Week 7/8:Last call for surgeries/Contemplating research direction

Week 7 was essentially our (mine and Aarons) last week in the hospital seeing patients/observing surgeries/etc. which we’ve become so used to the flow of things. Our last week Dr. Spector would be traveling, and we anticipated us being in lab in our newfound “free-time”, trying to finish up experiments/make whatever we could out of our lab work thus far. Coincidentally, our last major procedure was the same type as we had seen on our very first day of immersion, a mandible reconstruction with a free fibula flap. When I look back at these two experiences, it makes me think of just how far we had come/how much we have experienced in the short amount of time. I walked into the OR with a sense of confidence/familiarity, having accumulated enough knowledge/experience to give context to what’s going on in the room at each stage of the procedure. The surgery played out more or less as was discussed during their video-conference planning meeting the month prior, down to the minute details drilled over and over by the respective surgeons (ENT, Oral, and Plastics (Dr. Spector)). Additionally, for this procedure they were able to hookup the video camera attachment to the microscope, so we could watch with great detail the barely visible movement which Dr. Spector and his fellow were performing in order to isolate/anastamose the respective blood vessels. With the whole room operating smoothly/efficiently, Dr. Spector’s team finished up the operation hours earlier than our first reconstruction (roughly 8AM to 10PM at night).

My final week of immersion was spent in the lab. Initially, I was highly optimistic. After trouble-shooting my MeHA-Megel photocrosslinking protocol (requiring far greater concentration of Inrgacure photoinitiatior/UV exposure time), and undergone training/clearance on the confocal LSM at the college, I was eager to see how the long term viability of seeded HUVEC/encapsulated Pericytes would turn out. Admittedly, my approach in preparing whole subsets of my respective time-points en mass was atypical, and frankly poor experimental design, “placing all my eggs in one basket” if you will. However, given the limited amount of time I had left towards the end, I viewed it as my last chance at obtaining usable data. Alas, it didn’t, and that is all I would like to speak of on that subject if you will… The high degree of cell death could have been due to a number of issues given how substantially I had deviated from my lab’s normal photocrosslinking protocol (e.g. the Irgacure concentration at that point may have been highly cytotoxic). After learning from one of my lab mates from the bioprinting project that they’ve recently been coming into similar issues in photocrosslinking with that newest batch of material I had been using (possibly due to poor methacrylation) I decided to instead finish teaching several new long-term lab members the different assays/imaging/etc. which would be required if Dr. Spector would rather have his students conduct these in vitro studies in NYC versus me conducting them back in Ithaca after more material has been produced (methacrylation/purification is a time intensive process). I outlined the setup/obtained the components necessary for peristaltic pumping systems for conditioning the tissue-engineered microvessel constructs moving forward, as the new lab members were unfamiliar with these systems/process involved. I view it as a necessary component moving forward in preparation of micro-anastamosing these constructs to their rat model. Additionally, the long term viability of the cell lining can be tested at physiologically relevant hemodynamic conditions. I’ll have to wait until after Dr. Spector returns when the three of us (him, my PI, and myself) can discuss the logistics of how to complete these studies moving forward. I am greatly appreciative of the experience overall, having seen so much in the hospital, but am looking forward to getting back into the full swing of things back in Ithaca.

Week 6: A kink in the clockwork...

The most pronounced observation of the week was during another ALT free-flap procedure, in this case used to reconstruct soft tissue coverings for the patients exposed ankle/heel regions. We had seen a number of these type of procedures throughout the summer, most often utilizing the ALT as a well vascularized/large surface area donor site requiring relatively minimal post-op wound care, to cover these deep tissue wounds wherein a skin graft would be insufficient/pose low chance of healthy integration due to the lack of an underlying vascular bed (exposed bone). We have seen this patient throughout most of our immersion term, whom after sustaining a significant/traumatic injury to his leg months back in his home country, has resulted in significant tissue ischemia and little to no motion/sensation below his dislocated knee-joint. Since day one, Dr. Spector had been recommending a BKA (below knee amputation) as the best possible scenario to return functional use of his knee. The complications with his injury made the integration of the muscle-flap and/or skin grafts unlikely, would induce further trauma in the donor sites, and would not return functional usage of the foot anyway. The family and patient remained adamant about saving the remainder of his foot/leg despite these recommendations, and thus had undergone a slew of tissue debridements/irrigations as well as attempted closure with both Integra and autologous skin grafts. While unsuccessful in fully integrating/recovering, the patient wound sites appeared to be making some progress in that direction, leading to the optimistic family to push for the free-flap reconstruction.

For this procedure, Dr. Spector and team segmented the ALT donor tissue in order to cover both defect sites whilst still supplied by the same artery/vein for anastamosis. However, the procedure was complicated by a “hiccup” during a critical point in the procedure – the ischemic window. For starters, the operation was set to take place in the ambulatory surgical wing (where Dr. Spector hardly if ever perform these flap surgeries) and from his usual team, only one of his seasoned OR techs was in the room. When it came time for Dr. Spector and his fellow to perform microsurgery for the detached muscle flap, the circulating nurse had not initiated/setup the microscope, and we further found that this particular scope possessed a nonfunctional eye-piece. By this time, late in the evening, the main OR staff and those whom he could normally contact to obtain a replacement had already gone home. The circulating nurse had no idea of how to locate another scope, at which point Dr. Spector sends off one of his residents and med students to search for one in general surgery and bring it back, a difficult ordeal. When they returned, the scope they had brought up was not suited/sufficient for his intended usage. Eventually, we were able to get ahold of one of the knowledgeable staff members from home, getting permission to use his regular scope in general surgery (which thankfully, was no longer being utilized by another surgical team) and the procedure was finally able to be completed after an additional couple of hours for the micro-anastamosis.

This complicated series of events has made me question how prevalent these type of issues might be. The successful execution of these major operations depend on everyone apart of the surgical team fulfilling their respective roles, each functioning as an integral component in the clockwork nature of the OR. Any breakdown in those roles (e.g. improper setup, equipment checks, etc.) can bring the whole operation to a standstill. I could only imagine Dr. Spector’s level of frustration, but outwardly you would never really have thought it, exuding his usual cool/calm demeanor. I guess operating as a surgeon for all these years cultivates these type of nerves of steel to tackle these complications/issues which are bound to emerge, but really, the system should have been such (inbuilt checks, etc.) that they don’t come up in the first place.

Belated Week 8

I realized that in all the excitement of packing and getting ready to leave I never actually posted my last blog. The last week of Immersion, Dr. Bostrom was out of town, so I don't have much to report. I mostly spent the last week working more on my research project and starting my paper. It was a good way to finish up the summer, by reflecting on everything I had seen and done over the past 8 weeks. It made me realize how awesome this experience has been, allowing me to see so many procedures and technologies being used to help real people. It was nice to see the end result to remind us why we do what we do in the first place. I definitely gained a whole new perspective on what it takes to be a surgeon, and learned a lot about all of the behind the scenes issues not many people are aware of.

Week 7 & 8

Week 7 & 8. 

There’s only couple of days left. For the past few days, I thought I almost see every procedures and was a bit bored to repeated operations but the last two weeks gave me more experiences I expected. Dr. Milsom is an expert in laparoscopic procedure but I finally was able to see the open procedure. The patient admitted had extensively distended abdomen because of the stricture on the small intestine so he had to open her abdomen and got rid of the bad piece. I thought I fairly used to see the small intestine which I saw all the time in the mouse, but it was a bit more intimidating. It was easy to find the obstructed piece and it looked really horrible. The piece of loop of the small intestine was almost blocked by adhesion and hugely swollen. It looked like tied up with rubber band. I have pretty amazed by the fact that adhesion can do lots of bad things in the tissue although it is formed in normal healing process. In another case, he was admitted with huge pain in the abdomen. When we looked at his intestine, there was pretty stiff adhesion along with the small intestine and it made the small intestine tangled up. It was amazing that the swollen small intestine before the stricture was immediately returned to almost normal size once we released the adhesion. I keep realizing the thing that small thing can lead huge consequence, especially in bad way. That would be nice if there is simple drug that can inhibit excessive formation of adhesion after surgery or maybe some kind of biomaterial to prevent it. There was another impressive case of open procedure on Tuesday. That was a second time I saw him in the OR. I remember him because he had two stomas. He has been taken care of by the doctor but he was lying on the table to examine any blockage in his intestine with fluoscopy. As I wrote in previous report, his intestine was able to flow dyes smoothly from one end to the another. However, he came back to OR because he had been suffered from low quality of life. He said he couldn’t eat much although we didn’t find any obstruction so he finally decided to get another procedure. Dr. Milsom opened his abdomen and fixed stricture by strictureplasty near the first ileostomy and closed jejunostomy and rejoining separated piece. It was pretty long and hard. 

During summer immersion, I have got lots of fresh thought in mind. Especially, I think this time is so valuable since I could learn how other people have different interest and perspectives. I truly thank that I was able to work with Dr. Milsom who has active work on both clinics and research sides. I started my Ph.D to help people as a scientist but it is sometimes motivated by intellectual inquiry, which often does not have direct impact (or more say short-term effect) on patients. He kept encouraging me to develop something useful and helpful device,, thinking me what could be a real help to the world. It has been so precious time to be close to the real field and exposed to so much interesting things. By wrapping up my time here, I think I can say that my summer was fully immersed!

Week 8: Concluding with research

My last week of the Immersion term was focused on investigating the impact of stent type upon renal artery morphology which has implications for long-term durability. Thus, the week mainly consisted of establishing and implementing a protocol to make the appropriate measurements while being blinded to the stent type. I've finished the initial measurements, and will continue analyzing the data once I am unblinded back in Ithaca.

Overall, the Immersion term was a valuable experience for a multitude of reasons. Among the various experiences, I found observation of the clinical ramifications of atherosclerosis particularly illuminating. Although I'm not sure how I will incorporate this new clinical perspective into my research, I anticipate it can only help motivate me and provide a source for new ideas as I progress through my doctoral research.

Week 8: The Tasmanian Devil

With Dr. Spector out of town, I spent the final week of immersion in lab. A majority of my time was spent teaching one of the lab’s newer, longer-term members everything that I knew related to my project. This encompassed several protocols, from making PDMS molds, to preparing tumor cell-conditioned media, to seeding the sacrificial microfiber (SMF) constructs.

Aside from this, I also “created” a device that will potentially improve results for all SMF-related projects in the lab. The SMF constructs consist of a patent microchannel (formed using a sacrificial material, hence their name) within a collagen hydrogel, into which the lab seeds various cell types (e.g. aortic smooth muscle cells, endothelial cells) to form a vascular lining. However, one problem that has been mentioned frequently in lab meetings this summer (and I believe prior to this summer) was inconsistent attachment of cells circumferentially throughout the channel. A cell suspension is placed within the channel for an hour before media is placed around the construct. During this one hour, the lab usually orients the construct (within a mold, which is placed in a petri dish) up, down, and tilted for 20 minutes at a time to improve internal surface coverage, but has had varying success. Unfortunately, this also requires close monitoring of time within the incubation hour, limiting the amount of other work that can be done during that time. To make the seeding process more hands-off and consistent, I reappropriated an old peristaltic pump in the lab to clamp and continuously rotate a petri plate (holding up to three constructs) during the one-hour seeding incubation (the lab has named it the Tasmanian Devil after the Looney Tunes character). I think this will generate more consistent cell adhesion along the lumen, but the optimal rotation speed will need to be worked out before it is implemented in all SMF projects.

With all that, immersion term is officially over! I hope that some of the work I did in lab will make a lasting impact, and I am extremely grateful to have had the opportunity to shadow Dr. Spector in the many aspects of his work.

Week 7: C'mon, get flappy

This past week, we saw two flap cases in the OR. First was a mandible reconstruction with free fibula flap, a procedure we had seen in our first day of surgery. This time around though, we had much more context. Having seen the surgical planning meeting a few weeks ago, I entered the OR feeling confident in my knowledge of what was going to happen and with greater appreciation for the entire process. The room was swarming with people as soon as we entered, but in little time formed into a number of teams clad largely in blue. At least one OR tech was scrubbed and ready to assist each team. Oral surgery started by removing any teeth from the length of the mandible that would be cut out. At the same time, the plastics team was locating the vessels that supply the fibula flap, and cutting through several layers of tissue to isolate the fibula. ENT (ear, nose, throat) removed the mandible tumor from an incision below the jawline. In great contrast to last week, it was during this procedure that I was able to truly appreciate the efficiency of an OR in which everyone knows what is happening and how to perform their role appropriately. The anesthesiologists were very responsive to the surgeons’ requests to raise/lower the patient’s blood pressure (although I don't recall seeing an issue with anesthesia in the cases I’ve observed so far), the OR techs and circulating nurses knew what tools were needed and where to find them, and the correct microscope was ready to go when Dr. Spector needed it. We were even able to connect the video camera attached to the scope to the monitors in the OR so that everyone could watch the microsurgical anastomosis. With everything running smoothly, this case was completed hours sooner than our first mandible reconstruction had. This patient even received titanium implants in the fibula flap (posts onto which custom dental implants may be placed), which had not been done for the first one.

The next day, we saw a buccal tumor resection and reconstruction with radial forearm free flap. This was unique compared to cases we had seen before because the vasculature is much closer to the surface of the flap, and the flap was to be used to patch the defect in the patient’s inner cheek. ENT was involved in this case to remove the tumor, and to locate potential vessels at the recipient site. The vascular pedicle extended from the patient’s wrist to about halfway down the forearm, since the vessels would be tunneled from the patient's cheek down to the neck, where the flap would be anastomosed. Aside from navigating another crowded room, the main issue we encountered in this case was poor temperature regulation in the OR. Although we had set the thermostat to a low temperature, the room only seemed to be warming over time. After several calls to the engineering team, someone came with an IR gun to check the vents in the room. It turned out that one thermostat controlled multiple rooms, but there was a leak in the thermostat, causing it to sense cooler-than-actual air coming from our OR. We were all relieved to feel the temperature dropping once this was fixed. The most amazing part about all this was how the surgical team was able to continue working (i.e. do microsurgery) in these conditions; despite their discomfort and complaints, everyone was still able to do their jobs and ensure a successful procedure.