sutures newsletter

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

OpenNotes Gives Patients Access to Doctor Notes

Cedars-Sinai launched OpenNotes on Nov. 6. The communications tool allows patients to easily view their physicians' outpatient visit notes through our online patient portal, My CS-Link™. Research at other institutions has shown that patients who use OpenNotes reported that they were better prepared for visits and better understood their health conditions and treatment plans. All participating doctors chose to keep their notes open after the study ended.

» Read more

Challenging the Rectal Cancer Standard

Neoadjuvant chemoradiation followed by proctectomy with total mesorectal excision is the standard of care in the management of locally advanced rectal cancer. Unlike cancers of the colon, rectal cancer has always posed a unique challenge to the surgeon due to the narrow working space in the bony pelvis and the intimate relationship between the rectum and the pelvic autonomic nerves, vascular structures and the anal sphincter complex.

» Read more

Residents Present Work at American College of Surgeons

Four surgical residents from Cedars-Sinai gave three scientific forum podium presentations and three posters at the annual meeting of the American College of Surgeons last month in Washington, D.C. Halley Vora, MD, Ara Ko, MD, Monica Jain, MD, and Navpreet Dhillon, MD, represented Cedars-Sinai at the annual gathering, which drew more than 12,000 this year. The scientific forum is one of the most prestigious venues for research presentations in the surgical world.

» Read more

Two Minutes With ...

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery. This month’s installment features Xiaojiang Cui, PhD.



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New Guidelines for PCU Level of Care Begin Nov. 21

Cedars-Sinai is implementing new patient placement guidelines for Progressive Care Unit level of care beginning Monday, Nov. 21. The changes are expected to promote a more efficient process of assigning the appropriate level of patient care.

» Read more

Qualifications for Medical Executive Committee

Those interested in being a clinical chief and becoming a member of the Medical Executive Committee must meet certain qualifications and eligibility requirements. Please review the PDF to see if you meet the eligibility criteria.

» Read more

Circle of Friends Honorees for October

The Circle of Friends program honored 75 people in October. 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 Warns About Abuse of Testosterone Products

The U.S. Food and Drug Administration issued a new warning regarding the abuse potential of prescription testosterone products that can lead to serious side effects, including damage to the heart, brain, liver, mental health and endocrine system.

» Read more

Pharmacy and Therapeutics Committee Approvals

See highlights of the October meeting of the Pharmacy and Therapeutics Committee.

» Read more

CS-Link Tip: Changing Screen Color

As part of recent upgrades, screens for CS-Link™ have a new mint green color. If you don't like the color, it's easy to change. Go to the button on the top left of the screen. Scroll down to "personalize" and select "choose a theme."

» Read more

OpenNotes Gives Patients Access to Doctor Notes

Cedars-Sinai launched OpenNotes on Nov. 6. The communications tool allows patients to easily view their physicians' outpatient visit notes through our online patient portal, My CS-Link™.

Research at other institutions has shown that patients who use OpenNotes reported that they were better prepared for visits and better understood their health conditions and treatment plans. All participating doctors chose to keep their notes open after the study ended. Learn more about the OpenNotes study in the Annals of Internal Medicine.

"We tend to give patients a lot of information in a short period of time," said Richard V. Riggs, MD, vice president and chief medical information officer. "This program allows them to review the actual instructions and discussion from the office visit and also share them with other providers who may not be in the same network."

The majority of physicians who used OpenNotes in a Cedars-Sinai pilot found the program valuable and reported that it didn't hinder their ability to practice medicine. It's been implemented at a number of health systems, including the Mayo Clinic, Cleveland Clinic and Geisinger Health System. Organizations that have implemented this program have reported positive effects on patient engagement.

"OpenNotes is just one example of how our patients, as consumers, are looking to be engaged in their care and play a greater role in the health care choices they make," said John E. Jenrette, MD, executive vice president of the Cedars-Sinai Medical Network. "It supports our efforts in team-based care and keeping the patient at the center of everything we do."

OpenNotes is a voluntary program, and it includes a way to block information you do not wish to share with patients. It exists only within the outpatient context, and notes will automatically be hidden if written by a provider whose specialty is psychiatry or psychology or in an outpatient department whose specialty is psychiatry or psychology. And people granted proxy access for adults (e.g., a spouse) will not be able to see notes.

For more information, please visit the Service Center site or watch this video to hear more about the pilot project from Cedars-Sinai physicians and patients.

Challenging the Rectal Cancer Standard

By Karen Zaghiyan, MD, and Phillip Fleshner, MD

Neoadjuvant chemoradiation followed by proctectomy with total mesorectal excision (TME) is the standard of care in the management of locally advanced rectal cancer. Unlike cancers of the colon, rectal cancer has always posed a unique challenge to the surgeon due to the narrow working space in the bony pelvis and the intimate relationship between the rectum and the pelvic autonomic nerves, vascular structures and the anal sphincter complex.

In the 19th century, survival from rectal cancer was nil. In 1908, Sir William Ernest Miles revolutionized the surgical management of rectal cancer when he published his experience with the simultaneous abdominoperineal approach. After this milestone in rectal cancer surgery, survival improved but remained under 50 percent. The next breakthrough in rectal cancer surgery was the concept of TME described by Bill Heald in 1982. Sharp dissection in the avascular plane between the mesorectum and the pelvic autonomic nerves significantly reduced local recurrence. In fact, completeness of the mesorectal envelope has become a key prognostic feature of quality rectal cancer surgery. Another important evolution in the management of rectal cancer was preoperative chemoradiation through a number of large trials showing reduced local recurrence and improved overall survival. In addition, sphincter preservation became more common, as the importance of the distal margin diminished with preoperative chemoradiation.

Despite these advances, surgeons continue to struggle with surgery for rectal cancer, especially low cancers in male or obese patients. Although development of minimally invasive techniques such as laparoscopy and robotic surgery have attempted to tackle these problems, four recent multicenter randomized trials have been unable to show any advantage of laparoscopy or robotic surgery to open TME for rectal cancer.

A recent innovation in the surgical management of rectal cancer is a natural orifice approach known as the bottom-up TME or transanal TME (taTME). In this technique, the surgeon works through a transanal access platform to insufflate the rectum, after which the tumor is identified and distal margin marked. Next a full-thickness, endoluminal transection of the rectum is performed using an endoscope and standard laparoscopic instruments, and the rectum is fully mobilized posteriorly in the TME plane, anteriorly, and laterally. This dissection is then carried circumferentially until the peritoneal cavity is entered. Working simultaneously, a second surgical team via abdominal laparoscopic ports performs a high ligation of the inferior mesenteric artery and mobilizes the colon and splenic flexure. At the time of peritoneal entry from below, the abdominal team helps complete the dissection to fully dismount the rectum and deliver it transanally, without making an abdominal incision for extraction. Potential benefits of taTME include precise determination of the distal margin, avoidance of multiple staple firings across the rectum, potentially better oncologic results and autonomic nerve preservation, reduced postoperative pain, and fewer wound complications including infections and hernias.

We have performed several taTME operations with good results over the past several months and recently attended a cadaver course in Orlando, Florida, to refine our technique. As we embark on this journey to improve surgical results after rectal cancer surgery, we are tracking our results through the OSTRiCh national registry that will allow multicenter quality analysis to assure patient safety. It appears that taTME has the potential to revolutionize the surgical management of rectal cancer, and we are excited to be among early adopters of this technique.

Photo information:

  1. Transanal access platform through which taTME is performed
  2. Full-thickness, endoluminal transection of the rectum
  3. Transanal development of the TME plane between mesorectum and pelvic floor
  4. Anterior plane between prostate and rectum
  5. Entry into peritoneal cavity completing the proctectomy
  6. Abdomen after taTME showing the temporary ileostomy with NO abdominal extraction site

Residents Present Work at American College of Surgeons

Halley Vora, MD

Ara Ko, MD

Monica Jain, MD

Navpreet Dhillon, MD

Four surgical residents from Cedars-Sinai gave three scientific forum podium presentations and three posters at the annual meeting of the American College of Surgeons last month in Washington, D.C.

Halley Vora, MD, Ara Ko, MD, Monica Jain, MD, and Navpreet Dhillon, MD, represented Cedars-Sinai at the annual gathering, which drew more than 12,000. The scientific forum is one of the most prestigious venues for research presentations in the surgical world.

"We are very proud of the commitment to excellent academic research by our residents and faculty," said Rodrigo F. Alban, MD, associate director of the General Surgery Residency Program at Cedars-Sinai. "Strong resident participation from this institution continues to thrive and is now being recognized by leaders in different surgical specialties at the college level."

Founded in 1913 to raise the standards of surgical practice and care for patients, the American College of Surgeons is the largest organization of surgeons in the world, with more than 80,000 members.

Two Minutes With ...

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

Xiaojiang Cui, PhD, associate professor in the Department of Surgery and research scientist in the Women's Cancer Program at the Samuel Oschin Comprehensive Cancer Institute

Where did you grow up?

I was born in Shanghai, China, and grew up in Shanghai and Wuhan. I went to college in Shanghai.

Why did you decide to specialize in Research?

In college, I originally studied electrical engineering. During my sophomore year, I attended a seminar by a professor who had just come back from Germany after years of research training there. He talked about modern biology and the future of medicine. I was fascinated by the promise and decided to change my major to biochemistry. After I obtained PhD from the University of Texas at Austin, I decided to focus on cancer research.

What is the most rewarding aspect of your job?

To know that the results or products from my work may be used in the care of cancer patients. For example, our work showing that FOXC1 may be used as a single marker to identify and prognosticate basal-like breast cancer, just like ER to luminal breast cancer.

Outside the laboratory, where do you find inspiration?

By talking with colleagues at casual settings such as coffee breaks. Also, Cedars-Sinai cancer research seminar series.

What's at the top of your bucket list?

I hope to develop an anticancer drug or treatment which is effective against late-stage cancer with minimal side effects.

New Guidelines for PCU Level of Care Begin Nov. 21

Cedars-Sinai is implementing new patient placement guidelines for Progressive Care Unit (PCU) level of care beginning Monday, Nov. 21.

The new guidelines streamline much of the current five pages of PCU placement procedures into five main criteria and also impact the list of medications requiring PCU status. The changes are expected to promote a more efficient process of assigning the appropriate level of patient care including ICU avoidance when possible.

Teams from the medical staff, nursing, pharmacy and patient placement, with support from clinical transformation, collaborated to create the new guidelines. The executive sponsors of the initiative are Scott Weingarten, MD, senior vice president and chief clinical transformation officer, and Linda Burnes Bolton, DrPH, RN, FAAN, health system chief nursing executive, vice president for Nursing and chief nursing officer.

"The guidelines will assist the team in providing appropriate care in the right setting," said Burnes Bolton. "When fully operationalized the guidelines will facilitate appropriate patient placement, decrease inappropriate use of PCU status for patients and improve access to PCU beds to avoid ICU admission."

The new five main criteria for PCU placement are:

  • Ongoing nursing interventions and assessments every two hours (not to exceed eight occurrences)
  • Moderate to high risk of cardiac dysrhythmia
  • Moderate to high risk of respiratory decompensation
  • Invasive hemodynamic devices (e.g., PA catheter)
  • Use of medications which require PCU level of care

Nurses assigned to PCU patients have advanced training to care for these higher-acuity patients.

Earlier this month, staff training began to support implementation of the new criteria. Clinical decision support in CS-Link™ is expected to begin March 2017.

For more information or questions, please contact Todd Griner, MSN, RN, NEA-BC, at todd.griner@cshs.org or 310-962-7859.

Qualifications for Medical Executive Committee

Those interested in being a clinical chief and becoming a member of the Medical Executive Committee must meet certain qualifications and eligibility requirements. Please review the PDF below to see if you meet the eligibility criteria.

Do You Qualify for MEC Membership? (PDF)  

Circle of Friends Honorees for October

The Circle of Friends program honored 75 people in October.

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.

  • Daniel C. Allison, MD
  • Mary H. Alvarado
  • Paula J. Anastasia Davis, MN, RN, AOCN
  • Esther Baik, MD
  • C. Noel Bairey Merz, MD
  • Babak R. Bamshad, MD
  • Peyton Berookim, MD
  • Page A. Bertolotti, BSN, RN, OCN
  • Natalie Beyder, RN
  • Darina Brezhnev, PharmD
  • Eileen G. Brown, OCN, RN
  • Neil A. Buchbinder, MD
  • Kirk Y. Chang, MD
  • Martin Cooper, MD
  • Catherine M. Dang, MD
  • Robert W. Decker, MD
  • Stephen C. Deutsch, MD
  • Noam Z. Drazin, MD
  • Fardad Esmailian, MD
  • Sharmayne Farrior, RN
  • Rajinder Gandhi, RN
  • Ivor L. Geft, MD
  • Jeffrey S. Goodman, MD
  • Robert A. Gross, MD
  • Daniel A. S. Hoffman, DO
  • David M. Hoffman, MD
  • Lucia Jimenez Kinsey, LCSW
  • Jeffrey E. Johnson , MD
  • Neel R. Joshi, MD
  • Saibal Kar, MD
  • Beth Y. Karlan, MD
  • Robert F. Katz, MD
  • David Kawashiri, MD
  • Lennoux Laryea
  • Caroline Lee, MD
  • Andrew J. Li, MD
  • Simon K. Lo, MD
  • Hayden Lowenstein, MD
  • Rajendra Makkar, MD
  • Cindy Margolis, RN
  • Kelsey T. McCusker
  • Zab Mosenifar, MD
  • Youram Nassir, MD
  • Leslie Nieva
  • Tiffany Perry, MD
  • Edward H. Phillips, MD
  • Edwin M. Posadas, MD
  • Irving Posalski, MD
  • Jana Posalski, MD
  • Lupita Rabago
  • Shervin Rabizadeh, MD
  • Madison F. Richardson, MD
  • Bobbie J. Rimel, MD
  • Mario A. Rivera
  • Fred P. Rosenfelt, MD
  • Steven M. Rudd, MD
  • Royinna D. Ruzgal-Byrne
  • Alexander Salazar
  • Gregory P. Sarna, MD
  • Yoshinao Sasase, PT
  • Michael M. Shehata, MD
  • Olga Shichko, RN
  • Tara D. Smith
  • Thomas P. Sokol, MD
  • Andrew Ira Spitzer, MD
  • Steven W. Tabak, MD
  • Esperanza Tercero, LVN
  • Camille O. Thornton
  • Alfredo Trento, MD
  • Tatevik Tsaturyan, RN
  • Mark K. Urman, MD
  • Robert A. Vescio, MD
  • Robert N. Wolfe, MD
  • Lewis Y. Wyatt, MD
  • Patrick M. Yaffee, MD

FDA Warns About Abuse of Testosterone Products

The U.S. Food and Drug Administration issued a new warning regarding the abuse potential of prescription testosterone products that can lead to serious side effects, including damage to the heart, brain, liver, mental health and endocrine system.

Testosterone and other anabolic-androgenic steroids are abused by adults and adolescents, including athletes and body builders. Abuse of testosterone is associated with adverse outcomes including heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity and male infertility.

The FDA website has more information.

Pharmacy and Therapeutics Committee Approvals

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

P and T Committee Approvals - October 2016 (PDF)

CS-Link Tip: Changing Screen Color

As part of recent upgrades, screens for CS-Link™ have a new mint green color. If you don't like the color, it's easy to change.

Go to the button on the top left of the screen. Scroll down to "personalize" and select "choose a theme."

While under that personalize button, you can access the "SmartTool Accessibility Buttons." This button can change the highlight color of "SmartLinks" and "SmartLists," which can make screen reading easier.

More details on how to personalize your screen can be found here.

Learn to be more efficient by attending a Physician Efficiency Training session. The classes are held in Cafeteria Conference Room C. The schedule:

  • Thursday, Dec. 8, noon-1:30 p.m.
  • Tuesday, Dec. 13, 7:30 a.m.-9 a.m.

If you have questions, email groupeisphysicians@cshs.org.