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

 

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Emory University faculty and staff-developed patient kidney app now available

Propelled by a concise, direct, pictographic, and uncluttered design and message, Emory University's iChoose Kidney app for the iPad is now available as a free download from the iTunes App Store. The app can serve as a decision support tool for nephrologists, primary care physicians, social workers, nurses, and/or patient educators to use with end-stage renal disease (ESRD) patients to help improve informed decision-making for kidney failure treatment options. The iPhone version is nearing completion, and a corresponding website is in development.

iChoose chosen parameters for risk summary screen shot

Subtitled "Dialysis or Transplant?," the app presents various risk prediction models for dialysis vs. kidney transplant in response to such user-defined parameters as patient gender, age, race, ethnicity, patient time on dialysis, and patient history of various conditions associated with kidney decline. The risk models encompass one and three-year dialysis and transplant summaries, with the risk of death for transplant being lower than dialysis in all instances. There are also summaries comparing deceased donor transplants and living donor transplants. The data used to develop the risk models was based upon surveillance data from the United States Renal Data System from 2000-2011.

The app development team was led by Emory faculty transplant researcher Rachel Patzer, PhD, MPH, who has dual appointments in the Department of Surgery and the Department of Epidemiology. Team members included Mohua Basu, MPH, a staff epidemiologist at the Emory Transplant Center; transplant surgeon-scientist and dean of the Emory School of Medicine Christian Larsen, MD, DPhil; epidemiologist William McClellan, MD, Rollins School of Public Health (RSPH); health policy and management faculty member David Howard, PhD, RSPH; Kimberly Arriola, PhD, MPH, of the Department of Behavioral Sciences and Health Education, RSPH ; and Emory School of Medicine biovisualist Michael Konomos, MS, CMI. All team members are also affiliated with the Emory Transplant Center. Michael Patzer of Patzer LLC was the mobile app developer for the project.

iChoose 3-year risk summary screen shot

Dr. Patzer and her colleagues conducted a feasibility study of the app among patients with kidney disease receiving treatment at Emory Dialysis, and found that more than 40% had never had a physician discuss transplantation with them. Nearly 85% said the tool was useful in helping them make treatment decisions.

"Evidence suggests that nearly 1/3 of dialysis patients in the U.S. are not informed about transplantation as a treatment option for kidney disease," says Dr. Patzer. "Though the data exists to help patients make treatment decisions, it's not being used. iChoose takes less than a minute to complete, and is a simple, novel tool that can be used at the bedside to translate evidence-based information to patients." The team's next step will be a randomized study to evaluate the app's effectiveness in improving patient knowledge of treatment options.

Emory Transplant Center researchers are also developing an app to educate patients about the importance of taking their post-kidney-transplant medications. It is currently being evaluated through randomized testing with patients, and will ideally be available to ETC patients in a few months.

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Dr. T. Roderick Hester
Dr. Hester
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Closing the circle: Dr. T. Roderick Hester retires

As he wrapped up his Emory University School of Medicine, Emory Healthcare, and Paces Plastic Surgery affairs, Dr. T. Roderick Hester reportedly stated, "It's time for me to spend more time with my wife, children, grandchildren, and go fishing in Lake Oconee!" A prominent plastic and reconstructive surgeon for 35 years, Dr. Hester participated in the dramatic advances in breast reconstructive surgery that have become status quo today; squired the ascendance of his own private practice clinic into one of the top aesthetic surgery centers in the state and beyond; returned to Emory to lead the division of plastic surgery for nine years; and was a driving force behind the unification of Paces with Emory Healthcare in the spring of 2013. Undoubtedly, he deserves the catch of the day.

Dr. Hester received his MD and completed his general surgery and plastic surgery residencies at Emory, and was an Emory faculty member for 15 years before leaving in 1993 to found his Atlanta-based private practice clinic. Paces Plastic Surgery Center became a top-tier provider of comprehensive aesthetic services that included pre-operative assessment, safe and trustworthy operative care at the forefront of the field, overnight suites with hands-on nursing care, and leading edge long term care and spa services. Dr. Hester's former Emory colleague Dr. Foad Nahai joined Paces in 1998, and the two surgeons further secured Paces' reputation while also training the Emory plastic surgery residents who did their aesthetic surgery rotations at the facility.

In November 2001, Dr. Hester returned to Emory to serve as chief of the division of plastic and reconstructive surgery. He stepped down in January 2010, making way for current chief Dr. Grant Carlson, and remained on the Department of Surgery faculty while maintaining Paces' clinical activities.

In March 2013, Dr. Hester's perennial dream of officially uniting Paces with Emory became reality. The center joined The Emory Clinic as the Emory Aesthetic Center at Paces and expanded into a highly versatile, multidisciplinary operation under the Emory Healthcare umbrella. With this merger, Dr. Nahai returned to Emory as a professor of surgery, and Dr. Felmont Eaves, a former mentee of Dr. Nahai and Dr. Hester's during his plastic surgery residency at Emory, left his 15-year practice in Charlotte, NC, to assume the medical directorship of Paces and a full professorship at Emory. With the realization of his goals secured, Dr. Hester announced his retirement.

"Of course I'm sorry to see him go, but I salute Dr. Hester and respect his decision that now is the time to move on," says Dr. Carlson. "While it is common knowledge that he became one of the nation's leading plastic surgeons, his remarkable dedication to the field of medicine and the profound impact he had on patient care is what will continue to inspire us all."

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Don McClellan documents his heart surgery with Dr. Guyton at the helm

Mr. McClellan recovering post-surgery, and Dr. Guyton's team performing the procedure.
Mr. McClellan recovering post-surgery, and Dr. Guyton's team performing the procedure.

Retired WSB TV-Channel 2 broadcast reporter Don McClellan—also a Georgia Association of Broadcaster’s Georgia Hall of Fame inductee—recently chronicled his heart valve repair surgery at Emory University Hospital. Dr. Robert Guyton performed the surgery to repair Mr. McClellan’s leaking tricuspid heart valve so that he can return to his beloved running.

Anchored by Mr. McClellan’s chipper narration, the WSB feature includes footage of Dr. Guyton and his team in the OR during various phases of the surgery. Mr. McClellan makes such observations as, “Dr. Guyton encourages each (team member) to offer input, and a team member keeps track of what’s happening,” emphasized with a shot of an OR nurse filling out a surgical safety checklist.

"The valve seemed to be leaking mainly because the right ventricle had enlarged and was pulling the valve down into the right ventricle, so we put in as small a ring as we could without causing narrowing of the valve," Dr. Guyton explains, referring to the ring used to reinforce the annulus at the base of the valve leaflets. This procedure restores the annulus to its preferred size and shape and allows the leaflets to open and close completely.

"My own heart back in action," Mr. McClellan announces as the camera shows his beating heart after removal of the heart-lung machine.

At the conclusion of the spot, Mr. McClellan says,"Dr. Guyton projects four-or-five weeks before I can return to running, but whatever time it is, I'm grateful."

WSB’s Facebook post about the surgery received thousands of likes. The feature can be viewed here.

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Dr. Rachel Medbery
Dr. Medbery

Dr. Rachel Medbery receives SAGES Best Presentation Award

PGY-3 general surgery resident Dr. Rachel Medbery's presentation of "Impact of Operative Duration on Postoperative Pulmonary Complications in Laparoscopic Versus Open Colectomy" placed first in the Top Five Residents/Fellows Best Presentation Competition held during the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2013 Annual Meeting. Dr. Medbery was the first author of the study abstract, and her coauthors included Emory research informatics analyst Sebastian Perez, former resident and future Emory Surgery faculty member Dr. Ankit Patel (see below), former endosurgery fellow Dr. Nathanial Lytle, and faculty surgeon-researchers Dr. S. Scott Davis, Dr. Edward Lin, and senior author Dr. John Sweeney.

Traditionally, prolonged operative duration is associated with increased postoperative morbidity and mortality, though laparoscopic colectomy (LC)—which typically has a longer operative duration than open colectomy (OC)—has been shown to have decreased morbidity compared to OC. The study focused on defining the direct impact of operative duration on postoperative pulmonary complications (PPC) following LC and OC, which had yet to be analyzed.

Dr. Medbery and her coauthors queried the ACS/NSQIP 2009-2010 Public Use File for patients who underwent elective LC and OC. The associations between operative duration and a PPC (pneumonia, intubation >48 hours, and unplanned intubation) as well as 30-day mortality were evaluated in 13,741 laparoscopic and 11,678 open colectomies. Overall, PPCs occurred half as often following an LC (270 [2.0%] laparoscopic vs. 497 [4.3%] open; OR 0.45, 95% CI 0.39-0.53).

While the study concluded that operative duration is independently associated with increased risk of PPC in patients undergoing LC and OC, it found that a laparoscopic approach carries half the absolute risk of PPC and, when safe, should be preferentially used despite a potential for prolonged operative duration.

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Dr. Hart Squires
Dr. Squires

Dr. Hart Squires wins Annual GA-ACS Resident Research Competition

Dr. Malcolm Hart Squires, a PGY-4 general surgery resident in the second year of a two-year research sabbatical, won the Annual Resident Research Competition's first prize at the 2013 Annual Meeting of the Georgia Society of the American College of Surgeons (GSACS). Dr. Squires presented "Transplant Versus Resection for the Management of Hepatocellular Carcinoma Meeting Milan Criteria in the MELD Exception Era at a Single Institution in a UNOS Region with Short Wait Times." He shared first authorship with former faculty member Dr. Steven Hanish. Additional coauthors included members of the Emory divisions of general surgery, surgical oncology, and transplantation, as well as his sabbatical mentors and surgical oncologists Dr. David Kooby and senior author Dr. Shishir Maithel.

The study compared the outcomes of the Emory experience with liver transplant and liver resection to treat hepatocellular carcinoma (HCC) within Milan criteria (MC)—the standards used as a basis for selecting patients with cirrhosis and HCC for liver transplantation—in the Model for End Stage Liver Disease (MELD) exception era. The current MELD policy was enacted in 2006, and it allows patients with low mortality risk that fall into exceptional diagnosis categories such as HCC to be considered for liver transplant. The choice of transplant or resection under these conditions remains controversial.

All patients who underwent resection of HCC at Emory between 1/2000 and 8/2012 were identified for the study, 126 in all, while patients who underwent transplant were limited to those after 1/2006, equaling 131, when the current MELD exception policy was universally implemented. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS).

Among patients meeting MC, transplant demonstrated significantly greater 5-year OS (65.7% vs. 43.8%,p=0.005) and RFS (85.3% vs. 22.7%,p<0.001) versus resection. Compared to resection patients within MC with a raw MELD score <8 (n=30), transplant demonstrated similar OS (62.5% vs. 48.9%,p=0.43) with a trend towards greater RFS (71.6% vs. 30.8%,p=0.08). For patients with hepatitis C, those undergoing transplant (n=87) had significantly improved five-year outcomes compared to the 21 patients who met MC and underwent resection (OS:63.5% vs. 23.3%,p=0.001; RFS:83.5% vs. 23.7%,p<0.001).

Dr. Squires and his coauthors concluded that liver transplant is associated with improved survival compared to resection for HCC. For patients within Milan criteria, transplant appears to confer an oncologic advantage, even in those with preserved liver function. The study advised that transplant be considered for all patients meeting Milan criteria, particularly those with hepatitis C, when being managed in a UNOS region such as Emory that has short wait times for organ availability.

"Hart just presented it perfectly," says Dr. Maithel. "His overall delivery and question-answering were so polished, he immediately stood out from all the other participants. I watched him from the back of the room with a smile."

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Dr. Ankit Patel
Dr. Patel
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Dr. Karim Halazun
Dr. Halazun
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Dr. B. Rondi Gelbard
Dr. Gelbard

New faculty: Dr. Rondi Gelbard, Dr. Karim Halazun, and Dr. Ankit Patel

Division of General and GI Surgery

(Assistant Professor of Surgery) Emory has been the academic base of Ankit Patel, MD, since he received his BS in chemistry here in 2001, followed by medical school and his general surgery residency. He joins our faculty after completing his endosurgery fellowship at the Emory Endosurgery Unit under the mentorship of Dr. Edward Lin and Dr. Scott Davis, whom he will join as part of the bariatric surgery team at the Emory Bariatric Center-Midtown. He will also be an attending at the Atlanta VA Medical Center. Dr. Patel’s research interests include the integration of GI surgery with technology and robotics and reviewing outcomes for combined paraesophageal hernia repair with sleeve gastrectomy in obese patients.

Division of Transplantation

(Assistant Professor of Surgery) Karim J. Halazun, MD, joins our liver transplant program after completing his transplantation fellowship at Columbia University Medical Center, where he also did his general surgery residency and surgical research fellowship. After receiving his medical degree from the University of Leeds, UK, he did a basic surgical training rotation from 2002-2007 at the Yorkshire School of Surgery. Much of his time was spent at St. James University Hospital, considered the largest and busiest teaching hospital in Europe. Throughout his training he received such research awards as the Hepatobiliary and Transplant Fellow Award of the American Association for the Study of Liver Disease, the Young Investigator Award of the American Transplant Society, and the American Society of Transplantation’s Distinguished Fellow Research Award.

Trauma/Surgical Critical Care at Grady Memorial Hospital

(Assistant Professor of Surgery) Rondi B. Gelbard, MD, completed her clinical fellowship in trauma at the LAC + USC Medical Center in Los Angeles while working as a clinical instructor at the Keck School of Medicine. After her medical school years at UMDNJ-Robert Wood Johnson Medical School, she did her general surgery residency at NY Presbyterian Hospital-Columbia University Medical Center, followed by a clinical fellowship in surgical critical care at the University of Miami/Ryder Trauma Center. Dr. Gelbard was highly active in a variety of pursuits throughout her training, including serving as a moderator for QuantiaMD’s interactive physician community, being a resident advisory board member for Elsevier, serving in several safety and quality improvement initiatives at USC+LAC and New York Presbyterian, and participating in community-benefit projects that provided access to quality health care for uninsured patients.

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Emory reception at the ACS Clinical Congress

ACS 2013 Clinical Congress

Current and former faculty, residents, fellows, and staff of the Department of Surgery are invited to attend the Emory Surgery reception at the 100th Annual Clinical Congress of the American College of Surgeons in Washington, DC. The reception will be held on Tuesday, October 8, 2013, from 6:00-8:30 p.m. at the Marriott Wardman Park, Virginia Suite A, 2660 Woodley Road NW. Please RSVP to HSevents@emory.edu by September 30th. Contact Jimmy Owen at james.p.owen@emory.edu or 404.778.5429 with any questions.

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Upcoming events

EVENT DATE/TIME LOCATION
SURGICAL GRAND ROUNDS
The Legend and Love of the Distal Splenorenal Shunt: A Tribute to W. Dean Warren, MD
Presented by John R. Galloway, MD
– Professor of Surgery, Division of General and GI Surgery, Department of Surgery, Emory University School of Medicine
– Director, Nutritional Metabolic Services, Emory University Hospital
7:00 - 8:00 a.m., September 5, 2013 EUH auditorium
SURGICAL GRAND ROUNDS
19th Annual W. Dean Warren Lecture
Controversies in IPAA Surgery

Presented by Steven Wexner, MD, PhD (Hon)
– Director, Digestive Disease Center; Chairman, Department of Colorectal Surgery: Cleveland Clinic Florida
7:00 - 8:00 a.m., September 12, 2013 EUH auditorium
Department of Surgery Promotions Seminar: Career Development Reports, Service Portfolio, Teaching Portfolio, Networking, Service/Teaching Opportunities, Mock Promotions Committee
Presented by
Ken Newell, MD, PhD
– Vice Chair of Faculty Affairs, Department of Surgery, Emory University School of Medicine
5:00 - 6:30 p.m., September 16, 2013 EUH H-Wing Surgery Education Classroom
SURGICAL GRAND ROUNDS
Congenital Chest Wall Anomalies: Current Treatment Strategies
Presented by Sarah Hill, MD
– Chief Resident, Department of Surgery, Emory University School of Medicine
7:00 - 8:00 a.m., September 19, 2013 EUH auditorium
Surgery Division Chiefs Meeting 5:30 - 7:00 p.m., September 24, 2013 EUH Whitehead Room
     
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