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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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In the News, Medical Education, Stanford News, Surgery

Program for residents reflects “massive change” in surgeon mentality

Program for residents reflects "massive change" in surgeon mentality

Black Read, M.D, Cara Liebert, M.D, Micaela Esquivel, M.D, and Julia Park , M.D. all are  Stanford School of Medicine surgery resident taking part in the ropes course on Tuesday, September 9, 2014, as a  team-building exercise on the Li Ka Shing Center lawn on Stanford University campus. ( Norbert von der Groeben/ Stanford School of Medicine )

“The old-school surgeon mentality is that surgery is your life. The very existence of the program is an acknowledgment that a cultural shift is occurring.” Those are the thoughts of Lyen Huang, MD, a fourth-year resident, about Balance in Life, a Stanford Medicine program designed to offer support to its surgical residents. We’ve written about it on Scope before, and the current issue of San Francisco Magazine now also provides a look.

Explaining that surgical residents are “under enormous pressure to learn quickly and produce good patient outcomes—all while working 80-hour weeks on little sleep,” writer Elise Craig outlines Balance in Life’s offerings for residents: a fridge filled with healthy snacks, happy hours and team-building events, mentorships and friendly nudges to go to the dentist or doctor. And, she writes:

If having surgical residents take time away from the operating room for lawn games sounds a little juvenile, consider this: Recent surveys conducted by the American College of Surgeons found that 40 percent of surgeons reported burnout, 30 percent screened positive for depression, and almost half did not want their children to follow in their professional footsteps.

Some snacks and an afternoon ropes course might not sound like much, but [Ralph Greco, MD, the professor of surgery who helped build the program] and his residents argue that the unique program reflects a massive change.

Previously: New surgeons take time out for mental health, Using mindfulness interventions to help reduce physician burnout and A closer look at depression and distress among medical students
Photo, from a Fall 2014 team-building activity, by Norbert von der Groeben

Cardiovascular Medicine, Immunology, Medicine and Literature, Stanford News, Surgery

Stanford Medicine magazine’s big reads of 2014

Stanford Medicine magazine's big reads of 2014

brain attackThis year’s most-read Stanford Medicine magazine stories were all about the heart, surgery and the immune system – the themes of this year’s three issues. The top 10 (as determined by pageviews on our website):

Previously: Stanford Medicine magazine’s big reads of 2013 and Stanford Medicine magazine’s big reads of 2012
Illustration, from the article “Brain attack” in the Fall 2014 magazine issue, by Jeffrey Decoster

Anesthesiology, Neuroscience, Research, Stanford News, Surgery

Stanford anesthesiologist explores consciousness – and unconsciousness

Stanford anesthesiologist explores consciousness - and unconsciousness

face-275015_1280Anesthesiologist Divya Chander, MD, PhD, is one of a leading group of neuroscientists and anesthesiologists who are using high-tech monitoring equipment in the operating room to explore the nature of consciousness – which isn’t quite as simple as on or off, asleep or awake.

Stanford Medicine magazine profiled Chander’s work last summer, but I came across it when the title of one of Chander’s recently published papers grabbed my eye: “Electroencephalographic Variation During End Maintenance and Emergence from Surgical Anesthesia.” Okay, that might not pique your curiosity, but when I spotted the words, “for the first time” in the abstract I was hooked. I read on to learn that Chander and her team attach electrodes to the foreheads of patients during surgery, measuring the brain’s electrical signals.

After a bit of scrambling you might expect when trying to get in touch with someone who spends her days in the operating room, I managed to reach Chander on the phone. Our conversation strayed far from the bounds of her paper:

In this work, what did you do for the first time?

It’s not that no one has ever used an EEG during anesthesia. During the middle of the 20th century, several anesthesiologists attempted to record brain activity under increasing levels of anesthesia, just as many neuroscientists were using the EEG to characterize the stages of sleep. The process of recording EEG was really cumbersome back then, unlike today when you can stick a frontal set of leads on a patient’s forehead in the OR in a matter of seconds. Certain general stages of anesthesia were identified, but a formalized staging nomenclature, based on the relative contribution of dominant slow-wave oscillations in the EEG, had never been defined. Non-REM (slow-wave) and REM (rapid eye movement sleep) were staged in this way by sleep neurobiologists, but not anesthesiologists. In our study, we built upon the sleep stage classification system, to define maintenance patterns of general anesthesia. The formalized nomenclature helps us examine the stages of unconsciousness under anesthesia and communicate with other anesthesiologists.

What did you find?

We recorded the frontal EEGs (from the forehead) of 100 patients undergoing routine orthopedic surgeries. We discovered four primary electrical patterns that patients exhibit when they’re unconscious, and also as they’re waking up from anesthesia. The unconscious patterns show variety – not all patients’ brains look the same under anesthesia, despite similar drug exposure, meaning there are ‘neural phenotypes,’ or patterns of neuronal activity. The emergence patterns from anesthesia (pathways people’s brains take to reestablish conscious awareness after the anesthetic is turned off) bear some similarity to those pathways traversed when people are awakening from sleep.

When wakening from anesthesia, some people spend a relatively long time in non slow-wave anesthesia, which is similar to REM, the stage of sleep where dreams occur that usually precedes awakening. Others go straight from deep anesthesia, what we call slow-wave anesthesia (because of its dominant EEG patterns) to awakening. Interestingly, these patients were more likely to experience post-surgical pain, a situation akin to awakening from a deep sleep and experiencing confusion or discomfort; some childhood parasomnias like sleep terrors are characterized by moving abruptly from slow wave sleep to waking.

We began to see some tantalizing suggestions certain patterns of wake-ups from anesthesia might be more preferable. Could paying attention to these emergence trajectories prevent some problematic complications, like post-operative cognitive dysfunction? Could we ‘engineer’ or optimize anesthetic delivery to favor certain types of maintenance and emergence patterns? Can we monitor these patterns in a way that makes delivering anesthesia safer? Recognizing the variety of maintenance and emergence patterns under anesthesia also opens an entirely new possibility in the field of personalized medicine – imagine tailoring anesthetics to a person’s genome? I am trying to develop an initiative that addresses this in collaboration with Stanford’s new GenePool Biobank program.

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Medical Education, SMS Unplugged, Surgery

Rituals of the body – honoring the loss of bodily wholeness in medicine

Rituals of the body - honoring the loss of bodily wholeness in medicine

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

footWatching my first below-the-knee amputation on my surgery rotation, I felt a curious mix of revulsion and detachment. The woman on the operating table had a gangrenous infection that had spread across her foot. Her long history of smoking and her delay in seeking medical care meant that she had stiff, black toes by the time a surgeon first saw her. The only treatment was amputation.

In the operating room, the patient was draped such that only the leg was visible and exposed. The first incision was easy, a semicircle around the calf, and then the surgeons dissected down further until they hit bone. A bone saw sliced its way through the tibia, while the slimmer fibula was taken apart in chunks with a bone cutter. The skin and muscle were cut in a flap; the flaps were brought around over the bone and sewn together to create the stump.

The amputated leg sat on the scrub nurse’s table, next to a tray of retractors. The foot was balanced upright. The skin was smooth until the edge, where it gave way to jagged edges of flesh, remnants of blood vessels, and two cross-sections of bone. I felt unsettled with the amputated portion of the leg so close to me, a graphic reminder of what was lost.

What was it that troubled me? Maybe it had been the ordinariness of the moment when the body was divided up, its fibers severed with precision and focus, but no surprise, no significance. This patient would wake up some hours later, still groggy from the haze of anesthesia. Though she had signed a consent form, though this surgery had saved her, I wondered how she would she feel when she looked down at her leg.

Even in the absence of phantom pains or other sensory reminders of the missing part, dealing with an amputation is hard. It breaks the taken-for-grantedness of the body. It forces people to move through the world in new ways. These experiences made me think, can we imagine any ritual to mark a loss of bodily integrity? A pause to appreciate the work the body has done, and to prepare ourselves for its new form?

I witnessed many bodily transformations on my surgery rotation, as we do in medicine every day. But in our increasingly technical engagement with patients, do we forget the many social and cultural meanings of the body and its parts? Like why a patient may ask for his rib back after it is excised from his chest well to relieve obstruction, or why grieving parents of a stillborn child may want to bury the baby with her placenta? Perhaps a ritual could help physicians recover the awe and the empathy toward bodies we care for, and further connect to how our patients make sense of these changes.

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Cardiovascular Medicine, Medicine X, Patient Care, Surgery

Operation Heart: Engaging patients in caring for patients

Operation Heart: Engaging patients in caring for patients

Stanford’s Medicine X is a catalyst for new ideas about the future of medicine and health care. This new series, called The Engaged Patient, provides a forum for some of the patients who have participated in or are affiliated with the program. Our inaugural post comes from Sarah E. Kucharski.

mended heartRivulets of deep brown iodine trickled across the patient’s body as nurses swabbed with sponges and unfurled blue surgical drapes. I contemplated his bare feet. I wondered if they were cold. I wondered if he wore no socks so that the nurses might palpitate for his dorsalis pedis and posterior tibial pulses. And I thought about how many times the patient on the operating table had been me.

When given the opportunity to observe surgery, I had accepted eagerly. One hardly could have called it an exercise in learning self-care techniques — no matter how empowered I am as a patient, even I draw a line at doing by own arterial bypass. Rather I wanted to see how the other half lived. For once I entered the operating room wearing scrubs and surgical mask instead of an open-backed gown and an IV line pushing Versed through my veins.

My conscious presence meant I represented not just myself but my fellow patients who clamored for meaningful engagement. There is much talk about being able to view health care and the medical establishment from another perspective, but few truly have an opportunity to do so. It has been pointed out that doctors attend school to learn how to be doctors, yet patients do not attend school to learn how to be patients. More importantly there is no school to teach doctors how to be patients and, save for those patients whose condition manifests early enough to motivate medical school, no method of teaching patients how to be doctors. Collaborations to re-imagine health care for our joint benefit will be ineffective unless we expand medical education to regularly include the patient, which will facilitate empathy and improved health literacy through shared experiences.

As surgery preparations continued, the operating room nurses appeared apprehensive they were going to share an experience with me. I had signed on with a go big or go home philosophy — the aortic root and mitral valve replacement would be my first surgery. Each nurse’s eyes widened for two tell-tale seconds when I told them my novice status, and their voices caught as they tried to mitigate surprise, “Ooh.” Their apprehension meant I had something to prove. There would be no circumstance under which I would faint.

And with the loud whine of the sternum saw, we were underway.

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Cancer, Research, Science, Stanford News, Surgery, Technology

New molecular imaging could improve bladder-cancer detection

New molecular imaging could improve bladder-cancer detection

Joseph LiaoThey say a picture is worth a thousand words. For bladder-cancer surgeons, an image can be worth many lives.

That’s because a crucial method for detecting bladder cancer is to produce images that allow surgeons to identify abnormal-looking tissue, a method called cystoscopy. In a study published yesterday in Science Translational Medicine, Stanford researchers developed a new way to image the bladder that they say could detect bladder cancer with more accuracy and sensitivity than the standard methods. As described in our press release:

 The researchers identified a protein known as CD47 as a molecular imaging target to distinguish bladder cancer from benign tissues. In the future, this technique could improve bladder cancer detection, guide more precise cancer surgery and reduce unnecessary biopsies, therefore increasing cancer patients’ quality of life.

Identifying cancerous tumors can be challenging — some bladder cancer treatments cause inflammation, which looks very similar to abnormal, cancerous tissue. The only way to know for sure is to perform a biopsy, which can be stressful for the patient. As co-senior author Joseph Liao, MD, explained:

 Our motivation is to improve optical diagnosis of bladder cancer that can better differentiate cancer from non-cancer, which is exceedingly challenging at times. Molecular imaging offers the possibility of real-time cancer detection at the molecular level during diagnostic cystoscopy and tumor resection.

For their work, the researchers looked for a target that would distinguish cancer cells from benign cells and found it in CD47, a protein on a cell’s surface that cancer cells produce in higher quantities than normal cells. In previous work, co-senior author Irving Weissman, MD, developed a CD47 antibody that binds to the cancer cell’s surface and blocks the signal. They hypothesized it would be a good imaging target. More from our release:

 To test their hypothesis, the researchers added a fluorescent molecule to an antibody that binds to CD47. The modified antibodies were then introduced into intact bladders, which had been surgically removed from patients with invasive bladder cancer. Because they bladders were kept in good condition, the study’s imaging methods mirrored the way an urologist might use with a real patient.

After 30 minutes, they rinsed the bladder, so only the antibodies that bound to the CD47 protein remained. When they shine the tumor was exposed to with fluorescent light, the cancer cells “lit up” whereas normal or inflamed cells did not.

“Our goal through better imaging is to deliver a higher- quality cancer surgery and better cancer outcomes,” Liao told me. “I am very excited about the potential to translate our findings to the clinics in the near future.”

Previously: Healing hands: My experience being treated for bladder cancer, Drug may prevent bladder cancer progression, say Stanford researchers, Cellular culprit identified for invasive bladder cancer, according to Stanford study and Mathematical technique used to identify bladder cancer marker
Photo of Liao by Norbert von der Groeben

Cancer, In the News, Nutrition, Patient Care, Surgery

“Prehab” routines before cancer surgery help patients bounce back faster

Surgery_flickr_thinkpanamaIf you’ve ever had surgery, especially an orthopedic one, you’ve probably had rehabilitation therapy. In recent years, orthopedic surgery plans have begun to include a period of “prehabilitation” exercise to help prepare patients for their procedure. Now, researchers have demonstrated that a pre-surgery work-out routine combined with some dietary changes may be able to help cancer patients regain their baseline strength levels sooner. A story on NPR’s Shots blog described the recent study:

Researchers from McGill University in Montreal studied 77 patients scheduled for colorectal cancer surgery. A kinesiologist gave the patients aerobic exercises and strength training to do at home. A registered dietitian gave them nutritional counseling and prescribed a whey supplement to make up any protein deficits, and a psychologist provided anxiety-reducing relaxation exercises.

Half of the patients were told to start the program before surgery – an average of about 25 days before – and to continue afterward for eight weeks. The other group was told to start right after surgery.

Not surprisingly, the group assigned to prehabilitation did better on a presurgery test that measured how far they could walk in 6 minutes. And it paid off.

Two months after surgery, the prehabilitation group walked an average of 23.7 meters farther than when they started the study. Rehab-only patients walked an average of 21.8 meters less than when they started. (A change of 20 meters is considered clinically significant.) And a greater proportion of the prehabilitation group was back to baseline exercise capacity by then.

Because of the methology the researchers used, it’s not clear how the diet or the exercise prescribed in the pre-surgery regimen affected the outcome. Previous studies that looked at exercise-only regimens did not show post-surgery improvements. A larger study with a more varied pool of patients is likely needed for definitive answers.

Previously: Wellness after cancer: Stanford opens clinic to address survivors’ needs and A call for rehab services for cancer survivors
Photo by thinkpanama

Ask Stanford Med, Neuroscience, Surgery

A Stanford neurosurgeon discusses advances in treating brain tumors

A Stanford neurosurgeon discusses advances in treating brain tumors

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Last year, an estimated 70,000 people were diagnosed with a primary brain tumor, which originates and remains in the brain, and far more will develop metastatic brain tumors, those that begin as cancer elsewhere in the body and spread to the brain. Although physicians face a number of challenges in treating these tumors, the encouraging news is that advances in technology and new therapies are improving patient outcomes.

During a Stanford Health Library event on Thursday, Steven Chang, MD, director of the Stanford Neurogenetics Program and the Stanford Neuromolecular Innovation Program, will deliver an update on the latest in surgical and non-surgical treatments of brain tumors. (The lecture will also be webcasted for those unable to attend.) In anticipation of the talk, Chang answered some questions related to the topics he’ll be addressing.

Why has a greater understanding of genetics and the biology of tumors improved physicians’ understanding of how patients will respond to certain therapies?

Having a greater understanding of the genetics and biology of brain tumors helps neurosurgeons to tailor treatments for each patient. In essence, we are able to deliver personalized medicine if we understand which subsets of brain tumors respond to specific treatments. For example, we now understand that gliomas with certain genetic makers are more likely to respond to chemotherapy treatments. The presence or absence of these genetic markers will also help guide patients in determining which clinical trials it may be most appropriate for them to enroll in.

How have advances in brain-mapping technologies made a difference in treating low-grade gliomas, which are slow growing and often affect younger patients?

Low-grade gliomas don’t typically contrast enhance on brain MRI scans. Furthermore, low-grade gliomas are more likely than higher-grade gliomas to have appearances similar to normal brain tissue, with no obvious color or consistency distinction between tumor and normal brain. These factors make resection of low-grade gliomas potentially more complex than high-grade gliomas, which often have distinct appearances from normal brain tissue. Advances in brain-mapping technologies include both image guided navigation and electrophysiologic mapping. Image-guided navigation consists of the use of MR imaging to provide real-time guidance during tumor resections. High-speed computer workstations provide images that show neurosurgeons exactly where they are with respect to brain anatomy during tumor resections. Electrophysiologic mapping is the use of specific electrical simulations of the brain tissue to identify eloquent brain cortex. By mapping out these critical brain regions, the neurosurgeon can safely avoid them when performing tumor resection.

In what ways have improvements in imaging technology over the last decade changed the treatment approach for both surgical and non-surgical treatment of brain tumors?

Improvements in imaging technology over the last several years have provided valuable tools for neurosurgeons in the treatment of brain tumors. A significant advance in surgical treatment of brain tumors has been the development of intraoperative MRI scanners. This allows a surgeon to perform a tumor resection, and then, post resection, perform a set of MR imaging directly in the operating room. If this MR imaging shows residual tumor, the surgeon has an opportunity to perform a further resection prior to completing the surgical operation. Additional imaging advances include functional MR imaging. This provides a graphic representation of critical functions such as speech or motor function. This is useful in determining both whether a patient is inoperative candidate and in assessing risk of the surgical resection.

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