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Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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Research, Science, Stanford News, Surgery

Will scars become a thing of the past? Stanford scientists identify cellular culprit

Will scars become a thing of the past? Stanford scientists identify cellular culprit

346801775_c5a1e37a6d_zI have a scar on my chin from a fall I took while rollerskating when I was about 12. One minute I was blithely zooming along to Bob Seger’s hit Against the Wind (earworm alert!), reveling in my new ability to skillfully cross one foot in front of the other and thinking about that cute boy by the snack counter, and the next I was chin down skidding across the flat, grey and (I then realized) very hard floor to come to rest against the wooden wall in an ignominious heap.

Although the experience left an impression on my psyche, as well as my skin, I can’t claim any long-lasting problem from the thin line on my chin. After all, nearly all of us have something similar. But scars can also be debilitating and even dangerous.

Now plastic and reconstructive surgeon Michael Longaker, MD, and pathologist and stem cell expert Irving Weissman, MD, have identified the cell type in mice that is responsible for much of the development of a scar. They’ve shown that blocking this cell’s activity with a small molecule can reduce the degree of scarring. Because a similar drug molecule is already approved for use in humans to treat Type 2 diabetes, the researchers are hopeful that they can begin clinical trials in humans soon. The research was published today in Science.

As Longaker explained in our release on the study:

The biomedical burden of scarring is enormous. About 80 million incisions a year in this country heal with a scar, and that’s just on the skin alone. Internal scarring is responsible for many medical conditions, including liver cirrhosis, pulmonary fibrosis, intestinal adhesions and even the damage left behind after a heart attack.

Longaker and his colleagues found that a subset of a skin cell called a fibroblast is responsible for much of the collagen deposition that leads to scarring. Inhibiting the activity of a protein on the surface of the cells significantly reduced the amount of scarring during wound healing in laboratory mice – from about 30 percent of the original wound area down to about 5 percent -the researchers found. Furthermore, they showed the cells are also involved in the thickening and darkening of skin exposed to radiation therapy for cancer, as well as the spread of melanoma cancer cells in the animals.

Longaker’s been interested in how the skin heals for decades–ever since he learned as a student that, prior to the third trimester, human fetuses heal from trauma or surgery without any scarring. Now he’s excited to learn whether there’s a way to recapture that long-lost ability as adults and at least reduce the degree of scarring during skin repair.

“I’ve been obsessed with scarring for 25 years,” Longaker told me. “Now we’re bringing together the fields of wound healing and tumor development in remarkable new ways. It’s incredibly exciting.”

Longaker and Weissman are both also members of the Stanford Cancer Institute.

Previously: New medicine? A look at advances in wound healing, Stanford-developed device shown to reduce the size of existing scars in clinical trial and Mast cells not required for wound healing, according to Stanford study
Photo by Paulo Alegria

Events, Global Health, History, Pediatrics, Surgery, Transplants

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

Esquivel - croppedThese days, Carlos Esquivel, MD, PhD, is best known as one of the top pediatric liver transplant surgeons. But just a few decades ago, he worked as a generalist physician in an ill-equipped Costa Rican village located across from a river teeming with man-sized crocodiles.

Esquivel told a gripping tale of his journey from his native Costa Rica to Stanford during a recent Café Scientifque presentation. He described how he spent only a year in remote San Vito before traveling to the United States and joining the lab of innovative surgeon F.W. Blaisdell, MD, who took Esquivel under his wing and treated him like a son. On to Sweden, where Esquivel earned his post-doctorate degree, before mastering his transplantation skills with Thomas Starzl, MD, PhD, who is known as the “father of trasnplantation” and conducted the first human liver transplant in 1963.

Back then, transplant surgeons wore knee-high fishing waders to perform transplantations — they were that messy, Esquivel said. And few dared to do liver transplants in children. Fast-forward to today: Transplant surgeries are shorter, much less bloody, and much more survivable thanks to the improvements in technology and immunosuppressant drugs. Last year, the team at Lucile Packard Children’s Hospital Stanford tallied a 100 percent one-year survival rate, Esquivel told the audience.

Now, the primary problem is the shortage of organs. More than 120,000 people in the United States are waiting for a new organ. Kidneys are most in-demand, but thousands of people are also waiting for new livers. And like kidneys, livers can be taken from living donors, Esquivel said. Sometimes, an adult liver can even be split in two, saving the lives of another adult and a child.

Livers can regenerate, making it an ideal organ to donate. However, the donation surgery can cause complications and donation is a choice that potential donors — and their doctors — should consider carefully, Esquivel said.

Esquivel said surgeries are physically taxing, but also take a great deal of mental preparation. Before surgeries, he said he runs through all the scenarios, trying to prepare for every possibility.

To raise awareness about organ donation, Esquivel, an avid cyclist, completed an across-the-county bicycle race with a former transplant patient. And he has high hopes for the future. Once, transplanted livers only lasted 12 to 15 years, but today, some livers last as long as 30 years, Esquivel said.

Previously: How mentorship shaped a Stanford surgeon’s 30 years of liver transplants, Raising awareness about rare diseases and Record number of organ transplants saves five lives in a day
Photo courtesy of Lucile Packard Foundation for Children’s Health/ Toni Gauthier

Cardiovascular Medicine, Patient Care, Pediatrics, Stanford News, Surgery

Complex procedure helps teen with rare congenital heart defect

Complex procedure helps teen with rare congenital heart defect

broken heartPeople don’t usually associate teenagers with heart problems, but congenital heart defects are more common than you might think.

A recent Healthier, Happy Lives Blog post tells the story of Ray Santa Cruz, a high-school senior from Salinas, Calif. who began to suffer from a mysterious and severe chest pain when he exerted himself. It had gotten so bad he had trouble breathing and sleeping.

It turns out that Cruz had an anomalous aortic origin of a coronary artery, meaning that his arteries didn’t attach in the right places. Until very recently, most people with this condition went undiagnosed until a post-heart-attack autopsy. Even with a more timely diagnosis, many surgeons would try to operate in the same way they would on a 70-year old, which is “absolutely the wrong thing to do,” according to Frank Hanley, MD, the surgeon who ultimately fixed Cruz’s heart. A standard bypass operation is “what you do for Grandpa” but not young patients like Cruz.

Stanford physicians developed surgical techniques to fix the defect fifteen years ago, and since then, Lucile Packard Children’s Hospital has treated about 90 young patients, more than any other institution. Cruz had a very specific variation of the condition, for which neither of the standard procedures would have worked; Hanley tried something entirely new, and so far the complex procedure has been a success.

Check out the story to read more.

Previously: Baby with rare heart defect saved by innovative surgery, A nurse puts heart into her work at Adult Congenital Heart Program, Patient is “living to live instead of living to survive,” thanks to heart repair surgery and Should high school and college athletes be routinely screened for heart conditions?
Photo by Nicolas Raymond

Medical Education, Medical Schools, Stanford News, Surgery

After work, a Stanford surgeon brings stones to life

After work, a Stanford surgeon brings stones to life

MA15_Profs_Greco_480pxClassrooms, research, grant writing, faculty meetings… It can be easy to forget that professors have a life outside of the classroom, perhaps with surprising hobbies and talents. The new issue of Stanford Magazine highlights the extra-professional lives of some of the university’s extraordinary professors, including Ralph Greco, MD.

Greco is a sculptor of stone as well as a surgeon. His work decorates his home and has sold for as much as $8,500. Perhaps his most notable sculpture is the abstract “S” that graces the Department of Surgery. He created the work of art from a 400-pound marble boulder that was gifted to him at a graduation dinner when he was the director of the general surgery residency program.

It’s perhaps not surprising that the multi-faceted Greco is an advocate for work-life balance among surgeons. He established a support program after the suicide of a surgical resident, and because he says sculpting can be “too self centered,” he pursues other interests as well. Check out the article to learn more.

Previously: Program for residents reflects “massive change” in surgeon mentality and New surgeons take time out for mental health
Photo by Nicolo Sertorio

Cardiovascular Medicine, In the News, Pediatrics, Surgery

Marathon surgery at Stanford gives 6-year-old boy a chance to thrive

Marathon surgery at Stanford gives 6-year-old boy a chance to thrive

image.img.320.highA rare chromosomal disorder called Williams syndrome left 6-year-old Jordan Ervin with a host of medical problems, including severe heart defects. But it also gave him a gregarious personality and an infectious smile, one that made the multiple medical appointments and hospitalizations much easier to handle, according to his mother, Seville Spearman.

“Jordan is such a champ,’’  Spearman said in a recent Inside Stanford Medicine article. “He’s always been just a really happy kid.”

And in December, he became a much healthier one thanks to the skillful work of Stanford cardiothoracic surgeon Frank Hanley, MD. More from the piece:

It was a complicated case. The stenotic arteries caused severe pulmonary hypertension. In less-severe cases, in which there is only one area of stenosis near or at the pulmonary valve, doctors can perform a fairly simple surgical catheter procedure that uses a tiny balloon to expand the artery. But Jordan had multiple narrowings: 12 in his left lung and 14 in the right lung. The balloon technique is much less effective in this scenario, and no other surgical techniques have been developed to treat these stenoses. So Jordan would need a different approach.

That approach was developed by Hanley, who receives referrals from all over the world. He’s the pioneer of a one-stage, fix-all-the-defects surgery called unifocalization.

“We’re definitely on the leading edge of this kind of surgery,’’ said Hanley, who holds the Lawrence Crowley, MD, Endowed Professorship in Child Health. “Jordan is going to have perfectly normal life expectancy.”

Ervin is back in school in Illinois, where his parents are delighted with the outcome. His mother said in the story, “Everything is back to normal, but I will never take anything for granted again.”

Previously: How better understanding Williams syndrome could advance autism research, Pediatric surgeon fixes “heart that can’t be fixed” and Patient is “living to live instead of living to survive,” thanks to heart repair surgery
Photo by Norbert von der Groeben

Pediatrics, Pregnancy, Stanford News, Surgery

A difficult decision that saved three young lives

A difficult decision that saved three young lives

Estrada-Triplets_013I first met Lily Estrada and her identical triplets almost a year ago. The three babies, who were nearly ready to go home from Lucile Packard Children’s Hospital Stanford, looked pretty ordinary. In fact, that’s why I love the photo at the right, which was taken at the time. Baby Pedro, in blue, was gazing at his mom; Ayden, in orange, was wiggling; and William, in grey, was sucking contentedly on his pacifier.

But they had survived an extraordinarily complicated and rare prenatal disorder. The single placenta that connected all three boys to their mother during pregnancy developed a vascular problem called twin-to-twin transfusion syndrome. Blood flowing through the placenta was not being shared equally between the fetuses, straining their hearts and putting all of them at risk of dying before birth.

When Estrada was diagnosed in late 2013, she and her husband, Guillermo Luevanos, faced a difficult decision. A surgery on the placenta might help save the babies, but it was by no means a sure bet. And, at the time, no one at Stanford performed the procedure, although a new partnership between our maternal-fetal medicine experts and their counterparts at Texas Children’s Hospital, in Houston, provided an opportunity for Estrada to be treated there. In the Stanford Medicine magazine story I wrote about the case, Estrada described how her family felt:

“We were saddened and sort of confused,” Estrada says, recalling the first reactions that she and her husband had to the news. “It was: We could wait and see what happened, but the likelihood was that we were going to have no baby, or we could terminate one and see what happened with the other two, or take the risk, go to Houston, have the surgery and hope it worked for all three. But they didn’t guarantee anything.”

One piece of background that helped inform the couple’s decision was the fact that when the surgery worked, research had shown it helped moms stay pregnant about four weeks longer, allowing their babies more time to develop before birth. (Because the uterus gets so crowded, twins and other multiples are almost always born early, but a less premature delivery makes a huge difference for the babies’ health.) Sealing the connecting blood vessels also seemed to protect surviving fetuses in the event that one died. “We’re separating, or attempting to separate, their fates,” [Estrada’s obstetrician] Yair Blumenfeld, MD, says.

After a lot of counseling and discussion with the Stanford team, “we decided to go for it and do surgery,” Estrada says.

Once they had made the choice, they had no second thoughts. “My husband was a little bit stronger,” Estrada recalls. “He just wanted me to go for it, and see what happened.”

triplets-medresThe surgery, performed at Texas Children’s by Michael Belfort, MD, PhD, was a success. And, as my story describes, the collaboration between the two institutions is going well, too. Stanford researcher Christopher Contag, PhD, and colleagues are studying how to make better and safer surgical tools for future maternal-fetal surgeries, while surgeons here have advanced their capabilities and now offer the surgery for twin-to-twin transfusion here in Palo Alto.

Meanwhile, William, Ayden and Pedro are doing well. My favorite moment in preparing the story was when I got to see our new photo of them, above. As their mom told me, “They’re really happy babies.”

Previously: NIH puts focus on the placenta, the “fascinating” and “least understood” organStanford Medicine magazine reports on time’s intersection with healthPlacenta: the video game and Program focuses on the treatment of placental disorders
Photo of triplets as infants by Norbert von der Groeben; photo of triplets as toddlers by Gregg Segal

In the News, Medical Education, Mental Health, Surgery

Surgeon offers his perspective on balancing life and work

Surgeon offers his perspective on balancing life and work

5136926303_a3d0bb0767_bMany of us strive to balance our life and work so we can be successful, happy and healthy. Yet, for people with unpredictable work schedules, such as doctors who must treat medical emergencies that have no regard for the nine-to-five work week, it can be hard to achieve this balanced bliss.

Much has been written about this topic, but the candor of this recent blog post from Robert Sewell, MD, a general surgeon at Texas Health Harris Methodist Hospital, caught my eye. In the piece, which originally appeared on the Family Physician blog and was posted on KevinMD yesterday, Sewell gives a brief account of what it’s like to be a surgeon and discusses the challenges and rewards of this career choice. He starts by providing a bit of his own back story:

I got married during medical school, and like every surgeon back in those days I told my wife, “I will always have two wives, you and medicine.” While some spouses accepted that dictum, others, including mine, resented it. Shortly after starting my practice it became clear that our relationship had been strained to the breaking point by my singular focus on achieving my life’s goal.

Sewell acknowledges that it’s desirable to balance the amount of time you devote to your work and personal life, but that as a surgeon it’s not always possible to do so:

Perhaps the most important lesson I learned is that a successful life and marriage requires balance. Too much emphasis on any one aspect throws both you, and those around you, out of balance. This should have been obvious, but as a surgeon, it was an extremely difficult lesson to learn, largely because of the nature of what we do. A kid with acute appendicitis, or an accident victim who is bleeding out from a ruptured spleen, simply can’t wait for a recital or soccer game to be over.

In the last two decades I’ve witnessed a significant effort by many young physicians to push back against those career pressures, as they seek more balance in their lives. While that is certainly a good ideal, being a surgeon is simply not a nine to five job. It’s a calling, and if you are truly called to the profession it’s in your blood.

Previously: Helping those in academic medicine to both “work and live well”Program for residents reflects “massive change” in surgeon mentalityNew surgeons take time out for mental healthUsing mindfulness interventions to help reduce physician burnout and A closer look at depression and distress among medical students
Photo by Colin Harris

Cardiovascular Medicine, Pediatrics, Pregnancy, Surgery

Baby with rare heart defect saved by innovative surgery

Baby with rare heart defect saved by innovative surgery

jackson-lane-stanford-childrens560

Elyse Lane was 20-weeks pregnant when she learned that her unborn son had a rare and severe heart defect. Her baby was missing his pulmonary valve and his pulmonary artery was 10 times the normal size.

The outlook was bleak. The baby’s enlarged artery hampered his blood and oxygen flow, a condition called tetralogy of Fallot, and his missing pulmonary valve made the defect worse.

Fortunately, Lane and her husband, Andy Lane, a former Major League Baseball coach with the Chicago Cubs, were referred to Frank Hanley, MD, a cardiothoracic surgeon at Stanford Children’s Health. Hanley had experience with this kind of heart defect and knew how to perform the delicate surgery needed to repair their baby’s heart.

The Lanes recount the story of their son’s lifesaving surgery on the Lucile Packard Children’s Hospital blog:

When he was just five days old, Jackson underwent a 13-hour operation that would save his life. Hanley and his team did a complex overhaul of Jackson’s heart: they inserted a pulmonary valve, reduced the size of Jackson’s right pulmonary artery, and enlarged his small, disconnected, left pulmonary artery. Hanley also used an innovative and intricate procedure known as the LeCompte maneuver, which altered the pathway of Jackson’s right and left pulmonary arteries from the back of the heart and aorta to the front. This gave his severely compromised bronchial tubes room to grow and remodel after surgery was over.

As the story explains, Jackson’s heart will need some maintenance in the future, but he should live a normal and long life.

“He can now do anything he wants in life,” said Elyse Lane in in the blog piece. “He’s already made it through the biggest challenge.”

Previously: Patient is “living to live instead of living to survive,” thanks to heart repair surgery, A very special small package: Three-pound baby receives pacemaker, Advancing heart surgery for the most fragile babies, and Little hearts, big tools
Photo courtesy of Lucile Packard Children’s Hospital

Cardiovascular Medicine, Chronic Disease, Research, Stanford News, Surgery, Transplants

Growing number of donor hearts rejected for transplantation, Stanford study finds

Growing number of donor hearts rejected for transplantation, Stanford study finds

KhushAs a health writer, I’ve interviewed and written about numerous heart patients whose lives were saved when someone else died and donated their hearts for transplantation.

Those patients expressed both the anguish of hoping and praying for a new heart — when that means someone else has to die — and the overwhelming gratefulness for those donor hearts that saved their lives.

So when I wrote a story about a new Stanford study that shows an increasing number of donor hearts being rejected for transplantation, it struck a chord.

The study, published today online in the American Journal of Transplantation, found that the number of hearts rejected for transplant by surgeons and transplant centers is on the rise despite the growing need for such organs. As cardiologist Kiran Khush, MD, the lead author of the study, said in my story on the work, “We’ve become more conservative over the past 15-20 years in terms of acceptance, which is particularly troubling because of the national shortage of donor hearts and the growing number of critically ill patients awaiting heart transplantation.”

Khush and her colleagues sought to study national trends in donor-heart use by examining data from the federal government’s Organ Procurement and Transplantation Network on all donated hearts from 1995-2010. Of 82,053 potential donor hearts, 34 percent were accepted and 48 percent were declined. The remainder were used for other purposes such as research.

The researchers found a significant decrease in donor heart acceptance, from 44 percent in 1995 to 29 percent in 2006, which rebounded slightly to 32 percent in 2010. They also found, as I wrote in the story:

Among a portion of donor hearts that are referred to as “marginal” — those with undesirable qualities, such as being small or coming from an older donor — their use in transplantation varied significantly across geographical regions depending on choices made by the surgeons and the transplant centers.

The study explored possible reasons for so few organs being accepted. Increasing scrutiny by regulatory agencies of the 140 or so transplant centers across the country may have had the unintended result of making surgeons and centers more risk averse and as a result reject more hearts. Also, an increasing us of mechanical circulatory support devices that help keep patients alive while waiting for donor hears, may cause surgeons to wait longer for “better hearts.”

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