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Kocaaga B, Inan T, Yasar Nİ, Yalcin CE, Sungur FA, Kurkcuoglu O, Demiroz A, Komurcu H, Kizilkilic O, Aydin SY, Aydin Ulgen O, Güner FS, Arslan H. Innovative Use of an Injectable, Self-Healing Drug-Loaded Pectin-Based Hydrogel for Micro- and Supermicro-Vascular Anastomoses. Biomacromolecules 2024; 25:3959-3975. [PMID: 38934558 DOI: 10.1021/acs.biomac.4c00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Microvascular surgery plays a crucial role in reconnecting micrometer-scale vessel ends. Suturing remains the gold standard technique for small vessels; however, suturing the collapsed lumen of microvessels is challenging and time-consuming, with the risk of misplaced sutures leading to failure. Although multiple solutions have been reported, the emphasis has predominantly been on resolving challenges related to arteries rather than veins, and none has proven superior. In this study, we introduce an innovative solution to address these challenges through the development of an injectable lidocaine-loaded pectin hydrogel by using computational and experimental methods. To understand the extent of interactions between the drug and the pectin chain, molecular dynamics (MD) simulations and quantum mechanics (QM) calculations were conducted in the first step of the research. Then, a series of experimental studies were designed to prepare lidocaine-loaded injectable pectin-based hydrogels, and their characterization was performed by using Fourier transform infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), and rheological analysis. After all the results were evaluated, the drug-loaded pectin-based hydrogel exhibiting self-healing properties was selected as a potential candidate for in vivo studies to determine its performance during operation. In this context, the hydrogel was injected into the divided vessel ends and perivascular area, allowing for direct suturing through the gel matrix. While our hydrogel effectively prevented vasospasm and facilitated micro- and supermicro-vascular anastomoses, it was noted that it did not cause significant changes in late-stage imaging and histopathological analysis up to 6 months. We strongly believe that pectin-based hydrogel potentially enhanced microlevel arterial, lymphatic, and particularly venous anastomoses.
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Affiliation(s)
- Banu Kocaaga
- Department of Chemical Engineering, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
| | - Tugce Inan
- Department of Chemical Engineering, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
| | - Nesrin İsil Yasar
- Informatics Institute, Computational Science and Engineering Division, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
| | - Can Ege Yalcin
- Cerrahpasa Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Istanbul 34089, Turkey
| | - Fethiye Aylin Sungur
- Informatics Institute, Computational Science and Engineering Division, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
| | - Ozge Kurkcuoglu
- Department of Chemical Engineering, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
| | - Anil Demiroz
- Cerrahpasa Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Istanbul 34089, Turkey
| | - Hasan Komurcu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Balat Or-Ahayim Hastanesi, Istanbul 34087, Turkey
| | - Osman Kizilkilic
- Cerrahpasa Medical Faculty, Department of Interventional Radiology, Istanbul University-Cerrahpasa, Istanbul 34098, Turkey
| | - Servet Yekta Aydin
- Cerrahpasa Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Istanbul 34089, Turkey
| | - Ovgu Aydin Ulgen
- Cerrahpasa Medical Faculty, Department of Pathology, Istanbul University-Cerrahpasa, Istanbul 34098, Turkey
| | - Fatma Seniha Güner
- Department of Chemical Engineering, Istanbul Technical University, Maslak, 34469 Istanbul, Turkey
- Sabancı University Nanotechnology Research and Application Center, Istanbul 34956, Turkey
| | - Hakan Arslan
- Cerrahpasa Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Istanbul 34089, Turkey
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Chen J, Varagur K, Xun H, Wallam S, Karius A, Ospino R, Ji J, Sanka SA, Daines J, Skladman R, Aliu O, Sacks JM. Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps. J Reconstr Microsurg 2023; 39:549-558. [PMID: 36564049 DOI: 10.1055/a-2003-7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.
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Affiliation(s)
- Jonlin Chen
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sara Wallam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander Karius
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rafael Ospino
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jenny Ji
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Sai Anusha Sanka
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - John Daines
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
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Orădan AV, Dindelegan GC, Vinaşi RC, Muntean MV, Dindelegan MG, Chiriac L, Volovici V. Reduction of Anastomotic Time Through the Use of Cyanoacrylate in Microvascular Procedures. Plast Surg (Oakv) 2022; 30:335-342. [PMID: 36212098 PMCID: PMC9537713 DOI: 10.1177/22925503211019619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: Ever since the description of the first microvascular anastomosis, numerous alternative methods have been described to the classical approach. Tissue adhesive has shown promising result in previous studies and can be a fast and efficient alternative which still requires more studies to allow its clinical implementation. Methods: A randomized comparative experimental study was conducted on rats' femoral arteries and an end-to-end anastomosis was performed in order to compare 2 anastomosis techniques. In one group, a simple interrupted suture was utilized, whereas in the second group a combination between fewer sutures and tissue adhesive was used. The anastomotic time, total operative time, blood flow velocity before, immediately after and 48 hours after the procedure, as well as an independent grading of the anastomosis immediately after the procedure were performed. Magnetic resonance imaging (MRI) was performed in order to assess the degree of stenosis. After euthanasia, histology and scanning electron microscopy (SEM) were performed on the vessels in order to assess possible complications. Results: A total of 24 anastomoses were performed, of which 12 with a classic technique and 12 with an adhesive technique. All the anastomoses were patent with a significant reduction of anastomotic and total operative time. The grading of the anastomoses showed better results in the classic suture group. The blood flow velocities were not statistically significant between the 2 groups. On MRI there was one stenotic anastomosis, whereas histology and SEM showed more complications on the adhesive group. Conclusion: Anastomotic times were significantly lower with a non-significant trend toward more thrombotic complications in the adhesive group. Further improvement of the glue properties and refinement of the technique will likely make it a viable alternative to interrupted suturing in the future.
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Affiliation(s)
- Alex V. Orădan
- Department of Plastic Surgery, Clinical Rehabilitation
Hospital, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - George C. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- First Surgical Clinic, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ramona C. Vinaşi
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Neuroscience, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maximilian V. Muntean
- Department of Plastic Surgery, “Prof. Dr. I. Chiricuta”
Institute of Oncology, “Iuliu Hatieganu” University of Medicine and
Pharmacy, Cluj-Napoca, Romania
| | - Maximilian G. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Otorhinolaryngology, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Liviu Chiriac
- National Magnetic Resonance Center, Faculty of Physics,
Babeş-Bolyai University, Cluj Napoca, Romania
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
- Center for Medical Decision Making, Department of Public
Health, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
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Heitzer M, Ooms M, Katz MS, Peters F, Kilic K, Tolba R, Jockenhoevel S, Hermanns-Sachweh B, Hölzle F, Modabber A. Evaluation of the long-term results of vascular anastomosis using polyurethane adhesive and shape-memory stent in the rat carotid artery model. Microsurgery 2022; 42:480-489. [PMID: 35670105 DOI: 10.1002/micr.30926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/04/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In free flaps, 5%-10% of complications are related to failure of sutured vascular anastomoses. Adhesive-based microvascular anastomoses are potential alternatives but are associated with failure rates of 70% in research studies. VIVO is a new adhesive with slow biodegradation within 6 months that has shown a 100% patency rate in research studies over 2 h observation time but long-term patency has not been evaluated. The authors hypothesize that VIVO will enable a reliable microvascular procedure comparable to sutured anastomoses over a 28-day period. MATERIALS AND METHODS The right common carotid artery of 60 male Sprague Dawley rats, ~450 g, were used for microvascular end-to-end anastomosis. VIVO was applied with reduced sutures with a temporary catheter in one group and in the other with a custom-shaped memory stent. Anastomoses with eight interrupted sutures served as control. All groups were n = 20. Anastomosis time and bleeding were recorded for each procedure. Doppler flowmetry was performed 20 min, 1, 10, and 28 days postoperatively. Postmortem toluidine staining was used for semi-quantitative analysis of stenosis, thrombosis, necrosis, and aneurysm formation by histologic evaluation. RESULTS No occlusion was detected 20 min and 1 day postoperative, and after 28 days of observation in all anastomoses. The anastomosis time of the VIVO with catheter group was about 32% significantly faster than the VIVO with stent group. In the VIVO group with stent, the bleeding time was ~80% shorter than in the control group with 2.1 ± 0.3 and VIVO with catheter 2.0 ± 0.5 (p ≤ .001 each). Minor and nonsignificant stent-associated thrombus formation and stent-typical intraluminal stenosis were detected exclusively in the VIVO with stent group. CONCLUSION Within the limitations of a rat study, the use of VIVO in anastomosis showed promising results. VIVO with catheter was found to be advantageous.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Konrad Kilic
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - René Tolba
- Institute of Laboratory Animal Science and Experimental Surgery of RWTH-Aachen, Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid and Medical Textiles (BioTex), AME-Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | | | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
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A Novel Method of End-to-Side Microvascular Anastomosis Using T-Shaped Metal Stents: A Porcine Study. J Craniofac Surg 2021; 33:1222-1226. [PMID: 34802020 DOI: 10.1097/scs.0000000000008338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT End-to-side anastomosis requires highly specialized techniques. An easy end-to-side anastomosis technique enables anastomosis of vessels with different diameters and under various situations. We invented T-shaped metal stents and evaluated novel methods of end-to-side sutureless anastomosis, confirming their safety, effectiveness, and operability. We performed 8 end-to-side sutureless anastomoses in 4 7- to 11-month-old, male Mexican hairless piglets. After induction of anesthesia, the left femoral artery was resected by approximately 8 cm, and the superior and posterior stumps of the resected femoral artery underwent an end-to-side anastomosis with the right femoral artery by the placement of the metal stents with subsequent use of adhesive for the circumferential area. The patency of blood vessels and the presence of thrombosis were evaluated by ultrasonography or contrast-enhanced computed tomography and histology 4 weeks postoperatively. All the animals survived the procedure; no thrombosis was identified in any of the 8 anastomosis sites according to imaging studies performed 4 weeks postoperatively. Histological examination confirmed the probe patency of blood vessels and neointimal cell proliferation around stent branches. End-to-side anastomosis is possible with T-shaped metal stents. In the future, we aim for the practical application of these stents by improving their operability.
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Menezes Neto BFD, Oliveira Neto FVD, Secanho MS, Carvalho LB, Moragas WR, Fernandes MS. Submerged vascular anastomosis. A technique for vascular suturing in experimental microsurgery. Acta Cir Bras 2021; 36:e360807. [PMID: 34644775 PMCID: PMC8516427 DOI: 10.1590/acb360807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/24/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose: To evaluate the impact of submersion of the microsurgical anastomosis suture
area using saline (0.9% NaCl) in an experimental laboratory during the
training of medical students and resident physicians. Methods: Wistar rats (n = 10) were selected to have the two femoral arteries sectioned
and anastomosed end-to-end under optical magnification. They were randomly
divided, so that on one side suturing was performed under submersion with
saline, and the contralateral side was kept dry during the procedure. The
surgical times, as well as the patency within 30 min and 72 h of the
procedure, were evaluated. Results: Six male Wistar rats survived the surgical anesthetic procedure, with the
average initial weight of 243.3 g and the average artery diameter of 0.86
mm, with average time of 15.67 min for the submerged technique and 20.50 min
for the dry technique (p = 0.03). The failure rates were 17 and 50% for the
submerged group and the dry one, respectively (p = 0.62). Conclusions: Submerged microvascular suture does not compromise the patency of the vessel
or increase the time of anastomosis. Therefore, it is a strategy that can be
applied by the surgeon according to his/her technical preferences.
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Qassemyar Q, Michel G, Gianfermi M, Atlan M, Havet E, Luca-Pozner V. Sutureless venous microanastomosis using thermosensitive poloxamer and cyanoacrylate: experimental study on a rat model. J Plast Reconstr Aesthet Surg 2021; 75:433-438. [PMID: 34247962 DOI: 10.1016/j.bjps.2021.05.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 05/08/2021] [Accepted: 05/28/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Sutureless microvascular anastomoses could simplify the microvascular field, shortening operative time and improving the final outcome. The use of thermosensitive poloxamers (TP407) together with the application of cyanoacrylate as an alternative method for conventional sutures was well-documented for arteries, but not for veins. The purpose of our study was to prove the feasibility of this technique for venous anastomoses and compare it with the traditional hand-sewn technique on a rat model. MATERIALS AND METHODS Twenty male Sprague-Dawley rats that weighed between 265 and 310 g were used. In the sutureless group (SG), 20 left external jugular veins (LEJV) end-to-end anastomoses were performed using a T704 and cyanoacrylate glue. They were compared to 20 right external jugular veins (REJV) anastomoses sutured with conventional 10-0 stitches (control group - CG). Diameters of veins, anastomosis time, and patency rate at 15 days were reported. Foreign body reaction was assessed histologically. RESULTS The mean diameter of the LEJV was 0.94 ± 0.1 mm and 0.95 ± 0.09 mm for the REJV. The mean anastomosis time was 11.9 ± 1.37 min for the SG and 27.75 ± 3.31 min for the CG. In the latter group, the immediate patency rate was 95% and 90% at 15 days. For the SG group, 90% of the anastomoses were patent immediately and 85% at 15 days. CONCLUSION TP407 and cyanoacrylate could offer a fast and reliable technique for sutureless venous anastomoses. Before human application, effectiveness of this method remains to be confirmed in larger animals in a long-term follow-up.
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Affiliation(s)
- Q Qassemyar
- Department of Plastic and Reconstructive Surgery, University Hospital Armand-Trousseau, 26 avenue du Dr Arnold Netter, 75012 Paris, France; Faculty of Medicine, Sorbonne University, 91 boulevard de l'hôpital, 75013 Paris, France; Anatomy Department, University of Picardie, Rue des Louvels, 80000 Amiens, France
| | - G Michel
- Anatomy Department, University of Picardie, Rue des Louvels, 80000 Amiens, France
| | - M Gianfermi
- Anatomy Department, University of Picardie, Rue des Louvels, 80000 Amiens, France
| | - M Atlan
- Faculty of Medicine, Sorbonne University, 91 boulevard de l'hôpital, 75013 Paris, France; Department of Plastic Surgery, Tenon Hospital, 4 Rue de la Chine, 75020 Paris, France
| | - E Havet
- Anatomy Department, University of Picardie, Rue des Louvels, 80000 Amiens, France
| | - V Luca-Pozner
- Department of Plastic and Reconstructive Surgery, University Hospital Armand-Trousseau, 26 avenue du Dr Arnold Netter, 75012 Paris, France; Faculty of Medicine, Sorbonne University, 91 boulevard de l'hôpital, 75013 Paris, France.
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