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


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Melinda Kane
Melinda Kane
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Dr. Edward Lin
Edward Lin

Bariatric Center relocation to EUHM boosts patient experience and physician interaction

Medical Office Tower, Emory University Hospital Midtown
Medical Office Tower, Emory University Hospital Midtown

Before the Emory Bariatric Center opened its refurbished, consolidated location at Emory University Hospital Midtown (EUHM) several months ago, the service was split between two campuses, making interactions with the program difficult for patients and staff alike. For example, depending on the area of the program the Center's multi-disciplinary physicians and staff worked in, face-to-face conversations between them could be difficult to achieve.

The original separation of the Center's services was a logical consequence of growth. By necessity, the office at The Emory Clinic (TEC) was the source of all pre- and post-operative services as well as non-surgical weight loss services when the program began. Meanwhile, EUHM gradually became the Center's surgical headquarters, a situation that became permanent when the American College of Surgeons Bariatric Surgery Center Network (BSCN) granted level 1 accreditation as a bariatric surgical center of excellence to the EUHM location in 2007.

"With case volume picking up, our patients could get confused or frustrated, particularly if they were enrolled in a prescribed weight-loss regimen before surgery," says Melinda Kane, Emory Bariatrics' business manager. "They had to go the clinic to meet their dietitian, then to Midtown for surgery consults. As patient demand increased for our services, it became obvious that we had to be in one place, and we started lobbying for centralizing everything at Midtown."

Upon approval from Emory Healthcare leadership, the Center worked with architects from Design and Construction Management Incorporated (DCM), Structor Group, and Cousins Properties as well as both EUHM and TEC to transform the 7th floor of Midtown's Medical Office Tower into a safe and quality-driven facility designed to preserve the dignity and support the needs of the bariatric patient. Upon completion of the renovation, all furnishings and equipment, from the lobby to the bathroom to the exam rooms, provided the extra space and comfort that overweight and obese individuals and their families should expect from a state of the art bariatric facility. Special features included a demo gym where patients could receive instruction from exercise specialists on how to use the various types of machines they would encounter at their local gyms.

"The increased case volume and productivity has surpassed our most positive expectations, and patient satisfaction has notched up as well," says Dr. Edward Lin, surgical director of the Center. "Everything is here: support group meetings, monitoring visits, wellness coaching, pre-op admissions at the hospital proper. And if I'm meeting with a post-op patient who has concerns about maintaining their diet, I can walk down the hall, find a dietitian, and we can both alleviate their anxiety together."

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Dr. Stuart Hurst
Stuart Hurst
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Prof. Steven Sacks
Steven Sacks
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Prof. Tony Dorling
Tony Dorling

First stage of an international research-training enterprise: Dr. Hurst's King's College research sabbatical

For interested general surgery residents, the Emory Department of Surgery offers various opportunities for acquiring dedicated research time. Choices include assisting in one of the Department's productive laboratories, working in one of its many clinical research programs, or doing faculty-directed outcomes research. Residents can also work outside the Emory system, provided the mentor is reliable and the research objective well-considered. In addition to meeting these standards, Dr. Stuart Hurst's sabbatical at King's College London is an initial step in a joint international training cooperative.

During his two-year Elkin Fund-sponsored lab residency at King's, Dr. Hurst will study complement and coagulation cascades with Professor Steven Sacks, director of the Medical Research Council (MRC) Centre for Transplantation (King's equivalent of the Emory Transplant Center [ETC]), and Professor Tony Dorling, deputy director of the Centre. "Complement components are a key element of the innate immune system, which play a critical role in transplant rejection," says Dr. Hurst. "Assisting Prof. Sacks and Prof. Dorling in their work to further identify how complement modifies the immune response in graft rejection is very exciting. They are truly top players in this area of transplant immunology."

Prof. Sacks' lab generates numerous complement inhibitory biologics that he hopes to translate to the clinic. In addition to having significant potential in transplant indications, these therapeutics could also be suited to post-angioplasty/endarterectomy vascular remodeling and post-ischemic reperfusion injury. Prof. Dorling's work focuses on the role of such inflammatory factors as thrombin on the endogenous repair response, xenotransplantation, and investigations of the mechanisms of chronic allograft rejection and novel treatment regimes.

Dr. Allan Kirk, vice chair of research for the Emory Department of Surgery and scientific director of the ETC, sees a natural fit between the ETC and the MRC Centre. "We have wanted to find a way to work together for a long time, and forming a joint training initiative was a good way to start. Both sites have strong transplant programs and a real interest in developing academic clinicians. Ideally, King's first fellow will come to Emory in 2014. Meanwhile, Stuart has the opportunity to go to King's and perform valuable immunology research with luminaries like Prof. Sacks in areas that are not being done at the ETC. This arrangement offers all types of benefits. For example, King's has developed numerous new compounds that need to be tested in pre-clinical models of transplantation, and our work at Yerkes makes us the ideal group to foster those studies."

Underscoring Dr. Kirk's final point, Dr. Hurst says: "When I return to Emory, my hope is that I'll be able to apply the resources that are unique to the ETC to carry forward in a new way the research I'm doing with Profs. Sacks and Dorling."

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Dr. Thourani
Vinod Thourani
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The Edwards Sapien Transcatheter Heart Valve
The Edwards Sapien Transcatheter Heart Valve

New TAVR study shows alternative approaches offer comparable outcomes

According to a study in the October 2013 issue of The Annals of Thoracic Surgery, patients with aortic stenosis who are ineligible for surgical valve replacement as well as the traditional approach to transcatheter aortic valve replacement (TAVR) may have comparable outcomes when the surgeon uses an alternative access TAVR approach.

"Our experience demonstrated that cardiac surgeons and cardiologists must utilize a multitude of access options in TAVR to achieve minimal morbidity and mortality with excellent outcomes," says Dr. Vinod Thourani, an Emory University cardiothoracic surgeon-scientist and lead author of the study. Dr. Thourani also co-directs the Structural Heart and Valve Center at Emory University with Emory interventional cardiologist Dr. Vasilis Babaliaros.

TAVR using the transfemoral approach (via the groin) was recently approved in the United States for inoperable or high-risk patients with aortic stenosis, the most common acquired valvular disease in adults. Aortic stenosis is characterized by a narrowing of the opening to the aortic valve. Surgical aortic valve replacement is the treatment of choice; however, 25% of patients may be ineligible for surgery for reasons such as frailty or additional disease.

Transfemoral TAVR was approved for these high-risk or inoperable patients, but some patients have too much disease in the femoral artery to permit using the method.

To properly evaluate the outcomes from other TAVR approaches, Dr. Thourani and his Emory colleagues conducted an Emory-based retrospective review of 44 inoperable patients who underwent alternative access TAVR from November 2011 to April 2012. Alternative access approaches included transapical (TA; via the heart muscle), transaortic (Tao; via the aorta), and transcarotid (TCa; via the right common carotid artery) TAVR.

Of the 44 patients reviewed, 18 were eligible for TF, while 11 underwent TA, 12 underwent TAo, and three underwent TCa procedures.

Thirty days after the TAVR procedures, the researchers found no difference among the groups in mortality and no incidents of myocardial infarction or stroke. Study participants implanted using a non-TF approach, however, experienced longer average lengths of hospital stays.

"What we have learned from this study," said Dr. Thourani, "is that the TAVR physician, be they a cardiologist or cardiac surgeon, should feel comfortable utilizing a variety of TAVR techniques. This will allow the most appropriate tailoring of the TAVR procedure for optimal patient outcomes."

The FDA recently announced its approval of alternative access approaches for TAVR using the Edwards Sapien Transcatheter Heart Valve, making the procedure available to an expanded group of patients who have inoperable aortic valve stenosis. The new device labeling removes references to specific access points, now making it available for inoperable patients who require one of these alternative access points.

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Congratulations to the following faculty for their recent promotions:

Linda Cendales, MD, Associate Professor of Surgery, RT.

Edward Lin, DO, Professor of Surgery, CT.

Kurt Heiss, MD, Professor of Surgery, MEST.

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Dr. William B. Keeling
William B. Keeling

New faculty: Dr. Shipra Arya, Dr. William B. Keeling, and Dr. Jeffrey Miller

Division of Cardiothoracic Surgery

(Assistant Professor of Surgery) William B. Keeling, MD, was an assistant professor of surgery at University of Louisville School of Medicine and an attending at University Cardiothoracic Surgical Associates. He earned his medical degree at the University of Louisville in 2001, did his general surgery residency at the University of South Florida School of Medicine from 2001-2008, and completed his cardiothoracic surgery fellowship at Emory in 2011. Dr. Keeling will direct the cardiothoracic surgery program at Grady Memorial Hospital. His clinical interests include valve repair and thoracic aortic pathology, and his research focuses on targeted clinical investigations of adult cardiac surgical sub-populations.

Dr. Jeffrey Miller
Jeffrey Miller

(Assistant Professor of Surgery) Jeffrey S. Miller, MD, attended medical school and completed his general surgery residency at Baylor College of Medicine. He completed his cardiothoracic surgery residency at New York University Medical Center in 1999 and then returned to the Department of Surgery at Baylor as an assistant professor of surgery. In 2000 he joined Peachtree Cardiovascular Surgeons at Saint Joseph's Hospital and became surgical director of the cardiac transplant and mechanical circulatory support program. With the recent partnership between Saint Joseph's and Emory Healthcare, the cardiothoracic surgery programs at both facilities have integrated and Dr. Miller has joined the Emory Department of Surgery and The Emory Clinic. Dr. Miller will continue to see patients and perform surgery at Saint Joseph's while participating in the heart transplant program at Emory University Hospital. Dr. Miller specializes in heart transplantation, left ventricular assist devices, and robotically assisted cardiac and thoracic surgery.

Dr. Shipra Arya
Shipra Arya

Division of Vascular Surgery and Endovascular Therapy

(Assistant Professor of Surgery) Shipra Arya, MD, SM, received her Bachelor of Medicine, Bachelor of Surgery degrees from All India Institute of Medical Sciences in New Delhi, India, in 2004. She then completed her Master of Science in epidemiology at the Harvard School of Public Health in 2006, her general surgery residency at Creighton University Medical Center in 2011, and her fellowship in vascular surgery at the University of Michigan in 2013. Her clinical specialties are aortic aneurysmal disease, cerebrovascular disease, peripheral vascular disease, and renal and mesenteric arterial disease. Her research interests include health services investigations and healthcare resource utilization, with specific concentration on quality and effectiveness of vascular procedures and secondary prevention of vascular disease.

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Upcoming events

Mesothelioma: Progress Towards a Cure
Presented by distinguished visiting professor David J. Sugarbaker, MD
– Chief, Division of Thoracic Surgery, Brigham & Women’s Hospital
– Richard E. Wilson Professor of Surgical Oncology, Harvard Medical School
7:00 - 8:00 a.m., October 17, 2013 EUH auditorium
Changing the Surgical Approach to Breast Cancer Yet Again
Presented by William C. Wood, MD
– Professor of Surgery Emeritus, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine
7:00 - 8:00 a.m., October 24, 2013 EUH auditorium
Health Sciences Research Building Celebration 10:00 - 10:35 a.m., dedication, 10:45 a.m. - 12:00 p.m., tours, 12:00 - 1:00 p.m., lunch, October 24, 2013 1760 Haygood Drive, Emory University
2013 EHC Quality Conference 7:30 a.m. - 12:00 p.m., October 29, 2013 Cox Hall, 3rd floor ballroom
Department of Surgery Faculty Meeting 5:30 - 7:00 p.m., October 29, 2013 TEC B6300
Emory Medishare Haiti
Presented by Emory Medishare Surgery's attending faculty, resident, and medical student leaders, who will describe their experiences during the Emory Medishare June 2013 trip to Haiti.
SPECIAL START TIME: 6:30 - 7:30 a.m., October 31, 2013 EUH auditorium
Emory Medicine 2014 Annual Address
Presented by SOM Dean Dr. Chris Larsen
4:30 p.m., November 13, 2013 WHSCAB auditorium
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