Department of Surgery

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153. Quantification of Lymphangiogenesis in Murine Lymphedema Tail Model Using Intravital Microscopy
(Wolters Kluwer, 2023-05-19) Mohan, Ganesh; Khan, Imran; Diaz, Stephanie M.; Neumann, Colby R.; Jorge, Miguel D.; Sinha, Mithun; Gordillo, Gayle M.; Sen, Chandan K.; Hassanein, Aladdin H.; Surgery, School of Medicine
PURPOSE: Lymphedema is limb swelling caused by lymphatic dysfunction. It occurs in 30% of patients that undergo axillary lymph node dissection in the treatment of breast cancer. There is no cure for this disease. Understanding the mechanisms of lymphatic growth will play a pivotal role in developing therapeutic strategies against these conditions. Visualization of lymphangiogenesis and functional assessment remains a challenge. Intravital two-photon microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous non-viral vector gene delivery using a chip with nanochannel poration in a rapid (<100ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics. METHODS: The murine tail model of lymphedema was utilized. A 3 mm full thickness skin excision and lymphatic vessel disruption was performed 20 mm from the base of the tail in twelve C57BL/6 mice. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: Group I (control) was given pCMV6 (expression vector backbone alone) (n=6); Group II had pCMV6-Prox1 (n=6). Post-TNT (day 10), a 3 cm segment of murine tail was deskinned distal to the site of occlusion to optimize visualization. FITC-Dextran (2000 kD) injected intradermally at the distal tail region for lymphatic uptake. Lymphatic vessels are visualized at the second skin excision site with the Leica SP8 Confocal/Multiphoton Microscope and assessed for number of branching points to determine the newly formed lymphatics. Lymphatic vessel density was also observed by immunostaining with anti-Podoplanin antibody. RESULTS: The experimental group II exhibited increased branching points (3-fold) using filamentation analysis compared to control group I at the site of TNT treatment (n=6, p<0.05). Increased lymphatic vessel density was also observed with Podoplanin immunostaining post-TNT application. Intensity quantification of immunohistochemistry revealed greater expression of Podoplanin in Group II when compared to Group I (n=6, p<0.05). CONCLUSION: This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. Intravital microscopy can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.
177. Prophylactic Absorbable Antibiotic Beads For High Risk Implant-based Reconstruction: A Single Institution Pilot Study
(Wolters Kluwer, 2023-05-19) Ahmed, Shahnur; Lee, Jason T. C.; Roth, Dylan D.; Liu, Steven; Fisher, Carla S.; Fan, Betty; Imeokparia, Folasade; Ludwig, Kandice; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of Medicine
PURPOSE: Infections are problematic in implant-based reconstruction after mastectomies. Infection rates have been reported to be as high as 31%. Strategies to reduce the risk of infection include various antibiotic irrigation solutions, “no-touch” techniques, optimizing sterility, and empiric antibiotic use for skin flora coverage. Absorbable antibiotic beads have been well described for other indications, including orthopedic and pressure sore reconstruction. The purpose of this study is to evaluate the use of prophylactic biodegradable antibiotic beads during pre-pectoral and sub-pectoral implant-based breast reconstruction following mastectomy. METHODS: A single-center retrospective review of patients who underwent implant-based breast reconstruction post-mastectomy between 2019 to 2022. Patients were divided into two groups: Group I were deemed “high risk” by the senior author and received biodegradable antibiotic beads (1 gram vancomycin, 240 mg gentamicin) during tissue expander or implant reconstruction (pre-pectoral or subpectoral) while Group II (control) had no antibiotic beads. Demographic data, diabetes, body mass index (BMI), implant plane (pre-pectoral or sub-pectoral), smoking and use of mesh were recorded. Outcome variables included postoperative cellulitis or infection requiring oral or intravenous antibiotics and tissue expander loss at 90 days. RESULTS: In our study period, 19 patients (36 total implants/expanders) received biodegradable antibiotic beads during implant-based breast reconstruction (Group I). There were 174 patients (290 total expanders) who did not receive antibiotic beads (Group II). Patients in Group I had a history of previous expander/implant infection in 73.6%. Pre-pectoral placement of implants occurred in 84.2% of patients in Group I and 74.1% in Group II. Diabetes was prevalent in 15.8% of Group I compared to 5.7% seen in Group II patients. The mean BMI in Group I was 30.5 kg/m2 compared to 27.8 kg/m2 in Group II (p-value 0.88). Implant infection rate of Group I at 90 days was 8.3% (3/36 total expanders) compared to 8.6% (25/290 total expanders) in Group II. Implant loss in Group I was 5.5% (2/26 total expanders) compared to 7.6% (22/290) in Group II. CONCLUSION: The incidence of infection in high risk patients who have absorbable antibiotic beads placed during the time of reconstruction appears to be normalized to the control group in this pilot study, suggesting that absorbable antibiotic beads may decrease postoperative infection complications. Future studies may further clarify its benefit in selected groups.
1H NMR-Based Metabolic Signatures in the Liver and Brain in a Rat Model of Hepatic Encephalopathy
(ACS, 2020) Pathania, Anjana; Rawat, Atul; Dahiya, Sitender Singh; Dhanda, Saurabh; Barnwal, Ravi Pratap; Baishya, Bikash; Sandhir, Rajat; Surgery, School of Medicine
Hepatic encephalopathy (HE) is a debilitating neuropsychiatric complication associated with acute and chronic liver failure. It is characterized by diverse symptoms with variable severity that includes cognitive and motor deficits. The aim of the study is to assess metabolic alterations in the brain and liver using nuclear magnetic resonance (NMR) spectroscopy and subsequent multivariate analyses to characterize metabolic signatures associated with HE. HE was developed by bile duct ligation (BDL) that resulted in hepatic dysfunctions and cirrhosis as shown by liver function tests. Metabolic profiles from control and BDL rats indicated increased levels of lactate, branched-chain amino acids (BCAAs), glutamate, and choline in the liver, whereas levels of glucose, phenylalanine, and pyridoxine were decreased. In brain, the levels of lactate, acetate, succinate, citrate, and malate were increased, while glucose, creatine, isoleucine, leucine, and proline levels were decreased. Furthermore, neurotransmitters such as glutamate and GABA were increased, whereas choline and myo-inositol were decreased. The alterations in neurotransmitter levels resulted in cognitive and motor defects in BDL rats. A significant correlation was found among alterations in NAA/choline, choline/creatine, and NAA/creatine with behavioral deficits. Thus, the data suggests impairment in metabolic pathways such as the tricarboxylic acid (TCA) cycle, glycolysis, and ketogenesis in the liver and brain of animals with HE. The study highlights that metabolic signatures could be potential markers to monitor HE progression and to assess therapeutic interventions.
A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection
(Elsevier, 2019) Manghelli, Joshua L.; Carter, Daniel I.; Khiabani, Ali J.; Gauthier, Jason M.; Moon, Marc R.; Munfakh, Nabil A.; Damiano, Ralph J.; Corvera, Joel S.; Melby, Spencer J.; Surgery, School of Medicine
Objective Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection. Methods Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms. Results Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001). Conclusions Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.
2020 Women in Thoracic Surgery update on the status of women in cardiothoracic surgery
(Elsevier, 2020) Ceppa, DuyKhanh P.; Antonoff, Mara B.; Tong, Betty C.; Timsina, Lava; Ikonomidis, John S.; Worrell, Stephanie G.; Stephens, Elizabeth H.; Gillaspie, Erin A.; Schumacher, Lana; Molena, Daniela; Kane, Lauren C.; Blackmon, Shanda; Donington, Jessica S.; Surgery, School of Medicine
Background Women in Thoracic Surgery (WTS) has previously reported on the status of women in cardiothoracic (CT) surgery. We sought to provide a 10-year update on women in CT. Methods An anonymous REDCap survey link was emailed to female diplomats of the ABTS. Survey questions queried respondents regarding demographics, training, accolades, practice details, and career satisfaction. The survey link was open for 30 days. Results were compared to the 2019 Society of Thoracic Surgeons work force survey. Descriptive analyses were performed using frequency and proportions. Comparisons were performed using Student’s t-tests, Fisher exact and chi-squared tests. Results Of 354 female diplomats, 309 were contacted and 176 (57%) responded. The majority of respondents were age 36-50 (59%), Caucasian (67.4%), and graduated from traditional-track programs (91.4%). Most respondents reported practicing in an urban (64%) and academic setting (73.1%). 36.4% and 23.9% reported a general thoracic and adult cardiac practice (22.7% mixed practice, 9.6% congenital). Fifty percent of respondents reported salaries between $400,000-700,000 annually; 37.7% reported salaries <90% of their male colleagues. 21.6% of respondents in academia are full professor; 53.4% report having a leadership role. While 74.1% would pursue a career in CT again, only 27.3% agreed that CT surgery is a healthy and positive environment for women. Conclusions The number of women in CT surgery has steadily increased. While women are rising in academic rank and into leadership positions, salary disparities and the CT surgery work environment remain important issues in achieving a diverse work force.
23rd Annual Meeting of the American Society of Breast Surgeons: Back to In-Person Scientific Exploration
(Springer, 2022) Fisher, Carla S.; Teshome, Mediget; Blair, Sarah L.; Surgery, School of Medicine
24-Month results of the BRAVO study: A prospective, multi-center study evaluating the clinical outcomes of a ventral hernia cohort treated with OviTex® 1S permanent reinforced tissue matrix
(Elsevier, 2022-09-27) DeNoto, George, III.; Ceppa, Eugene P.; Pacella, Salvatore J.; Sawyer, Michael; Slayden, Geoffrey; Takata, Mark; Tuma, Gary; Yunis, Jonathan; Surgery, School of Medicine
Background: This study evaluated the performance of OviTex® 1S (TELA Bio Inc., Malvern, PA, USA) over 24 months when used for ventral hernia repair. Methods: This was a prospective, single-arm, multi-center clinical trial (ClinicalTrials.gov/NCT03074474). A ninety-two patient cohort with ventral hernias were enrolled. The surgical approach (open, laparoscopic, or robotic) and plane of placement (retrorectus, intraperitoneal, or pre-peritoneal) were at the discretion of the surgeon. Patients were characterized as high risk for a surgical site occurrence (SSO) based on the following comorbidities: BMI between 30 and 40, active smoker, chronic obstructive pulmonary disease (COPD), diabetes mellitus, coronary artery disease, advanced age ( ≥ 75 years). Subjects underwent physical examinations to evaluate safety events and completed quality of life surveys at 1 months, 3 months, 12 months, and 24 months post-surgery. Results: Sixty-five of the 92 enrolled patients (70.7%) completed 24-month follow-up. The Kaplan Meier estimate for risk of recurrence at day 730 (24 months) was 2.6%; among subjects who completed their 24-month visit or had a previous recurrence, the unadjusted rate of recurrence was 4.5% (3/66). SSOs were observed in 38.0% of patients (35/92). The most prevalent SSO was surgical site infection occurring in 20.7% (19/92) of patients, followed by seroma formation, which occurred in 13.0% of patients; however, only 3.3% required intervention. HerQLes and EQ-5D assessments showed improvement from baseline as soon as 3 months post-surgery. Continued improvement was observed through 24 months. Conclusions: Overall the BRAVO study demonstrates that use of the ovine reinforced tissue matrix OviTex 1S is a viable option for use in ventral hernia repair. Additional studies with longer term follow-up data are needed to draw definitive conclusions on the use of OviTex 1S.
571 Effectiveness of Compression Garments with Silicone versus Compression Garments Alone on Hypertrophic Scar
(Oxford University Press, 2023-05-15) Robertson, Karen; Wang, David; Tran, Khoa; Yun, EJun; Stevens, Katelyn; Hartman, Brett; Surgery, School of Medicine
Introduction: Only a few studies have looked at the effects of custom compression garments with silicone sheeting sewn into the garments versus garments alone on scar management. This retrospective study hypothesizes that garments with silicone will improve the Modified Vancouver Scar Scale (mVSS) total scores and sub-scores of pliability, vascularity and height of hypertrophic scars(HTS) when compared to garments alone. Methods: This is a retrospective study of patients that were autografted or required >21 days to heal and placed in compression garments with or without silicone between 2013 and 2020. Charts were reviewed and mVSS scores from 91 patients with 191 scar locations (134 silicone/57 non-silicone) were collected at 1,3,6,9,12 months. Descriptive statistics were used to describe the sample characteristics. The mean mVSS score and mean sub-scores for pliability, height and vascularity were computed at 1,3,6,9,12 months and reported for the silicone and non-silicone groups. Results: When comparing the two groups at 9-months (with 45% of initial scars scored), the silicone group had a greater decrease in numerical value and overall % change from 1 to 9-months as compared to the non-silicone group in all areas. The results at 12-months (with 30% of initial scars scored) demonstrated the non-silicone group had a greater decrease in numerical value and % change in height and overall score. Pliability had a 25% improvement in silicone group compared to 16% change in non-silicone group. Vascularity % change was similar with a 47% change in non-silicone group and 46% change in silicone group. The scars in silicone group that were analyzed at 12-months were consistently scored higher across prior months.  Conclusions: Silicone group demonstrated improved %change in all categories at 9-months and in pliability %change at 12-months despite the decreased sample size. Pliability is improved with the use of silicone garments. Although the 12-month %change in mean for height, vascularity and total score did not show improvement over non-silicone, this reflects the return patients having significant scarring throughout treatment and needing continued interventions. These returning patients had scars in the non-silicone group as well that were also rated resulting in the disparity in the groups. The patients in the silicone group with improved scars did not continue follow-up at 12-months. Further research with focus on 9-18 month follow-up mVSS scores is warranted. Applicability of Research to Practice: Effectiveness of adding silicone to garments in scar treatment.
A follow-up on quantitative and qualitative olfactory dysfunction and other symptoms in patients recovering from COVID-19 smell loss
(ERS, 2022-06-01) Ohla, Kathrin; Veldhuizen, Maria G.; Green, Tomer; Hannum, Mackenzie E.; Bakke, Alyssa J.; Moein, Shima T.; Tognetti, Arnaud; Postma, Elbrich M.; Pellegrino, Robert; Hwang, Daniel Liang-Dar; Albayay, Javier; Koyama, Sachiko; Nolden, Alissa A.; Thomas-Danguin, Thierry; Mucignat-Caretta, Carla; Menger, Nick S.; Croijmans, Ilja; Öztürk, Lina; Yanık, Hüseyin; Pierron, Denis; Pereda-Loth, Veronica; Nunez-Parra, Alexia; Martinez Pineda, Aldair M.; Gillespie, David; Farruggia, Michael C.; Cecchetto, Cinzia; Fornazieri, Marco A.; Philpott, Carl; Voznessenskaya, Vera; Cooper, Keiland W.; Rohlfs Dominguez, Paloma; Calcinoni, Orietta; de Groot, Jasper; Boesveldt, Sanne; Bhutani, Surabhi; Weir, Elisabeth M.; Exten, Cara; Joseph, Paule V.; Parma, Valentina; Hayes, John E.; Niv, Masha Y.; Surgery, School of Medicine
Background: Sudden smell loss is a specific early symptom of COVID-19, which, prior to the emergence of Omicron, had estimated prevalence of ~40% to 75%. Chemosensory impairments affect physical and mental health, and dietary behavior. Thus, it is critical to understand the rate and time course of smell recovery. The aim of this cohort study was to characterize smell function and recovery up to 11 months post COVID-19 infection. Methods: This longitudinal survey of individuals suffering COVID-19-related smell loss assessed disease symptoms and gustatory and olfactory function. Participants (n=12,313) who completed an initial survey (S1) about respiratory symptoms, chemosensory function and COVID-19 diagnosis between April and September 2020, were invited to complete a follow-up survey (S2). Between September 2020 and February 2021, 27.5% participants responded (n=3,386), with 1,468 being diagnosed with COVID-19 and suffering co-occurring smell and taste loss at the beginning of their illness. Results: At follow-up (median time since COVID-19 onset ~200 days), ~60% of women and ~48% of men reported less than 80% of their pre-illness smell ability. Taste typically recovered faster than smell, and taste loss rarely persisted if smell recovered. Prevalence of parosmia and phantosmia was ~10% of participants in S1 and increased substantially in S2: ~47% for parosmia and ~25% for phantosmia. Persistent smell impairment was associated with more symptoms overall, suggesting it may be a key marker of long-COVID illness. The ability to smell during COVID-19 was rated slightly lower by those who did not eventually recover their pre-illness ability to smell at S2. Conclusions: While smell ability improves for many individuals who lost it during acute COVID-19, the prevalence of parosmia and phantosmia increases substantially over time. Olfactory dysfunction is associated with broader persistent symptoms of COVID-19, and may last for many months following acute COVID-19. Taste loss in the absence of smell loss is rare. Persistent qualitative smell symptoms are emerging as common long-term sequelae; more research into treatment options is strongly warranted given that even conservative estimates suggest millions of individuals may experience parosmia following COVID-19. Healthcare providers worldwide need to be prepared to treat post COVID-19 secondary effects on physical and mental health.
A human skeletal muscle stem/myotube model reveals multiple signaling targets of cancer secretome in skeletal muscle
(Elsevier, 2023-03-31) Wang, Ruizhong; Kumar, Brijesh; Bhat-Nakshatri, Poornima; Khatpe, Aditi S.; Murphy, Michael P.; Wanczyk, Kristen E.; Simpson, Edward; Chen, Duojiao; Gao, Hongyu; Liu, Yunlong; Doud, Emma H.; Mosley, Amber L.; Nakshatri, Harikrishna; Surgery, School of Medicine
Skeletal muscle dysfunction or reprogramming due to the effects of the cancer secretome is observed in multiple malignancies. Although mouse models are routinely used to study skeletal muscle defects in cancer, because of species specificity of certain cytokines/chemokines in the secretome, a human model system is required. Here, we establish simplified multiple skeletal muscle stem cell lines (hMuSCs), which can be differentiated into myotubes. Using single nuclei ATAC-seq (snATAC-seq) and RNA-seq (snRNA-seq), we document chromatin accessibility and transcriptomic changes associated with the transition of hMuSCs to myotubes. Cancer secretome accelerated stem to myotube differentiation, altered the alternative splicing machinery and increased inflammatory, glucocorticoid receptor, and wound healing pathways in hMuSCs. Additionally, cancer secretome reduced metabolic and survival pathway associated miR-486, AKT, and p53 signaling in hMuSCs. hMuSCs underwent myotube differentiation when engrafted into NSG mice and thus providing a humanized in vivo skeletal muscle model system to study cancer cachexia.

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