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

 

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Dr. Felix Fernandez
Felix Fernandez

Related lung cancer studies reveal survival disparities at 2014 ACS Clinical Congress

Dr. Sancheti receives the Best Poster award from Craig Derkay, MD, vice-chair of the ACS 2014 Meeting Program Committee, and Audra Duncan, MD, executive member of the committee.
Dr. Sancheti receives the Best Poster Award from Craig Derkay, MD, vice-chair of the ACS 2014 Meeting Program Committee, and Audra Duncan, MD, executive member of the committee.

Two Emory studies based on reviewed data from the National Cancer Data Base (NCDB) of the American College of Surgeons and the American Cancer Society were highlights of the October 2014 ACS Clinical Congress in San Francisco. The studies reached similar conclusions and were the largest database analyses of their types to date. Cardiothoracic surgeon-scientist Felix Fernandez, MD, was the senior author and team leader of both studies.

Data from an NCDB Participant User File (PUF) for non-small cell lung cancer was integral to the studies. PUFs contain patient level data that do not identify hospitals, health care providers, or patients. Winship Cancer Institute and Department of Surgery oncology scientist Theresa Gillespie, PhD, is the PI and awardee of the file. Representation and analysis of the data was assisted by Winship's Biostatistics and Bioinformatics Shared Resource (BBISR). BBISR is supported by an NCI P30 Cancer Center Support Grant overseen by Walter Curran, MD, MPH, executive director of Winship.

Emory cardiothoracic surgeon-researcher Manu Sancheti, MD, presented "Risk Factors for 30-Day Mortality after Pulmonary Resection for Lung Cancer from the National Cancer Data Base: An Analysis of over 200,000 Patients" at the Posters of Exceptional Merit program of the ACS meeting, for which he received the Best Scientific Poster Presentation Award. The study team included Dr. Gillespie, Dr. Fernandez, and additional Emory faculty and staff Dana Nickleach, MA, Yuan Liu, PhD, Kristin Higgins, MD, Suresh Ramalingam, MD, and Joseph Lipscomb, PhD.

The study examined non-clinical factors associated with short-term mortality after pulmonary resection that could identify disparities in care, and focused on 215,758 patients from the NCDB who had surgical resection for non-small cell lung cancer during the period of 2003-2011. The team controlled for known clinical risk factors of short-term mortality, including comorbidity score, age, and extent of resection. They then reviewed other socioeconomic factors, including lack of health insurance, low income, low levels of education, and treatment at a non-academic center, and found that these factors were independently associated with higher 30-day mortality.

"Academic/research programs showed slight survival advantage, possibly due to the patient population being younger, more female, more likely to have insurance, and other factors," Dr. Sancheti says.

Thoracic surgery resident Onkar Khullar, MD, presented "Socioeconomic Risk Factors for Long-Term Mortality after Pulmonary Resection for Lung Cancer: An Analysis of More than 90,000 Patients from the National Cancer Data Base," which has been accepted for publication in the Journal of the American College of Surgeons. The other team members were the same as the prior study, minus Dr. Sancheti.

The study selected almost 235,000 patients from the NCDB diagnosed with non-small cell lung cancer between 2003 and 2006, approximately 93,000 of whom underwent surgery. About 60% of patients diagnosed with stage I cancer survived at least five years after surgery, compared to 40%, 31% and 20% for stage II, III, and IV, respectively.

After accounting for tumor stage, positive lymph nodes, and age at diagnosis, factors such as lack of insurance, lower income, and lower education level were associated with worse overall survival after surgery. For example, patients with the lowest education level and lowest income level had a 10% increased risk of death, and not being insured imparted a 23% increased risk.

"While the stage of the cancer is a more important influence on patient outcomes," says Dr. Fernandez, "understanding all of the factors tied to survival can identify groups of people who need more attention for quality improvement."

The scope of the study did not allow for analysis of how the socioeconomic factors interacted, and acknowledged that the reported disparities required further, detailed investigation.

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Dr. Stuart Knechtle
Stuart Knechtle

Dr. Knechtle leaves Emory

To say that Stuart Knechtle, MD, was qualified to direct the clinical liver transplantation program of the Emory Transplant Center when he came to Emory in 2008 would be an understatement. As a faculty member of the University of Wisconsin for 17 years, he had operated a successful NIH-funded transplant immunology research lab and amassed six patents in the process; directed the liver transplantation, kidney transplantation, and transplant clinical trials programs of UW Hospital and Clinics; and led the teams that performed Wisconsin's first living donor liver transplant and the state's first combined liver-pancreas transplant.

After his arrival, Dr. Knechtle began expanding the scope of Emory's liver transplant program by collaborating with colleagues in the departments of medicine, radiology, anesthesia, and surgery. He was appointed chief of the division of transplantation of the Emory Department of Surgery in 2009, chief of pediatric liver transplant surgery at Children's Healthcare of Atlanta at Egleston in July 2010, and Carlos and Marguerite Mason Chair of Liver Transplant Surgery in November of that same year.

In 2009, he led the team that performed Georgia's first domino liver transplant, an extremely rare procedure in which a viable liver from a deceased donor is transplanted into the first recipient, and the first recipient's organ is then transplanted into a second recipient. In October 2011, he directed the first living donor, parent-to-child liver transplant at CHOA in five years, and in 2012 he led the teams that performed the liver and kidney portions of Georgia's first triple organ transplant.

While at Emory, Dr. Knechtle's research included studies of the immunologic mechanisms of transplant rejection and immunologic tolerance in organ transplantation encompassing human clinical trials and non-human primate models, examinations of liver transplant access and outcomes as well as cost and healthcare resource utilization, and development of a method to monitor kidney transplant patients by measuring chemokines in their urine rather than blood tests. According to the Blue Ridge Institute for Medical Research, which publishes ranking tables online of annual NIH funding, Dr. Knechtle was the fifth top NIH-funded academic surgery investigator for 2013.

As 2014 draws to a close, Dr. Knechtle will leave Emory to serve as executive director of the Duke Transplant Center at Duke University School of Medicine. Liver transplant surgeon and researcher Joseph Magliocca, MD, will assume surgical leadership of the liver transplant programs at Emory and CHOA.

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Dr. Karim Halazun
Karim Halazun

Dr. Halazun chosen for ASTS Vanguard Prize

The Foundation of the American Society of Transplant Surgeons has awarded Karim Halazun, MD, the 2015 ASTS Vanguard Prize for his paper entitled, “Standing the Test of Time: Outcomes of a Decade of Prioritizing Patients with HCC, Results of the UNOS Natural Geographic Experiment,” published in Hepatology.

The Vanguard Prize was established by the ASTS to recognize and honor outstanding contributions by its junior members for best papers published within the preceding eighteen months.

The paper compared survival for patients undergoing liver transplantation for hepatocellular carcinoma (HCC ) in long waiting times regions (LWTR) and short waiting times regions (SWTR) by analyzing national data from the United Network for Organ Sharing database. The authors concluded that patients with 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.

The results suggest that early access to liver transplantation for patients with HCC is detrimental to overall survival despite decreasing the risk of wait list dropout. Improved survival in the LWTR existed both on an intent-to-treat analysis and in a post-transplant survival analysis, despite a higher proportion of T3 patients being transplanted in the LWTR. Listing and being transplanted in the LWTR was associated with better outcome in multivariable analysis, conferring a 20% greater chance of improved survival when compared to listing in a SWTR.

“One possible explanation 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,” says Dr. Halazun. “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, which can prevent progression during waiting time as well as decrease the risk of seeding during transplantation.

“Tumor biology is currently crudely assessed in HCC patients by way of radiologic imaging. Time however, may be the best available index of tumor biology, as aggressive cancers will manifest themselves if observed for a long enough period.”

The award will be formally presented to Dr. Halazun at the 15th ASTS State of the Art Winter Symposium: Transplant: The Ultimate Team Sport, which is scheduled for January 15-18, 2015, at the Loews Miami Beach Hotel.

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Dr. Shipra Arya
Shipra Arya

Dr. Arya selected for Surgical Outcomes Club Research Fellowship

Shipra Arya, MD, SM, was awarded a one-year Surgical Outcomes Club Research Fellowship at SOC’s 10th Annual Scientific Session on October 26th in San Francisco.

SOC is dedicated to advancing health services and outcomes research in surgery, and its fellowship provides an avenue for young investigators to acquire the skills and knowledge to develop, execute, and publish studies in these areas under the guidance of highly qualified mentors and advisors.

Dr. Arya’s mentor will be SOC member and vascular surgeon-scientist Philip P. Goodney, MD, of The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and Dartmouth-Hitchcock Medical Center. Dr. Goodney’s research focuses on improving the patterns and outcomes of care provided to patients with peripheral vascular disease. With funding from the NHLBI, the Society for Vascular Surgery, and the Peripheral Vascular Surgery Society, he has examined the utilization and effectiveness of newer treatments for vascular disease, as well as disparities in the provision of vascular care.

For the fellowship, Dr. Arya plans to investigate the effectiveness of vascular surgical interventions in the elderly, perioperative decision-making, and healthcare resource utilization. She will also pursue methodological training in the use of such administrative databases as those maintained by the Department of Veterans Affairs and the Centers for Medicare and Medicaid Services.

Under the auspices of Atlanta Clinical & Translational Science Institute, Dr. Arya is currently leading a multi-pronged comparative effectiveness pilot study with Emory transplant and epidemiology investigator Rachel Patzer, PhD, that is evaluating the factors associated with prolonged catheter use and the delay or failure of fistula maturation in the first year of dialysis, as well as the costs of creating and maintaining a fistula or graft for dialysis access in different patient populations.

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Dr. Lauren Postlewait
Lauren Postlewait

Sabbatical resident receives 2015 Conquer Cancer Foundation of ASCO Merit Award

PGY3 resident Lauren Postlewait, MD, who is doing a two year research sabbatical with mentor and surgical oncologist Shishir Maithel, MD, has been selected to receive a 2015 Conquer Cancer Foundation of American Society of Clinical Oncology Merit Award for the abstract, "The Optimal Length of the Proximal Resection Margin in Patients with Proximal Gastric Adenocarcinoma: A Multi-Institutional Study of the U.S. Gastric Cancer Collaborative." Dr. Postlewait is listed as first author.

Each year, a limited number of Merit Awards are awarded to fellows and residents whose research is expressed in high-quality abstracts that are recognized for their scientific merit. The award will allow Dr. Postlewait to present the abstract at the 2015 ASCO Gastrointestinal Cancers Symposium on January 15-17 in San Francisco.

The study concluded that the length of the proximal margin is not associated with local recurrence, recurrence-free survival, or overall survival for an abdominal-approach resection of proximal gastric adenocarcinoma. Other key findings were that even though a positive microscopic margin is associated with advanced N-stage, it is not independently associated with recurrence or survival; that a grossly negative proximal margin is sufficient when performing an abdominal-approach resection of proximal gastric adenocarcinoma; and that efforts to achieve a specific margin distance, especially if they necessitate an esophagectomy, should be abandoned.

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EM-ProLEAD Class of 2015 includes three Emory Surgery faculty members

The first installment of the Emory Medicine Professional Leadership Enrichment and Development Program (EM-ProLEAD) will begin January 2015 and last until October. The program is designed to foster and develop professionals across the entire Emory Medicine enterprise, and will focus on enriching leadership skills, enhancing business knowledge, and developing strong partnerships across Emory. The program is lead by Douglas Morris, MD, director and CEO of the Emory Clinic, and Harold Simon, MD, MBA, vice chair of the Department of Pediatrics.

Please join us in congratulating the Department of Surgery members of the 2015 EM-ProLEAD class: Cullen Morris, MD, Rachel Patzer, PhD, and Ravi Veeraswamy, MD.

The launch of EM-ProLEAD was announced in August 2014. The program evolved from combining two very successful and popular faculty development programs: The Department of Pediatrics' PEP (The Executive Program), initiated by Lucky Jain, MD, in 2005, and Emory Clinic's PLDP (Physician Leadership Development Program), started by Dr. Morris in 2013.

Candidates were nominated by their department chair or division director and reviewed by the Em-ProLEAD Advisory Committee. The selection process was difficult due to the number of impressive nominees. Those not selected for this year will be eligible to reapply for the 2016 course.

For additional information or questions related to Emory ProLEAD, please contact Michael Cabe in the Emory Clinic Office of Development Programs at michael.cabe@emoryhealthcare.org.

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Abstract deadline approaching for Annual Surgery Research Symposium

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The abstract submission deadline for the 14th Annual Surgery Research Symposium is midnight, December 11, 2014.

Trainees in a dedicated laboratory rotation should submit their research, though the call for abstracts in both basic and clinical science categories is open to all trainees. All submissions will be considered for both oral and poster presentation. The highest scoring abstracts in each category will be selected for seven minute oral presentations. Additional highly ranked abstracts will be allotted slots for poster presentation.

Cash awards for 1st and 2nd place in oral presentations in both clinical and basic science categories will be given, as well as awards for the top poster in each category.

The symposium will be held on April 30, 2015. John Alverdy, MD, the Sara and Harold Lincoln Thompson Professor of Surgery and director of surgical treatment of obesity, University of Chicago, will be the featured speaker.

Please contact Griselda McCorquodale at gmccorq@emory.edu for abstract and submission requirements.

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Upcoming events

EVENT DATE/TIME LOCATION
Department of Surgery Division Chiefs Meeting 5:30 p.m.–7:00 p.m., Nov. 25, 2014 Surgery Education Office, EUH, H108 & H110
SURGICAL GRAND ROUNDS
Daniel Collier Elkin: A Man In Full
Presented by Thomas F. Dodson, MD
– Professor of Surgery and Chief, Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine
– Associate Chairman, Department of Surgery, Emory University School of Medicine
– Vice Chairman for Education, Department of Surgery, Emory University School of Medicine
7:00 a.m.–8:00 a.m., Dec. 4, 2014 EUH auditorium
SURGICAL GRAND ROUNDS
Living Donor Liver Transplantation – The Left Lobe
Presented by B. Daniel Campos, MD
– Assistant Professor of Surgery, Division of Transplantation, Department of Surgery, Emory University School of Medicine
7:00 a.m.–8:00 a.m., Dec. 11, 2014 EUH auditorium
SURGICAL GRAND ROUNDS
Oncoplastic Breast Surgery and the Changing Landscape of Breast Reconstruction

Presented by Ximena Pinell-White, MD
– Chief Resident, Department of Surgery, Emory University School of Medicine
7:00 a.m.–8:00 a.m., Dec. 18, 2014 EUH auditorium
     
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