sutures newsletter

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

Mark Your Calendar


Surgery Grand Rounds

Click the "read more" to see information about upcoming Surgery Grand Rounds.

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Grand Rounds

Click here to view a schedule of all upcoming grand rounds.


Educational Schedule

Click the PDF link below to see the Department of Surgery's educational schedule for March.

Educational Schedule - March 2014 (PDF)


Surgery Scheduling

Click the "read more" for hours and contact information for surgery scheduling.

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The New Healthcare - Surgeons Should Take the Lead

By Harry C. Sax, MD, MHCM

Although terms used in healthcare reform are ambiguous, surgeons routinely deal with ambiguity and make definitive decisions in the best interests of their patients. In fact, in the new healthcare world, surgeons will play a greater role in expeditiously and efficiently dealing with disease and restoring patients to improved health and function.

» Read more

Physiatrists Prove Valuable to Spine Center Patients

There is an emerging emphasis on using nonsurgical spine specialists (spine-trained physiatrists) for initial evaluation and patient management. The goal at the Spine Center is to produce improved functional outcomes as well as to create a better overall experience for the patient population.

» Read more

Cedars-Sinai Innovation Helps Patients in China

With help from a Cedars-Sinai medical team, surgeons in Luoyang, China, have become proficient at a procedure to correct anorectal malformations in children. And thanks to an enterprising solution by the Cedars-Sinai doctors, the Chinese surgeons now have an affordable alternative to a muscle stimulator needed to do the job.

» Read more

Cook-Off Celebrates Sinus Center-OR Connection

The partnership between the Sinus Center and the operating room staff turned into a tasty competition recently, during the Hot Wings Cook-Off sponsored by the Sinus Center.
 

» Read more

Circle of Friends Honorees for January

The Circle of Friends program honored 88 people in January. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai.

» Read more

FDA Reviews Saxagliptin Risk; Victrelis Label Changed

Pharmacy Focus

The U.S. Food and Drug Administration has requested clinical trial data from the manufacturer of saxagliptin to investigate a possible association between use of the Type 2 diabetes drug and heart failure. Also, the FDA said the label of the hepatitis C drug Victrelis has been updated to include information about serious reported cases of pancytopenia.

» Read more

The New Healthcare - Surgeons Should Take the Lead

Harry C. Sax, MD, MHCM

By Harry C. Sax, MD, MHCM
Professor and Executive Vice Chair, Department of Surgery
Physician Liaison, Cedars-Sinai Medicine Clinical Transformation Initiative

Last month, Bruce Gewertz, MD, surgeon-in-chief, outlined the challenges we are facing with healthcare reform and a shift from a volume-based, fee-for-service practice to one of populations and "value." Although these terms are ambiguous, surgeons routinely deal with ambiguity and make definitive decisions in the best interests of their patients.

In fact, in the new healthcare world, surgeons will play a greater role in expeditiously and efficiently dealing with disease and restoring patients to improved health and function. As surgeons share risk for the total care of the patient, there will be increased efficiency by eliminating unnecessary testing, improving the coordination of care and shortening the time required for the patient to be in the hospital. Minimally invasive techniques will be honed, allowing more outpatient and short-stay procedures and increasing value.

Not surprisingly, there is healthy skepticism from the medical staff regarding the new initiatives intended to adapt to the changing world. It is easy to think the status quo will continue and that our healthy finances won't change. But the shot across the bow with our exclusion from exchange networks was a wake-up call.

It is not a stretch to recognize that individual practitioners are at the same risk for exclusion as the hospital systems. Some may choose to not take insurance — in the short term a potential option, until the market saturates. Others will take advantage of the multitudes of performance data available, and understand how to use best practices, good judgment and skills to tap into a large and expanding pool of patients.

Cedars-Sinai has several important programs supporting this effort:

  • A major effort is underway to reduce length of stay with real-time interventions. Physician advocates are meeting daily with nursing, case management, and social work to help your patients get to the OR and then have well-coordinated post-discharge care. You may be contacted to clarify questions and care plans in support of your efforts.
  • In preparation for public reporting, unblinded performance data such as length of stay will be shared among groups of clinicians with similar practices, to allow those with opportunity for improvement to learn from their colleagues. The insurance companies already have these data, as well as costs — it will be important to understand how we look to the outside.
  • New population health programs focusing on the continuum of care will open opportunities for surgeons to intervene earlier and prevent costly admissions.
  • Neil Romanoff, MD, associate chief medical officer, vice president for Medical Affairs and chief Patient Safety officer, is leading the development of preferred home health providers that will have a higher quality and range of services, allowing you to confidently treat many of your patients at home after discharge and reduce readmissions.

Recently at a morbidity and mortality conference, Ken Adashek, MD, related a story (confirmed by Leo Gordon, MD) from one of the giants of American surgery, Mark Ravitch ("A Modest Proposal," Surgical Rounds, June 1982). Ravitch said the most efficient way to practice medicine is to have surgeons admit everyone out of the emergency room. They would rapidly identify and operate on those with surgical disease and rule out significant pathology among the rest. Those remaining patients would then be transferred to nonoperative disciplines for care. There were smiles around the room, yet the premise is not far off.

Surgeons are capable of leading the charge and adapting to a changing environment, just as we deal with unexpected pathology or a patient who decompensates postoperatively. Surgeons have a unique, proactive skill set that will be valued in the new era of healthcare. The future is exciting and the opportunities unlimited.

And if you doubt that, think about if you could only have only one doctor in a town: Is there any question it would be a general surgeon?

Physiatrists Prove Valuable to Spine Center Patients

The Cedars-Sinai Spine Center consists of orthopedic surgeons, neurosurgeons, neurologists, Physical Medicine and Rehabilitation spine physicians (physiatrists) and psychologists, as well as nine spine-trained physician assistants and a cadre of specialty-trained nurses and administrative personnel, all working in a cohesive team-oriented environment.

There is an emerging emphasis on using nonsurgical spine specialists (spine-trained physiatrists) for initial evaluation and patient management. The goal at the Spine Center is to produce improved functional outcomes as well as to create a better overall experience for the patient population.

The path to costly and often-devastating chronic low back pain often is known to relate to psychosocial factors rather than anatomic pathology. These factors — marital status, job dissatisfaction, depression, fear, litigation — can be addressed during conservative management in the hope of producing improved functional outcomes with and without the need for surgery.

Before seeing a surgeon, patients experiencing spinal problems are encouraged to see a physiatrist, who may be better able to recommend viable alternatives to surgery. A physiatrist is a physician with specialty training in musculoskeletal and neurological conditions.

As nonsurgical experts, physiatrists often provide patients with a different perspective on treatment options. When surgery is an appropriate option, these physicians can arrange a consultation quickly with the type of spinal surgeon best suited for their particular needs.

The Spine Center recently began a joint project with the Anesthesia Pre-Procedure Evaluation Center to ensure that patients contemplating higher-risk surgical procedures are evaluated adequately before the day of the actual surgery. Without doubt, this process will improve the safety, success rate and overall perioperative experience for this select group of patients and their families.

Lastly, the Spine Center has just finished evaluating an outstanding group of orthopedic and neurosurgical fellowship candidates, four of whom will join the center to complete their training over the next several years.

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)

Cook-Off Celebrates Sinus Center-OR Connection

Brie Dean, surgical tech, (second from right) won an iPad mini at the Hot Wings Cook-Off. With her are (from left) Martin Hopp, MD, PhD, Mahmoud Samie and Mark Gavens.

The partnership between the Sinus Center and the operating room staff turned into a tasty competition recently, during the Hot Wings Cook-Off sponsored by the Sinus Center.

Gwen Blackman, surgical tech, (left, with Martin Hopp, MD, PhD) also won an iPad mini.

Staff members from 3OR (from left) Arlene Gabat, RN, Inigo Noriega, RN, and Vivian Escalante, surgical tech.

Eight people put their culinary skills to the test during the Jan. 30 cook-off in the 3OR nurses lounge. The winners were Brie Dean and Gwen Blackman, surgical techs in 3OR. Dean and Blackman each won an iPad mini. Each participant received a Starbucks gift card.

More than 30 nurses, physicians and allied health professionals attended the event. Judges included Mark Gavens, senior vice president for Clinical Care Services and chief operating officer; Mahmoud Samie, director of Service Line Operations; Narine Vardanyan, MHA, administrative service associate; Martin Hopp, MD, PhD, medical director of the Sinus Center; and Bernadette Carandang, CN III.

The Sinus Center staff put the event together to thank the OR for its continued partnership and to enjoy one another's company.

Nurses in 3OR and the physicians of the Sinus Center have a special relationship in that collectively, they make it possible to continue the collection of patient data for numerous Sinus Center quality-assurance programs:

  • The Sino Nasal Outcome Test (SNOT-22)
  • The Eustachian Tube Dysfunction Q7
  • Appropriateness of Surgery

The relationship also has aided several Institutional Review Board studies and, most important, helps lead to excellent patient care.

More than 88 percent of patients show improvement one year after sinus surgery at the Sinus Center, and an important reason for that is the great relationship between the OR team and the skilled surgeons of the Sinus Center.

Circle of Friends Honorees for January

The Circle of Friends program honored 88 people in January.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • Kimberly B. Adams, RN, BSN
  • Afshin Afrashteh, MD
  • Keith L. Agre, MD
  • Kapil K. Anand, MD
  • Jennifer T. Anger, MD, MPH
  • Jose C. Araujo
  • Joel D. Barron, MD
  • Keith L. Black, MD
  • Earl W. Brien, MD
  • Barbara Brown
  • Mathew H. Bui, MD
  • John P. Bunag, RN
  • Christiane Michele J. Burnison, MD
  • Marlon C. Bustamante, BSN, PHN, RN
  • Ilana Cass, MD
  • Sahlu Chirum, RN, MSN
  • Arthur K. Cho, MD
  • Myles J. Cohen, MD
  • Odelia B. Cooper, MD
  • Christine C. Corcoran, RN, BC, BSN
  • Stephen R. Corday, MD
  • Moise Danielpour, MD
  • Fabrizio Diana, RN, MSN
  • Alice R. Dick, MD
  • Jenifer Diorio, RN, BSN, PHN
  • Kristian A. Drilon
  • Richard Essner, MD
  • Margaret R. Farrell, RN, BSN
  • Charles A. Forscher, MD
  • Gerhard J. Fuchs, MD
  • Gloria A. Gomez
  • Richard E. Gould, MD
  • Andrew E. Hendifar, MD
  • Jeremy R. Herman, MD
  • David M. Hoffman, MD
  • Jethro L. Hu, MD
  • Stanley C. Jordan, MD
  • Saibal Kar, MD
  • Beth Y. Karlan, MD
  • Ali Khoynezhad, MD, PhD
  • Ellen B. Klapper, MD
  • Robert Klapper, MD
  • Thomas J. Kremen, MD
  • Deborah Lehman, MD
  • Ronald S. Leuchter, MD
  • Andrew J. Li, MD
  • Jamie Libo, RN
  • Michael C. Lill, MD
  • Howard L. Liu, MD
  • Adam N. Mamelak, MD
  • Adeline M. Marcelo, RN, BC, BSN
  • Philomena McAndrew, MD
  • Shlomo Melmed, MD
  • Cynthia L. Mena, RN
  • Scott Anthony Mondejar, RN
  • Mamoo Nakamura, MD
  • Youram Nassir, MD
  • Ronald B. Natale, MD
  • Roy D. Nini, MD
  • Nicholas N. Nissen, MD
  • Mark S. Noah, MD
  • Elvia Oyarzo
  • Brad Penenberg, MD
  • Anne L. Peters, MD
  • Margareta D. Pisarska, MD
  • James Round, RN
  • Jay N. Schapira, MD
  • Mara J. Schulman, MSW
  • Randolph Sherman, MD
  • Khawar M. Siddique, MD
  • Robert J. Siegel, MD
  • Allan W. Silberman, MD, PhD
  • Lisa Singh, CNMT
  • Andrew Ira Spitzer, MD
  • Jasminka Stegic, MS, ANP-BC, CCRN
  • Mihaela D. Te Winkel, ACNP-BC, MSN
  • David B. Thordarson, MD
  • Tram T. Tran, MD
  • Alfredo Trento, MD
  • Marissa Usatin, RN
  • Alicia R. Venegas, ADN, BA, CPAN
  • Swamy R. Venuturupalli, MD
  • Robert A. Vescio, MD
  • Jamie S. Vitale, BA, RN, BSN
  • Sara S. Well
  • Edward M. Wolin, MD
  • Clarissa O. Yatco-Sardea, BSN, RNC
  • Shelby Young

FDA Reviews Saxagliptin Risk; Victrelis Label Changed

Pharmacy Focus

The U.S. Food and Drug Administration has requested clinical trial data from the manufacturer of saxagliptin to investigate a possible association between use of the Type 2 diabetes drug and heart failure. In addition, the FDA said the label of the hepatitis C drug Victrelis (boceprevir) has been updated to include information about serious reported cases of pancytopenia.

The FDA's request regarding saxagliptin resulted from a study published in the New England Journal of Medicine, which reported an increased rate of hospitalization for heart failure with use of saxagliptin (marketed as Onglyza and Kombiglyze XR) compared to an inactive treatment.

The study did not find increased rates of death or other major cardiovascular risks, including heart attack or stroke, in patients who received saxagliptin. The manufacturer is expected to submit the trial data to FDA by early March.

At this time, the FDA considers information from the study to be preliminary. Analysis of the saxagliptin clinical trial data is part of a broader evaluation of all Type 2 diabetes drug therapies and cardiovascular risk.

The FDA says patients should not stop taking saxagliptin.

To learn more, visit this FDA Web page.

Risk of Pancytopenia Added to Victrelis Label

The FDA said the label of the hepatitis C drug Victrelis has been updated to include information about serious cases of pancytopenia that have been reported in patients receiving Victrelis in combination with peginterferon alfa and ribavirin. Complete blood counts (with white blood cell differential counts) should be obtained at pretreatment and at treatment weeks two, four, eight and 12, the FDA said. Blood counts should be monitored closely at other times, as clinically appropriate.

The label also was updated to include the risk of agranulocytosis, thrombocytopenia, pneumonia and sepsis.

The complete revised label can be viewed here.