July 2014 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine


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Surgical Critical Care Initiative (SC2i) will adapt lessons of war to complex civilian care

Surgical Critical Care Initiative (SC2i) leaderhsip group.
SC2i leadership, from left: Timothy Buchman, PhD, MD; Allan Kirk, MD, PhD; Benjamin Potter, MD, deputy director of SC2i, vice-chair for research, Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences; Eric Elster, MD; Stephen Ahlers, PhD, director, Undersea and Operational Medicine, Naval Medical Research Center; Christopher Dente, MD; and Todd Radano, CEO, DecisionQ.

Emory University School of Medicine; Duke University School of Medicine; Uniformed Services University of the Health Sciences; Henry M. Jackson Foundation for the Advancement of Military Medicine; Naval Medical Research Center; Walter Reed National Military Medical Center; and DecisionQ Corporation are partnering to translate remarkable advances in combat casualty care and surgical research resulting from military experiences with critically injured service members to civilian practice. Known as the Surgical Critical Care Initiative (SC2i), the collaborative effort is sponsored by the Defense Health Program of the Department of Defense (DoD). SC2i's national PI is Eric Elster, MD, professor and chairman, Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences.

Emory was chosen as the consortium's initial civilian site because of its established role in academic surgery, its system-wide integrated critical care network that includes one of the nation's busiest Level I trauma centers at Grady Memorial Hospital, and its status as the site of an earlier DoD-funded study led by Emory surgeon-researcher Christopher Dente, MD, that is developing a wound closure algorithm similar to the DoD's formula for military casualties.

Allan Kirk, MD, PhD, former vice chair of research of the Emory Department of Surgery and now chair of the Department of Surgery at Duke University Medical Center, serves as the PI for the SC2i at Duke and oversees the SC2i's civilian investigative partnerships. Dr. Kirk is a recognized authority in organ transplantation and its related immunology and is also interested in the fundamental relationships between injury, critical illness, and immune function. Duke Hospital's Level I trauma center and critical care services possess the degree of sophistication, reputation, and large patient base that can add further benefit to the initiative's endeavor.

Much of the Emory-based footwork will be undertaken by local PI Timothy Buchman, PhD, MD, director of the Emory Critical Care Center, and the afore-mentioned Dr. Dente, associate director of trauma at Grady Hospital and the partnership's lead site investigator at Grady. Drs. Buchman and Dente have extensive clinical and research experience in trauma and surgical critical care and lead the types of clinical services that can directly apply and evaluate the DoD's systems.

One of the byproducts of recent armed conflicts was the increase in catastrophic injuries that were survivable because of new types of body armor and the far-forward deployment of advanced medical resources. However, there were no established precedents for caring for such complex and life-threatening injuries, which resulted in treatment decisions being left to physicians' judgment. In an effort to standardize care in these extreme circumstances and control variable costs and outcomes, the DoD developed biomarker panels and decision-making algorithms that corresponded to the different types of severe injuries experienced by combat-wounded patients. The goal of the SC2i is to validate, enhance, and adapt these tools to treat critical injuries and illnesses in civilian settings and, by doing so, transmit valuable data back to the DoD to further refine its battlefield procedures.

"This program has the potential to revolutionize the way critically injured patients are cared for," says Dr. Dente. "Our goal is to work to implement real time models that will improve outcomes in surgical critical care, and do so in a more time and cost efficient manner."

Patients with acute illnesses and trauma can reach life-threatening states very rapidly, requiring split second treatment decisions that have substantial biological and fiscal implications. The challenge is to integrate the substantial amount of information available to inform those decisions in a time span that is clinically relevant. "We hope to realign the trajectory of a patient's course from a rapidly downward slope to recovery with better decision-making based on multiple sources of clinical information and biomedical data," says Dr. Kirk. "We want our medical practice to focus on what is right for a particular individual at a specific moment, and not solely on what may seem right for critical care populations in general."

The SC2i plans to achieve this goal by integrating and analyzing massive amounts of information, including immune-related data from biological samples acquired by informed consent, in real-time settings such as Emory and Duke's trauma centers and ICUs. The clinical teams will work with DecisionQ, a private company that specializes in data mining and creating mathematical, predictive models, to design a system that will swiftly pair these multiple data streams with the DoD's decision-making algorithms so that clinical professionals can receive informed recommendations for treating specific patient scenarios.

In addition to trauma and critical care, the decision-making tools that will be validated and enhanced by the SC2i are expected to help optimize outcomes across other disciplines that require complex medical decision making, including emergency medicine, orthopaedics, transplantation, and oncology.

Visit the SC2i's official website.

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Drs. Delman and Masters develop minimally invasive groin dissection

Dr. Master and Dr. Delman performing videoscopic gorin dissection.
Dr. Master and Dr. Delman performing videoscopic groin dissection.

Working under the banner of the multidisciplinary Winship Cancer Institute of Emory University, Emory surgical oncologist Dr. Keith Delman and Emory urologic oncologist Dr. Viraj Master often cross paths and compare notes. When the two surgeons found they shared a deep concern about the extremely high complication rates associated with the traditional, open method of removing cancerous lymph nodes in the groin, they began to discuss the possible ramifications of applying current, modern-day surgical tools to the problem. As their alternative approach took shape, they designed it to be a bilateral procedure that would involve two surgeons with separate endoscopic setups working simultaneously on the same patient.

The new procedure is called videoscopic groin dissection, and Drs. Delman and Masters have performed over 100 of the operations so far with excellent results. "The minimally invasive advantages are magnified by the fact that two people are doing the procedure," says Dr. Delman. "The operative duration is greatly reduced, there is reduced anesthesia risk, and perhaps most importantly, we can help each other as we work, consult each other about our particular surgical areas, and apply two minds to solving problems rather than just one."

The method features other significant diversions from the standard approach. Patients must be positioned with their legs bent outwards so that the two surgeons can literally fit within the operative field. By adapting a previously described version of the minimally invasive approach to melanoma patients, the large incisions of the past have been replaced with three tiny keyhole slits in the leg through which the endoscopic camera and tools are inserted. Most significantly, instead of just removing the cancerous lymph nodes, Drs. Delman and Master remove all of the lymph nodes and the fat they nest in, effectively cleaning out the groin space beneath the lower part of the abdominal wall, after which the instruments are withdrawn and the keyholes closed.

"Thus far, the procedure is literally transforming the recovery time that this operation used to have associated with it," says Dr. Delman.

As news of the success of videoscopic groin dissection has spread, Dr. Delman and Master have begun teaching the procedure to surgical oncologists from major academic centers in the United States and around the world, which clarifies it as a revolutionary advance in the treatment of patients with presumed cancerous lymph nodes.

Watch a video on the procedure.

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Karim Halazun
Karim Halazun

Relationship between waiting times and transplant outcomes for HCC patients examined

It may seem counter-intuitive that patients with hepatocelluar carcinoma (HCC) who undergo liver transplant after a short time on the waiting list have a statistically lower chance of survival than those who wait longer, but this is the primary conclusion that Emory transplant surgeon scientist Dr. Karim Halazun and his colleagues reached in a recent study. The results of the study, which compared outcomes for HCC patients that had liver transplants in long waiting times regions (LWTR) and short waiting times regions (SWTR), were published by Hepatology as "Standing the test of time: Outcomes of a decade of prioritizing patients with HCC, results of the UNOS natural geographic experiment." The research team's conclusions speak to the unintended fallout from HCC patients being given priority on liver transplant lists.

Since the implementation of the Milan criteria in 2002—which defined the basis for selecting patients with cirrhosis and hepatocellular carcinoma for liver transplantation—and its adoption by UNOS, a growing proportion of patients transplanted have HCC. Dr. Halazun and his collaborators saw that the well documented variability in waiting times between regions and the pre-transplant treatment algorithms that have resulted depending on where patients are listed offered a natural framework for studying the impact of these conditions and trends on survival.

The investigators based their study on 6,160 HCC patients from the UNOS database that received exception points between 2002-2012 in LWTR regions 5 and 9 and SWTR regions 3 and 10. Data from regions 5 and 9 were combined and compared to data from regions 3 and 10. Survival was studied in three patient cohorts: an intent-to-treat cohort, a post-transplant cohort, and a cohort examining overall survival in transplanted patients only (survival from listing to last post-transplant follow-up). Multivariable analysis and log rank testing were used to analyze the data.

Median time on the list in the LWTR was 7.6 months compared to 1.6 months for SWTR with a significantly higher incidence of death on the waiting list in LWTR than in SWTR (8.4% vs. 1.6%, p<0.0001). Patients in the LWTR were more likely to receive loco-regional therapy, to have T3 tumors at listing, and to receive expanded criteria donor (ECD) or donor after cardiac death (DCD) grafts than patients in the SWTR (p<0.0001 for all). For all three cohorts, survival was significantly better in the LWTR compared to the SWTR (p<0.0001 for all 3 survival points). In fact, being listed/transplanted in a SWTR was an independent predictor of poor patient survival on multivariate analysis (p<0.0001, HR=1.545, CI 1.375-1.736). The investigators concluded that expediting patients with HCC to transplant at too fast a rate may adversely affect patient outcomes.

"We arrived at several possible explanations for this situation," says Dr. Halazun. "One is that HCC patients can be transplanted in short waiting times regions before physicians know how aggressive their particular tumors are, which can lead to poorer outcomes. In long waiting times regions, patients with tumors that progress drop off the list if the tumor becomes too advanced. Another hypothesis is that HCC patients in long waiting times regions have the opportunity to receive neo-adjuvant treatment such as transarterial chemo-embolization (TACE), which can prevent progression during waiting time as well as decrease the risk of seeding during transplantation. We believe that equally good post-transplant outcomes can come from standing the test of time with no evidence of tumor progression, or being successfully down-staged from T3 to T2 status results via TACE."

While the study calls into question what the best management of HCC patients nationwide should be, the authors admit that their study is limited by several factors, including its retrospective nature, reliance on registry data, and the lack of data on tumor recurrence, causes of mortality, and tumor explant data for which the collection has only recently begun.

"There are many variables that could modify or better clarify our conclusions, such as the differences in management of HCC in different centers that could account for variability in T3 tumor numbers and chemoembolization rates between regions," says Dr. Halazun. "However, because of the population-based evidence that overall waiting time is an independent predictor of poor outcome, we urge that further iterations in allocation policy towards HCC be considered."

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Emory Liver app wins Award of Excellence

Screenshot from Emory's Surgical Anatomy of the Liver iPad app.

Emory’s Surgical Anatomy of the Liver iPad app received an Award of Excellence in the Didactic/Instructional Commercial Interactive Media category at this year’s Association of Medical Illustrators Annual Conference, held at the Mayo Clinic from July 23-26. Awards of Excellence are given to artwork that has met the highest standards of the profession. The judges consider the intended purpose, degree of problem solving, concept, accuracy of medical or scientific content, creativity, medium/software used, technical execution, clarity, and appropriateness to the audience.

A product of the Carlos and Davis Center for Surgical Anatomy and Technique (CSAT), the liver app initiated CSAT’s new focus on electronic education. Intended for trainees, medical students, instructors, and anyone interested in a quick way to learn or teach liver anatomy, the interactive 3D app allows users to mentally map the anatomy of the liver in ways that were never before possible with print illustrations or imaging studies.

To create the app, Emory surgical oncologist Dr. Shishir Maithel guided Emory SOM medical illustrator Michael Konomos through the intensive process of accurately sculpting the complex anatomy of the liver, with the end product achieving a synthesis of radiographic, cadaveric, and surgical references as well as the distillation of hundreds of hours of liver surgery. CSAT medical illustrator Andy Matlock contributed 3D animations that display the typical configuration of the liver as it pertains to surgical anatomy.

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Emory connections prevalent in paper on groundbreakers in plastic surgery

The Emory plastic surgery group, mid 1980s.
The Emory plastic surgery group, mid 1980s, standing, left to right; John Bostwick, Wilbur Baird, Foad Nahai, John Coleman, John Culbertson. Sitting, left to right: T. Roderick Hester, Maurice Jurkiewicz.

"Innovation has been the primary driver, and perhaps the unifying core competency, of plastic surgery for at least a century," Dr. Charles Hultman and Dr. Jonathan Friedstat state in a paper published in the June edition of Annals of Plastic Surgery. "The best way to manage the future is to create it. Therefore, the survival of plastic surgery as a subspecialty in health care is dependent upon continued innovation." By defining the advancements and pioneers of the past and present, the coauthors assert, contemporary plastic surgeons can accurately define their current world and predict what their world will become.

To arrive as close as possible to a consensus, Drs. Hultman and Friedstat, both faculty plastic surgeons of the UNC School of Medicine, conducted an anonymous, web-based survey of all members of the American Council of Academic Plastic Surgeons (ACAPS) and the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS). Respondents were asked to list their top five choices in such categories as the most influential surgeons of the 20th century, the most influential currently in practice, and the most important innovations from the past and the present. After tallying and separating the responses by organization, the coauthors published the results, and innovations and innovators with Emory associations appear throughout. Interestingly, Dr. Hultman himself did his plastic surgery residency at Emory from 1998-2000.

John McCraw, an Emory plastic surgery resident from 1972-1974 and one of the earliest surgeons to experiment with flap-based reconstruction, placed 5th in the ACAPS list for the most influential plastic surgeons of the 20th century. The late Maurice Jurkiewicz, chief of the Emory division of plastic surgery from 1971-1993, followed at 7th and also placed 6th in the SESPRS listing. Dr. Jurkiewicz is often credited with advocating plastic surgery as an intellectual surgical endeavor rather than merely a technology. SESPRS ranked the late TRAM flap maven and former Emory clinical faculty member Carl Hartrampf the 7th most influential surgeon, the late Stephen Mathes the 8th, and the late John Bostwick the 10th. In the years following his general surgery residency (1972-1975) and plastic surgery residency (1975-1977) at Emory, Dr. Mathes deciphered the vascular anatomy of flaps throughout the body and how to safely move these tissues when needed for reconstructive surgery. Dr. Bostwick, chief of Emory plastic surgery from 1992 until his untimely death in 2001, was a pioneer in the use of tissue from the patient's body for breast reconstruction, authored the two-volume atlas Plastic and Reconstructive Breast Surgery, an early touchstone in the field, and co-authored A Woman's Decision: Breast Care, Treatment & Reconstruction.

Of the ten most influential plastic surgeons currently in practice, ACAPS ranked current Emory faculty member Foad Nahai 10th, while SESPRS ranked him 2nd. In the category of most influential and innovative contributions to plastic surgery, the use of muscle flaps in reconstructive surgery co-developed by Dr. Nahai and his seventies-era Emory colleagues Dr. Mathes and Dr. McCraw, was listed 3rd by ACAPS and 5th by SESPRS. Dr. Hartrampf's refinement of the TRAM flap, which used abdominal skin and fat to create a breast mound and heralded a new phase of breast reconstruction, was voted 1st in this category by ACAPS and 2nd by SESPRS.

During the course of the study, the authors identify incremental change and disruptive change as the forces of innovation that have determined the progress of plastic surgery. Incremental change sustains and refines existing innovations, while disruption dramatically improves products or services in ways that the market does not expect and eventually displaces older technologies. To Drs. Hultman and Friedstat, the disciplined and creative interaction between these two influences has given the development of plastic surgery its rich history. As they illustrate this concept, the co-authors trace the incremental changes in breast reconstruction that gradually advanced the field, until "surgeons like John McCraw, Carl Hartrampf, and John Bostwick learned to use patients' own tissue for total autologous reconstruction, disrupting and resetting the expectation for both the provider and the patient."

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Manu Sancheti
Manu Sancheti

New faculty: Dr. Veronica Jones and Dr. Manu Sancheti

Division of Cardiothoracic Surgery

(Assistant Professor of Surgery) Manu S. Sancheti, MD, received his MD from the University of Alabama School of Medicine in 2006, after which he did a general surgery residency at St. Luke’s-Roosevelt Hospital Center in New York City from 2006-2011. He joined our faculty after completing his Emory cardiothoracic surgery residency, general thoracic track.

Dr. Sancheti’s clinical specialties are thoracic oncology, minimally invasive thoracic surgery, esophageal surgery, and lung transplantation. His research interests include thoracic surgical minimally invasive techniques, outcomes in thoracic oncology, and cost and quality improvements in thoracic surgical services.

Veronica Jones
Veronica Jones

Division of Surgical Oncology

(Assistant Professor of Surgery) Veronica C. Jones, MD, received her MD at Meharry Medical College in Nashville, completed her general surgery residency at Baylor University Medical Center in Dallas, and did her breast surgical oncology fellowship under the mentorship of Dr. Sheryl Gabram at Emory University.

Her clinical specialties include benign and malignant breast disease and populations at high risk for development of breast cancer, while her research focuses on disparities in breast cancer outcomes, access to care, rehabilitative needs in the breast cancer survivorship population, and new technologies in breast cancer care.

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Upcoming events

Medawar's Dream: A Sixty Year Journey Towards Clinical Tolerance
Presented by Juliet Ann Emamaullee, MD
– Chief Resident, Department of Surgery, Emory University School of Medicine
7:00 a.m. – 8:00 a.m., August 7, 2014 EUH auditorium
Inpatient Management of Surgical Patients with Type 2 Diabetes
Presented by Guillermo E. Umpierrez, MD
– Professor of Medicine, Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine
– Chief of Diabetes and Endocrinology, Grady Health Systems
7:00 a.m. – 8:00 a.m., August 14, 2014 EUH auditorium
Robotic-Assisted Bypass Surgery and Hybrid Coronary Revascularization: The Emory Experience
Presented by Michael E. Halkos, MD, MSc
– Assistant Professor of Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
– Scientific Director, Clinical Research Unit of the Division of Cardiothoracic Surgery, Department of Surgery, Emory
– Associate Program Director, Integrated Cardiothoracic Surgery Residency, Emory
7:00 a.m. – 8:00 a.m., August 21, 2014 EUH auditorium
Department of Surgery Division Chiefs Meeting 5:30 p.m. – 7:00 p.m., August 26, 2014 Surgery Education Office, EUH, H108 & H110
Evolution, Beauty, and Surgery
Presented by Felmont F. Eaves, III, MD
– Professor of Surgery, Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine
– Medical Director, Emory Aesthetic Center at Paces
7:00 a.m. – 8:00 a.m., August 28, 2014 EUH auditorium
Winship Win the Fight 5K Run/Walk
Register here.
Sept. 27, 2014 Emory University's McDonough Field
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