Alternative Surgical Approaches to


In an effort to reduce complications associated with conventional
glaucoma surgery, new surgical options are being developed by
medical device companies. Each approach exploits a specific strategy
to reduce the pressure within the eye.
The adoption of new surgical approaches into a physician practice that treats a chronic disease like
glaucoma is no simple matter. The slow course of the disease makes it difficult for researchers and
developers of new surgical approaches to determine if patients fare better with the new intervention,
often taking many years and several large studies to achieve a reasonable degree of certainty.
Additionally, since the most common classic glaucoma surgeries — shunts and trabeculectomy —
are associated with some potentially hazardous outcomes, when surgical intervention is considered
for a patient the disease is often serious enough that vision is threatened.
While these classic techniques have risks, they also have an established track record. The results,
both good and bad, are well known. New surgical techniques offer the promise of less risky
treatment, but their problems and long-term effectiveness is less understood.

Three Surgical Alternatives

Several new surgical approaches have been developed in an effort to reduce complications associated
with conventional glaucoma surgery. Each approach exploits a specific strategy to reduce the
pressure within the eye.
 The Ex-Press mini glaucoma shunt can be used with conventional trabeculectomy techniques
to standardize the operation and perhaps reduce the chances of the eye pressure getting too low
in the immediate post-operative period, which is occasionally a problem with conventional
 The Trabectome device removes tissue from the drain inside the eye (the trabecular
meshwork) using an electro-surgical handpiece that disrupts the tissue.
 Canaloplasty involves the dilation of the entrance to the outflow pathways in the wall of the
eye (Schlem's canal) in addition to constructing an artificial fluid outflow mechanism within
the eye wall to reduce the pressure in the eye.
While each of these techniques has potential advantages, there are limited data to support long-term
efficacy and even less data that is not derived from studies directly supported by the companies that
develop these products.
At the current time the clear indications for these procedures are still being determined. Many
questions remain as to how these approaches should best be utilized in the treatment of glaucoma.
Is it right for you?
If you are a glaucoma patient, you might consider one of these new surgical approaches in
consultation with your physician if:
 you do not have advanced disease, and
 you do not require a very low target intraocular pressure.
It is important to recognize that the long-term effectiveness of these approaches is not yet known.
Conventional surgery such as trabeculectomy continues to be an acceptable and appropriate option
especially in patients with advanced disease.
Important questions to ask your physician about a new surgical procedure would be:
1. the number of these procedures they have performed,
2. their success rate with the procedure, and
3. if they have any financial conflicts with these emerging technologies.

The EX–PRESS® Glaucoma Filtration Device
Lumenal Control Makes Predictability Standard Procedure
The EX-PRESS® Glaucoma Filtration Device is intended to reduce IOP in glaucoma patients when medication and
conventional surgical treatments have failed. The device channels aqueous humor through a secure lumen (of either
50 μm or 200 μm) to a half-thickness scleral flap, creating a subconjunctival filtration bleb. This Lumenal Controlmeans
uniform filtration; uniform filtration helps to stabilize IOP during and after the procedure; and stable IOP means
greater predictability.

What's new in general surgery
Kathryn A Collins, MD, PhD, FACS
Wenliang Chen, MD, PhD

. | This topic last updated: Sep 08. The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. 2016. Literature review current through: Aug 2016.Contributor disclosures All topics are updated as new evidence becomes available and our peer review process is complete. The most recent What's New entries are at the top of each subsection.


and avoidance of DOACs in individuals with a BMI >40 kg/m2 or weight ≥120 kg. Showering after uncomplicated surgery (April 2016) When a patient can resume bathing/showering after uncomplicated surgery is not well defined. The rate of surgical site infection was not significantly different between the groups. suggesting that showering is safe following an initial period of wound coverage (48 hours). more ventilator-free days. patients who received NIV had fewer reintubations. Although encouraging. Clinicians should continue to individualize NIV and utilize it on a trial basis in this population. apixaban. administered at 325 mg orally followed by 81 mg daily for seven days. The role of NIV was studied in a trial of nearly 300 spontaneously breathing patients who developed acute hypoxemic respiratory failure following abdominal surgery. the lower than expected rate of ARDS in this study may have limited the potential to detect a study drug effect. The indications for NIV in medical patients with respiratory failure are well defined. A recent trial randomly assigned 444 patients undergoing procedures classified as clean or clean-contaminated to showering with the wound undressed 48 hours after surgery or no showering until stitches were removed (median time 10 days). rivaroxaban) in patients with obesity. However. The International Society of Thrombosis and Hemostasis (ISTH) has issued guidance on this subject [2]. Aspirin. The exclusion of patients requiring immediate reintubation and lower than expected rates of reintubation in general limits interpretation of this study. and fewer healthcare-associated infections. Compared with patients treated with oxygen only. The efficacy of HFNC following extubation was studied in over 500 patients (mostly postoperative or neurologic) who had been mechanically ventilated for an average of only one to . the indications in patients with postoperative respiratory failure are less clear. Noninvasive ventilation for postoperative respiratory failure (April 2016) Patient selection is critical for the success of noninvasive ventilation (NIV). dabigatran. High-flow oxygen following extubation (March 2016) High-flow oxygen delivered via nasal cannula (HFNC) is being increasingly used in intensive care and high-dependency units since it can deliver high amounts of supplemental oxygen and a small amount of positive expiratory pressure. However. Dosing of direct oral anticoagulants in obese patients (June 2016) Limited data are available to guide dosing of direct oral anticoagulants (DOACs. The major recommendations include use of DOACs at standard doses for those with a body mass index (BMI) ≤40 kg/m2 or weight <120 kg. The ability of aspirin to prevent ARDS was tested in a randomized trial of 390 patients who were assessed upon presentation to an emergency department to be at risk of developing ARDS.Aspirin does not prevent acute respiratory distress syndrome in adults (July 2016) Preclinical and clinical observational studies have suggested a potential role for aspirin in the prevention of acute respiratory distress syndrome (ARDS). had no effect on the incidence of ARDS at one week (approximately 10 percent in each group). these results do not support the routine administration of NIV for the treatment of respiratory failure in surgical patients. edoxaban.

HFNC led to a reduction in the rate of reintubation and respiratory failure at 72 hours. the results may not apply to other patient populations. since critically ill medical patients and patients at high risk of reintubation were excluded from this study. However.two days and considered at low risk of reintubation. These findings suggest that HFNC may be useful in patients who are at low risk for reintubation. Patients were randomly assigned to conventional low-flow oxygen or HFNC immediately following extubation. .


We advocate routine closure of all mesenteric defects during gastric bypass to reduce the overall risk of small bowel obstruction. mesenteric closure reduced the incidence of reoperation for small bowel obstruction at three years (6 versus 10 percent). In a recent metaanalysis of randomized trials of alternative agents for preventing central venous hemodialysis catheter malfunction. citrate. HAL resulted in greater pain. A quarter of the patients did not see a physician in follow-up. Given its low morbidity and cost. availability. and higher costs. The results of this systematic review confirm our practice of using heparin to minimize catheter malfunction. given its ease of use. which were primarily due to kinking of the small bowel anastomosis. RBL remains the first-line treatment for symptomatic internal hemorrhoids. which was typically instillation of heparin 5000 units into each catheter port. however. BARIATRIC SURGERY Closure of mesenteric defects during laparoscopic gastric bypass (April 2016) Laparoscopic gastric bypass is one of the most commonly performed bariatric procedures. This was examined in a study of more than 11. various antimicrobial agents) and systemic anticoagulation (eg. warfarin) have also been tried. but fewer recurrences within 12 months of the procedure. In a recent trial of 337 patients with grade II or III internal hemorrhoids randomly assigned to treatment with HAL or rubber band ligation (RBL). In a randomized trial including over 2500 laparoscopic gastric bypass procedures with or without mesenteric defect closure.8 percent). HEPATOBILIARY AND PANCREATIC SURGERY Adverse outcomes with lack of follow-up following emergency department visit for biliary colic (April 2016) Proper follow-up of patients being discharged from the emergency department following an episode of symptomatic gallstones is important to avoid adverse outcomes. COLORECTAL SURGERY Hemorrhoidal artery ligation not superior to rubber band ligation for internal hemorrhoids (August 2016) Doppler-guided transanal hemorrhoidal artery ligation (HAL) is a relatively new procedure that uses Doppler ultrasound to identify and ligate the hemorrhoidal arterial blood supply.Locking solutions for preventing hemodialysis catheter malfunction (July 2016) Heparin is commonly used as a locking solution to prevent hemodialysis catheter malfunction. Alternative locking solutions (eg. more serious adverse events requiring hospitalization. the additional recurrences in the RBL group were largely attributable to repeated procedures in patients with multiple hemorrhoids. recombinant tissue plasminogen activator. Future refinements in the technique of small bowel anastomosis may reduce the risk of early postoperative complications. but increased the incidence of early severe postoperative complications (4.000 Texas Medicare patients age 66 and older with symptomatic gallstones who were discharged from the emergency department without undergoing cholecystectomy. However. and relatively low cost compared with alternative agents. the incidence of malfunction was not significantly different with use of alternative locking solutions or systemic agents compared with usual care. Subsequent emergency hospitalization was required in 78 percent of those . Repeat RBL is common in this group since typically only one hemorrhoid column is banded at each RBL session. mesenteric defects created during the procedure are a major cause of small bowel obstruction.3 versus 2.

. Of the patients with biliary colic. This study reinforces the importance of appropriate follow-up and management for patients with symptomatic gallstones. 17 percent required emergency cholecystectomy.patients (compared with 8 percent of those who saw a surgeon and 15 percent of those who saw a physician other than a surgeon). with a complication rate of 41 percent (compared with a 19 percent complication rate for elective cholecystectomy).


In a systematic review of 12 observational studies of splenic function after angioembolization for splenic trauma. and long term showed significant improvements in metabolic parameters (eg. including systemic therapies and amniotic membrane transplantation to prevent permanent ocular sequelae. A recent systematic review included 15 randomized trials of adults and children with severe burns (>20 percent total body surface area) treated with oxandrolone. detects hyperfibrinolysis. have reported inconsistent outcomes. and management of SJS/TEN. intermediate phase. The guidelines provide evidence-based recommendations for the diagnosis. a testosterone analog. versus placebo or blank controls. less nitrogen loss. most studies found that splenic function was preserved. and airway mucosal involvement are also addressed. Following initial transfusion triggered by activation of a massive transfusion protocol. a severe and potentially fatal mucocutaneous drug reaction. However. urogenital. Immunocompetence following splenic embolization for trauma (April 2016) Routine immunization is recommended following splenectomy. respectively). 111 injured patients were randomly assigned to subsequent transfusions based upon TEG parameters or conventional coagulation assays. Thromboelastography (TEG) is a point-of-care testing method that rapidly provides information on the properties of clot formation. Although there were no differences in the overall volume of transfusion at 24 hours. uncertainty remains since the studies used different parameters to assess splenic function and the best parameter/test to assess immunocompetence in this population has not been . such as intravenous immune globulins. 5 mg twice daily in children and patients >65 years of age). Thromboelastography-guided transfusion in trauma patients (July 2016) Coagulopathy associated with trauma is evident in 25 to 35 percent of severely injured civilian patients and is associated with increased morbidity and mortality.4 percent. Meta-analyses of individual outcome measures in the acute phase. infection. Mortality rates were significantly lower for the TEG group compared with the conventional group at 6 hours and 28 days (7.6 versus 36. Specific areas covered include initial management. the standard assay group received more plasma and platelets during the first several hours of resuscitation. improved wound healing). shortened length of stay. we suggest TEG-based goal-directed resuscitation for trauma patients requiring massive transfusion. New guidelines for the management of Stevens-Johnson/toxic epidermal necrolysis syndrome (August 2016) The British Association of Dermatologists released new guidelines for the management of Stevens- Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). and cyclosporine. Where TEG is available.1 versus 21. as well as the management of oral. which improve protein balance. and 19. increased lean body mass. The treatment of eye involvement. The results of a randomized trial are consistent with observations suggesting that TEG-parameter-guided resuscitation may improve outcomes. and may offer an advantage over standard coagulation assays. liver dysfunction). Trials evaluating anabolic steroids. but the need for immunization following nonsurgical treatment of splenic injury is unclear. systemic corticosteroids. less weight loss. and therapies intended to reduce mortality. severity assessment. and no significant differences in adverse events (mortality. These results support our recommendation to treat all patients with moderate-to-severe burns with oxandrolone (10 mg twice daily in adults. supportive care.Oxandrolone to treat moderate-to-severe burns (August 2016) Many pharmacological therapies have been tried to reverse the damaging effects of the hypermetabolic response to severe injury.8 percent.

Overall. . these studies support our practice of not immunizing patients following splenic embolization. splenic salvage surgery.determined. or nonoperative management.


M0). laparoscopic gastrectomy is performed with increasing frequency for early gastric cancers in high-volume centers with the requisite expertise. severe morbidity. however. Further trials in Western countries are required before laparoscopic surgery can be recommended for the routine treatment of all gastric cancers. which could impact successful use of laparoscopic surgery. and more likely to have poorly differentiated tumors than Asian populations. Western populations. Patients in Western countries are generally older. more obese.Laparoscopic versus open surgery for advanced gastric cancer (May 2016) Open gastrectomy is the standard surgical treatment for gastric cancer worldwide. mainly in Asia. however. and completion of a D2 lymphadenectomy were similar in both groups. A recent randomized trial conducted in China compared the safety and efficacy of laparoscopic versus open resection in 1056 patients with advanced gastric cancers (T2- 4a. follow-up has been inadequate for meaningful assessment of oncologic outcomes. N0-3. may have different outcomes since surgeon experience and patient characteristics are different. . Rates of postoperative mortality and morbidity.


drug-eluting stent). Ticagrelor in patients with peripheral artery disease (July 2016) Patients with a history of myocardial infarction and concomitant lower extremity peripheral artery disease (PAD) are at increased risk for both systemic and limb ischemic events. we do not recommend genotyping for clopidogrel loss of function genetic variants or testing for clopidogrel hypo/nonresponsiveness. ticagrelor 60 mg twice daily. found that the risk of stroke was lower among noncarriers of the CYP2C19 loss of function allele than those who carried the allele.93).Bioresorbable drug-eluting iliac artery stenting for PAD (July 2016) Metal stents are commonly used to treat suboptimal transluminal angioplasty. At one and two years follow-up. Although these results are encouraging. Whether adding a second agent offers additional benefits in this population is unclear. However. binary restenosis rates (>50 percent) were 12. Among the subset of patients with previously identified PAD (n = 1143). use of ticagrelor reduced the absolute rate of major adverse cardiovascular events (MACE) by 4. and freedom from target lesion revascularization was 91. but restenosis remains a problem. respectively. A recent feasibility study reported the first clinical use of a drug-eluting (everolimus) bioresorbable vascular scaffold to treat 66 patients with symptomatic peripheral artery disease in the iliac or femoral arteries. Genetically determined clopidogrel nonresponsiveness and DAPT outcomes (June 2016) Dual antiplatelet therapy (DAPT).1 percent and reduced the risk for peripheral revascularization for limb ischemia (hazard ratio [HR] 0.1 percent. who had genotyping for CYP2C19 genetic variants performed. many patients on DAPT experience ischemic events. respectively. the presence of the CYP2C19 loss of function allele has been correlated with clopidogrel resistance. Stenting versus surgery for carotid artery stenosis (March 2016) . 95% CI 0. lowers the risk of subsequent ischemic events in patients with established atherosclerotic cardiovascular disease.2 and 88. or placebo in addition to low-dose aspirin. but may increase stent thrombosis. A 2016 subgroup analysis of 2933 individuals in CHANCE. further trials are needed to determine if the benefits of dual therapy outweigh the bleeding risk. There were no procedure-related amputations or deaths at two years follow-up. One potential cause of treatment failure is failure to properly metabolizeclopidogrel. direct comparisons with drug-eluting balloons and drug-eluting polymer-coated metal stents are needed. compared with aspirin alone. Bioresorbable scaffolds have been used in the coronary circulation.63. The CHANCE trial of patients with transient ischemic attack or minor stroke found that DAPT was more effective in preventing subsequent stroke than aspirin alone.12 percent absolute excess of major bleeding. Given methodologic issues with data ascertainment.2 percent.1 and 16. We do not use dual antiplatelet therapy in patients with PAD in the absence of other indications (eg.43-0. with a 0. Long-term antiplatelet therapy with aspirin is recommended for these patients. A recent large multicenter trial randomly assigned over 21. While the evidence seems to be increasing that genetic variation may determine outcome with the use of clopidogrel. compared with placebo.000 patients with prior myocardial infarction (MI) to ticagrelor 90 mg twice daily.

The cumulative five-year rates of stroke-free survival at CAS and CEA were 93. Given the serious risks associated with ALI (prolonged hospitalization. and 10 other observational studies). In a randomized trial of the protease-activated receptor 1 antagonistvorapaxar in symptomatic stable patients with PAD. ●The ACT I randomized trial in patients with asymptomatic 70 to 99 percent carotid stenosis assigned 1453 patients to either CAS or CEA.3 versus 3. respectively. whether to reverse the anticoagulant effects of heparin is controversial.Two recent studies have compared carotid artery stenting (CAS) and carotid endarterectomy (CEA) for treatment of carotid artery stenosis. limb loss. a large registry study. these results suggest a need for additional trials to determine whether vorapaxar is beneficial following revascularization. without . the prespecified statistical margin for noninferiority of stenting compared with endarterectomy was met. Vorapaxar for lower extremity peripheral artery disease (March 2016) Patients with peripheral artery disease (PAD) are at increased risk of limb ischemic events. reperfusion surgery. Use of protamine reduced the risk of major bleeding complications requiring reoperation compared with not using protamine. For the primary composite endpoint (death. Because of higher rates of short-term complications with CAS. although the periprocedural risk of stroke and death is higher with CAS. Vorapaxar reduced the rate of ALI at three years (2.9 percent). Protamine for heparin reversal following carotid endarterectomy (March 2016) Following open carotid endarterectomy. mortality).3 percent) was similar to that for ischemic stroke (0. we continue to prefer CEA for most medically stable patients who have symptomatic carotid stenosis or who have a life expectancy of at least five years and high grade (≥80 percent) asymptomatic carotid stenosis at baseline or progression to ≥80 percent stenosis despite intensive medical therapy. The periprocedural risk of stroke and death was significantly increased with CAS compared with CEA for patients age 70 and older.2 for ages 65 to 69 and 4. or myocardial infarction within 30 days of the procedure or ipsilateral stroke within one year).9 percent) and myocardial infarction (1. pooled patient-level data from four trials found that the periprocedural risk of stroke and death increased with age (hazard ratio [HR] 2.1 and 94.000 patients from 12 studies (one randomized trial.2 for age ≥80 years) for patients assigned to CAS. A recent systematic review and meta-analysis of protamine use after anticoagulation for carotid endarterectomy assessed outcomes in over 10. stroke.7 percent. ●In a meta-analysis of older adult patients with symptomatic carotid disease. while there was no increase in periprocedural risk by age for CEA. the event rate for acute limb ischemia (ALI) at one year (1. Accumulating evidence suggests that both CAS and CEA provide similar long-term outcomes for patients with asymptomatic and symptomatic carotid occlusive disease. although most patients (71 percent) had a prior vascular intervention.9 percent with placebo) regardless of the cause.

increasing the risk of stroke. myocardial infarction. These results support our practice of heparin reversal after endarterectomy. or mortality. OTHER GENERAL SURGERY .

or increasing subcutaneous air on physical exam. thymectomy improved multiple clinical outcomes. suction did not affect the occurrence of prolonged air leak.Thymectomy for myasthenia gravis (August 2016) Lacking evidence from randomized trials. In a meta-analysis of randomized trials of suction versus no suction on chest drains following lung resection. worsening pneumothorax on follow-up postoperative chest radiographs. the benefit of thymectomy is supported by the results of the multicenter. Now. assessor-blinded MGTX trial. Based on the lack of benefit and disadvantages associated with ongoing suction. In one study of over 2000 patients undergoing bariatric . including quantitative strength testing. we suggest not routinely using ongoing chest tube suction following elective lung resection (not lung reduction surgery or pneumonectomy). we recommend thymectomy for patients age <60 years with nonthymomatous. Thymectomy is also indicated in all patients with thymoma if resection is feasible. Based on these results and prior observational data. thymectomy for patients with nonthymomatous myasthenia gravis (MG) had been controversial. Routine chest tube suction unnecessary following nonpneumonectomy lung resection (April 2016) Whether ongoing suction to the chest tube improves or worsens pleural leaks following elective lung resection (not lung reduction surgery or pneumonectomy) is controversial. average alternating-day prednisone requirements (44 versus 60 mg). However. Bariatric surgery benefits joint pain and physical function (April 2016) Morbid obesity is associated with significant joint pain and limitations in physical activities. and hospitalization for acute exacerbations (9 versus 37 percent). which enrolled 126 subjects with generalized acetylcholine receptor (AChR) antibody- associated MG and randomly assigned them to thymectomy plus alternate- day prednisone or alternate-day prednisone alone. for patients with postoperative pneumothorax. generalized acetylcholine receptor (AChR) antibody-associated MG. the chest tube should be connected to suction. need forazathioprine immunosuppression (17 versus 48 percent). which may ameliorate these problems. Bariatric surgery is effective in promoting weight loss. Over a three-year period.

. M. When the ligament complex tears. along with the resulting instability. Instability is generally defined as the inability to bear physiological loads with an associated loss of normal wrist alignment. It consists of dorsal. Diagnosis can be difficult in early injuries.. Mayo Clinic orthopedic surgeons James for severe obesity. hip. they can lead to functional disabilities and progressive degenerative osteoarthritis. the scaphoid tends to flex while the lunate extends. early diagnosis and appropriate treatment may restore normal function and prevent further damage to the joint. for example. Although arthritis can occur even after surgical repair or reconstruction. and Ronald L. 50 to 75 percent reported significant improvements in body. Scapholunate injuries: A paradigm shift? Scapholunate ligament injury The scapholunate is an interosseous carpal ligament that provides stability to the proximal carpal row. M. and physical functions at one year after surgery.D. and knee pain.. Injuries to the scapholunate. This study demonstrates that bariatric surgery can improve patient outcomes that are beyond the metabolic syndrome. are among the most common and significant ligament injuries. Improvements in knee and hip pain were sustained at three years.D. creating translational and rotational instability between the two. When not properly diagnosed and treated. They introduced the defining terms "dorsal intercalated carpal instability" and "volar intercalated instability" and described other problems related to abnormal wrist motion. Since then. They often occur during sports when an athlete falls on an outstretched hand. and the diagnostic gold standard remains wrist arthroscopy. carpal instability has continued to vex hand surgeons. proximal and palmar segments that bridge the scaphoid and lunate. Linscheid. Dobyns. were among the first to conceptualize and describe traumatic carpal instability in 1972.

." Dr. an orthopedic surgeon at Mayo Clinic's campus in Rochester. Dobyns and Linscheid. Therapeutic options range from splinting and casting or arthroscopic treatment to ligament reconstruction using autograft tendons. allowing physicians to see and measure discrepancies in joint motion and altered carpal loading from these subtle ligament injuries." explains Sanjeev (Sanj) Kakar. "The team at Mayo is currently studying patients with scapholunate instability using this technology with the goal of precisely identifying which part of the ligament is injured and directing treatment to that area as opposed to a shotgun approach where one treatment suits all. however. Minnesota. Through the collaborative efforts of Mayo Clinic radiologists. noninvasive detection of abnormal joint motion. basic science specialists and hand surgeons. Nearly 40 years after the seminal work of Drs. it also helps locate the exact site of ligament injury. .D." Lunate during wrist flexion and extension Not only does 4-D CT technology allow earlier and better assessment of dynamic joint instabilities. biomedical engineers. "Three-D movies of the patient's wrist can be played back. "This state-of-the-art CT technology provides information about carpal motion in real time at velocities similar to those of activities of daily living. Kakar says. advances in the understanding of wrist biomechanics and kinematics have led to improvements in the early. the results of surgery remain unpredictable. the role of 4-D computerized tomography (CT) imaging has shown promise for the noninvasive diagnosis of dynamic carpal instability.Wrist in live motion In the last few years. M. Building a better ligament Management of scapholunate instability is both complex and controversial. which can only be detected during joint motion.

including Dr. Kakar. and a number of techniques have been proposed to overcome them. "Although it requires a lot more research. Kakar says.D.D. So Mayo Clinic researchers. van Wijnen. M. scaffold technology has great potential for stem cell engineering and ligament regeneration. they describe the successful creation of a collagen-rich extracellular matrix using adipose tissue-derived human mesenchymal stem cells seeded on a composite polymer neoligament. Scaffold for ligament regeneration In a study published in the November 2015 issue of Tissue Engineering Part A. But the problem of poor tissue regeneration continues to be a vexing one. and Michael J." Dr. Ph. Yaszemski.D.. and final results are at least a few years away. are experimenting with the use of scaffolds seeded with progenitor cells and growth factors to regenerate ligamentous tissue. Ph.. "We are trying to further optimize the scaffold.Reconstruction presents special challenges for hand surgeons.." .Andre J.