May 2013 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine


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Dr. Puskas presents interim results of new design mechanical heart valve trial at AATS meeting

Dr. John Puskas consults with a patient.
Dr. Puskas consults with a patient.

Representing a network of investigators from 36 cardiothoracic surgical centers in the U.S. and Europe, Dr. John Puskas, professor of surgery and associate chief, division of cardiothoracic surgery, Emory University School of Medicine, reported preliminary data from the Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) at the 93rd Annual Meeting of the American Association for Thoracic Surgery on May 6, 2013.

Under FDA investigational device exemption, the trial is evaluating whether patients implanted with a newer generation mechanical heart valve, manufactured by On-X Life Technologies, can be safely maintained with reduced levels of such anticoagulation drugs as warfarin, which are prescribed to prevent blood clots from developing on or around the valve but can increase risk of excessive bleeding. The trial's reduced anticoagulation is less aggressive than what has previously been recommended by the American Heart Association and American College of Cardiology.

For more than 40 years, patients under 65 years of age requiring heart valve replacement have had to choose between either a mechanical valve that offers life-long durability but requires aggressive warfarin anticoagulation, or a biological (cow or pig) valve that will wear out in 10-20 years but does not require anticoagulation.

The interim report shows that the use of the On-X mechanical aortic valve combined with lower dose anticoagulation therapy and low-dose aspirin resulted in a reduction of 55 to 60% of the incidence of adverse bleeding events. There was no notable increases in stroke, transient ischemic attack, or total neurological events.

"Several design features of the On-X valve differ from earlier mechanical valves, resulting in more laminar flow of blood through the valve, lower pressure gradients, smaller regurgitant closing volumes, and less hemolysis," says Dr. Puskas. "If longer term follow-up confirms what we've found so far, guidelines for anticoagulation could be re-written and patients may enjoy a more favorable trade-off between bleeding and clotting complications after mechanical valve replacement."

As part of the PROACT trial, a control group of patients received standard treatment of warfarin administered to maintain a target range of the International Normalized Ratio (INR) of 2.0-3.0. The second treatment group received low-dose warfarin, targeting an INR of 1.5-2.0.

From June 2006 until October 2009, 375 Aortic Valve Replacement (AVR) patients were randomized into control (190) and treatment (185) groups three months after surgery. All patients had received standard therapy for the first three months, including 81 mg aspirin daily. Mean age was 55.8 years in the control group and 54.1 years in the treatment group. Approximately 80% of the patients were male and 93% were in sinus rhythm before valve replacement. Patients were followed for an average of 3.82 years. The treatment group experienced significantly lower major bleeding rates.

"Anticoagulation may be safely reduced in AVR patients after implantation of this approved bileaflet mechanical prosthesis," Dr. Puskas concluded. "In combination with low-dose aspirin, this therapy resulted in significantly lower risk of bleeding than customary aggressive anticoagulation, without significant increase in clots or strokes."

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Dr. Kenneth Newell
Dr. Newell

Dr. Newell named vice chair of faculty affairs

Dr. Kenneth Newell, professor of surgery and transplant surgeon-scientist of the Emory University School of Medicine, has been named vice chair of faculty affairs of the Department of Surgery. The title was previously held by Dr. Grace Rozycki, who is now executive vice chair of the Department of Surgery at Indiana University School of Medicine. In his new role, Dr. Newell will be responsible for overseeing the mechanisms and processes of development and promotions for faculty of the Department of Surgery.

Dr. Newell has been an active member of the Faculty Development and Promotions Committee of the Department of Surgery for the past four years, and also sits on the MEST Committee of the School of Medicine. The MEST Committee considers and approves promotions to the MEST track, the faculty medical educator and service designation instituted in 2011 as a means of recognizing faculty who have a major institutional and regional impact. Prior to the MEST Committee, Dr. Newell served on the Faculty Committee on Appointments and Promotions (FCAP), which advises the Dean on appointments and promotions in the tenure and clinical tracks.

As vice chair, Dr. Newell will work closely with Dr. John Sweeney, interim chair of the Department of Surgery, and Lisa Carlson, director of academic affairs for the Department, to educate faculty on the components of the promotions process, the necessary criteria and documentation for promotion, the types of achievements and progress that contribute to successful promotions, the requirements of the various faculty tracks and how to meet them, the resources that exist to facilitate development, and such track specifics as the importance of superior scholarship, teaching, and service to acquiring tenured positions.

"The primary goals of the Faculty Development Committee are to improve the transparency of the promotion process and to meet and council new faculty members in order to help them prepare more effectively for promotion," Dr. Newell says. "I'm also happy to meet with any faculty, be they long-standing, recently appointed, or somewhere in-between, to discuss issues of promotion or faculty appointments."

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Dr. Ingram recognized as a Health-Care Hero by the Atlanta Business Chronicle

Dr. Jessica Kramer, Emory/Grady burn fellow; Katie Holloway, a clinical pharmacist specialist who provides clinical services in the Burn ICU; Dr. Ingram; and Dr. Sheryl Gabram, Emory surgeon-in-chief of Grady Memorial Hospital.
(left to right) Dr. Jessica Kramer, Emory/Grady burn fellow; Katie Holloway, a clinical pharmacist specialist who provides clinical services in the Burn ICU; Dr. Ingram; and Dr. Sheryl Gabram, Emory surgeon-in-chief of Grady Memorial Hospital.

In the second acknowledgement this year of the superior quality of his care and his passionate dedication to his patients, Dr. Walter Ingram was the physician category winner in the Atlanta Business Chronicle's 16th Annual Health-Care Heroes Awards—earlier this year, Dr. Ingram also received the Senior Sage Award of the Grady Health Foundation. The Chronicle honored Dr. Ingram and several other Atlanta health professionals on May 16 at the Cobb Energy Centre Performing Arts Centre. The keynote speaker was U.S. Surgeon General Dr. Regina Benjamin.

The physician's category applauds those who have demonstrated extraordinary service to patients or the community and have exemplified the highest standards of the profession. An associate professor of surgery of the Emory University School of Medicine, Dr. Ingram has directed the Grady Burn Center of Grady Memorial Hospital since 1994. Throughout the years he has standardized wound care protocols, expanded hydrotherapy facilities, upgraded and refined pain control processes, initiated services for patients with complex wound problems secondary to burns, and led the effort that resulted in verification of the Burn Center from the American Burn Association (ABA), the highest recommendation a burn center can receive. As one of the largest burn services in the country, the center admits over 500 burn patients per year and provides the vast majority of pediatric burn care in Georgia.

Interestingly, the Chronicle's announcement of the award mentioned that Dr. Ingram was a NASA aerospace engineer before he enrolled in medical school, and that he worked from 1981-1982 on a team at McDonnell Douglas Technical Service Co. in Houston that was developing mathematical models to determine orbit patterns for space shuttle navigation. The inspiration to pursue medicine took him away from that vocation, and in August 1982 he entered the University of Texas Health Science Center, embarking on a path that would replace the translation of abstractions to empower space travel with the direct, exacting, and complex responsibility of caring for burn victims. Undoubtedly, Dr. Ingram's patients would agree that he made the right decision.

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Congratulations to our 2012-2013 graduating chiefs!

2012-2013 chief residents with Dr. Delman and Dr. Sweeney

The photo above—snapped by Stephen Konigsberg, PA-C, Emory Vascular Surgery—features our 2012-2013 chief residents at the annual chiefs banquet, held on Saturday, May 18, at the Druid Hills Golf Club. The photo includes Dr. Keith Delman (4th from left), program director of the general surgery residency, and Dr. John Sweeney (6th from left), interim chair of the Department of Surgery at Emory. The residents are (left to right) Colin Brady, who will go on to a plastic surgery fellowship at Emory; Neil Saunders, surgical oncology fellowship, Ohio State University; Raul Badell, transplant surgery fellowship, Emory; Renee Gasgarth, plastic surgery fellowship, University of Miami; Harrell Lightfoot, cardiothoracic fellowship, University of Texas, Southwestern; and Andrew Page, surgical oncology fellowship, Johns Hopkins University. Keren Bashan was unable to attend the banquet. She will be doing a burns fellowship at Grady Memorial Hospital.

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Dr. Jonathan Bromberg
Dr. Bromberg

Save the date: 12th Annual Emory Surgery Research Symposium

The 12th Annual Department of Surgery Research Symposium of the Emory University School of Medicine will commence at 7:00 a.m. on Thursday, June 13, at surgical grand rounds in the EUH auditorium. "Anatomy of Tolerance" will be presented by distinguished visiting professor Jonathan S. Bromberg, MD, of the University of Maryland School of Medicine. Dr. Bromberg is professor of surgery and microbiology and immunology; chief and director of research of the division of transplantation; and director of strategic planning for transplantation services.

Best known for his innovative research involving immunosuppressive therapies, Dr. Bromberg has devoted his career to investigating the role of immunology in transplantation, with a current focus on the effects of chemokines and cell migration on the immune response. Over the course of 20 years, his work has been continuously supported by the NIH.

Dr. Bromberg’s various research accomplishments include being the first investigator to show that sphingosine-1 phosphate (S1P) and the S1P receptor 1 regulate T cell migration from tissues into afferent lymphatics and subsequently into draining lymph nodes, and discovering that the immunosuppressant FTY720—an analogue of S1P—acts through activation of the ABC transporter molecules in T cell surface to change the efflux of lipid mediators of cell migration.

The symposium will resume at 1:00 p.m. in SOM Lecture Hall 130, and will showcase the research of the Department of Surgery’s medical students, postdocs, residents, and fellows. The schedule is as follows:

1:00-2:50 p.m. Basic Science Session
2:50-4:00 p.m. Poster Session, SOM Commons Lobby
4:00-6:30 p.m. Clinical Session

First and second place cash awards for oral presentations in both clinical and basic science categories will be presented, as well as awards for the top poster in each category. Dr. Bromberg will assist in ranking the posters and presentations, and all winners will be invited to dinner with faculty immediately following the symposium.

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SSAT Annual Meeting 2013

Emory Endosurgery Unit presents at SSAT meeting

The 54th annual meeting of the Society for the Surgery of the Alimentary Tract was held in conjunction with Digestive Diseases Week, May 17-21, in Orlando, Florida. Dr. Juan Toro, clinical research fellow of the Emory Endosurgery Unit, presented the technical video "Laparoscopic Hilar Resection with Roux-en-Y Hepaticojejunostomy" and the poster "Detecting Performance Variance in Complex Surgical Procedures: Analysis of a Step-Wise Technique for Laparoscopic Right Hepatectomy." Both projects were mentored by Dr. Juan Sarmiento, associate professor of surgery of the Emory University School of Medicine and director of the hepaticopancreaticobiliary service, and were clear representations of the unit's dedication to refining endoscopic and laparoscopic procedures while giving surgical residents the opportunity to participate in these procedures.

The video documented unit surgeons' technique for the performance of right and left extended hepatectomies using Roux-en-Y hepaticojejunostomy, an approach that allows superior visualization, while the poster described the unit's implementation of the manufacturing productivity tools Six Sigma (SS) and Lean Management (LM) to measure performance efficiency, detect unwanted variances, and implement process improvement to standardize the performance of laparoscopic right hepatectomy, a technically challenging operation.

Additional endosurgery clinical fellow Dr. Nathan Lytle presented the video "Surgical Treatment Options for Delayed Gastric Emptying," which evolved from procedures he performed with Dr. S. Scott Davis, associate program director of the Emory endosurgery fellowship, and Dr. Edward Lin, director of the Endosurgery Unit. The video demonstrated the four surgical options used by unit surgeons to treat a common condition that is also difficult to eradicate.

Upon completion of his fellowship in June, Dr. Lytle will join Kaiser Healthcare in Atlanta as a minimally invasive surgeon. Dr. Toro will remain a visiting scholar with the Department of Surgery until December 2013.

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Detail from the title page of Vesalius's 1543 work on human anatomy, "De Humani Corporis Fabrica."
Detail from the title page of Vesalius's 1543 work on human anatomy, "De Humani Corporis Fabrica."

Serendipity yields display of medical, surgical treasures

From Doane's "Surgery Illustrated."
From Doane's "Surgery Illustrated."

A major conference. A new exhibition space. Inter-library access to digital tools. Put them together and the result is "Medical Treasures at Emory: A Display of Rare Medical Books, Letters, and Artifacts," featuring materials from the Woodruff Health Sciences Center Library's (WHSCL) historical collections.

The exhibit is on display at WHSCL through October 2013. The opening reception for the exhibit coincided with the annual meeting of the American Association for the History of Medicine, held at the Emory Conference Center.

Notable artifacts in the exhibition include a kit of Civil War surgeon's instruments, primarily used for amputation. Books include 18th- and 19th-century works on surgery, human anatomy, and alternative medical practices. An 1836 volume, "Surgery Illustrated" by A. Sidney Doane, depicts surgery before anesthetic pain control and prevention of bacterial infection became standard practice. What is believed to be the only remaining copy of "Plates Illustrative of Diseases of the Intestinal Tract" by L.B.V. Woolsey was presented as a gift to WHSCL in 1987. Dr. Woolsey was a member of the 1882 graduating class of Emory College and earned his medical degree from Atlanta Medical College in 1884.

A prominent exhibit case details how a medical landmark, "De Humani Corporis Fabrica" (On the Structure of the Human Body) by Andreas Vesalius, was acquired by Emory in 1930. The purchase, made through donations received from faculty, students, and alumni of the medical school, was the result of a serendipitous visit to Boston by medical school dean Russell H. Oppenheimer just as the book was offered for sale by a bookseller sympathetic to the strained finances of the then-fledgling A.W. Calhoun Medical Library, WHSCL's original moniker.

Emory's volume is thought to be one of only five copies of a variation published between the first edition (1543) and the second (1551). The book, the oldest volume housed in the Manuscript, Archives, and Rare Book Library (MARBL) of Emory's Robert W. Woodruff Library, is preserved in a climate-controlled vault in the Special Collections area.

Via a kiosk in the exhibition, visitors are able to "page through" some of the rare books and documents on display. The Digitization and Digital Curation Team of the Robert Woodruff Library, working with the WHSCL, has contributed digitized versions of works in Emory's special collections to the Medical Heritage Library, an open application digital library.

According to Bonita Bryan, department head of collection services, WHSCL has always wanted to mount a display of its exceptional resources. "There was a commitment to be ready by spring. We did a first pass through our catalogue and donated items, identifying rarities. We discovered that some of the books in circulation were volumes from the late 1800's. They weren't rare when they were first catalogued."

Dr. Robert Gaynes, associate professor of medicine (infectious diseases), assisted by senior library specialist Matthew Miller, physically examined and choose the items for the exhibition. The Preservation Office of the Emory University Libraries assisted in the conservation and repair of damaged books and paper, including the notes of Dr. Crawford W. Long, the Georgia physician for whom Emory University Hospital Midtown was originally named. The notes provide proof that Dr. Long had already introduced ether anesthesia before its first documented use at MGH in 1846. "Crawford Long's journal was intact, but falling apart," says Ms. Bryan. "We appreciate the expertise of Robert Woodruff Library. Everyone had a different part to play. WHSC Library developed a closer relationship with MARBL."

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Upcoming events

Surgery Division Chiefs Meeting 5:30 - 7:00 p.m., May 28, 2013 EUH Whitehead Room
8th Annual H. Harlan Stone, MD, Lecture in Trauma
Damage Control: Revolution, Rejuvenation and Recapitulation
Presented by Michael F. Rotondo, MD
– Professor and Chairman, Department of Surgery, Brody School of Medicine, East Carolina University
– Director, Center of Excellence for Trauma and Surgical Critical Care, Vidant Health
– Chief of Surgery, Vidant Medical Center
– Chair, Committee on Trauma, American College of Surgeons
7:00 - 8:00 a.m., May 30, 2013 EUH auditorium
Joseph B. Whitehead Lectureship
Intestinal Transplantation

Presented by Thomas M. Fishbein, MD
MedStar Georgetown University Hospital:
– Professor, Departments of Surgery and Pediatrics
– Executive Director, Georgetown Transplant Institute
– Director, Liver Diseases and Transplant Program
7:00 - 8:00 a.m., June 6, 2013 EUH auditorium
12th Annual Department of Surgery Research Symposium
Anatomy of Tolerance

Presented by Jonathan S. Bromberg, MD
University of Maryland School of Medicine:
– Professor of Surgery and Microbiology and Immunology
– Chief, Division of Transplantation
– Director of Research, Division of Transplantation
– Director of Strategic Planning for Transplantation Services
7:00 - 8:00 a.m., June 13, 2013 EUH auditorium
The Emory Global Surgery Program
Presented by Jonathan D. Pollock, MD
– Assistant Professor of Surgery, Division of General and GI Surgery, Department of Surgery, Emory University School of Medicine
– Founding Director, Emory Global Surgery Program
– Assistant Program Director, Pan-African Academy of Christian Surgeons, Soddo Christian Hospital, Soddo, Wollaita, Ethiopia, and Myungsung Christian Medical Center, Addis Ababa, Ethiopia
7:00 - 8:00 a.m., June 20, 2013 EUH auditorium
Surgery Division Chiefs Meeting 5:30 - 7:00 p.m., June 25, 2013 EUH Whitehead Room
Immediate Breast Reconstruction After Surgery for Breast Cancer: Disparity or Difference

Presented by Erin B. Bowman, MD
– Breast Surgical Oncology Fellow, Department of Surgery, Emory University School of Medicine
7:00 - 8:00 a.m., June 27, 2013 EUH auditorium
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