to construct reinforcement scaffold 200. In these embodiments, reinforcement scaffold 200 can also serve as a vehicle for delivery of the bioactive agent. The term bioactive agent, as used herein, is used in its broadest sense and includes any substance or mixture of substances that have clinical use, for example, biocidal agents, antimicrobial agents, antibiotics, anti-proliferatives, medicaments, growth factors, anti-clotting agents, clotting agents, analgesics, anesthetics, anti-inflammatory agents, wound repair agents, chemotherapeutics, biologics, protein therapeutics, monoclonal and polyclonal antibodies, DNA, RNA, peptides, polysaccharides, lectins, lipids, probiotics, diagnostic agents, angiogenics, anti-angiogenic drugs, polymeric drugs, and combinations thereof.

[0045] With reference to FIG. 1, in operation, gastrectomy device 100 is inserted into a patient, such as, for example, an oral cavity M of a patient and is distally advanced toward a stomach ST of the patient along an enteral pathway EP that extends from the oral cavity M, through an esophagus of the patient, and into the stomach ST. Gastrectomy device 100 is further guided through the esophagus and positioned in a selected location in the stomach ST of the patient.

[0046] Upon positioning gastrectomy device 100 within the selected location in the stomach ST, sail member 140 is translated distally to bow outwardly relative to elongate tube 110 towards the expanded position (not shown). As sail member 140 bows outwardly towards the expanded position, elongate tube 110 is urged towards and into complementary mating relation with a lesser curvature portion C1 of the stomach ST, while sail member 140 is urged towards and into complementary mating relation with a greater curvature portion C2 of the stomach ST. As such, the orientation of gastrectomy device 100 with elongate tube 110 extending along the lesser curvature portion C1 of the stomach ST between the esophageal sphincter E and the pyloric sphincter P can be readily achieved. As a result of this configuration of gastrectomy device 100 in the expanded position, the above-described orientation of gastrectomy device 100 within the stomach ST is maintained despite spasms, folding, spiraling, and/or shifting of the stomach ST.

[0047] Once the proper orientation of gastrectomy device 100 has been achieved, suction is applied, by vacuum source VS, within channel 116 for suctioning any remaining contents within the stomach ST into channel 116 of elongate tube 110 through apertures 128. Application of suction within channel 116 also suctions the lesser curvature portion C1 of the stomach ST to outer surface or periphery of elongate tube 110, to ensure and maintain the complementary mating relation of elongate tube 110 with the lesser curvature portion C1 of the stomach ST.

[0048] With elongate tube 110 maintained in position relative to the lesser curvature portion C1 of the stomach ST as a result of the applied suction, sail member 140 may be translated proximally relative to elongate tube 110 such that sail member 140 is pulled inwardly relative to elongate tube 110. As suction is maintained at this point, elongate tube 110 is maintained in the position detailed above despite contraction of sail member 140.

[0049] With additional reference to FIG. 2, once sail member 140 has been returned to the unexpanded position, transection of the stomach ST adjacent elongate tube 110 on an opposite side of elongate tube 110 relative to the lesser curvature portion C1 of the stomach ST may be effected. In particular, one or more small incisions are created in the abdomen of the patient for receiving instruments therein to perform the transection procedure. Access ports, such as, for example, cannulae (not shown) are inserted into the small incisions made in the abdomen to maintain the small incisions open. A surgical tool, for example, a surgical stapler (not shown), is inserted into the patient through the cannula and used to transect the stomach ST. Transecting the stomach ST separates the stomach ST into a resected portion R and a new stomach portion SN. It is contemplated that any number of open or laparoscopic stomach resection techniques/devices may be used including surgical staplers, vessel sealing devices, suturing, scalpels, etc.

[0050] Transection in this manner reduces a size of the stomach ST (i.e., the overall internal volume of stomach ST is reduced from its normal, pre-transection volume) and reforms the shape of the stomach ST to assume a tubular configuration that generally approximates the outer dimension of elongate tube 110 and extends between the esophageal sphincter E and the pyloric sphincter P. As can be appreciated, the diameter of elongate tube 110 may be selected in accordance with a desired diameter of the tubular-shape reformed stomach ST. The resected portion R can be grasped by a separate forceps F and removed. Gastrectomy device 100 may then be removed from the stomach ST of patient.

[0051] With reference to FIGS. 3A and 3B, after stomach ST has been reduced in size by, for example, the method described above, reinforcement scaffold 200 may then be applied to the outer surface of stomach ST. Reinforcement scaffold 200 is cut to a suitable length that approximates the circumference of the reduced size stomach ST. In some embodiments, a plurality of variously sized reinforcement scaffolds are provided and the appropriately sized reinforcement scaffold is selected by a clinician. Reinforcement scaffold 200 is grasped by a surgical tool (not shown) and inserted into the patient through one of the cannulae. It is contemplated that an additional surgical tool is inserted through another one of the cannulae to assist in manipulating reinforcement scaffold 200 within the surgical site. A needle (not shown) having a suture (not shown) attached thereto may also be inserted laparoscopically into the surgical site.

[0052] Once reinforcement scaffold 200 is within the surgical site, to attach reinforcement scaffold 200 to stomach ST, a first end 202a of reinforcement scaffold 200 is attached to a transection line T formed in stomach ST (i.e., the portion of stomach ST at which the transection was performed) via suturing. In some embodiments, first end 202a of reinforcement scaffold 200 may be attached to any portion of stomach ST rather than transection line T. In some embodiments, first end 202a of reinforcement scaffold 200 may be attached to transection line T by a variety of fastening mechanisms other than or in addition to suturing, such as, for example, stapling, gluing, or a fastening member, for example, a toothed clip.

[0053] With first end 202a of reinforcement scaffold 200 attached to transection line T, a second end 202b of reinforcement scaffold 200 may be wrapped around the outer surface or periphery OS of stomach ST such that reinforcement scaffold 200 forms a sleeve about the stomach ST. Wrapping of reinforcement scaffold 200 about stomach ST is continued until reinforcement scaffold 200 engages and enshrouds the outer surface OS of stomach ST. Second end 202b of reinforcement scaffold 200 is then attached to transection line T such that reinforcement scaffold 200 assumes the shape and size of the reduced size stomach ST. In some embodiments, first and second ends 202a, 202b of reinforcement scaffold 200 overlap one another at transection line T. It is further contemplated that reinforcement scaffold 200 may be wrapped about stomach ST more than once.

[0054] With reinforcement scaffold 200 wrapped about and secured to stomach ST, reinforcement scaffold 200 resists and/or prevents stomach ST from dilating from the reduced size achieved during the sleeve gastrectomy procedure. As such, if the patient consumes a greater volume of food than which the reduced internal volume of stomach ST can hold, reinforcement scaffold 200 will substantially maintain stomach ST at its reduced size. In some embodiments, reinforcement scaffold 200 may be fabricated from a material having a threshold amount of pliability to allow stomach ST to dilate a selected amount.

[0055] With reference to FIGS. 4A and 4B, another method of reinforcing the reduced size stomach is disclosed. The method is similar to the method described above, and therefore will only be described with respect to its difference(s). The method differs from the method described above in the manner in which a reinforcement scaffold is applied to stomach ST.

[0056] In particular, instead of applying only one reinforcement scaffold, a first reinforcement scaffold 300 and a second reinforcement scaffold 310 are provided, each being similar to reinforcement scaffold 200 described above. Reinforcement scaffolds 300, 310 are each configured to be applied to stomach ST after stomach ST has been reduced in size by a sleeve gastrectomy procedure, for example, the procedure described above.

[0057] In use, a first end 302a of first reinforcement scaffold 300 is attached to transection line T formed in stomach ST. With first end 302a of first reinforcement scaffold 300 attached to transection line T, a second end 302b of first reinforcement scaffold 300 may be wrapped around the outer surface of a first longitudinal section A of stomach ST, for example, a posterior section of stomach ST. Wrapping of first reinforcement scaffold 300 about stomach ST is continued until reinforcement scaffold 300 engages and enshrouds the outer surface of first longitudinal section A of stomach ST. Second end 302b of first reinforcement scaffold 300 is then attached to a portion C of stomach ST that is opposite to transection line T such that first reinforcement scaffold 300 assumes the shape and size of the first longitudinal section A of stomach ST and adheres thereto.

[0058] With first reinforcement scaffold 300 attached to stomach ST, second reinforcement scaffold 310 is then applied to stomach ST. In particular, a first end 312a of second reinforcement scaffold 310 is attached to transection line T and a second end 312b of second reinforcement scaffold 310 is wrapped around the outer surface of second longitudinal section B of stomach ST, for example, an anterior section of stomach ST. Wrapping of second reinforcement scaffold 310 about stomach ST is continued until second reinforcement scaffold 310 engages and enshrouds the outer surface of second longitudinal section B of stomach ST. Second end 312b of second reinforcement scaffold 310 is then attached to the portion C of stomach ST that is opposite to transection line T such that second reinforcement scaffold 310 assumes the shape and size of the second longitudinal section B of stomach ST and adheres thereto. As such, an entire circumference of stomach ST is covered by first and second reinforcement scaffolds 300, 310 to maintain stomach ST in its reduced size state.

[0059] It is contemplated that first ends 302a, 312a of first reinforcement scaffold or member 300 and second reinforcement scaffold or member 310, respectively, and second ends 302b, 312b of first reinforcement scaffold 300 and second reinforcement scaffold 310, respectively, may overlap one another. In some embodiments, more than two reinforcement scaffolds may be wrapped around and attached to stomach ST to maintain stomach ST in its reduced size state.

[0060] It is further contemplated that first reinforcement scaffold 300 and second reinforcement scaffold 310 may be fabricated to exhibit different physical and/or chemical characteristics from one another so that together they provide certain desirable characteristics. For example, first reinforcement scaffold 300 may be more rigid than second reinforcement scaffold 310 such that second longitudinal section B of stomach ST may be allowed to expand more than first longitudinal section A of stomach ST. In some embodiments, reinforcement scaffolds 300, 310 may be cut from a roll of reinforcement scaffold.

[0061] Persons skilled in the art will understand that the structures and methods specifically described herein and shown in the accompanying figures are non-limiting exemplary embodiments, and that the description, disclosure, and figures should be construed merely as exemplary of particular embodiments. It is to be understood, therefore, that the present disclosure is not limited to the precise embodiments described herein, and that various other changes and modifications may be effected by one skilled in the art without departing from the scope or spirit of the disclosure. Additionally, the elements and features shown or described in connection with certain embodiments may be combined with the elements and features of certain other embodiments without departing from the scope of the present disclosure, and that such modifications and variations are also included within the scope of the present disclosure. Accordingly, the subject matter of the present disclosure is not limited by what has been particularly shown and described.