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History, Research, Surgery

Ancient surgical technique still used to rebuild noses today

Ancient surgical technique still used to rebuild noses today

When facial surgeon Sam Most, MD, first contacted me about doing a story on one of his favorite procedures called the “forehead flap,” which he uses for major nose reconstructions, he sent along photos of what a patient looks like prior to surgery.

The photos make it clear real fast how unfortunate it is to lose your nose. The nose is the focal point of the face. It’s what people notice first. The numbers of people losing their noses due to skin cancer is on the rise, and many, are left wearing uncomfortable, unflattering prostheses for years.

Enter surgeons like Most, part artist, part scientist — a sculptor of noses. According to Most, it’s the most difficult facial plastic surgery procedure. And key among the many necessary tools needed to succeed is the “forehead flap” — a procedure that originated with cobblers in ancient India. My article tells the story of this fascinating surgery, which was first introduced into Western medicine in 1794:

Most is quick to recount the historical significance of the forehead flap, Most is quick to recount the historical significance of the forehead flap technique, which originated in India probably before the birth of Christ but wasn’t widely known to Western medicine until 1794 with the publication of a letter to the editor in Gentlemen’s Magazine of London. The letter provided the first account in English literature of the procedure.

At the time, India was a colony of the British. A sultan, angry at the occupation, offered bounties for the amputated ears, noses and hands of British sympathizers. The letter describes the nasal reconstruction of an Indian bullock driver who, having been imprisoned by the sultan, had his nose and one of his hands cut off for delivering supplies to British troops. It goes into detail how the driver’s nose was rebuilt 12 months later, after he joined the Bombay Army of the East India Company.

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Education, Stanford Medicine Unplugged, Surgery

Ten percent more: Skirting the line between life and death in surgery

Ten percent more: Skirting the line between life and death in surgery

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

surgeryI was in the middle of my surgery rotation and was scrubbed in on a gastrectomy. A gastrectomy is a procedure to remove a patient’s stomach; in this case because of a stomach cancer. It’s a major operation that requires the manipulation of delicate structures but it offers an excellent outcome for many patients.

My job during the gastrectomy was to be a retractor – a classic medical student role. Retraction is a simple mechanical job that involves pushing skin, muscle, and other tissue out of the way in order to help the surgeons visualize the field in which they are working. More specifically, the attending surgeon handed me a metal plate and told me to use it to push down hard on the intestines so that we could get a good view of the stomach and associated blood vessels in the area. I was positioned behind the resident, who would be the one taking advantage of that view.

I pushed down with my left hand as the attending and resident went about clipping vessels and clearing tissue. Suddenly, the field of view filled up with blood. Some bleeding is to be expected during any surgery, particularly one like this. But this was more than expected.

The attending immediately started calling out orders. He told the resident to find the source of bleeding so that we could ligate it or clip it off. He asked the anesthesiologist to get blood ready in case we needed a transfusion. And then he turned to me and said, “Akhilesh, I need you to push down 10 percent harder. If we lose the field of view here, we might not find it again.”

I pushed down harder, and the search for the source of bleeding continued. The attending told us not to panic (when the attending says “Don’t panic,” that’s how you know there’s a reason to panic). He turned his attention back to me.

“Akhi, I need 10 percent more pressure.” And then: “20 percent more.”

I was getting tired.

“I know you’re getting tired bro, but give me 10 percent more.”

Finally, after a great deal of suctioning, searching, and approximately 130 percent more pressure, we found the source and stopped the bleeding. Everyone paused for a second to breathe a sigh of relief, and then it was back to the procedure.

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Imaging, Research, Science, Stanford News, Surgery

A dye to try: New compound provides improved imaging, safety

A dye to try: New compound provides improved imaging, safety

The NIR-II dye can clearly resolve blood vessels in the hindlimb as well as in the brain with unprecedented clarity. Furthermore, the dye allows clear resolution of tumors in the center of the mouse’s brain and is capable of ultra-sensitive tumor detection.

A team of Stanford-led researchers has created a dye capable of identifying tumors in a variety of tissues and providing surgeons with real-time video feedback during surgery.

And the best part of this molecular fluorescent dye? It’s much safer for humans than many other existing dyes because it can be excreted through urine within 24 hours, the researchers say.

They explain in a recent Stanford News article:

“The difficulty is how to make a dye that is both fluorescent in the infrared and water soluble,” said Alex Antaris, a chemistry graduate student and the first author on a recent paper in the journal Nature Materials. “A lot of dyes can glow but are not dissolvable in water, so we can’t have them flowing in human blood. Making a dye that is both is really the difficulty. We struggled for about three years or so and finally we succeeded.”

The new dye also provides more detailed images than were previously available, making it helpful for diagnostics or for guiding surgery, Antaris said.

The paper’s senior authors are Hongjie Dai, PhD, professor of chemistry, and Zhen Cheng, PhD, associate professor of radiology, and Xuechan Hong, PhD, of Wuhan University, China.

Previously: Better tumor-imaging contrast agent: the surgical equivalent of “cut along dotted line”?, Stanford instructor called out for his innovative — and beautiful — imaging work and New molecular imaging could improve bladder-cancer detection  
Image by Alexander Antaris

Ask Stanford Med, Pediatrics, Surgery

Surgery to find your voice: A Q&A with a pediatric otolaryngologist

Surgery to find your voice: A Q&A with a pediatric otolaryngologist

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When we’re in a noisy restaurant, it’s really difficult to hear my young niece speak. She can only talk very quietly, because she has a paralyzed vocal cord.

Like many children born very premature, the nerve going to her vocal cord was likely damaged when she had heart surgery soon after she was born. Her inability to be heard frustrates her, especially now that she is in school. However, a rare surgery may bring her the hope of a near-normal voice.

Stanford surgeons recently began performing laryngeal reinnervation surgery, which essentially rewires the paralyzed vocal cord with a new nerve supply. I recently spoke with Anna Messner, MD, a professor of otolaryngology and pediatrics who sees patients at Lucile Packard Children’s Hospital Stanford, about laryngeal reinnervation surgery.

What standard surgical procedures are used to treat unilateral vocal cord paralysis?

In general, the surgical procedures bulk up the paralyzed vocal cord to move it towards the midline of the body, making it easier for the other vocal cord to compensate and close. There are two standard surgeries. We can do injection laryngoplasty, where we inject a substance into the paralyzed vocal cord to thicken it. Unfortunately, this procedure often needs to be repeated multiple times, if it works at all. We can also insert a medialization implant in teenagers and adults, but this doesn’t work for growing kids. If we put an implant into a 2-year-old, it wouldn’t be an appropriate size when he is 10.

How does laryngeal reinnervation surgery work?

No matter what we do, we can’t make the vocal cord move. We can never make it perfect again. What we can do is hook up one of the other nerves in the neck to the recurrent laryngeal nerve that goes to the vocal cord. And that helps some new nerve fibers go to the vocal cord, making the vocal cord stronger and thicker. As a result, the voices on these kids improve significantly.

The surgery itself is fairly straightforward and only takes about an hour. The children typical go home the same day or just stay overnight, and they feel back to normal in a couple of days. But then we have to wait five to six months for the nerve fibers to grow before we can see real improvement in the voice. The only downside is that it takes a long time to see the effects of the surgery.

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Research, Stanford News, Surgery

Immune cell linked to surgery recovery time, Stanford scientists find

Immune cell linked to surgery recovery time, Stanford scientists find

surgery shotWe don’t think about doctors getting sick, or about them feeling just as lousy and miserable as the rest of us when they’re recovering. But it happens.

“In medical school I had a chest surgery and had a horrible recovery — in the hospital 10 days, and exhausted for about two months,” recalled Dan Sessler, MD, professor and chair of the Department of Outcomes Research at the Cleveland Clinic, when I spoke with him recently. “I was so tired I couldn’t pick up a remote and turn on the television.”

Sessler did recover — his was a successful surgery — but going into the operation neither he nor his doctor had any inkling that Sessler wouldn’t experience the normal two-week recovery.

Now, research published online in the journal Anesthesiology could lead to an “immune stress test” where blood taken from a patient prior to surgery could help predict when the patients would be back on their feet. The investigators, including co-senior authors/Stanford physicians Garry Nolan, PhD, and Martin Angst, MD, collected blood from 25 hip replacement patients and exposed the blood to chemicals to mimic how the immune system would respond to a traumatic event like surgery. They found the behavior of a white blood cell called a monocyte was related to how quickly patients recovered.

The researchers are working to replicate the findings in a larger study of 80 patients, and they plan to adapt their findings into a test that can run on standard hospital lab machines. As I wrote in our press release about the practical benefits of such a test:

Knowing the likely recuperation times will help patients plan better for their return to work and other post-surgery commitments. For patients at risk for longer recovery times, doctors could schedule additional physical therapy or special care, or the surgery could be postponed while exercise, dietary changes and stress-release techniques are implemented.

As for Sessler, who was not involved in this study, he said he sees great value in adapting the paper’s results into a test. Predicting a patient’s recovery is “clinically important, and we don’t do a good job” of it, he said.

Kim Smuga-Otto is a student in UC Santa Cruz’s science communication program and a former writing intern in the medical school’s Office of Communication and Public Affairs.

Previously: Discovery may help predict how many days it will take for individual surgery patients to bounce back, New device identifies immune cells at an unprecedented level of detail, inside and out and The importance of human connection as part of the patient experience
Photo by ChaNaWiT

Education, Mental Health, Research, Surgery, Women's Health

Stereotype perception linked to psychological health in female surgeons

Stereotype perception linked to psychological health in female surgeons

8116089104_be12619731_oFemale surgeons who believe there’s a stereotype that men are better doctors are more likely to suffer from psychological distress, according to a recent study led by a former Stanford resident.

First author Arghavan Salles, MD, PhD, looked at the correlation between the perception of a stereotype — whether individuals think others believe certain groups are superior physicians — and the overall mental well-being of residents.

The team surveyed 382 residents from 14 medical specialties. To examine views on stereotypes, participants were asked: “Do you think residents in your program expect men or women to generally be better [doctors]?” They were also given standard psychological assessments.

Female surgeons were the only group where stereotype perception was correlated with psychological health. Surgery has traditionally been dominated by men and remains a specialty chosen by about twice as many men as women, leading to the persistence of gender stereotypes.

“As a surgical resident, I was aware of the stereotype that men are better surgeons than women. Although I found the stereotype upsetting, I didn’t think about it too much,” Salles told me. Then, after studying stereotype perception while pursuing a doctorate in education, Salles decided to combine her two specialties to determine whether residents experience stereotype threat; a question that no one had asked before.

The link she found has implications for physician productivity and patient care, Salles said.

“I think it’s important to realize that in the world of medicine, although the ratio of males to females is changing, some of these old stereotypes still have an impact on the practitioners,” said co-senior author Claudia Mueller, MD, PhD.

The belief that others think women aren’t good enough adds an unnecessary stressor to the female residents’ already harried lives, Mueller said. It could also contribute to the high attrition rate of females in surgical disciplines, the study states.

Mueller said the study, which appears in the Journal of the American College of Surgeonsis noteworthy for its rare integration of two quite disparate fields, surgery and psychology.

The authors suggest that simply increasing the number of female surgeons may help dissipate the stereotype. Sharing information about the stereotype may also help, as could investigating any practices that may have a differential effect on men and women, the researchers write.

Salles is now querying residents, faculty members and members of the public to see how prevalent stereotypes about gender-based differences in ability actually are.

Previously: How two women from different worlds are changing the face of surgery, Keeping an even keel: Stanford surgery residents learn to balance work and life and Stanford Medicine magazine opens up the world of surgery
Photo by Phalinn Ooi

Cardiovascular Medicine, Patient Care, Surgery

61-year-old grandfather gets new heart valve at Lucile Packard Children’s Hospital Stanford

61-year-old grandfather gets new heart valve at Lucile Packard Children's Hospital Stanford

Dr. George Lui, M.D., Dr. Dan Murphy, M.D., Mr. Sang Hee Yoon, Mrs. Min Wha Yoon, and Dr. Katsuhide Maeda, M.D. at Stanford Children’s Health Care on Tuesday, October 6, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )One little-known fact about children’s hospitals: A number of their patients are not children.

I wrote about one such patient recently, a 61-year-old San Jose grandfather who received a new heart valve at Lucile Packard Children’s Hospital Stanford in May. Sang Hee Yoon was born in South Korea at a time when many babies with heart defects died in infancy. He was one of the first people there to receive a surgical repair for his heart condition, called tetraology of Fallot. The repair worked well for many years, but eventually he needed a replacement for a malfunctioning heart valve.

When the time came, the doctors on our adult congenital heart disease team were here to help. My story explains the unusual challenges of their field, which is growing rapidly as 20,000 teenagers with congenital heart defects “graduate” to adult medical care each year:

“Patients come back at 40 or 50 years old, telling us, ‘My doctor said I was cured,’” said George Lui, MD, medical director of the Adult Congenital Heart Program at Stanford, a collaboration between the Heart Center at Lucile Packard Children’s Hospital and Stanford Health Care. Some patients’ childhood surgical repairs were initially judged so successful that they never expected to return to a cardiologist, said Lui… In other cases, the first surgery was so unusual and risky that the surgeon discouraged the patient from undergoing further operations.

But most adults with repaired congenital heart defects are not cured, doctors have learned. As the discipline has matured, cardiologists have honed their understanding of how to help patients like Yoon navigate the risks of living with lingering heart problems, as well as learning how congenital defects interact with cardiovascular problems people acquire with age.

Mr. Yoon’s new heart valve has made a big difference – he and his wife told me that his health is better than ever before. Prior to his surgery at Stanford, his malfunctioning heart valve meant that his body never quite got enough oxygen. He often felt achy or had tightness in his chest, especially at high altitudes. All that is resolved now. The couple’s four children and 10 grandchildren are thrilled:

“They are so happy about my condition,” [Yoon] said. “Not only family members but everybody I know is saying, ‘You look so healthy!’” The Yoons have already visited Kings Canyon National Park, a destination they chose for its mountainous scenery. “I feel such gratitude that now I can enjoy my new life,” Yoon said.

Previously: Patient is “living to live instead of living to survive” thanks to heart repair surgery, Little hearts, big tools and Surgeon building a heart valve that can grow and repair itself
Photo – of Mr. and Mrs. Yoon with his doctors (from left to right) George Lui, MD, Daniel Murphy, MD, and Katsuhide Maeda, MD – courtesy of Lucile Packard Children’s Hospital Stanford

Emergency Medicine, Pregnancy, Research, Surgery, Videos

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

If you nick your skin, it’s easy to stop the bleeding by applying a coagulant powder directly to the cut. Yet, bleeding wounds inside the body are beyond the reach of such blood-stopping powders.

Now, Christian Kastrup, PhD, an assistant professor at the University of British Columbia, and a team of researchers, biochemical engineers and emergency physicians, have developed a way to clot internal wounds by creating a self-propelled powder that moves against the flow of blood.

“Bleeding is the number one killer of young people, and maternal death from postpartum hemorrhage can be as high as one in 50 births in low resource settings so these are extreme problems,” Kastrup explained in a UBC press release. “People have developed hundreds of agents that can clot blood but the issue is that it’s hard to push these therapies against severe blood flow, especially far enough upstream to reach the leaking vessels. Here, for the first time, we’ve come up with an agent that can do that.”

To give blood-clotting powder a push, Kastrup and his colleagues added calcium carbonate to the coagulant powder. The carbonate forms porous micro-particles that latch onto the clotting agent (tranexamic acid). As the particles release carbon dioxide gas, fizzing and moving like mini-antacid tablets, they launch the clotting agent toward the source of bleeding.

More rigorous testing and development needs to be done before this agent is ready for use in humans, as the press release and study explain. But it’s possible that in the near future this powder could be used to treat otherwise unreachable cuts such as those in postpartum hemorrhages, sinus operations and internal combat wounds.

Previously: New obstetric hemorrhage tool kit released todayIn poorest countries, increase in midwives could save lives of mothers and their babiesTeen benefited by Stanford surgeon’s passion for trauma care
Video courtesy of UBC

Education, Medical Schools, Sports, Surgery

Applying athletic and musical coaching techniques to surgical training

Applying athletic and musical coaching techniques to surgical training

5866567170_aa28901818_zPerforming in a harmonious group is a key characteristic in the success of athletes, musicians and surgeons. With this in mind, physicians at the University of Texas Medical Branch at Galveston worked with members of the Choral Arts Society of Washington D.C. and the U.S. National Rowing Team to develop a new coaching model for training surgeons that draws on strategies from the musical and sports world.

Findings (subscription required) from the study were recently published in a special edition of the journal Surgical Clinics of North America. A release offers more details about the training approach:

It has been shown that deliberate practice is crucial to expert performance. Deliberate practice, which entails setting a well-defined goal, being motivated to improve and having ample opportunities for practice and refinement of performance through structured feedback, is a hallmark of this model.

The model also employs a coaching team that is well rehearsed in the day’s training procedure and is in constant communication so that trainees receive immediate correction when needed.

“Coaching teams not only are more efficient at communicating but also have been shown to make fewer mistakes in high-risk and high-intensity work environments, compared with individuals,” said [Kimberly Brown, MD, associate professor of surgery at the University of Texas Medical Branch at Galveston.] “This fact is of greater relevance when performance requires multiple skills, judgments and experiences.”

Brown said that when all of the coaches and learners are actively engaged throughout the training session, the other team members also contribute more to their highest capacity. This leads to a multiplying effect on the team as a whole, resulting in a team’s best possible performance.

Previously: Spanish-speaking families prefer surgical care in their native language, study finds, Clementines help surgeons-in-training to practice and Surgical checklists and teamwork can save lives
Photo by Army Medicine

Patient Care, Pediatrics, Research, Stanford News, Surgery

Spanish-speaking families prefer surgical care in their native language, study finds

Spanish-speaking families prefer surgical care in their native language, study finds

Bruzoni-scrubsFive years ago, when Matias Bruzoni, MD, was a new pediatric surgical fellow at Lucile Packard Children’s Hospital Stanford, his fluency in Spanish meant that he often accompanied other surgeons to consult with Hispanic families who spoke little English.

“I went with the attending surgeon, and would help explain the operation in Spanish, and then the family would say to me ‘Great, would you mind being our surgeon?'” he recalled recently. “And I’d say, ‘But I’m a fellow’ and they would say ‘We’d rather stay with you.'”

The families greatly valued their linguistic and cultural connection to Bruzoni. As he had more of these interactions, Bruzoni realized the hospital’s entire pediatric general surgery team held a mostly untapped linguistic resource. Many of its members – including receptionists, nurse practitioners and triage staff – spoke fluent Spanish.

After Bruzoni finished his training, he organized this group of caregivers into the hospital’s Hispanic Center for Pediatric Surgery, which offers patients and families the ability to receive all of their pre- and post-surgical care in Spanish. Every interaction, from registering the patient to giving post-surgical instructions, happens in the families’ first language. Bruzoni wondered how this approach would compare to using trained medical interpreters, whose services are offered to all non-English-speaking families at the hospital.

A new study, published in the most recent issue of the Journal of Pediatric Surgery, shows what his research found. From our press release:

Spanish-speaking families that discussed their children’s care in Spanish reported a higher level of satisfaction and higher ratings of the quality of information they received compared with the families in the control group and those that worked through an interpreter. Spanish-speaking families rated the importance of discussing care in their native language more highly than English-speaking families, the study found.

Although socioeconomic status was not assessed in this study, Bruzoni noted that Hispanic families of low socioeconomic status may have an even greater need than others to receive care in their native language. “There is a big cultural barrier,” Bruzoni said. “Because of these patients’ circumstances, it is even more important to work with them using their own language.”

Bruzoni plans to continue studying how to deliver better surgical care to California’s growing population of Hispanic children.

Previously: Stanford student earns national recognition for research on medical communication, An app to break through language barriers with patients and Advice for parents whose kids need surgery
Photo courtesy of Lucile Packard Children’s Hospital Stanford

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