sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY August 2016 | Archived Issues

Pharmacy and Therapeutics Committee Approvals

Pharmacy Focus

Highlights of the June meeting of the Pharmacy and Therapeutics Committee are summarized in the PDF link below.

P and T Approvals - June 2016 (PDF)


Mark Your Calendar


Surgery Grand Rounds

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

» Read more


Grand Rounds

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


Education Schedule

Click the PDF links below to see the Department of Surgery's education schedule.

Education Schedule - August 2016 (PDF)

Education Schedule - September 2016 (PDF)  


Surgery Scheduling

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

» Read more

Paired Exchange Program Facilitates 3 Kidney Transplants

By Irene K. Kim, MD
Director, Kidney Paired Exchange Program

On a Sunday morning in May, the Cedars-Sinai Kidney Transplant Program performed its third successful kidney transplant paired exchange. Six simultaneous operating rooms were run to facilitate three laparoscopic donor nephrectomies and three kidney transplant patients, all of whom are doing well with excellent graft function.

» Read more

Cedars-Sinai Helps Open Hospital for Acute Care Patients

The California Rehabilitation Institute has opened in Century City as the largest acute inpatient rehabilitation hospital on the West Coast. The 138-bed facility is a joint venture of Cedars-Sinai, UCLA Health and Select Medical, a leading provider of long-term acute care and rehabilitation services in hospitals and outpatient locations.

» Read more

Cedars-Sinai, Rams Partner to Promote Health and Wellness

Cedars-Sinai is playing an important role in the return of the Los Angeles Rams, partnering with the storied NFL team to promote health and wellness for children and families across the region. With the football season getting underway, the two organizations are preparing to roll out community outreach programs that highlight the importance of exercise, healthy eating, preventive healthcare and health education.

» Read more

12 MDs Start Surgery Residencies

Here's a look at the 12 physicians who recently began their residences in the Cedars-Sinai Department of Surgery.

» Read more

Vrahas Starts as Founding Chair of Orthopaedics

Mark Vrahas, MD, began serving as the founding chair of Cedars-Sinai's new Department of Orthopaedics on Aug. 8. He arrives at Cedars-Sinai with an international reputation for clinical excellence, and building and leading highly effective orthopedic trauma programs. He was most recently the Robert W. Lovett Professor of Orthopaedic Surgery at Harvard Medical School and vice chair for Population Health and OR Operations at Massachusetts General Hospital's Department of Orthopaedic Surgery.

» Read more

U.S. News Ranks Cedars-Sinai Nationally in 11 Specialties

Cedars-Sinai has 11 medical specialties nationally ranked and has been named to the Honor Roll in U.S. News & World Report's "America's Best Hospitals 2016-17" issue that was released this week. Cedars-Sinai was ranked in the top 20 hospitals nationwide (it was number 17), placing it among a group of top healthcare organizations.

» Read more

Burnes Bolton to Receive National Nursing Award

Linda Burnes Bolton, DrPH, RN, FAAN, is one of five to be recently recognized nationally by the American Academy of Nursing for a distinguished career in nursing and healthcare. The academy's highest honor, which comes with the special designation of "Living Legend," will be awarded at a ceremony in Washington on Oct. 20.

» Read more

Two Minutes With ...

This question-and-answer feature will help you get to know some of the physicians in the Cedars-Sinai Department of Surgery. This month's installment features Eric Ley, MD, director of the Surgical Intensive Care Unit, and Farin Amersi, MD, associate director of the Surgical Residency Program.

» Read more

FDA: Monitoring System Coming off Market

Alere Inc. is voluntarily withdrawing its INRatio and INRatio2 PT/INR Monitoring System from the market due to potentially inaccurate results. Alere is working with the U.S. Food and Drug Administration to determine the appropriate timing for the removal of the product.

» Read more

Liver Transplant Program Sets New Marks

The Liver Transplant Program continues to break new ground with both its clinical volume and outcomes. The program performed 66 liver transplants in 2015-16, its highest volume ever and an increase of 44 transplants from 2014-15.

» Read more

Vascularized Lymph Node Transfer

The Frontier of Lymphedema Management

Secondary lymphedema is a vexing problem that is not well understood. Up to 40 percent of axillary lymph node dissection and 10 percent of sentinel node biopsy patients develop some degree of lymphatic dysfunction. While there is currently no definitive cure for secondary lymphedema, there is an increasing interest in treatments.

» Read more

Circle of Friends Honorees for July

CoF

The Circle of Friends program honored 92 people in July. 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

Paired Exchange Program Facilitates 3 Kidney Transplants

kim-irene

Irene K. Kim, MD

By Irene K. Kim, MD, Director, Kidney Paired Exchange Program

On a Sunday morning in May, the Cedars-Sinai Kidney Transplant Program performed its third successful kidney transplant paired exchange. Six simultaneous operating rooms were run to facilitate three laparoscopic donor nephrectomies and three kidney transplant patients, all of whom are doing well with excellent graft function.

"It was the tremendous effort of the kidney transplant team and the O.R. staff that enabled this paired exchange," said J. Louis Cohen, MD, surgical director of the Kidney Transplant Program.

For renal transplant patients who have a potential living kidney donor, living donor kidney transplant has the best graft outcomes and enables shorter waiting time for transplant. However, patients who are highly sensitized against HLA antigens and have pre-formed antibodies may not be compatible with their living donors, prohibiting transplant.

Paired exchange programs, in which incompatible donor/recipient pairs can be entered, facilitate transplant by allowing pairs to "swap" living donor kidneys with other pairs. Cedars-Sinai participates in several national kidney registries, including the National Kidney Registry and the United Network for Organ Sharing. Kidney paired exchange is another mechanism, in addition to desensitization strategies, that enables transplantation for difficult-to-transplant patients.

The paired exchange that took place in May was an internal chain that was instigated by an altruistic nondirected kidney donor, who was found to be immunologically compatible with a highly sensitized patient incompatible with a friend who was also interested in serving as a living donor. Discovery of this compatible swap set off the chain, which ended with a nonsensitized patient on the deceased donor waiting list.

Hyung Kim, MD, director of the Division of Urology, Brian Benway, MD, and Gerhard Fuchs, MD, were the surgeons who performed the donor surgeries. J. Louis Cohen, MD, Donald Dafoe, MD, and Irene Kim, MD, were the transplant surgeons who performed the renal transplants. The two highly sensitized patients who were transplanted also received additional immunotherapy, under the direction of Stanley Jordan, MD, and members of the Cedars-Sinai Transplant Immunotherapy Program. In addition, kidney paired exchange, living donor and waitlist teams, and particularly, Ellen Shukhman, RN, deserve much of the recognition for orchestrating these transplants.

The Cedars-Sinai kidney transplant team will continue to perform kidney paired exchanges, building on the success of this and previous exchanges. Patients who believe they are not compatible with a potential living donor may not realize they have kidney paired exchange as an option to facilitate their transplant.

For more information regarding Cedars-Sinai Kidney Paired Exchange Program, please contact Irene Kim, MD, director, at 310-248-8503.

Cedars-Sinai Helps Open Hospital for Acute Care Patients

California Rehabilitation Center

The California Rehabilitation Institute has opened in Century City as the largest acute inpatient rehabilitation hospital on the West Coast.

The 138-bed facility is a joint venture of Cedars-Sinai, UCLA Health and Select Medical, a leading provider of long-term acute care and rehabilitation services in hospitals and outpatient locations.

The new hospital offers a broad range of treatment and therapy services to meet a growing demand for highly specialized care among patients with spinal cord and brain injuries, neurological disorders, strokes, amputations and other acute conditions. It is expected to draw patients from Southern California and around the nation.

"We are excited that two of the nation's best healthcare institutions and Select Medical's highly regarded rehabilitation expertise have come together to develop a world-class rehabilitation hospital," said Thomas M. Priselac, president and CEO. "This collaboration will allow us to better meet the needs of our own community, the region and the West."

The comprehensive facility greatly expands the area's acute rehabilitation services. Until now, the inpatient rehabilitation units at Cedars-Sinai and UCLA frequently have been filled to capacity, and prospective patients often have been referred to other institutions.

Select Medical will operate the new hospital. The partnership behind it was announced in December 2013. Since then, extensive renovations have been undertaken at the site, formerly known as Century City Hospital.

Cedars-Sinai patients began arriving on Monday and Tuesday.

With the opening of the new hospital, Cedars-Sinai will close its 28-bed inpatient rehabilitation unit, located on the seventh floor of South Tower. Patients will be given the choice of being transported to the new rehabilitation hospital, discharged home or moved to other facilities based on their needs. Outpatient rehabilitation services will not be affected.

Richard Riggs, MD, chair of the Department of Physical Medicine and Rehabilitation, and medical director of the rehabilitation unit since 1997, said the interdisciplinary team model as well as the quality and research outcomes cultivated in the unit aided in formulating national standards of care for inpatient rehabilitation patients and their families.

Pamela Roberts, PhD, director of the Department of Physical Medicine and Rehabilitation, and her team have been instrumental in facilitating both the exemplary outcomes and interdisciplinary team processes that helped lay the foundation for the new rehabilitation hospital.

"We are proud of the work we did at our rehabilitation unit for the past 40 years," said Linda Burnes Bolton, DrPH, RN, FAAN, health system chief nurse executive, vice president and chief nursing officer. "We look forward to this new opportunity to provide a wider range of services and enhanced, specialized care to our rehabilitation patients."

Cedars-Sinai, Rams Partner to Promote Health and Wellness


The Los Angeles Rams are shown practicing at their training facility in Irvine. Cedars-Sinai is the official health partner of the Rams.

Cedars-Sinai is playing an important role in the return of the Los Angeles Rams, partnering with the storied NFL team to promote health and wellness for children and families across the region.

With the football season getting underway, the two organizations are preparing to roll out community outreach programs that highlight the importance of exercise, healthy eating, preventive healthcare and health education.

As the official health partner of the Los Angeles Rams, Cedars-Sinai will team up with the local sports franchise to host local events for Play 60, the NFL's national campaign to encourage kids to be active for at least 60 minutes a day.

"The Rams have come home, and we're very excited to join with them to promote healthier living for families throughout Los Angeles," said Thomas M. Priselac, president and CEO of Cedars-Sinai. "This is a true partnership of two organizations that are committed to working together to improve the health of communities."

As a Rams homecoming partner, Cedars-Sinai will have signage prominently displayed during home games at the Los Angeles Memorial Coliseum and at the Rams' training camp in Irvine (for an inside look at training camp, you can watch this season of HBO's popular sports reality series Hard Knocks: Training Camp with the Los Angeles Rams). Cedars-Sinai also ran a full-page ad in USA Today to promote the partnership with the Rams.

On game days, Cedars-Sinai will serve as a presenting sponsor of the Kids Zone at all Rams home games, a fun and interactive play area that will be open during pregame just outside the Coliseum in the Rams Fan Fest area.

Through the partnership, Cedars-Sinai employees will be eligible to win tickets for each of the Rams' seven regular season home games at the L.A. Memorial Coliseum. About 100 tickets will be distributed for each game through a raffle.

More internal events and Rams promotions are being planned as well. Stay tuned for more details as the regular season approaches.

The preseason kicked off Saturday, Aug. 13, when the Rams hosted their first game in Los Angeles in 22 years. The first regular season home game is Sunday, Sept. 18.


Los Angeles Rams 2016 Regular Season Schedule
(Home games are in bold)

Sept. 12 at San Francisco

Sept. 18 vs. Seattle

Sept. 25 at Tampa Bay

Oct. 2 at Arizona

Oct. 9 vs. Buffalo

Oct. 16 at Detroit

Oct. 23 vs. New York Giants (London)

Bye week

Nov. 6 vs. Carolina

Nov. 13 at New York Jets

Nov. 20 vs. Miami

Nov. 27 at New Orleans

Dec. 4 at New England

Dec. 11 vs. Atlanta

Dec. 15 at Seattle

Dec. 24 vs. San Francisco

Jan. 1 vs. Arizona

12 MDs Start Surgery Residencies

Twelve physicians recently began their residences in the Cedars-Sinai Department of Surgery. Listed with their medical schools, they are:

Residents

Lauren Evans, MD
First year
General Surgery
Albany Medical College

Jaewon Lee, MD
First year
General Surgery
Tufts University School of Medicine

Pratik Mehta, MD
Fourth year
General Surgery
St. George’s University-Grenada

Deven Patel, MD
First year
General Surgery
Michigan State University

Adam Truong, MD
First year
General Surgery
University of California, Irvine School of Medicine

Tonya An, MD
First year
Orthopaedic Surgery
Washington University School of Medicine in St. Louis

Phillip Behrens, MD
First year
Orthopaedic Surgery
Indiana University School of Medicine

Samuel Stephenson
First year
Orthopaedic Surgery
David Geffen School of Medicine at UCLA

Michael Sun
First year
Orthopaedic Surgery
University of Vermont College of Medicine

Sean Fischer
First year
Urology
Duke University School of Medicine

Hanson Zhao
First year
Urology
SUNY Downstate Medical Center College of Medicine

Adel Aiteli
First year
Podiatry
Western University of Health Sciences

Vrahas Starts as Founding Chair of Orthopaedics

Mark Vrahas, MD

Mark Vrahas, MD, began serving as the founding chair of Cedars-Sinai's new Department of Orthopaedics Monday, Aug. 8.

"The creation of the Department of Orthopaedics will bring together some of the nation's leading experts in the field," said Mark Gavens, executive vice president of Health System Hospital Operations and chief operating officer. "Dr. Vrahas' successful record of implementing innovative, forward-thinking initiatives will enhance our current programs in Orthopaedics and ensure they continue to meet the needs of our patients and communities."

Vrahas arrives at Cedars-Sinai with an international reputation for clinical excellence, and building and leading highly effective orthopedic trauma programs. He was most recently the Robert W. Lovett Professor of Orthopaedic Surgery at Harvard Medical School and vice chair for Population Health and OR Operations at Massachusetts General Hospital's Department of Orthopaedic Surgery. Also, he also was chief of Partners Orthopaedic Trauma Program at Mass General and Brigham and Women's Hospital in Boston.

Vrahas founded the Harvard Orthopedic Trauma Initiative as an effort to foster collaboration among orthopedic trauma services at all Harvard-affiliated teaching hospitals — Mass General, Brigham and Women's, Beth Israel Deaconess Medical Center and Boston Children's Hospital.

"Under Vrahas' new leadership, we are excited that Orthopaedics will thrive as an innovative service line that will advance orthopedic and clinical care for our patients," said Shlomo Melmed, MB, executive vice president of Academic Affairs and dean of the medical faculty.

He is widely recognized as an expert in orthopedic trauma, and pelvic and acetabular surgery. He lectures around the world, publishes extensively and serves as an editorial board member for leading orthopedic journals. He has successfully mentored dozens of residents and fellows in orthopedic trauma surgery and research.

Vrahas completed medical school and residency at the University of Pittsburgh, followed by fellowships in biomechanics research at the University of Iowa and in orthopedic trauma and adult reconstruction at the University of Toronto. He was chief of Orthopaedic Trauma at Charity Hospital in New Orleans before arriving in Boston in 1999.

U.S. News Ranks Cedars-Sinai Nationally in 11 Specialties

Cedars-Sinai has 11 medical specialties nationally ranked and has been named to the Honor Roll in U.S. News & World Report's "America's Best Hospitals 2016-17" issue that was released this week.

Cedars-Sinai was ranked in the top 20 hospitals nationwide (it was number 17), placing it among a group of top healthcare organizations. In addition, the institution was ranked fourth in California and second in the Los Angeles metro area.

The 11 Cedars-Sinai specialties ranked nationally were cardiology and heart surgery; diabetes; ear, nose and throat; gastroenterology; geriatrics; gynecology; nephrology; neurology and neurosurgery; orthopedics; pulmonary; and urology.

The U.S. News rankings are based on measures of quality, patient safety, mortality, hospital volume and other factors, including reputation as determined by physician surveys.

"While we should be justifiably proud of our performance, it also is important to keep these rankings and the proliferation of other 'hospital scorecards' in perspective," said Thomas M. Priselac, president and CEO. "External validations should not distract us from our most important work — providing the highest-quality care possible. "With this in mind, the U.S. News rankings are one of the many ways we acknowledge the outstanding work that goes on daily at Cedars-Sinai."

Burnes Bolton to Receive National Nursing Award

Linda Burnes Bolton, DrPH, RN, FAAN

Linda Burnes Bolton, DrPH, RN, FAAN, is one of five recognized nationally by the American Academy of Nursing for a distinguished career in nursing and healthcare.

The academy's highest honor, which comes with the special designation of "Living Legend," will be awarded at a ceremony in Washington on Oct. 20.

"It is an honor to receive Living Legend recognition from my colleagues," said Burnes Bolton. "I stand on the shoulders of nurses in science, academia, practice and community that have contributed to improving health and healthcare across the world."

Added academy President Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN: "We are thrilled to designate these incredibly deserving individuals as Academy Living Legends for the many contributions they have made to the nursing profession and healthcare. Each of them embodies excellence, leadership and enduring commitment to promoting the health of people."

Last month, Burnes Bolton announced her retirement as health system chief nursing executive, vice president for Nursing and chief nursing officer.

Once her position has been filled, Burnes Bolton will begin serving in the new position of chief health equity officer. In her new role, she will examine disparities in healthcare, a topic that has garnered increasing attention from local, state and national health organizations.

Two Minutes With ...

This question-and-answer feature will help you get to know some of the physicians in the Cedars-Sinai Department of Surgery.

Eric Ley, MD, director, Surgical Intensive Care Unit

Where did you grow up?

I grew up at the Los Angeles County General Hospital during my first night of intern call.

Why did you decide to specialize in trauma surgery?

As a medical student, I found trauma exciting because the specialty focuses on patients who present with an urgent, acute problem that the trauma team can fix. Trauma was one of a number of specialties that I considered. While in college I thought my future was in ophthalmology because I really enjoyed working in a neurophysiology lab that focused on vision research. When I started my internship, I considered cardiac surgery because operating on hearts seemed amazing. During residency, colorectal surgery held my interest because it seemed like a higher level of general surgery. Trauma was the right choice for me because the cases were exciting. I could establish an elective general surgery practice. Critical care encouraged me to use a different part of my brain, and I enjoyed reading and publishing trauma related papers. I am very happy with my career choice as the trauma community is a close-knit group of friends.

What is the most rewarding aspect of your job?

My job has four areas each with its own rewards: clinical, teaching, research and administration. The most fulfilling aspect of my job is when I can surgically correct the damage related to a traumatic injury and then allow a patient to return to a normal life. Teaching residents to transform from impressionable and easily frightened interns to confident chief residents who can direct complicated surgical cases is satisfying. The ability to conduct clinical and benchtop research keeps me focused on the current and future direction of trauma and acute care surgery. Administratively, I enjoy directing an outstanding surgical intensive care unit, which I believe provides the best care in the nation to critically ill surgical patients.

How do you unwind at the end of the day?

The best way for me to unwind at the end of the day is to play with my kids. We have a small garden in the backyard filled with trampled cherry tomato plants that my kids like to pick and overwater. I also buried colored stones there that they dig up as if they are pirates looking for treasure, which may or may not help the garden.

Is there something you have never seen that you would like to see in the near future?

Something I would really like to see is every car on the road equipped with tools that allow for autonomous driving as I think that the mortality related to motor vehicle collisions would drastically decrease. Advances such as adaptive cruise control, braking assist and autopilot will improve car safety in ways that are barely comprehensible.



Farin Amersi, MD, associate director, Surgical Residency Program

Where did you grow up?

I grew up in Dar-es-salaam, Tanzania. My father was born and raised in Tanzania, and had a ketchup factory. Hence my love for ketchup and my favorite saying at every restaurant: "Everything tastes better with ketchup." My parents decided to move to the United States in order for their children to get a better education. I moved to Los Angeles at the age of 16. Went away to Pittsburgh for medical school, and came back home to Los Angeles for residency and have been here ever since.

Why did you decide to specialize in surgical oncology?

I decided in fourth year of general surgery residency to go into surgical oncology. During my rotation on surgical oncology, I loved not only the technical aspects of complex surgical oncological resections, but also the discussions on the multimodality approaches to treatment of cancer patients.

What is the most rewarding aspect of your job?

My patients: being a part of their journey as they go through the fear of their diagnosis, pain and then exhilaration year after year as they remain cancer free.

What is the funniest thing a patient has ever said to you?

"Dr. Amersi, you're Persian, and you just don't realize it."

What did your parent(s) always tell you that you now have to admit was correct?

Be nice to everyone; you never know when you will need someone's help.

If you could spend the day doing one thing, what would it be?

Learning how to make crepes at my husband's creperie.

FDA: Monitoring System Coming off Market

Alere Inc. is voluntarily withdrawing its INRatio and INRatio2 PT/INR Monitoring System from the market due to potentially inaccurate results.

Alere is working with the U.S. Food and Drug Administration to determine the appropriate timing for the removal of the product and will provide guidance on transitioning patients to an alternate solution to allow them to continue anti-coagulation monitoring.

The FDA website has more information.

Liver Transplant Program Sets New Marks

By Nicholas Nissen, MD

The Liver Transplant Program continues to break new ground with both its clinical volume and outcomes. The program performed 66 liver transplants in 2015-16, its highest volume ever and an increase of 44 transplants from 2014-15. In addition, patient and graft survival, which are the two benchmarks most commonly reported in transplant programs, both exceeded 90 percent.

As with all other solid organs, liver transplantation volume is driven primarily through a waitlist process. Unlike kidney transplant allocation, in which organ allocation depends on how long a patient is on the waitlist and how closely the donor organ and the recipient match, the liver transplant waitlist is driven primarily through severity of illness.

The MELD score, which is a mathematical formula taking into account bilirubin, INR and creatinine, is used to rank patients on the liver transplant waitlist. As such, sicker patients (those with a higher MELD score) are higher on the waitlist and are more likely to undergo transplantation. The increase in transplant volume seen recently is in part due to collaborative measures between the transplant team, the surgical intensive care unit team and the transfer center aimed at facilitating transfer and optimizing care of the critically ill liver patients.

The challenges presented by these patients have also led to research opportunities for the transplant group. Alagappan Annamalai, MD, has published research on mechanism of ascites formation in sick patients, and on predictors of outcome in intensive care unit transplant patients. Irene Kim, MD, is studying mechanisms of immunosuppression and the unique aspects of immunosuppression in critically ill liver patients. The newest member of the liver transplant surgical faculty, Tsuyoshi Todo, is working jointly with hepatology faculty in defining factors leading to fatty liver disease and redefining the MELD-exception system.

The last two years have been witness to incredible advances in the field of liver transplant and hepatobiliary surgery. Hepatitis C, formerly almost impossible to treat and the leading cause of graft loss after transplantation, has been nearly eradicated with a new generation of new medications. Fatty liver disease is now recognized as the leading cause of cirrhosis and will be the etiology for liver transplantation in the decades to come. New treatments for hepatocellular cancer have led to increased access for liver transplant for these patients and increased ability to control disease at all stages, even in those who recur after transplant.

For more information on the liver transplant or hepatobiliary surgery, please contact the surgical director, Nicholas Nissen, MD, at nicholas.nissen@cshs.org.

Vascularized Lymph Node Transfer

The Frontier of Lymphedema Management

By Edward Ray, MD, and Randy Sherman, MD

Secondary lymphedema is a vexing problem that is not well understood. Up to 40 percent of axillary lymph node dissection and 10 percent of sentinel node biopsy patients develop some degree of lymphatic dysfunction. Once clinically apparent, it may gradually worsen, manifesting as progressive swelling, recurrent infections, pain and diminished quality of life. Over time, fatty deposition and skin changes become irreversible. While there is currently no definitive cure for secondary lymphedema, there is an increasing interest in treatments that may stem the progression of this disease or reduce its severity. Toward this goal, microsurgical procedures to address lymphatic dysfunction are under investigation at Cedars-Sinai and academic centers around the world.

Currently, first-line management of lymphedema involves skin care, compressive garments, manual lymph drainage techniques and intermittent pneumatic compression devices. This approach requires strict patient compliance and adherence to an onerous regimen. Surgical approaches have focused on either debulking lymphedematous tissues or re-establishing extremity lymph flow. In current practice, the latter employs lymphovenous bypass or vascularized lymph node transfer.

Lymphovenous bypass aims to channel lymph into veins or venules, effectively bypassing areas of lymphatic obstruction. Because of the low morbidity and modest but observable symptomatic improvement achieved, this technique has held promise since it was first studied in the 1960s. The technical challenge of performing "supermicrosurgery" is the primary factor limiting its use in most centers.

A decade ago, the first series of successful microvascular lymph node autotransplantations into the axilla and forearm were published. A significant proliferation of research into vascularized lymph node transfer has occurred since then. The idea of bringing vascularized lymphatic tissue into an affected extremity dates back over 50 years, when researchers used tunneled omentum to help drain lymphedematous extremities. This approach suffered from high morbidity and a questionable degree of clinical improvement.

In contrast, vascularized lymph node transfer from a healthy donor site appears to have lasting benefits, though the exact mechanism is not yet well understood. Theories include:

  • The transferred nodes act as pumps, siphoning lymph into the venous drainage system.
  • The nodes promote lymphangiogenesis, "sprouting" new conduits that reestablish lymphatic channel continuity.

The low morbidity and lower technical difficulty of this procedure has prompted wider adoption of vascularized lymph node transfer.

Contributing to the enhanced success of these microvascular procedures are recent advances in imaging. Most notably, fluorescence lymphography is a powerful tool that allows dynamic visualization of lymphatic channels following injection of indocyanine green, a dye that is absorbed quickly into the lymphatic system. This is helpful in multiple ways. First, the severity of a patient’s disease, even in early stages, can be assessed by observing the movement of the fluorescent dye and peristalsis of lymphatic channels. Second, it helps to identify the overall lymphatic anatomy and site(s) of lymphatic obstruction. Third, follow-up lymphography studies have been shown to accurately demonstrate improvement in lymphatic function. More traditional lymphoscintigraphy and gamma probe detection are still used to identify and avoid extremity sentinel nodes to minimize the risk of causing lymphatic dysfunction at vascularized lymph node transfer donor sites (e.g., the axilla or groin).

Current vascularized lymph node transfer technique involves several important steps. First, the patient must be identified as an appropriate candidate with early-stage disease and some residual lymphatic function if success is to be expected. Second, appropriate lymph node donor sites are planned before surgery and radiolabeled tracer is injected in distal donor extremities to help identify and preserve the sentinel nodal basins. Third, the harvested flap of tissue containing the donor lymph nodes is transferred to the recipient site (axilla and/or forearm, e.g.) and the flap vessels are anastomosed to appropriate recipient vessels using standard microvascular technique.

Outcome studies have demonstrated symptomatic and objective improvement in extremity lymphedema following these microvascular procedures in appropriately selected patients. Objective measurements of lymphedema severity are difficult, however, as each factor studied (pain, extremity girth and volume) tend to fluctuate day-to-day and improve very slowly. What has become clear is that surgical options tend to work best when administered during the early phases of secondary lymphedema, and that once advanced stages of the disease are manifest, these modalities fail to provide noticeable benefit. At Cedars-Sinai and elsewhere, these techniques are being refined to improve patient selection and achieve predictable results.

Circle of Friends Honorees for July

The Circle of Friends program honored 92 people in July.

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.

  • Betsy Applebaum
  • Walid S. Ayoub, MD
  • Nadereh Azad, RN
  • C. Noel Bairey Merz, MD
  • Tina G. Ban, RN
  • Jennifer Barnes, RN
  • Keith L. Black, MD
  • Neil A. Buchbinder, MD
  • David H. Chang, MD
  • William W. Chow, MD
  • Harry Chu, RN
  • Scott W. Cohen, MD
  • Stephen T. Copen, MD
  • Stephen R. Corday, MD
  • Moise Danielpour, MD
  • Mayette F. David, BSN, RN, CCRN
  • Noam Z. Drazin, MD
  • Naomi Drucker, RN
  • Jonathan C. Ellis, MD
  • Alan Engelberg, MD
  • Shahrooz Eshaghian, MD
  • L'Tanya P. Fatherree
  • Miriam J. Flores, LVN
  • Joyce N. Fox, MD
  • John D. Friedman, MD
  • Clark B. Fuller, MD
  • Carlie Galloway, MSW
  • Anita B. Gattenuo
  • Tamara N. George, MSW
  • Bruce L. Gewertz, MD
  • Armando E. Giuliano, MD
  • Steven B. Graff-Radford, DDS
  • Leland M. Green, MD
  • Jaclyn E. Guell, RN-BC
  • Antoine Hage, MD
  • Michele A. Hamilton, MD
  • John G. Harold, MD
  • Brittany D. Harris
  • Keith W. Hoshal, MSN, RN-BC
  • Carmella Irani
  • Laith H. Jamil, MD
  • Afshin S. Javaherian, DPM
  • Stacey Jean-Pierre, PA-C
  • Stanley C. Jordan, MD
  • Rosa B. Kassaseya
  • David Kawashiri, MD
  • Hyung L. Kim, MD
  • Asher Kimchi, MD
  • Lilliana Landers
  • Magda Leavitt, MSN, RN
  • Ronald S. Leuchter, MD
  • Rajendra Makkar, MD
  • Philomena McAndrew, MD
  • Leslie Memsic, MD
  • Joel D. Mittleman, MD
  • Jason Mollenbrink, MSN, RN
  • Esther Morrison, RN
  • Kyle K. Mosqueda
  • Mamoo Nakamura, MD
  • Shawn S. Nasseri, MD
  • Yosef Y. Nasseri, MD
  • Edward Kazuhisa Nomoto, MD
  • Arthur J. Ochoa, JD
  • Willie Payne
  • Alice Peng, MD
  • Angel Angelo Prado, LVN
  • Florian Rader, MD
  • Bobbie J. Rimel, MD
  • Regina M. Rogers
  • Katherine J. Rosenthal, MSN, RN, OCN, CCRP
  • Jeremy D. Rudnick, MD
  • Allen I. Salick, MD
  • Tracy Salseth, ACNP-BC
  • Wouter I. Schievink, MD
  • Prediman K. Shah, MD
  • Lenore M. Skydell (Strum), RN-C
  • R. Kendrick "Ken" Slate, MD
  • Jodi Slavica, BSN, CCRN
  • Lauren Smith, BSN, RN, CCRN
  • Carlos E. Sosa
  • Jerrold H. Steiner, MD
  • Charles D. Swerdlow, MD
  • Hitoshi "Tommy" Tomizawa, MD, MPH
  • Alfredo Trento, MD
  • Conrad J. Tseng, MD
  • Mark K. Urman, MD
  • Robert A. Vescio, MD
  • Jason L. Weiner, Rabbi
  • Matthew T. Wilson, MD
  • Robert N. Wolfe, MD
  • Edward M. Wolin, MD
  • Yu-Tung Wong, MD