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El-Mallah JC, Greene AC, Clegg TJ, Shah SJ, El-Mallah SN, Vining CC, Dixon MEB, Peng JS. Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy. J Surg Oncol 2024; 129:869-875. [PMID: 38185838 DOI: 10.1002/jso.27574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND AND OBJECTIVES The accepted approach to pain management following open pancreatoduodenectomy (PD) remains controversial, with the most recent enhanced recovery after surgery (ERAS) protocols recommending epidural anesthesia (EA). Few studies have investigated intrathecal (IT) morphine, combined with transversus abdominis plane (TAP) blocks. We aim to compare the different approaches to pain management for open PD. METHODS Patients who underwent open PD at our institution from 2020 to 2022 were included in the study. Patient characteristics, pain management, and postoperative outcomes between EA, IT morphine with TAP blocks, and TAP blocks only were compared using univariate analysis. RESULTS Fifty patients were included in the study (58% male, median age 66 years [interquartile range, IQR: 58-73]). Most patients received IT morphine (N = 24, 48%) or EA (N = 18, 36%). The TAP block-only group required higher doses of postoperative narcotics while hospitalized (p = 0.004) and at discharge (p = 0.017). The IT morphine patients had a shorter median time to Foley removal (p = 0.007). Postoperative pain scores, non-opioid administration, postoperative bolus requirements, postoperative outcomes, and length of stay were similar between pain modalities. CONCLUSIONS IT morphine and EA showed comparable efficacy with superior results compared to TAP blocks alone. Integration of IT morphine into PD ERAS protocols should be considered.
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Affiliation(s)
- Jessica C El-Mallah
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Alicia C Greene
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Taylor J Clegg
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Sejal J Shah
- Department of Anesthesia, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Saif N El-Mallah
- Department of Anesthesia, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Charles C Vining
- Department of Surgery, Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Matthew E B Dixon
- Department of Surgery, Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Surgery, Division of Surgical Oncology, RUSH University Medical Center, Chicago, IIllinois, USA
| | - June S Peng
- Department of Surgery, Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Waldron OP, El-Mallah JC, Lochan D, Wen C, Landmesser ME, Asgardoon M, Dawes J, Horchler SN, Schlidt K, Agrawal S, Wang Y, Ravnic DJ. Ushering in the era of regenerative surgery. Minerva Surg 2024; 79:166-182. [PMID: 38088753 DOI: 10.23736/s2724-5691.23.10113-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Tissue loss, irrespective of etiology, often requires extensive reconstruction. In many instances, the need exceeds what current treatments and technologies modern medicine can offer. Tissue engineering has made immense strides within the past few decades due to advances in biologics, biomaterials, and manufacturing. The convergence of these three domains has created limitless potential for future surgical care. Unfortunately, there still exists a disconnect on how to best implant these 'replacement parts' and care for the patient. It is therefore vital to develop paradigms for the integration of advanced surgical and tissue engineering technologies. This paper explores the convergence between tissue engineering and reconstructive surgery. We will describe the clinical problem of tissue loss, discuss currently available solutions, address limitations, and propose processes for integrating surgery and tissue engineering, thereby ushering in the era of regenerative surgery.
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Affiliation(s)
- Olivia P Waldron
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
| | - Jessica C El-Mallah
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Dev Lochan
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
| | - Connie Wen
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, USA
| | - Mary E Landmesser
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mohammadhossein Asgardoon
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jazzmyn Dawes
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
| | - Summer N Horchler
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
| | - Kevin Schlidt
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
| | - Shailaja Agrawal
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Yong Wang
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, USA
| | - Dino J Ravnic
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA, USA -
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA, USA
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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Ataie Z, Horchler S, Jaberi A, Koduru SV, El-Mallah JC, Sun M, Kheirabadi S, Kedzierski A, Risbud A, Silva ARAE, Ravnic DJ, Sheikhi A. Accelerating Patterned Vascularization Using Granular Hydrogel Scaffolds and Surgical Micropuncture. Small 2024; 20:e2307928. [PMID: 37824280 DOI: 10.1002/smll.202307928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Indexed: 10/14/2023]
Abstract
Bulk hydrogel scaffolds are common in reconstructive surgery. They allow for the staged repair of soft tissue loss by providing a base for revascularization. Unfortunately, they are limited by both slow and random vascularization, which may manifest as treatment failure or suboptimal repair. Rapidly inducing patterned vascularization within biomaterials has profound translational implications for current clinical treatment paradigms and the scaleup of regenerative engineering platforms. To address this long-standing challenge, a novel microsurgical approach and granular hydrogel scaffold (GHS) technology are co-developed to hasten and pattern microvascular network formation. In surgical micropuncture (MP), targeted recipient blood vessels are perforated using a microneedle to accelerate cell extravasation and angiogenic outgrowth. By combining MP with an adjacent GHS with precisely tailored void space architecture, microvascular pattern formation as assessed by density, diameter, length, and intercapillary distance is rapidly guided. This work opens new translational opportunities for microvascular engineering, advancing reconstructive surgery, and regenerative medicine.
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Affiliation(s)
- Zaman Ataie
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Summer Horchler
- Division of Plastic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Arian Jaberi
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Srinivas V Koduru
- Division of Plastic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Jessica C El-Mallah
- Division of Plastic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Mingjie Sun
- Division of Plastic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Sina Kheirabadi
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Alexander Kedzierski
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Aneesh Risbud
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | | | - Dino J Ravnic
- Division of Plastic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
- Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Amir Sheikhi
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
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Horchler SN, Hancock PC, Sun M, Liu AT, Massand S, El-Mallah JC, Goldenberg D, Waldron O, Landmesser ME, Agrawal S, Koduru SV, Ravnic DJ. Vascular persistence following precision micropuncture. Microcirculation 2024; 31:e12835. [PMID: 37947797 PMCID: PMC10842157 DOI: 10.1111/micc.12835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/16/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The success of engineered tissues continues to be limited by time to vascularization and perfusion. Recently, we described a simple microsurgical approach, termed micropuncture (MP), which could be used to rapidly vascularize an adjacently placed scaffold from the recipient macrovasculature. Here we studied the long-term persistence of the MP-induced microvasculature. METHODS Segmental 60 μm diameter MPs were created in the recipient rat femoral artery and vein followed by coverage with a simple Type 1 collagen scaffold. The recipient vasculature and scaffold were then wrapped en bloc with a silicone sheet to isolate intrinsic vascularization. Scaffolds were harvested at 28 days post-implantation for detailed analysis, including using a novel artificial intelligence (AI) approach. RESULTS MP scaffolds demonstrated a sustained increase of vascular density compared to internal non-MP control scaffolds (p < 0.05) secondary to increases in both vessel diameters (p < 0.05) and branch counts (p < 0.05). MP scaffolds also demonstrated statistically significant increases in red blood cell (RBC) perfused lumens. CONCLUSIONS This study further highlights that the intrinsic MP-induced vasculature continues to persist long-term. Its combination of rapid and stable angiogenesis represents a novel surgical platform for engineered scaffold and graft perfusion.
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Affiliation(s)
- Summer N. Horchler
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
| | - Patrick C. Hancock
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
| | - Mingjie Sun
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Alexander T. Liu
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Sameer Massand
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jessica C. El-Mallah
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Dana Goldenberg
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
| | - Olivia Waldron
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
| | - Mary E. Landmesser
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Shailaja Agrawal
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Srinivas V. Koduru
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Cellular and Molecular Physiology, Penn State College of Medicine, Hershey, PA, USA
| | - Dino J. Ravnic
- Irvin S. Zubar Plastic Surgery Research Laboratory, Penn State College of Medicine, Hershey, PA
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA 16802
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