Surgery

A new online tool can help seniors with advanced heart disease decide between two possible medical interventions - Coronary Artery Bypass Graft surgery or Percutaneous Coronary Intervention, a.k.a. angioplasty.

To use the tool, seniors enter in their age, gender, diabetes status, tobacco use and heart disease history. The tool then calculates a predicted five-year survival rate, based on outcomes of similar patients who underwent these procedures. These predictions are derived from data extracted from the medical records of more than 100,000 Medicare patients, and analyzed using a model recently published in a study led by Mark Hlatky, MD, professor of health research and policy and of cardiovascular medicine at Stanford.

I had the pleasure of working with the amazing team of health researchers and programmers who developed this medical decision tool in a little under a month. For me, it was a sneak preview into the future of personalized medicine, where a person can review surgical outcomes of real-world patients with similar health histories, to reach an informed decision on a treatment plan with their physician.

“Studies usually focus on the results for the average patient, and not on how much the results vary among individuals. This model is a step towards personalizing treatment recommendations, based on each individual’s unique characteristics,” Hlatky told me. “The other exciting thing about this new methodology is that with relative ease, it can be applied to other medical conditions such as cancer and stroke.”

Hlatky will present his model and findings at the Institute of Medicine workshop “Observational Studies in a Learning Environment,” which can be viewed via a webcast on April 24-25.

Previously: Is stenting or surgery better for diabetics? New study provides answer, New test for heart disease associated with higher rates of procedures, increased spending and To stent or not to stent: not always an easy answer
Illustration by Dawn Johnson/iStock

Marjorie McFadden is not your typical 90-year-old. McFadden retired from her public-school job at the age of 85 and remained very social afterwards, regularly attending social gatherings and playing bingo and pinochle with friends. A condition called achalasia, an unusual tightening of the muscles at the lower end of the esophagus, changed all of that, and McFadden found herself unable to swallow food or water and losing a pound of weight a day. But an innovative procedure at Stanford - the per oral endoscopic myotomy, or POEM - now means McFadden is back to enjoying social gatherings again. Her story is captured in the Stanford Hospital video above.

Previously: Hope for those suffering from a rare throat disease

Congenital heart defects, abnormalities in the heart that occur during fetal development, are the most common type of birth defect, with the Centers for Disease Control and Prevention estimating that one million American adults are currently living with one. Some types of congenital heart defects can be mild and require no medical treatment, while others such as transposition of the great arteries were once fatal and today require lifelong cardiac care.

In transposition of the great arteries (TGA), the aorta and pulmonary artery, two major vessels that carry blood away from the heart are transposed. This causes blood from the lungs to flow back into the lungs and blood from the body to flow back into the body without getting the proper amount of oxygen. Brooke Stone was diagnosed with the condition as a newborn and, like many infants, underwent a complex surgery to correct her blood flow. While Stone’s congenital heart defect was successfully repaired in infancy, the surgical fix meant she had to sit out of gym class as a child, and it produced some deadly complications for her later in life.

But thanks to a second life-saving surgery performed last September at Lucile Packard Children’s Hospital, Stone can now enjoy a full life. In today’s Inside Stanford Medicine, my colleague offers a closer look at Stone’s story and how Frank Hanley, MD, director of the Children’s Heart Center at Packard Children’s, is pioneering a new approach to improve surgical repairs for TGA:

Instead of backing away from the [conventional approach, which had poor patient outcomes], he looked closer to understand its limitations. “The idea that everyone who needed the procedure could just be slam-dunked into the arterial switch was wrong,” he said. “We focused on setting rigid criteria for accepting people into the program, and setting up a five-point report card after left-ventricle training to ensure that we were selecting appropriate patients who would have good outcomes.”

Today, Hanley may be the only surgeon in the United States doing the procedure. A careful process of multiyear monitoring, patient selection and rigorous evaluation is key to his successful approach. Over the past 15 years, as the criteria for selection and the procedure have evolved, the survival rate for Hanley’s patients has grown to exceed 90 percent. So far, Hanley has managed 36 patients with a failing Mustard/Senning procedures, and estimates that thousands more in the United States may still need lifesaving intervention of some kind.

The story goes on to explain how Packard Children’s is working in tandem with the multidisciplinary Adult Congenital Heart Program at Stanford to better provide monitoring and care of survivors of congenital heart surgery.

Previously: Advancing heart surgery for the most fragile babies and Little hearts, big tools
Photo by Chris Conroy

In this recently posted TedxStanford talk, Sherry Wren, MD, a general surgeon at Stanford, offers some staggering statistics about surgery and global health. One particularly eye-opening fact she shares is that two billion people lack basic access to surgical care. Wren goes on to discuss reasons why surgery is not part of the global health agenda and argues we need to reject the current dogma that surgery is not cost effect or part of basic health. The video is worth watching and offers compelling evidence on why investment is needed to fund surgical training in low-income countries.

Previously: Teaching surgeons new skills for medical missions and Intervention program helps reduce pneumonia among surgery patients

Research published in the latest issue of Surgery examines the connection between surgical outcomes and diet and suggests that what patients eat prior to a procedure may influence their recovery.

In the study (subscription required), researchers at Brigham and Women’s Hospital placed one group of mice on a high-fat diet, which consisted of 60 percent calories from fat, and fed a control group a more normal diet, containing 10 percent calories from fat. A few weeks prior to surgery, some of the animals on the high-fat diet were switched to the control group diet. According to a release:

During surgery, the researchers performed procedures that would occur during a typical operation and observed that such surgical trauma rapidly affected the fat tissues located both near and away from the trauma site. This resulted in increased inflammation and decreased specialized fat hormone synthesis, especially in the young adult mice and those that had a simulated wound infection.

However, reducing food intake before surgery tended to reverse these activities for all mice age groups, even in the setting of the simulated infection. The results suggest that while fat is a very dominant tissue in the human body, its ability to rapidly change might be leveraged to lessen complications in humans during stressful situations such as surgery.

Researchers say further study is needed to determine whether altering patients’ nutrition might benefit their recovery by reducing “the incidence and severity of surgical complications brought on by over-exuberant inflammation and other stressors.”

Previously: How music therapy may benefit surgery patients and Easing pain and improving recovery with hypnosis
Photo by Ozaki Lab, Brigham and Women’s Hospital

A story in today’s San Francisco Chronicle highlights a new surgical approach for treating achalasia, a rare throat disease that affects the ability of the esophagus to move toward the stomach and makes it hard for those who suffer from the disorder to swallow. Writer Drew Joseph describes peroral endoscopic myotomy, or POEM - a technique developed by Japanese surgeons. It is performed by only a handful of doctors in the United States, including Stanford’s Homero Rivas, MD:

Called peroral endoscopic myotomy, or POEM, the surgery is a less invasive means of accomplishing what a traditional operation has done - relaxing the muscle to allow food to enter the stomach.

Both POEM and the traditional procedure involve surgeons making a small cut in the muscle - called the lower esophageal sphincter - to loosen it. But while the standard operation requires doctors to make incisions in the patient’s abdomen, POEM leaves patients with no external cuts.

Instead, doctors insert an endoscope down the patient’s mouth and tear a little slit in the esophagus to gain access to the muscle. Surgeons say the new minimal approach helps patients recover faster.

We’ve written before about the increasing number of breast cancer patients who opt to have both breasts removed, despite having cancer in only one. A CNN.com article today explores the reasons for these rising numbers and mentions a Stanford-developed online support tool, which was designed to help patients weigh their treatment options.

Previously: BRCA patients use Stanford-developed online tool to better understand treatment options, A closer look at preventive breast cancer surgery and Researchers unsure why some breast cancer patients choose double mastectomies

Pediatric surgeons have been slow to adopt a technique that could keep their patients safer during a common but risky hospital procedure. But the Stanford scientist behind a new study of the procedure hopes his new research findings will provide the push they need to change their ways.

The procedure is insertion of a central venous catheter, a type of intravenous line that gives access to the largest vein in the body. It’s used when the a peripheral IV (the kind that goes in the patient’s hand or arm) is not appropriate - for instance, if a patient needs to receive a large volume of IV fluid, or needs a chemotherapy drug that could damage small veins. Inserting a central line requires poking a needle deep inside the body, into one of three major veins that feed to the very biggest vein, the vena cava. Once the needle is in the vein, it provides a pathway for threading in the catheter.

Since 2010, the American College of Surgeons has recommended that surgeons use ultrasound to see what they’re doing during this procedure. The new study provides fresh, kid-focused evidence that this is the right thing to do, as our press release on the research explains:

“Although it’s a common procedure and is sometimes perceived as benign, it’s not,” said Sanjeev Dutta, MD, senior author of the new study. “We found that, even in the hands of experienced pediatric surgeons, the use of ultrasound can mitigate the risk of complications when placing central lines.” Dutta is a pediatric surgeon at Packard Children’s and an associate professor of surgery at the School of Medicine. The research was published online today in the Journal of the American College of Surgeons.

In the study, when pediatric surgeons used ultrasound, they were able to successfully guide the needle safely into a vein 65 percent of the time on the first try, and 95 percent of the time within three tries. In contrast, when they used only anatomic landmarks to guide insertion, success rates were 45 percent on the first attempt and 74 percent after three attempts. Previous research has shown that needle placement into a vein for central line insertion is associated with few complications if it succeeds on the first try, but after three attempts, the risk of complications jumps sharply. Complications of a failed insertion can include bleeding in the chest cavity, lung puncture that causes air to be trapped in the chest cavity, puncture of the carotid artery and, rarely, fatal complications such as strokes

Surgeons practice drilling burr holes during Stanford course

Sherry Wren, MD, a general surgeon at Stanford, has volunteered multiple times for humanitarian missions in Africa with Doctors Without Borders. There, she has treated patients for everything from head traumas to difficult births to gunshot wounds; in the process, she has learned to use hand drills for brain surgery and papaya paste as a salve for severe burns, as well as how to serve as her own anesthesiologist while operating on a patient.

This month, Wren taught a continuing medical education course at Stanford to pass along the skills she learned from these first-hand experience to other surgeons and physicians interested in volunteering for similar medical missions. She recruited experts in neurosurgery, ob/gyn, and other fields to help teach the course, and she drew a large and appreciative crowd of students.

In today’s issue of Inside Stanford Medicine, I describe the course (which she calls a “labor of love”), Wren’s “MacGyver-like skills,” and her ability to “make do” with whichever supplies are available:

Developing countries may not have well-stocked supply closets; there may be no blood bank nearby; anesthesia may be limited; sonograms may be nonexistent.

“We wanted to make physicians understand that it’s all about somehow ‘making it work,’ Wren said. ‘You survive on your wits, making do with what’s on hand.”

…

The course itself was something of a lesson in MacGyver-like inventiveness. Students used pigs’ feet to practice ligament repair. Breech births were simulated from sleeping bags. An orthopaedic company donated thousands of dollars worth of fake bones; hand drills ordered online were used for bone-drilling practice.

Previously: What I did this summer: Stanford medical student works to improve pediatric surgical care in Tanzania
Photo by Sherry Wren

Steven Schwaitzberg, MD, chief of surgery at the Cambridge Health Alliance at the Harvard Medical School Teaching Hospital, is on the hunt for technology to allow for video conferencing and real-time translation in a wide range of languages. As he discusses in this recently posted TEDxBeaconStreet talk, he plans to use the universal translator to teach surgeons around the world to perform laparoscopic surgery.

Despite all the existing translation software currently on the market, finding a communications system that’s good enough to teach surgery has proven difficult. So Schwaitzberg is working with IBM Human Ability and Accessibility Center to string together technologies to work towards building a universal translator for surgery. He demos the prototype in the above video and explains how, in addition to training surgeons in other countries to perform minimally invasive procedures, it could create a dialogue and help physicians in the United States understand how to reduce health costs while improving outcomes. It’s worth watching.

Previously: Clementines help surgeons-in-training to practice and Surgery for chronic acid reflux goes scarless