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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY February 2014 | Archived Issues

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Educational Schedule - March 2014 (PDF)


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Cedars-Sinai Innovation Helps Patients in China

The Cedars-Sinai team took part in surgeries on 15 children during October's mission to Luoyang, China.

When a medical team from Cedars-Sinai first traveled to Luoyang, China, in 2011 to perform surgeries on orphans with anorectal malformations, the plan was twofold — to help the children, and to teach the surgical procedures to the Chinese doctors.

Over time, the local surgeons became proficient at the posterior sagittal anorectoplasty (PSARP), or pull-through procedure, in which the child's anus is repositioned to an appropriate location. However, despite their new skills, the Chinese surgeons were unable to perform the procedure without the Cedars-Sinai team being present. That's because they lacked a costly instrument necessary for the PSARP to be properly performed — a Peña Muscle Stimulator.

Philip K. Frykman, MD, PhD, (top photo, left) and Keith Kimble, MD, (bottom photo, left) modified a nerve stimulator to make an affordable alternative to the Peña Muscle Stimulator.

With a bit of ingenuity, and a pair of alligator clips, Philip K. Frykman, MD, associate director of Pediatric Surgery at Cedars-Sinai and the leader of the China mission medical team, and Keith Kimble, MD, a pediatric anesthesiologist at Cedars-Sinai, created a low-cost substitute for the Peña stimulator. They modified a peripheral nerve stimulator, a $150 device the size of a juice box that is commonly used in anesthesia.

"Regarding the Peña stimulator, it turned out there were a couple of problems," Frykman said. "They don't sell the Peña stimulators in China — there's an import restriction — and at $12,000, they are unaffordable for hospitals outside of the bigger centers like Hong Kong or Shanghai."

The Peña Muscle Stimulator sends a small electric current through the patient's skin to the underlying delicate muscles, which allows the surgeon to identify anatomical features and thus gauge the optimal placement of the new anal opening. Not only is the cost of the instrument beyond the means of all but the wealthiest hospitals in the developing world, but the probe and wires on the Peña stimulator must be sterilized with ethylene oxide gas.

"Heat and steam are the normal forms of sterilization, but they can't be used on the Peña probe," Frykman said. "In our region in China, there was only one hospital where we could sterilize the probe, which we could only do once a day."

With plans to perform several surgeries each day during the medical missions, the Cedars-Sinai team needed an alternative to the Peña stimulator. For Kimble, the answer was clear — adapt the smaller, less expensive peripheral muscle stimulator used by anesthesiologists.

The Chinese surgeons are now able to perform the PSARP procedures on their own.

"The body of the stimulator does not need to be sterilized, because it's going to be off the field, but the wires and what you're going to use for contacts, that does have to be sterile," Kimble said. "What we did was cobble together some wires and alligator clips, literally in my garage, and we soldered the alligator clips onto disposable EKG wires, the proximal ends of which just happened to fit into the holes of the portable nerve stimulator."

Kimble then attached the alligator clips to 22-gauge hypodermic needles, which were used to contact the patient's skin and define the muscle complexes during the pull-through surgery.

"This is every bit as simple as it sounds," Kimble said. "And it worked well."

Frykman and Kimble used their modified nerve stimulator in five surgeries. In each procedure, they also used a Peña Muscle Stimulator, which the Cedars-Sinai team had brought, for a side-by-side comparison. Although alternative devices to the Peña stimulator have been created and written about before, Kimble and Frykman were the first to test a modified device against the gold standard of the Peña.

Their findings, which they published last year in the European Journal of Pediatric Surgery, showed that their modified peripheral nerve stimulator was as useful as the Peña stimulator in surgeries on infants. Also cited as authors in the paper were Scott Short, MD, Cedars-Sinai Department of Surgery; Shiwei Zhai, MD, New Hope Foundation in Beijing; and Gregory Frykman, MD, an independent consultant (and Philip Frykman's brother) from Bethesda, MD.

The authors identified two drawbacks to their modified peripheral nerve stimulator. One is that the probes on the modified device are less convenient to use than the probe on the Peña. The second is that, due to its lower power range, the modified nerve stimulator might not deliver an adequate electrical current for use with older or larger patients.

The device has proved successful enough, however, that Philip Frykman and Kimble are now looking into producing the low-cost device for sale.

"We're starting a nonprofit company to make low-cost instruments for the underserved developing world," Frykman said. "We're working on videos as well so that any of the surgeons who want to learn will have the opportunity."

Previously in Sutures:

Cedars-Sinai Team Expands Mission in China (January 2013)

Previously in Medical Staff Pulse:

Two Chinese Orphans Treated by Cedars-Sinai Team Find Their 'Forever Homes' (May 11, 2012)

A New Chance for Hope (Jan. 6, 2012)