Insights & Innovations

Adults who have moderate to severe obstructive sleep apnea (OSA) may benefit from a surgical option known as maxillomandibular advancement (MMA). ChristianaCare is currently one of the few health systems in the region performing this surgery

The American Academy of Sleep Medicine estimates that at least 25 million people in the United States have OSA. The condition occurs when muscles and soft tissue in a person’s throat repeatedly relax and collapse during sleep, blocking their airway and causing recurrent waking to restore breathing, which can seriously disrupt sleep and lead to reduced blood oxygen levels, according to Daniel J. Meara, MD, DMD, FACS, the chair of ChristianaCare’s Department of Oral and Maxillofacial Surgery and Hospital Dentistry.

Some of the major risk factors for OSA include obesity, smoking, alcohol consumption, asthma and chronic nasal congestion.

Men are several times more likely to have OSA than premenopausal women; however, the prevalence among women increases following menopause, Dr. Meara said. While the condition may affect people at any stage of life, it’s most common in middle-aged and older adults.

Symptoms of OSA include loud snoring, difficulty sleeping, pauses in breathing while asleep, frequently waking to urinate, morning dry mouth, headaches, daytime sleepiness, impaired concentration and impotence. Left untreated, Dr. Meara warned that the condition can cause a host of health concerns.

“People with OSA are at higher risk for hypertension and cardiovascular disorders, such as irregular heartbeat, heart attack and stroke,” Dr. Meara said. “They’re also more likely to develop metabolic syndrome, diabetes, liver disease, cognitive impairment, depression and anxiety. Further, when OSA is poorly controlled, there is significant negative impact on quality of life. That’s why it’s so vitally important that they receive treatment.”

For adults, making lifestyle changes or using oral appliances may be sufficient for managing the condition in its mild form, but those with moderate to severe disease typically require continuous positive airway pressure (CPAP) therapy, which is the gold-standard for treatment. However, compliance with CPAP can be low, necessitating alternative treatments, primarily surgery. Surgical options include uvulopalatopharyngoplasty (UP3), hypoglossal nerve stimulation (HNS; which uses an implanted electronic device to open a patient’s airway during sleep) and maxillomandibular advancement jaw surgery, according to Dr. Meara.

However, when UP3 and HNS techniques either aren’t appropriate or have failed to resolve the problem, MMA has proved to be a strong alternative.

“The surgery is performed on patients in a hospital operating room under general anesthesia,” Dr. Meara said. “MMA involves making incisions in the upper and lower jaw bones and moving them forward. This opens the upper airway to enhance airflow and improve breathing during sleep. The procedure generally lasts several hours and requires a hospital stay.”

Possible postoperative side effects include pain, bleeding, swelling, nasal congestion, teeth bite changes, weight loss, and temporary numbness in the lips, mouth or face. There also is a minor risk for complications, including infection and damage to teeth.

In most cases, patients are able to return to their daily activities and work in approximately four to six weeks.

“Research has found that MMA is highly effective, with a high success rate,” Dr. Meara noted. “For patients, the biggest benefit is that the procedure is a more permanent solution to OSA, whereas many of the other treatments require the nightly wearing of sometimes uncomfortable equipment that have their own side effects.”

Patients seeking state-of-the-art eye care in Delaware can now receive virtually all types of ophthalmic surgery close to home, as ChristianaCare has added three new fellowship-trained physicians to the staff within the past two years.

Glaucoma specialist Tomilade Adepoju, MD, who completed her ophthalmology residency at Nassau University Medical Center, in East Meadow, N.Y., and her glaucoma fellowship at Boston University Eye Associates, came on board in September 2022. Medical retina and uveitis specialist Benjamin Christopher Chaon, MD, the medical director of the Wilmington Eye Clinic and an associate professor of ophthalmology at Temple University, in Philadelphia, joined the staff in the summer of 2023. And, most recently, ChristianaCare has recruited the first neuro-ophthalmologist in the state of Delaware, Muhammad Asad Fraz, MD, who completed his neurology residency at Henry Ford Hospital, in Detroit, and a fellowship in neuro-ophthalmology at the University of Pennsylvania, in Philadelphia.

“Between the three of us, we are able to cover just about every area of ophthalmology, which means that we no longer have to refer patients with very complex eye conditions to practices in Philadelphia or Baltimore,” Dr. Adepoju said. “Our program is also affiliated with the Temple University ophthalmology residency, an exceptional training program, so we have residents who operate with us and learn from us in the clinic and operating room.”

As the population continues to age, the demand for cataract surgery is growing dramatically.

“We perform the simplest to the most complex surgeries,” she said. “Because we offer these procedures in the hospital setting, where we can manage patients holistically in collaboration with our colleagues in rheumatology, endocrinology and critical care, we are particularly well suited to care for the most challenging and difficult cases, such as people with long-standing diabetes and many other comorbidities. The majority of our patients are already somehow being cared for within the ChristianaCare system, so having the whole care team under the same umbrella is very helpful.”

Surgeries are performed at ChristianaCare’s Wilmington Hospital, which is also the primary location for the ophthalmology practice. Here, patients have access to laser procedures, minimally invasive surgeries, and traditional surgical options depending on their clinical situation.

“In this facility, we have a new Heidelberg Spectralis optical coherence tomography machine, which provides noninvasive imaging of the retina for the diagnosis of retinal disease and allows us to assess the optic nerve for patients with glaucoma,” Dr. Adepoju noted. “We also have two lasers for the treatment of glaucoma that may not yet be at the point of needing traditional incisional surgery, as well as a micropulse photocoagulation laser to treat more severe glaucoma in the OR setting. All of our equipment is state of the art.”

Within the next one to two years, the group also hopes to expand to a second location offering medical and surgical ophthalmic services at Christiana Hospital in Newark. Demand is high: Both Drs. Adepoju and Chaon are booked into early 2025 and Dr. Fraz through March 2025. However, the practice has dramatically increased the number of patients it is able to see, conducting between 300 and 400 diabetic screenings per month and performing between 10 and 14 surgeries monthly for each surgeon. The team works closely with referring providers to ensure that patients who need urgent ophthalmic care can be evaluated at ChristianaCare in a timely fashion.

“We also plan to expand and add one more specialist to the ophthalmology team within the coming year,” Dr. Adepoju said. “We are growing very quickly because there is such a need in this community for ophthalmic surgical care.”

When patients undergo imaging studies such as MRIs, CT scans and ultrasounds to screen for a variety of cancerous or noncancerous conditions, sometimes the scan reveals an unexpected finding: a nodule on the thyroid.

“Someone may have a traumatic injury and get a CT scan of their entire body, or they are experiencing neck pain or a muscle sprain or an issue with their cervical spine, and they get an MRI,” explained Leon Kushnir, MD, FACS, a fellowship-trained endocrine surgeon who joined the staff at ChristianaCare’s Helen F. Graham Cancer Center & Research Institute in the summer of 2024 after several years as the program director of the general surgery residency program at Inspira Health Network in southern New Jersey. He joined an experienced team that includes Arvind Sabesan, MD, FACS, a surgical oncologist with a special interest in endocrine surgery, and Alison Segal, a physician assistant with more than 25 years of surgical expertise.

“During that imaging, an incidental thyroid nodule is seen, which suddenly becomes a significant concern for the patient,” Dr. Kushnir continued. “They don’t really know how to react. Could it be cancerous?”

Many patients experience a lot of anxiety after they are told about this finding and want to be seen by an expert as soon as possible. Although the vast majority (up to 90%) of thyroid nodules are benign, they still require proper management—and patient education and consultation.

With Dr. Kushnir’s assistance, ChristianaCare has launched a new clinical pathway for the management of thyroid nodules. This process removes the burden of these findings off of the referring physician and immediately puts the case in the hands of an expert.

“When an incidental thyroid nodule is identified on imaging, it is flagged on the radiology report and the ordering physician is immediately given the information to refer the patient to myself or my partner, Dr. Sabesan,” Dr. Kushnir explained. “We will take care of everything from there.”

Within the past 10 years, genetic analysis has significantly improved the ability of surgeons, like Dr. Kushnir, and the pathologists he works with to accurately diagnose these nodules.

“When I first started my training, biopsy results were not very specific. We often performed extensive diagnostic surgeries on nodules that turned out to be benign,” he said. “Today, it’s relatively unusual for us to be doing a surgery when we don’t know definitively whether or not it is cancer.”

Dr. Kushnir envisions the thyroid nodule clinical pathway as a seamless process for the patient and the referring provider.

“Apple is very successful and famous because they make it very easy to use their products,” he noted. “We need to also make it very easy for our colleagues and patients to get expert care in a timely and easy fashion. One or two clicks will enable our referring providers to contact us, and we will get the patient in our door for a workup and in-office biopsy as soon as possible.”

Most of the time, incidental thyroid nodules turn out to be benign; Dr. Kushnir estimated that they are cancerous only between 5% and 10% of the time. However, time is still of the essence with these findings; “a lump on the thyroid” often still represents an emotional emergency to the patient.

“In my experience, whenever a patient sees that sort of incidental finding, they get very scared,” Dr. Kushnir said. “That’s especially acute when somebody has a personal or family history of cancer.”

Unfortunately, in the past, it could often take several months between identifying an incidental thyroid nodule on a scan and finally ruling cancer in or out.

“We’re going to change that,” Dr. Kushnir noted. “We want to make that transition from identifying a nodule, to counseling and biopsy, to having an answer as easy and quick as possible. Our goal is to have the patient seen in our office within one to two weeks after the initial diagnosis. At this visit, they will have a full consultation with a biopsy of the nodule if necessary, and results available the following week.”

ChristianaCare’s Center for Breast Reconstruction is the only such program in Delaware offering microsurgery fellowship−trained plastic surgeons. This enables the program, which has three microsurgery-trained surgeons—two of whom are women—to offer the full range of breast reconstruction modalities, including flap reconstructive surgeries in which microsurgeons use a patient’s own body tissue to reconstruct the breast. Occasionally, patients request an all-female team, and ChristianaCare is able to provide that.

In flap surgery, the most common area where surgeons find tissue to use is the lower abdomen. If surgeons can’t use abdominal tissue, perhaps because the woman is too thin or has had surgery on the abdomen before, they may be able to use tissue from the lower back, buttock or upper thigh. Using a person’s own tissue to reconstruct a breast has several benefits. First, it allows for a more natural look.

“The biggest advantage is that the reconstructed breast is made up of your own body tissue and replaces like for like,” said Stephanie Caterson, MD, the director of the Center for Breast Reconstruction at ChristianaCare. “With flap reconstruction after a mastectomy, the breast is replaced with skin and fat from the lower abdomen, which feels very natural for the patient. It also ‘ages’ much like a natural breast. If a patient gains or loses weight, the flap tissue fluctuates with the body over time, resulting in long-lasting symmetry.”

The second benefit of flap surgery is that it doesn’t use implants that require a lifetime of annual visits for imaging and assessment.

“Implant reconstruction is a great option for many people, but we need to remember that they are manmade products that will undergo normal wear and tear,” Dr. Caterson said. “If the outer lining of an implant breaks, it should be replaced. We recommend annual clinic visits to monitor the implants, and after five years, we start performing implant imaging to ensure the implant is intact. With implants, there is the lifetime risk of potentially having multiple surgical interventions. There is not a lot of maintenance surgery that goes with flap surgeries.”

Third, flap surgery is a better option for patients who have undergone, or are going to undergo, radiation for their breast cancer treatment.

“Implants and radiation basically don’t get along very well,” Dr. Caterson noted. “With radiation, sometimes scar tissue can build up around the implant, or the skin around the implant can really tighten up and change the shape, look and feel of the implant. We often recommend flap reconstruction after radiation to bring healthy tissue into the radiated field.”

Dr. Caterson pointed out that ChristianaCare offers the full range of breast reconstruction options, from implant reconstruction all the way through the complex tissue reconstructions. She said flap surgery isn’t for everyone, as it involves longer procedure and recovery times than implant surgery.

The most common type of flap surgery is the deep inferior epigastric perforator (DIEP) flap, which uses the lower abdominal skin and fat to reconstruct the breast. DIEP flap surgeries can take between four to eight hours for one breast or eight to 12 hours for two breasts. A patient must be otherwise healthy to be considered a good candidate for this long procedure.

“Basic implant reconstruction may be one or two additional hours if you are doing it at the same time as the mastectomy,” Dr. Caterson said. While an implant surgery involves one night in the hospital and then usually a three-week recovery, DIEP involves three to four days in the hospital and six to eight weeks recovery time, she added.

“What sets our group apart is that each of our fellowship-trained microsurgeons offers the full range of breast reconstruction options, creating personalized surgical plans tailored to each patient’s medical needs and personal preferences.” Dr. Caterson noted.

Another unique part of the breast reconstruction care practice at ChristianaCare is the team approach with surgeons, physician assistants, schedulers, office staff and medical assistants all working together cohesively.

“I can’t tell you how proud I feel when I’m sitting in my office and I overhear a patient stop at our medical assistant’s desk on the way out to thank them for being so kind and supportive, or helping them with their drain, or whatever it might be,” Dr. Caterson recounted. “A breast cancer diagnosis is often the most challenging thing a woman has gone through in their life, and we would like our office to be a support system for them. We try to be the silver lining of what they have gone through

Robotic technology allows colorectal surgeons at ChristianaCare to perform complex abdominal surgeries to treat patients and save lives. Indeed, the techniques enabled by robotics can improve patient outcomes and reduce costs of care.  

Caitlyn M. Costanzo, MD, is a distinguished general and colorectal surgeon at ChristianaCare. She performs a wide variety of surgical procedures for the treatment of benign and malignant colorectal pathology. This includes segmental small and large bowel resections, low anterior resections (LAR), abdominoperineal resections, and complex reconstructions to restore bowel continuity. In the past, Dr. Costanzo primarily used laparoscopy for her procedures. Now, she has successfully incorporated the da Vinci Xi (Intuitive Surgical) surgical technology into her surgical practice.

The da Vinci Xi is a robotic surgical system that includes a patient cart that consists of four surgical arms and a surgeon console, where Dr. Costanzo sits and controls the robotic arms. The enhanced technology enables surgeons to visualize human anatomy in high-definition 3D. The surgical arms have multiple degrees of freedom and have built-in tremor-filtration technology.  With the assistance of Firefly fluorescence imaging, Dr. Costanzo can identify important anatomy and ensure that the blood supply to the intestine is adequate for healing.

“Robotic surgical technology can improve patient outcomes by reducing intestinal manipulation,” she explained. “The entire surgery can be performed within the abdominal cavity, which allows patients to recover bowel function sooner.”  

What Dr. Costanzo is referring to is an intracorporeal anastomosis, or ICA. Once a segment of intestine is removed, the restoration of bowel continuity is performed in the abdomen, so that there is no exposure of bowel to the outside environment. The reduction of external intestinal manipulation allows patients to have a quicker return of bowel function and thereby a shorter length of stay. Dr. Costanzo’s robotic surgery patients leave, on average, 1.5 days sooner than laparoscopic patients. 

The robotic platform is especially helpful in certain patient populations. When the human anatomy makes it difficult to see or feel, the robotic technology enables surgeons to work in confined spaces, for example deep in the pelvis. Additionally, the ability to restore intestinal continuity while inside the abdomen means that the challenges of being able to deliver the intestine outside of the body are obsolete.

“Surgical technology is always advancing, yet I believe that robotics has proven to be the biggest advancement during my generation of surgery,” said Dr. Costanzo.

She is excited to be able to offer this modality to her patients.  

With all the hype surrounding the new weight-loss medications, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), clinicians may be getting questions from patients about treating morbid obesity via pharmacotherapy versus bariatric surgery. So, what can—and should—clinicians tell these patients?

“Medications are for short-term weight loss, are more expensive, have less of an effect and they provide less sustainability,” said Mingwei Ni, MD, a bariatric surgeon at ChristianaCare. “Bariatric surgery is obviously more invasive, but it is more effective in the treatment of morbid obesity and its associated diseases. Surgery works much faster than medication and will maintain weight loss for a lifetime. Patients who undergo bariatric surgery will lose 60% to 70% of their excess body weight versus 20% to 30% with medication. That is a huge difference.”

Roughly one-third of Americans are obese, and more than half of these people are considered morbidly obese (body mass index, ≥40 kg/m²). Morbid obesity is one of the main causes of many chronic and life-threatening diseases, including hypertension, type 2 diabetes, stroke, coronary artery disease, heart failure, kidney failure and peripheral vascular disease. Morbid obesity is also a very strong risk factor for numerous types of cancer, including breast and colon cancer.

Weight-loss medications have been on the market for 30 years, with many of the older drugs working by, for example, suppressing the absorption of fat or by increasing metabolism. The GLP-1 RAs, currently injectable medications, work by making the stomach wall move less, thus keeping food in the stomach longer. The result is that people feel full very quickly and are less hungry.

The two most common options for bariatric surgery are sleeve gastrectomy and gastric bypass. While bariatric surgery can treat the medical comorbidities that are associated with morbid obesity, the GLP-1 RAs are only able to treat diabetes—and not as well as bariatric surgery.

“Weight-loss surgery will help you lose weight in order to treat comorbidities such as diabetes, hypertension and sleep apnea, and will prevent heart attack and stroke,” Dr. Ni said. “The newer weight-loss medications don’t really treat these medical comorbidities, and the medications can cause GI symptoms that people can’t tolerate, such as stomach pain, nausea, vomiting, diarrhea and heartburn.”

Surgery also has a much higher chance of bringing patients’ BMI back to a healthy level. Of note, the weight loss is a more sustainable option compared with weight-loss medications. For example, with the GLP-1 RAs, when patients stop using them, they usually gain the weight back.

“Bariatric surgery will hopefully last a lifetime, especially if the patient is willing to change their lifestyle and work with a dietitian,” Dr. Ni said.

The new weight-loss medications are also very expensive at roughly $1,000 per month per patient, he added.

“The cost of surgery is much lower and insurance covers it,” Dr. Ni said. “The copay out of pocket depends on insurance, but Medicaid and Medicare almost cover 100%.”

That said, sometimes both bariatric surgery and weight-loss medications are used concomitantly.

“Weight-loss treatment can be a combination of the medication, surgery and lifestyle changes such as diet and exercise,” Dr. Ni noted. “It’s a really multidisciplinary approach to treat this disease.”

At ChristianaCare, a team approach is used to treat a patient with morbid obesity.

“It’s very important to work with a well-trained experienced team of dietitians, psychologists, a physician who will optimize the patient for surgery, bariatric surgeons, a nurse practitioner who can follow the patient long term and a support group for patients to attend before and after surgery,” Dr. Ni explained.

For example, ChristianaCare offers free online educational seminars for patients given by two bariatric surgeons. They also offer a 174-page healthy recipe book on the ChristianaCare bariatric website, which is free for download.

“In general, weight-loss surgery is as safe as gallbladder surgery or knee replacement surgery. It’s a small incision to do the surgery,” Dr. Ni said. “We offer outpatient sleeve gastrectomy for patients with suitable indications.”

Dr. Ni added that all patients undergoing bariatric surgery go home without the need for narcotics. “Pain is usually controlled by non-narcotic medications such as [acetaminophen] and a muscle relaxant,” he said. “Bariatric surgery is a very good and a very safe option.”

Bariatric surgeons at ChristianaCare are using weight-loss procedures as a tool for patients with obesity to foster improved health metrics across a number of disease states.

Patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy have not only lost weight but have also seen positive improvements in comorbid type 2 diabetes, hypertension, and cardiovascular and kidney disease, as well as reduced levels of low-density lipoprotein (“bad cholesterol”) and hemoglobin A1c. Many of these patients have struggled maintaining a healthy weight despite other interventions such as exercise programs, dietary changes and even medications, according to Elizabeth McCarthy, MD, a minimally invasive bariatric surgeon at ChristianaCare.

“For a lot of patients, bariatric surgery is the last stop in their weight-loss journey,” Dr. McCarthy said. “They have been living with obesity for some time and are dealing with a number of health complications as a result. Some have even been told they will die unless they lose weight and have the surgery. Our goal at ChristianaCare is to guide these patients and their families through surgery, and we provide them with support before, during and after their procedures to help them get the best results.”

Because of type 2 diabetes, cardiovascular disease, kidney disease and hypertension, among other potential health problems, many patients undergoing bariatric procedures—most of which involve sleeve gastrectomy at ChristianaCare—are on multiple medications before surgery. However, after surgery, most patients can expect to take medications at lower doses or come off them altogether, according to Dr. McCarthy.

However, management of these patients doesn’t stop immediately after surgery. In fact, patients are monitored postoperatively for an indefinite period to ensure they are maintaining a healthy weight and still doing well with any comorbid conditions, she said.

“If they are struggling with weight, even postoperatively, we provide them with the education and resources they need to get back on track,” she added.

This education is actually a continuation of the patient instruction that begins preoperatively. Before surgery, patients typically meet with a nutritionist to review their diet and a psychiatrist to assess for underlying disordered eating or mental health conditions that may contribute to weight gain or hinder weight loss.

In addition, ChristianaCare has developed an online seminar that patients are encouraged to view before their initial surgical consultation. It reviews what to expect in the lead-up to surgery, during the procedure and after it. Primary care physicians and practitioners should encourage patients who are interested to sign up and learn more about bariatric surgery, Dr. McCarthy said.

On top of that, bariatric surgery patients at ChristianaCare are required to take several virtual classes, via Microsoft Teams, delivered by the Weight Management team. These classes advise patients on diet and exercise and, in general, “how to stay committed and engaged in their health journey” after surgery, Dr. McCarthy explained. “There’s a lot of work that’s involved getting to surgery, and it can take up to a year.”

That said, the goal is not to make the process more difficult; rather, it’s designed to ensure success. Currently, bariatric surgery is recommended for adults with a body mass index more than 35 kg/m² and a medical comorbidity such as type 2 diabetes, hypertension and sleep apnea, as well for those with a BMI greater than 40 kg/m², as they are at increased risk for these and other comorbidities, including infertility and polycystic ovary syndrome. However, less than 1% of patients who meet the criteria for surgery nationally ultimately are referred for these procedures.

“A lot of that is due to the stigma surrounding obesity,” Dr. McCarthy explained. “That’s why it’s so important for us to create an environment where patients feel supported.”

Some of that support is provided by the patients themselves. The bariatric surgery team at ChristianaCare oversees a monthly online support group led by patients who have had the procedure within the system and includes topics from the team’s dietitians, surgeons and other providers directly involved in the bariatric patient’s care.

“Patients share their experiences and encourage each other to maintain a healthy lifestyle and get the most from their surgery,” Dr. McCarthy said. “Surgery is a great tool to get you where you want to go, but it’s just that: a tool. Patients will need to keep working to be successful, and being successful requires support. That’s why we strive to have an excellent supportive practice with a multidisciplinary team that works with all of our patients preoperatively and postoperatively. That separates ChristianaCare from a lot of surgical practices.”

When a patient presents with complicated diverticulitis—with perforation, abscess, obstruction and/or fistula—to ChristianaCare, admission to the hospital is usually required.

Indeed, if the patient has peritonitis, surgical removal of a portion of the colon is required. Traditionally, this would entail removal of the sigmoid colon and creation of a colostomy. More recently, however, research has shown that it is safe and effective to remove the sigmoid colon and divert stool via an ileostomy, according to David C. Palange, DO, a colon and rectal surgeon at ChristianaCare’s Helen F. Graham Cancer Center and Research Institute. At ChristianaCare, this procedure is performed using state-of-the-art tools and approaches.

“If you become my patient, particularly for elective procedures, you’re getting a robotic or laparoscopic surgery with all incisions the size of my thumbnail,” Dr. Palange said. “Through minimally invasive techniques for robotic-assisted or laparoscopic surgery, you definitely decrease the chances of wound infection and pain.”

In fact, with the use of the robot, “the surgeon can suture and staple and perform other tasks” more quickly and accurately, reducing the risk for postoperative infection, time under anesthesia and other potential complications, he added.

A colostomy reversal remains a challenging procedure due to residual scar tissue. In contrast, ileostomy reversal is relatively easy for the surgeon to perform. As a result, with ileostomy a patient can anticipate a fuller recovery, restoring normal bowel movements, according to Dr. Palange.

Patients undergoing colostomy have about a 50% chance for reversal, but the percentage with ileostomy is much higher, he said.

Recovery times from surgery for complicated diverticulitis vary, Dr. Palange added. If a minimally invasive surgery is performed using enhanced recovery after surgery protocols, a patient typically stays in the hospital two to five days, with recovery expected to take two weeks and complete healing taking place within six weeks. With open procedures, hospital stays and recovery and healing times are much longer, Dr. Palange said.

Generally, about one in four patients with diverticulitis develop complicated disease. For the far more common uncomplicated, non-severe form of the condition, which involves localized inflammation of the diverticulum, a more conservative treatment approach is used.

Traditionally, uncomplicated diverticulitis has been managed with antibiotics and a liquid diet, and most patients recover at home without hospitalization. However, at ChristianaCare, Dr. Palange and his colleagues adhere to updated guidelines from the American Gastroenterological Association, which recommend “selective, rather than routine, antibiotic use in immunocompetent patients with mild disease.”

While antibiotics have long been the first-line therapy for acute uncomplicated diverticulitis, recent evidence suggests there is no benefit from their use in immunocompetent patients with mild acute uncomplicated diverticulitis, according to Dr. Palange.

“Historically, the use of antibiotics for acute cases has been in response to what was believed to be an immediate infection, but it is now understood that it’s the inflammation and not the infection that causes the symptoms,” he said. “This newer approach of selective use of antibiotics has not yet been widely adopted, but we’re using it here to prevent overuse of antibiotics, which can later lead to resistance and unnecessary side effects.”

Dr. Palange added: “Colonic diverticulitis remains a painful, unpredictable gastrointestinal disease that can lead to serious complications, chronic symptoms and poor quality of life. At ChristianaCare, we strive to use the latest, evidence-based approaches to give our diverticulitis patients the best possible outcomes.”

Evolving screening techniques, coupled with minimallyinvasive surgical solutions, are allowing physicians at ChristianaCare to look beyond gallstones in caring for patients with abdominal pain.

“We used to always think there was only one issue with the gallbladder—gallstones,” said Michael B. Goldberg MD, a minimally invasive surgeon practicing at ChristianaCare. “Now we know that it’s not actually only gallstones that give people gallbladder symptoms and upper right quadrant pain. There is much more to it.”

Patients experiencing this type of pain, which is often quite debilitating, may have biliary dyskinesia, a condition in which the gallbladder is not squeezing as hard or as fast as it should. Biliary dyskinesia can result in insufficient amounts of bile being ejected from the gallbladder into the small intestine.

Conversely, some patients may also have biliary hyperkinesia, when the gallbladder squeezes too fast and too hard, causing recurring biliary colic.

Both conditions can cause significant pain and discomfort. However, when testing indicates no presence of gallstones, patients’ pain would often go untreated.

“People who were suffering from right upper-quadrant abdominal pain and the inability to tolerate meals would get an ultrasound and it would look normal—with no gallstones—and we thought that was the end of the story,” Dr. Goldberg said.

Now, hepatobiliary iminodiacetic acid (HIDA) scans allow for far more detailed review of gallbladder function, enabling specialists to more properly identify the cause of their patients’ symptoms.

“The HIDA scan can show us exactly how the gallbladder is functioning, and allows for more investigation in order to help our patients who are experiencing gallbladder symptoms without gallstones,” Dr. Goldberg said.

If the gallbladder is determined to be functioning incorrectly and needs to be surgically removed, current techniques allow for far easier procedures with greatly reduced recovery times.

“We use the latest minimally invasive techniques including laparoscopic and robotic surgery with smaller incisions,” Dr. Goldberg said. “It used to be that people needed to stay in the hospital when they had gallbladder surgery. Now it is done on an outpatient basis.”

Most people are able to manage the discomfort of gastroesophageal reflux disease (GERD) with lifestyle changes and medications. However, patients who have failed medical management or who don’t want to be on proton pump inhibitors, due to potential side effects, are candidates for surgery, according to Anthony R. Tascone, MD, a bariatric and foregut surgeon at ChristianaCare.

Other patients should be considered candidates for a surgical intervention are those who have Barrett’s esophagus, esophagitis or stricture from changes in their esophagus from reflux, he said. For all surgery patients, Dr. Tascone and his colleagues are using state-of-the-art procedures to achieve optimal outcomes in GERD.

For decades, fundoplication has been the gold standard for GERD surgery. During the procedure, the surgeon takes the top part of the stomach and wraps it around the bottom of the esophagus, with the goal, essentially, of bolstering the lower esophageal sphincter (LES). The procedure can entail a partial or total (Nissen) wrap, depending on the severity of esophageal motility.

Today, these procedures are minimally invasive and many surgeons at ChristianaCare are performing GERD surgeries robotically. Following surgery, most patients see improvement in their symptoms and can either be taken off medications completely or continue them at lower doses. More than four in five patients undergoing these procedures will see complete resolution of symptoms, with no need for medication.

“There are pluses and minuses to each of these approaches while the surgical outcomes for both are excellent,” Dr. Tascone said. “An important benefit of fundoplication is that the patient’s native tissue is used.”

Another GERD procedure performed at ChristianaCare involves implantation of the LINX reflux management system (J&J Med Tech), a novel device composed of a ring of magnets designed to strengthen the LES. Following surgical insertion, the LINX device is in the “closed position most of the time” to keep acid in the stomach, according to Dr. Tascone.

“The LINX has the ability to open and close so that food and drink can pass through it and patients can burp or vomit, as needed, when air forms in the stomach,” he said. “That is harder to do following fundoplication.”

In general, outcomes following LINX implantation are similar to those for fundoplication, which research leads to improved symptom control and quality of life in 90% of patients.¹ Still, a downside of LINX is that up to 40% of patients develop dysphasia during the few months following the procedure.²

Another recent addition to the surgical armamentarium for GERD at ChristianaCare is gastric bypass, particularly for patients with elevated body mass index. In addition to treating GERD, gastric bypass helps treat common comorbidities, including hypertension, type 2 diabetes, obstructive sleep apnea, and hyperlipidemia, by fostering weight loss.

“So, patients will get more bang for their buck when undergoing gastric bypass surgery,” Dr. Tascone said. “The outcomes for all of these procedures are very similar, though recovery is slightly different for each option. Laparoscopic surgery has a quicker recovery time and less pain than open surgery. The primary care doctor and the surgeon can work together to help decide which is best for the patient.”

References

1. John M, Irvine T, Thompson SK, et al. Antireflux surgery in patients with gastroesophageal reflux but a negative 24-hour pH study—late outcomes. J Gastrointest Surg. 2024:S1091-255X(24)00449-9.
2. Fadel MG, Tarazi M, Dave M, et al. Magnetic sphincter augmentation in the management of gastro-esophageal reflux disease: a systematic review and meta-analysis. Int J Surg. 2024 May 9.

At The Hernia Center at ChristianaCare, surgeons are using innovative technological approaches, paired with highly customized individual care plans, to provide cutting-edge treatment. The approach allows for low-risk procedures with faster recovery times, for patients with either minor or major surgical needs.

“Historically, patients have been a bit wary of hernia surgery for lots of different reasons,” said Peter M. Santoro, MD, the director of robotic surgery and medical director of The Hernia Center at ChristianaCare. “They may have heard from a friend or family member how painful it was, or how hard it was to recover from the procedure. Maybe they know people who had issues with mesh or other complications from their surgery.”

Much of this, according to Dr. Santoro, was due to the fact that hernia repair has often required open surgery necessitating large incisions. Too frequently, this meant that patients were faced with complicated procedures, long hospital stays and often painful, time-consuming recoveries.

However, over the past two decades, minimally invasive techniques have revolutionized many surgical specialties, hernia care included. As technology has rapidly advanced, developments in robotic surgery have allowed for previously unthinkable improvements in both surgical accuracy and patient recovery.

“From the smallest hernias to the most complex cases that require abdominal wall reconstruction, we’ve been able to move from big-incision operations to minimally invasive surgery,” Dr. Santoro said. "A huge part of that has been the advancement of robotic surgery, which has taken hernia treatment to a level that has never previously been seen, from a technical standpoint, as well as through patient satisfaction and recovery. It’s changed the way we take care of patients with hernias.”

The most recent advancement has been in the management of complex ventral hernias, which require abdominal wall reconstruction via transversus abdominis release (TAR) procedures.

“These TAR procedures traditionally could only be conducted as an open operation, and were reserved for the most complex ventral abdominal wall hernias,” Dr. Santoro said. “The postoperative course was typically very rocky, with significant complications on a fairly routine basis.”

Now, robotic abdominal wall reconstruction via the robotic TAR procedure has enabled surgeons to adopt novel techniques in order to vastly minimize the risks associated with these procedures.

“Robotic TAR has completely revolutionized the way we deal with complex abdominal wall hernias and abdominal wall reconstruction,” Dr. Santoro said. “It’s taken an operation that was associated with about a week-long hospital stay, with a high risk of perioperative complications, and reduced it to an overnight stay with very rare incidence of complications and a much easier recovery course for the patient.”

Currently, most patients undergoing hernia repair surgery—particularly when robotic techniques are used—can expect a same-day discharge from the hospital and a speedy return to normal activities.

“A minor subset of patients may require a one-night stay in the hospital, but the vast majority will be able to go home the same day,” Dr. Santoro said.

In addition, unlike with open procedures, postoperative pain following minimally invasive surgery can frequently be managed without the use of opioids or other narcotic medications. While heavy lifting and strenuous physical activity is typically limited for a four-week period, patients can expect to be up and about within hours of their procedure, a fact that strongly benefits the recovery process.

“I expect patients to be walking around, going up and down stairs, getting in and out of the car even the same day as the operation, and certainly by the next day,” Dr. Santoro said. “We don’t want patients to be sedentary after surgery.”

As the exact needs of patients depend upon multiple factors, Dr. Santoro and his colleagues put great effort into developing and communicating plans that are unique to each person.

“With hernia surgery, the surgical process is very patient-specific,” Dr. Santoro said. “It’s a highly tailored approach even compared with other types of medicine. Every patient that has a hernia is different, and we take a very individual approach for every patient. We provide comprehensive hernia care for the state of Delaware and the surrounding areas, and medical personnel should feel very confident that their patients will be well taken care of.”

For patients with uveitis, a rare inflammatory eye disease that can lead to blindness, advances in diagnosis and treatment are allowing for lessened therapeutic burden, with fewer side effects.

“Typically, we think of uveitis as having either infectious or noninfectious causes,” explained Benjamin C. Chaon, MD, medical director of the Wilmington Eye Clinic at ChristianaCare and an ophthalmologist who specializes in treating patients with ocular inflammatory and retinal diseases. “Uveitis can be associated with infections, such as syphilis, toxoplasmosis, or Lyme disease, or it can be noninfectious and associated with an underlying systemic autoimmune disease like sarcoidosis, rheumatoid arthritis, or inflammatory bowel disease. Or, it may not be associated with any underlying systemic disease and just impact the eye, such as Birdshot Chorioretinopathy.”

While the various types of uveitis share the basic feature of inflammation occurring in the vascular structures of the eye, the wide variety of causes can complicate diagnosis.

“The most important distinction we make in the initial diagnosis of uveitis is whether it’s infectious or noninfectious,” Dr. Chaon said. “Sometimes this can be difficult to determine, particularly if a patient develops uveitis following cataract surgery or another type of ocular surgery.”

In recent years, advancements in metagenomic deep-sequencing technology have helped to ease the diagnostic process. This technique allows ophthalmologists to take a small sample of fluid from the front part of the eye during a patient’s clinic visit and conduct testing to determine whether there is the presence of bacteria or fungus.

“This was not always possible in the past, as we often needed larger sample volumes to culture,” Dr. Chaon said. “This was difficult to do from the eye, as it is such a small space. This new technology allows us to more readily make the diagnosis of an infectious uveitic condition. That has been an exciting development in the field of uveitis in the last few years.”

Treatment, too, has advanced, moving beyond the use of corticosteroids. The advent of biologic therapies for the management of uveitis has allowed specialists to significantly decrease their reliance on steroids.

“It used to be that corticosteroids were the mainstay of uveitis treatment, but steroids have a lot of systemic side effects,” Dr. Chaon said. “Biologics are medications we use for patients with other rheumatologic conditions, such as adalimumab or infliximab, which target specific inflammatory molecules. Often these medications are helpful with getting control of the uveitis and allowing us to get patients off of—or to a lower dose of—steroids.”

Advances in regional steroid therapy have also allowed for more targeted treatment options with potentially fewer systemic side effects. For patients with vision-threatening complications of uveitis like macular edema, ophthalmologists historically relied on periocular steroid injections into the sub-Tenon’s space around the eye, with patients often requiring treatment every three to four months.

Recent data from the PeriOcular versus INTravitreal Corticosteroids for uveitic macular edema or “POINT” trial¹ has demonstrated that intravitreal delivery of steroid medication directly into the vitreous cavity is superior to periocular steroid injections in the improvement and/or resolution of macular edema.¹ Still, patients being treated with an intravitreal steroid medication, like the dexamethasone intravitreal implant (Ozurdex, Allergan), may need injections every few months, which can be quite burdensome, particularly for working-age individuals that uveitis disproportionately effects.

“That’s a lot of injections for patients, and every injection in the eye carries with it a small risk of infection,” Dr. Chaon said.

In contrast, the intravitreal steroid injection Yutiq (fluocinolone, Alimera Sciences) can provide up to 36 months of inflammation control in one dose. Another new medication called Xipere (triamcinolone, Bausch & Lomb) uses a novel drug delivery mechanism to allow the steroid to be injected into the suprachoroidal space—the area between the choroid and the sclera. Research has shown that this approach may result in more effective control of inflammation and a lower risk of increased intraocular pressure.

Although those with uveitis may require regular clinical visits to monitor their disease, reducing the frequency of injections can result in greatly increased patient satisfaction.

“In a lot of cases, uveitis tends to be a chronic disease, and patients do tend to need chronic treatment,” Dr. Chaon said. “So, treatment options that may lessen their treatment burden can be a big relief.”

Reference

1. Thorne JE, Sugar EA, Holbrook JT, et al; Multicenter Uveitis Steroid Treatment Trial Research Group. Ophthalmology. 2019;126(2):283-295.

A partnership between ChristianaCare cardiologists and oncologists is enhancing heart care for breast cancer patients receiving high-risk chemotherapy.

The Cardio-Oncology Program was established five years ago by physician leaders from the health system’s Women’s Cardiology Clinic and the Helen F. Graham Cancer Center & Research Institute to prevent and effectively treat cardiotoxicity in breast cancer patients on chemotherapy. The program also sees women with lymphoma and ovarian and uterine cancers who receive high-risk chemotherapy and need to be monitored for cardiotoxicity.

There is a growing need for ongoing patient surveillance because of the emergence of new chemotherapy drugs that can cause cardiotoxicity, and because breast cancer survivors are living longer and dealing with the lasting effects of treatment, according to Dr. Horn.

“Fortunately, there are a number of actions cardiologists can take to address the complication, including prescribing medications, recommending adjustments to care plans and suggesting lifestyle modifications,” Dr. Sernyak noted. “Sometimes, chemotherapy can even be paused to give the heart time to recover from cardiotoxicity, and then resumed so treatment can be completed.”

At ChristianaCare, the Cardio-Oncology Program is structured with patient convenience and efficiency in mind. When women receive a referral, clinic staff schedule appointments for them to have an echocardiogram and see a cardiologist within one week to avoid any delay in the start of their chemotherapy.

“The appointments happen on the same day,” Dr. Sernyak explained. “First, they have their echo and immediately afterward they meet with a doctor to review their results and discuss appropriate next steps based on the findings.”

Patients then return for follow-up testing every three months and appointments with a cardiologist every six months throughout their chemotherapy regimen and beyond to evaluate their heart function and identify and treat any cardiotoxicity that may develop, Dr. Horn added.

Program cardiologists keep referring physicians closely up to date on patients’ status through the ChristianaCare electronic medical record system and personal consultations.

“We emphasize building strong, collaborative working relationships,” Dr. Sernyak said. “The oncologists appreciate the expertise our cardiologists bring to the care team, which enables them to focus on treating breast cancer. It’s a partnership designed to deliver an exceptional patient experience and achieve the best possible medical outcomes.”

To refer a patient to the Cardio-Oncology program at ChristianaCare, please call (302) 623-1929 or fill in the form on this page.

At least 6.5 million people aged 40 years and older in the United States have peripheral artery disease (PAD). Like many chronic cardiovascular conditions, the prevalence of PAD increases with age: By age 70, more than 10% of men and nearly 10% of women will be diagnosed with the disorder. By age 80, those figures increase to more than 25% and 20%, respectively.¹

PAD’s most severe manifestation is critical limb ischemia (CLI). Recent research indicates that as many as 1 in 4 people who develop CLI will have an amputation within one year of their diagnosis.² A 2021 study found that the rate of hospital admissions for CLI increased from 0.9% to 1.4% between 2011 and 2017, while PAD admissions nearly doubled, going from 4.5% to 8.9%, over the same period.³

Both the equipment and surgical techniques used to manage PAD and CLI are rapidly evolving. One of the most novel therapies now available at ChristianaCare is transcatheter arterialization of deep veins (TADV), which is used to treat patients with the most severe CLI who have run out of revascularization options. TADV is designed to reestablish blood flow by diverting arterial flow from the tibial artery to deep veins in the foot.

“We connect the vein to the artery and backfill the tissues of the wound to get oxygen to that area,” Dr. Leung explained. “With advances like these, as well as increased awareness among referring physicians to send their patients to specialists like our team if they have PAD, I believe we are making progress in reducing the number of amputations that are done.”

He continued: “This is a rapidly evolving field with lots of innovations and novel devices and, at ChristianaCare, our patients have access to those options, including investigational procedures in clinical trials. We are involved in the development of complex revascularization techniques, such as pedal access and pedal loop revascularization to treat the very small arteries in the foot. Even though this is not generally done that frequently, it is something we do here on a routine basis.”

ChristianaCare was also involved in the trials introducing drug-eluting balloons and drug-eluting stents, which had become common in the treatment of cardiovascular disease, to treat peripheral vascular disease.

“This is now standard of care, but our patients had access to these technologies in trials before they were commercially available,” said Dr. Leung, who also stressed the importance of podiatry and wound care in the management of these patients. “Our team of vascular interventionalists regularly visits our affiliated off-site wound care center to evaluate patients for surgery, as it is more convenient for patients to be seen there.”

The interventional vascular team works closely with ChristianaCare’s team of vascular surgeons and a multidisciplinary group of experts including infectious disease physicians, endocrinologists and nephrologists, as well as the many podiatrists who work in the area. In addition, cardiologist Vikash Rambhujun, MD, has returned to ChristianaCare after a one-year fellowship at Yale University Hospital, where he studied vascular medicine and procedural care of PAD. His work is expected to complement that of the others on the multidisciplinary team.

“We also partner with primary care physicians to raise awareness,” Dr. Leung said. “Many of the patients we see have come into the emergency department with disease that is already quite advanced. By working with primary care and family practice and encouraging them to send patients to us early on, we can improve their outcomes.”

To refer a patient with Peripheral Artery Disease to ChristianaCare, please call (302) 733-5625 or fill in the form on this page.

References

1.     CDC. Peripheral arterial disease (PAD). Accessed May 13, 2024. https://www.cdc.gov/heartdisease/PAD.htm#

2.     Mustapha JA, Saab FA, Ranger WR, et al. Treatment of peripheral artery disease and critical limb ischemia: an observational Michigan Medicare analysis. J Crit Limb Ischem. 2023;3(2):E56-E63.

3.     Anantha-Narayanan M, Doshi RP, Patel K, et al. Contemporary trends in hospital admissions and outcomes in patients with critical limb ischemia: an analysis from the National Inpatient Sample Database. Circ Cardiovasc Qual Outcomes. 2021;14(2):e007539.

“The preservation of sexual function is a major factor for men in choosing PAE,” Dr. Grilli said. “Many also prefer the procedure over surgery because it doesn’t involve the insertion of a scope into the urethra and is substantially more comfortable for the patient.”

ChristianaCare closely monitors the effectiveness of PAE by surveying patients before and multiple times after the procedure. The results show 95% of patients report significant improvement in their BPH symptoms.

Dr. Grilli is part of a highly skilled team of four vascular interventional radiologists at ChristianaCare who specialize in performing PAE with the latest equipment and technology. Together, they perform a high volume of the procedures, which translates to greater clinical expertise and better patient outcomes.

“As a doctor, it’s very gratifying to be able to help men regain normal urinary function and experience improved quality of life,” he said.

To refer a patient for Prostate Artery Embolization at ChristianaCare, please call (302) 733-5625 or fill in the form on this page.

Atrial fibrillation, or Afib, is a heart arrhythmia associated with an increased risk for stroke, heart failure and other cardiovascular comorbidities. It is more commonly diagnosed in men and those of advancing age; roughly three-fourths of those with the condition are 65 years or older. Up to 6.1 million people in the United States have Afib, a figure that is projected to reach nearly 12 million by 2030.¹

Because of patients’ increased risk, it is imperative to mitigate any structural issues with the heart that can lead to stroke, according to Kevin Tsai, MD, a clinical cardiac electrophysiologist at ChristianaCare.   

“The irregular heart rhythm in Afib can cause blood to pool in the left atrial appendage (LAA), a small pouch in the upper left chamber of the heart, which increases the risk of clot formation,” Dr. Tsai said. “If a clot dislodges and travels through the bloodstream to the brain, it can cause a stroke.”

When patients with Afib arrive at ChristianaCare, clinicians assess for symptoms and treat risk factors associated with the condition, including hypertension, heart disease, diabetes, obesity, alcohol/tobacco use and sleep apnea. Patients’ stroke risk is assessed by a score calculated using multiple risk factors, including presence of congestive heart failure, hypertension and diabetes as well as history of stroke and vascular disease, among other factors, according to Dr. Tsai.  

Anticoagulants (blood thinners) are traditionally prescribed to reduce patients’ stroke risk. However, in patients unable to tolerate long-term anticoagulants, perhaps due to fall or bleeding risks, ChristianaCare offers occlusion of the LAA, which has been shown to be effective in reducing Afib-related stroke.²

In addition, treatment of Afib focuses on controlling heart rate or rhythm. The aim is generally to control heart rate without converting Afib to a normal rhythm. This treatment is commonly used for patients who tolerate Afib well without symptoms. Rhythm control aims to restore and maintain normal rhythm and is commonly used for patients who have limiting symptoms from Afib.

“Roughly 20% of patients with Afib have no symptoms and, for them, we typically employ the rate control strategy,” Dr. Tsai said. “However, the remaining 80% have symptoms that can greatly diminish quality of life, such as palpitations, shortness of breath and fatigue. Rhythm control strategy is used in these patients to reduce the overall Afib burden by modifying electrical properties of the heart with antiarrhythmic medications and/or catheter-based ablations.”

Although catheter ablation has been shown to be more effective in maintaining normal rhythm, antiarrhythmic medication is currently first-line therapy, according to Dr. Tsai. In patients with Afib that is refractory to antiarrhythmic therapy, catheter ablation can be considered. (Future guidelines may change with recent large clinical trials showing favorable results with the approach; it currently has a class Ia indication with reduction in mortality in patients with heart dysfunction and heart failure due to Afib.)

Generally, the goal of ablation is to disable the cells in the heart that are responsible for triggering and propagating Afib. Two common ablation methods are cryoablation (freezing these cells) or radiofrequency ablation (heating the cells). Both approaches are offered at ChristianaCare, and they can be performed safely and effectively as outpatient procedures.

In cryoablation, electrophysiologists use a balloon catheter to freeze the targeted heart cells, disabling their ability to transmit electrical currents. This procedure can be tricky, however, because if the seal between the balloon, which contains nitrogen refrigerants, and the cardiac tissue isn’t closed, the flow of warm blood can make the procedure less effective, according to Dr. Tsai. The freezing strategy, although mostly safe, can damage nearby structures.

In radiofrequency ablation, electrophysiologists use a catheter to deliver heat to the targeted cardiac cells, rendering them unable to transmit electrical signals. This heating strategy, in rare cases, can also cause collateral damage to nearby structures, Dr. Tsai said.

The most recent advancement in Afib is pulsed-field ablation (PFA), which was approved by the FDA in December 2023 and involves a large electrical current (1 microsecond in duration) that causes cardiac cells to undergo apoptosis. ChristianaCare is expected to begin offering PFA within the next year, and Dr. Tsai believes it will change the treatment landscape of rhythm control for Afib.

“The benefit of PFA is that different tissues in your body absorb the electrical field at different amplitudes,” Dr. Tsai explained. “You can deliver PFA and it will only affect the cardiac cells without adverse effects to nearby structures, including the esophagus, arteries/veins and the phrenic nerve.”

To refer a patient with Atrial Fibrillation to ChristianaCare, please call (302) 623-1929 or fill in the form on this page.

References

1.     Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142-1147.

2.     Moras E, Gandhi K, Yakkali S, et al. Left atrial appendage occlusion as a strategy for reducing stroke risk in nonvalvular atrial fibrillation. Cardiol Rev. 2024 Jul 30. doi:10.1097/CRD.0000000000000757

ChristianaCare’s new multidisciplinary Center for Aortic Health brings together some of the region’s leading subspecialty experts in cardiovascular care, including vascular surgeons, cardiologists, cardiothoracic surgeons, interventional radiologists and others, to centralize the care of patients with aortic disease and improve their outcomes.

“Aortic pathology requires specialized management, and we provide the most optimal care for these patients when we work together seamlessly,” said one of the Center’s co-directors, vascular surgeon Kathryn E. Bowser, MD. “There are cutting-edge developments constantly going on in this field, and a center like this one is needed to give patients the best options.”

Led by Dr. Bowser, preventive cardiologist Stephen Meng, MD, and cardiothoracic surgeon J. Daniel Robb, MBBS FRCS, the Center proactively identifies patients with aortic pathology such as aortic aneurysms and aortic dissection before these conditions become emergent; provides them with the latest in medical, surgical and endovascular management; and maintains ongoing coordinated longitudinal care for months and years afterward. Other patients presenting with life-threatening acute aortic dissection receive emergency lifesaving complex surgery and are similarly followed longitudinally.

“The team at the Center for Aortic Health utilizes a multidisciplinary approach that emphasizes patients’ long-term heart health,” said Dr. Robb, who serves as a co-director of the Center along with Drs. Bowser and Meng. “We also pride ourselves in having expertise and experience with multiple surgical and treatment approaches so that we can truly offer patients the best options for their specific needs. We strongly believe that these various approaches are best used in a multidisciplinary team setting to provide patients with inclusive and optimal care.”

For surgical procedures, the Center offers a state-of-the-art hybrid OR, located in the Gerret and Tatiana Copeland Heart & Vascular Interventional Suites, where both open surgery and endovascular procedures can be performed in the same space, with access to advanced imaging technologies including angiography, ultrasound and CT. It’s the only OR of its kind in Delaware. Within the next year, a second hybrid OR will be constructed, increasing the Center’s capacity to manage complex cases.

Thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR) have become the first choice of treatment in many patients with thoracic and abdominal aortic aneurysms, respectively. However, many patients have anatomy that is not suitable for standard TEVAR/EVAR procedures, according to Dr. Robb. Novel endograft devices have made TEVAR/EVAR possible for more patients, and ChristianaCare is recognized by device manufacturers as a high-volume institution with the expertise needed to implant these newer models.

“For example, in 2023, we became the first center in Delaware to implant the Gore^Ò TAG^Ò Thoracic Branch Endoprosthesis, a novel endograft designed to repair the descending thoracic aorta in cases of aneurysm, transection or dissection,” Dr. Bowser said. “Within the next few months, we will also be offering Gore’s Thoracoabdominal Branch Endoprosthesis, another endograft option that allows us to tailor treatment to a patient’s specific anatomy. These are just two examples of the ongoing developments in the field to which patients in the Center for Aortic Health will have access.”

“Patient selection is clearly key to achieving the best possible outcomes in these procedures,” Dr. Robb added.

Another aspect of this customized care for aortic disease is seen in women.

“We are learning more about aortic pathology in women,” Dr. Bowser noted. “Most existing research had primarily been done in men, but more recent studies demonstrate that we must account for differences not only in vasculature size but other factors that may affect care decisions.”

For example, studies have shown that women have a threefold increase in the risk for aortic dissection or rupture, and acute aortic syndromes, such as aortic dissection, occur at smaller aneurysm sizes in women than men.²

“A 5-cm aneurysm in a woman is much more likely to rupture than a similarly sized aneurysm in a man,” Dr. Bowser said. “Our center incorporates all of the latest research into our decision making to create a personalized treatment plan for each patient.”

It was a very specific decision to name the program the “Center for Aortic Health,” according to Dr. Meng.

“We are not just focused on pathology and surgery,” he said. “Our program is distinguished by a patient-centered focus that aims to prevent catastrophes with education and screening. For example, we have been in discussion with the program at Nemours Children’s Health about transitioning some of their pediatric aortic patients into our care as they reach adulthood. There are familial conditions such as Marfan syndrome, Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome that can raise the risk of aortic pathology conditions. We believe it is important to have a lifelong care plan, not only for the patient but for their family members who may be affected. The Center for Aortic Health offers our community convenient access to world-class expertise right here in their local area.”

To refer a patient to the Center of Aortic Health at ChristianaCare, please call (302) 733-5700 or fill in the form on this page.

References

1.     Czerny M, Grabenwöger M, Berger T, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65(2):ezad426.

2.     Boczar KE, Cheung K, Boodhwani M, et al. Sex differences in thoracic aortic aneurysm growth. Hypertension. 2019;73(1):190-196.

Transcatheter aortic valve replacement (TAVR) at ChristianaCare is revolutionizing the treatment of severe aortic stenosis in older adults.

“TAVR has almost completely replaced open-heart surgery for these patients over the past decade,” said interventional cardiologist and fellowship program director Erin Fender, MD. Dr. Fender is part of a multidisciplinary team that specializes in performing the minimally invasive procedure for the health system’s Structural Heart Disease Program.

“These benefits make the TAVR procedure a safe and effective option for the majority of older adults with serious cases of aortic stenosis, including patients in their 80s and 90s,” Dr. Fender noted. “Our interventional cardiologists do hundreds of procedures a year, supported by cardiac surgeons, cardiac nurses and other professionals with extensive experience in TAVR. This multidisciplinary approach and large number of cases translates to advanced expertise that ensures patients receive high quality care.”

ChristianaCare’s TAVR success rate is 99%, and many large clinical trials have repeatedly demonstrated that the long-term survival rates for TAVR equals that of surgery.

“We’re proud to be Delaware’s leader in performing the procedure,” Dr. Fender said.

At ChristianaCare, patients benefit from a timely and efficient TAVR process. When a patient is referred, a cardiac nurse immediately contacts them to arrange every aspect of their care and address any questions or concerns they may have. The nurse assists the patient in scheduling necessary testing and appointments with an interventional cardiologist and cardiac surgeon—often all on the same day to maximize convenience.

After the TAVR, patients return to ChristianaCare for postoperative checkups and then are seamlessly transitioned back to the care of their local doctor. Through the process, the TAVR team keeps the referring physician informed about their patient, the outcome of the procedure and instructions for follow-up care.

“We strive to develop collaborative relationships with doctors by providing thorough communication and being available for consults when needed,” Dr. Fender explained. “By the time the patient meets with me or one of my colleagues, we’ve already reviewed their testing results and are prepared to recommend a course of action, including scheduling their procedure, if appropriate. All of this typically happens within just a few weeks. It’s a well-coordinated pathway focused on delivering an excellent patient experience.”

To refer a patient for TAVR at ChristianaCare, please call (302) 733-1507 or fill in the form on this page.