Aho, Johnathon M.

Background Esophageal pathology such as perforation or malignancy often necessitates esophageal reconstruction. However, the optimal method of esophageal primary repair and anastomosis are unclear. We aim to determine stress to failure of esophageal anastomosis for full thickness and mucosal‐submucosal anastomotic techniques. Methods Six esophagi from freshly sacrificed 60 kilogram swine were transected at the mid thoracic portion of the esophagus. Esophageal anastomoses were created and subsequently primarily anastomosed using 2‐0 running continuous polyglactin (Vicryl, Ethicon, Somerville, NJ) suture either as full thickness or partial thickness (mucosa‐submucosa alone). The sutured specimens were then mounted on cannulae. Using a syringe pump system, the esophagi were infused with colored saline while monitoring pressure continuously with optical tracking for detection of fluid leak. Data acquisition software was used to collect stress‐to‐failure data. Synchronized video and pressure data were analyzed post hoc for visualization of the leak and concurrent pressure to determine failure pressure. Results The full‐thickness anastomosis failed at a mean ± (SEM) pressure of 15.33 ± (1.45) mmHg while the mucosal‐submucosal anastomosis failed at a mean ± (SEM) pressure of 36.33 ± (3.76) mmHg, ( P = 0.02, unpaired t ‐test with Welch's correction). MATLAB (MathWorks, Natick, MA) was used calculate the statistical results. Conclusion While the optimal in vivo method for esophageal anastomosis is unclear, we present evidence that an anastomosis incorporating only the mucosa and submucosa may be superior to full thickness. Additional research is needed to further clarify optimal technique and post‐operative outcomes. Support or Funding Information Dr. Aho reports funding from a Grant from the National Heart, Lung, and Blood Institute T32 HL105355, a component of the National Institutes of Health (NIH).

Esophageal diseases often necessitate resection of tissue. Current reconstruction options using autologous conduits such as stomach, colon, and small bowel have significant morbidity. Given these limitations in current therapy, we have developed a large animal model to regenerate short segments of esophageal tissue after circumferential full thickness resection. This is performed by implantation of an electrospun polyurethane tissue engineered graft which results in esophageal regrowth. These implantations have been performed both with cell based seeding the polymer scaffold and without with comparable regenerative results. It is possible that esophageal regeneration in this model has unequal contributions from either the proximal or distal esophagus. To determine preferential directionality of regeneration we aim to utilize biomechanical markers to suggest that there are unequal proximal and distal contributions to regenerated tissue. Given limited availability of regenerated tissue, use of a non‐destructive method to perform this testing would have significant utility. Through using our previously validated non‐destructive sonometric ex vivo method we aim to determine differences in mechanical behavior of the regenerated tissue in comparison to proximal and distal esophageal tissues. Using this method we are able to determine longitudinal and circumferential moduli and derive strain energy functions and parameters. Within this work we demonstrate that there are differences in mechanical behavior and that the regenerated tissue behaves more comparably to proximal esophageal tissue suggesting preferential regrowth and unequal contribution to regenerated tissue. This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

AbstractBackgroundComprehensive analysis of trauma care between high‐, middle‐, and low‐income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high‐volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting.MethodsPost hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post‐operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality.ResultsThere were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%, p = 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC, p = 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status.ConclusionUse and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010–2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (66.1) months. A median of 3 [1–3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.

Approximately 350,000 ventral hernia repairs are performed in the United States each year. Patients expect fast recovery after laparoscopic ventral hernia repair (LVHR) and undisturbed postoperative quality of life (QOL). We examined the utility of a brief, validated 10-point Linear Analog Self-Assessment coupled with the Visual Analog Scale pain scale to discern risk factors for decreased postoperative QOL. Between January 2011 and May 2013, we prospectively assessed patient-reported outcomes for patients who underwent LVHR. Visual Analog Scale pain scale and Linear Analog Self-Assessment items were recorded preoperatively and postoperatively at four hours, one day, and seven days. Eighteen patients were included, 11 were female (61%) and 8 > 60 years old (44%). Patient-reported fatigue increased clinically and statistically from baseline over time ( P = 0.007) as did pain ( P < 0.001). There was a statistically significant difference in QOL scores over time by gender with women reporting worse scores than men ( P = 0.001). In conclusion, our study detected significant changes from baseline in both fatigue and pain over the seven days after LVHR. Age is associated with postoperative differences in physical well-being. Gender is associated with differences in postoperative course in QOL and physical well-being.

Abstract Implanted neural stimulation and recording devices hold vast potential to treat a variety of neurological conditions, but the invasiveness, complexity, and cost of the implantation procedure greatly reduce access to an otherwise promising therapeutic approach. To address this need, a novel electrode that begins as an uncured, flowable prepolymer that can be injected around a neuroanatomical target to minimize surgical manipulation is developed. Referred to as the Injectrode, the electrode conforms to target structures forming an electrically conductive interface which is orders of magnitude less stiff than conventional neuromodulation electrodes. To validate the Injectrode, detailed electrochemical and microscopy characterization of its material properties is performed and the feasibility of using it to stimulate the nervous system electrically in rats and swine is validated. The silicone‐metal‐particle composite performs very similarly to pure wire of the same metal (silver) in all measures, including exhibiting a favorable cathodic charge storage capacity (CSC C ) and charge injection limits compared to the clinical LivaNova stimulation electrode and silver wire electrodes. By virtue of its simplicity, the Injectrode has the potential to be less invasive, more robust, and more cost‐effective than traditional electrode designs, which could increase the adoption of neuromodulation therapies for existing and new indications.

AbstractBackgroundAdhesive small bowel obstruction (ASBO) severity has been associated with important clinical outcomes. However, the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) disease severity grading system for ASBO. We stratified patients’ ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs.MethodsThis was a single‐center study of hospitalized adult patients with SBO during 2015–2017. Clinical data and estimated total cost (direct + indirect) were abstracted. AAST EGS grades (I–IV) stratified disease severity. Costs were normalized to the median grade I cost. Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index.ResultsThere were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n = 132), II (23%, n = 49), III (7%, n = 16), and IV (8%, n = 17). Relative to grade I, median normalized cost increased by 1.4‐fold for grade II, 1.6‐fold for grade III, and 4.3‐fold for grade IV disease. No considerable differences in patient comorbidity between grades were observed. Pair‐wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p < 0.001). Non‐operative management was associated with lower normalized cost compared to operative management (1.1 vs. 4.5, p < 0.0001). In patients who failed non‐operative management, normalized cost was increased 7.2‐fold. Collectively, the AAST EGS grade correlated well with cost (Spearman's p = 0.7, p < 0.0001). After adjustment for covariates, AAST EGS grade maintained a persistent relationship with cost.ConclusionIncreasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted.Level of evidenceIII, economic/decision.

AbstractBackgroundSnake envenomation is associated with major morbidity especially in low‐ and middle‐income countries and may require fasciotomy. We determined patient factors associated with the need for fasciotomy after venomous snake bites in children located in KwaZulu‐Natal, South Africa.MethodsSingle institutional review of historical data (2012–2017) for children (<18 years) sustaining snake envenomation was performed. Clinical data, management, and outcomes were abstracted. Syndromes after snake bite were classified according to Blaylock nomenclature: progressive painful swelling (PPS), progressive weakness (PW), or bleeding (B), as it is difficult to reliably identify the species of snake after a bite. Comparative and multivariable analyses to determine factors associated with fasciotomy were performed.ResultsThere were 72 children; mean age was 7 (±3) years, 59% male. Feet were most commonly affected (n = 27, 38%) followed by legs (n = 18, 25%). Syndromes (according to Blaylock) included PPS (n = 63, 88%), PW (n = 5, 7%), and B (n = 4, 5%). Eighteen patients underwent fasciotomy, and one required above knee amputation. Nine patients received anti‐venom. Few patients (15%) received prophylactic beta‐lactam antibiotics. Hemoglobin < 11 mg/dL, leukocytosis, INR >1.2, and age‐adjusted shock index were associated with fasciotomy. On regression, age‐adjusted shock index and hemoglobin concentration < 11 mg/dL, presentation >24 h after snake bite, and INR >1.2 were independently associated with fasciotomy. Model sensitivity was 0.89 and demonstrated good fit.ConclusionsPatient factors were associated with the fasciotomy. These factors, coupled with clinical examination, may identify those who need early operative intervention. Improving time to treatment and the appropriate administration of anti‐venom will minimize the need for surgery.Level of evidenceIII