Skip Navigation
request an appointment my chart notification lp musc-logo-white-01 facebook twitter youtube blog find a provider circle arrow
MUSC mobile menu

OR Notes

Take a front row seat to complex and innovative surgeries and procedures
Twitter: @MUSCHealthPN

Posts

 

 

MUSC Health Virtual Grand Rounds on Figure 1

September 22, 6 pm EST

MUSC Children's Health pediatric neurosurgeon Ramin Eskandari, M.D., and MUSC Health craniofacial surgeon Jason P. Ulm, M.D., will lead the event.


Photo Caption: Pediatric neurosurgeon Ramin M. Eskandari, M.D. and plastic surgeon Jason P. Ulm, M.D., perform a surgery to correct craniosynostosis.

Craniosynostosis, the premature fusion of one or more of the brain’s sutures, is estimated to occur in as many as one in 2500 births.1 Fusion of the sutures typically occurs before birth or very soon thereafter. Some cases of craniosynostosis can be attributed to a genetic cause (“syndromic craniosynostosis”) but most cases are nonsyndromic. Nonsyndromic craniosynostosis can involve one or multiple sutures.

Early detection of craniosynostosis is crucial for prompt referral to tertiary care centers with experience in treating the condition and for better outcomes.  Detection can be challenging as the increased prevalence of purely cosmetic head shape deformities, such as those due to positional pressure, can be mistaken for craniosynostosis and vice versa.2 For example, the recommendation for infants to sleep on their back to avoid SIDS has led to a sharp increase in positional head deformities that can be mistaken for a lambdoid suture synostosis. Unlike craniosynostosis, positional head shape deformities typically improve with time and as the child becomes ambulatory.

Guidelines suggest that physicians refer suspected cases of craniosynostosis to a specialist for evaluation based on characteristic morphological changes and not on advanced imaging (the overuse of which has been demonstrated) to minimize radiation risk to the child.1 This is particularly important as specialists can many times distinguish between true craniosynostosis and positional head deformities through examination and history, sparing the latter group unnecessary exposure to radiation. If the specialist suspects craniosynostosis, then computed tomography can be obtained to confirm the diagnosis.

In severe cases of nonsyndromal craniosynostosis, the premature closure of one or more sutures of the brain threatens to impede brain growth, to increase intracranial pressure, and to lead to head shape abnormalities as the brain, blocked by the fused suture, grows into other areas of the skull. In these cases, surgical treatment is indicated.1

Surgery for craniosynostosis is sometimes performed as a two-stage operation, though timing of surgery to correct craniosynostosis remains controversial.3 A first operation can be done early if there is increased intracranial pressure to open the sutures and relieve the pressure, after which infants may wear helmets to encourage more normal skull growth. After the child is older (usually around a year old) and has had time to build more bone in the skull (which may be needed in the reconstruction), a second operation is performed to correct any remaining deformity.

To obtain enough bone to perform the reconstruction without resorting to synthetic products, surgeons often use “split thickness grafts,” in which a portion of the patient’s own skull is split into two pieces of thinner bone to be used for filling gaps.4 These “split-thickness bone grafts” are one of the reasons the second stage of surgery is timed to occur when the child is older, when the bone is sufficiently thick to split. 

Craniofacial surgery can be associated with large amounts of blood loss and the need for multiple transfusions, which can lead to serious adverse effects such as TRALI.1 Appropriate steps should be taken to minimize blood loss and the need for transfusion, such as careful dissection of the scalp layer by layer, with an electrocautery device used to close off small vessels. Planning surgery using 3D models of the patient’s skull and eventually practicing on those skulls before the surgery can reduce operative time, blood loss, and the need for transfusion.

“One of these reasons these models are so wonderful to have before surgery is that you can look at the model of the patient’s skull, measure it, and even cut it and you can essentially plan the entire operation before walking into the operating room,” said MUSC Children's Health pediatric neurosurgeon Ramin Eskandari, M.D., who performs these surgeries to correct craniosynostosis  in collaboration with MUSC Health craniofacial surgeon Jason P. Ulm, M.D.

Join Eskandari and Ulm on September 22 at 6 pm EST on the free case-sharing app Figure 1 (available on iOS and Android; http://figure1.com) for an MUSC Health Virtual Grand Rounds on surgical correction of nonsyndromal craniosynostosis.

References

1 Mathijssen IMJ. Guideline for care of patients with the diagnoses of craniosynostosis: working group on craniosynostosis. J Craniofac Surg 2015;26: 1735–1807)
2Persing JA. Management considerations in the treatment of craniosynostosis. Plast Reconstr Surg. 2008 Apr;121(4 Suppl):1-11.
3 Utria AF, et al. Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience. J Neurosurg Pediatr. 2016 Aug 9:1-6.
4 Vercler CJ, et al. Split Cranial Bone Grafting in Children Younger Than 3 Years Old: Debunking a Surgical Myth. Plast Reconstr Surg. 2014 Jun; 133(6): 822e–827e.

Noninavsive comptued tomography of the heart reveals diseased heart vessels.

Caption: Noninvasive computed tomography of the heart reveals diseased heart vessels.


The MUSC Health Heart and Vascular Center (HVC) produces some of the most revealing coronary computed tomography  images in the U.S., having been the first in the nation to take delivery in 2014 of the industry’s most advanced technology, the SOMATOM Force (Siemen  Healthcare, Forchheim, Germany). This tool is producing more than 2,000 high-fidelity noninvasive imaging studies a year at the HVC, enabling dozens of research projects that are advancing understanding of coronary artery disease. For example, the Force’s improved temporal resolution enables radiologists to better freeze cardiac movement, providing clearer images of the heart muscle so they can quantify its thickness as part of their evaluation.

Visualizing disease directly as it manifests moves medicine closer to quantifying it.

 “We’re truly seeing things in great detail, such as narrowing of the heart vessels, the makeup of atherosclerotic lesions, and whether they look stable or unstable,” said U. Joseph Schoepf, M.D., Director of the Division of Cardiovascular Imaging at MUSC Health. “We’re not looking at functional sequelae as we did in the past. We’re looking at the disease directly. We can put a number on things.”  

Cardiologist Sheldon E. Litwin, M.D., Alicia Spaulding-Paolozzi Professor of Cardiac Imaging, said the more quantitative data cardiologists have, the more precisely they can treat patients.

 “Cardiology has been under fire for putting in too many stents, in part because the tests we’ve used to decide who gets a stent are somewhat subjective,” said Litwin. “With CT, we can now derive quantitative estimates of blood flow and use these numbers to better decide which patients should receive stents.”

 As coronary computed tomographic angiography evolves, the transformation of cardiovascular disease characterization will continue, delivering better ways to diagnose and treat CAD. “We believe there is benefit to visualizing coronary artery disease directly, rather than relying on an incomplete understanding of how risk factors and surrogate markers actually translate into atherosclerosis,” said Litwin. “It’s a superior approach.”

 To learn more about cardiovascular imaging research at MUSC Health, read the article “Windows to the Heart” in the summer issue of Progressnotes

Transanal Total Mesorectal Excision

 

MUSC Health colorectal surgeon Virgilio V. George, M.D., narrates this surgical video illustrating the key steps in transanal total mesorectal excision (TaTME), a new minimally invasive surgery for removing tumors in the lower third of the rectum.

For even experienced colorectal surgeons, excision of tumors in the lower third of the rectum by either open or conventional laparoscopic methods is extremely challenging, particularly in obese patients; in male patients, who have a narrow pelvis; and in patients whose anatomy has been altered by previous radiotherapy.

TaTME has garnered a great deal of attention and created much excitement in the field of rectal surgery because it represents a reversal of perspective—literally—about how to best excise tumors and the surrounding mesorectal envelope in the lower third of the rectum. Unlike traditional TME, which involves introduction of a laparoscopic camera and specialized laparoscopic tools through small slits in the abdomen to excise these tumors from above, TaTME reverses the process and introduces these tools via a multichannel port in the anus so that the tumor can be visualized and removed from below.

Read more about this new procedure in the article "Up From Below" in the Summer 2016 issue of Progressnotes, MUSC's medical magazine.

Brain Imaging Before and After Thrombectomy

Imaging before (left) and after (right) the 4.5-minute thrombectomy using the ADAPT technique and the ACE68 catheter

Minutes count for patients who are experiencing a stroke caused by a blood clot blocking the blood supply to a part of their brain. The longer the blood supply is cut off, the worse the damage.

In early June 2016, Jonathan Lena, M.D., a new neuroendovascular surgeon at the MUSC Health Comprehensive Stroke & Cerebrovascular Center, performed a thrombectomy in record time—five minutes instead of the 40 to 45 minutes that is often required—using the new ACE68 catheter (Penumbra) and the ADAPT technique that was pioneered at MUSC Health. The ACE68 device employs the latest technology available to aspirate large clots to restore blood flow to the brain, and perhaps more importantly, the ACE68 design optimizes navigation through the tortuous vessels to enable fast and effective thrombectomy procedures. Lena was the first in the world to perform a thrombectomy using the new ACE68 catheter.

 The ADAPT technique aims to remove a large-vessel clot in its entirety with a large-diameter aspiration catheter. For ADAPT, this large catheter is inserted via the femoral artery and advanced to the site of the clot, where suction is applied to remove the clot and restore blood flow to the brain. If the first-pass attempt is unsuccessful, stent retrievers can then be used.

This technique was developed by MUSC Health neuroendovascular surgeons M. Imran Chaudry, M.D., Alejandro M. Spiotta, M.D., Aquilla S. Turk, D.O., and Raymond D. Turner, M.D., who reported their initial findings in a seminal 2014 article in the Journal of Neurointerventional Surgery (doi: 10.1136/neurintsurg-2013-010713) and longer-term results from a single center (MUSC Health) in an article published online ahead of print on April 18, 2016 (doi: 10.1136/neurintsurg-2015-012211) in the same journal.

In the April 2016 article, the MUSC Health team reported the results of a retrospective analysis, showing  that  blood vessels were successfully reopened in 180 (94.2%) of 191 consecutive patients with acute ischemic stroke who underwent thrombectomy using direct aspiration (ADAPT) at MUSC Health. Direct aspiration alone was used in 145 cases; additional use of stent retrievers was required in another 43 cases. The time to open the blood vessel was 29.6 minutes with ADAPT if aspiration was successful and 61.4 minutes if other devices were required. Good 90-day outcomes were achieved in 57.7% of patients who underwent direct aspiration only and 43.2% of those who required adjunct therapies. Many other institutions have adopted ADAPT and are reporting promising results in their own series of patients.

“The goal in ADAPT is to take the largest-bore catheter available up to the blood clot and put suction where it’s blocked and pull the clot out of the head to reestablish blood flow in that blood vessel,” said Turk. “Obviously, the larger the catheter or tube that you can use, the bigger clot you can suck out and the more effective it can be.”

Up until early June, the biggest catheter available had been the ACE64, a .064-inch inner diameter catheter. The bigger inner diameter of the ACE68 catheter—.068 inch instead of .064—makes it possible to aspirate bigger clots in a single pass, and it has been specially designed to navigate more easily through the blood vessels. The MUSC Health endovascular team has worked closely with Penumbra in the design of the catheter to optimize it for use with the ADAPT technique.

“The new technology of the ACE68 aspiration catheter made the overall experience and procedure a lot quicker, a lot easier, and a lot safer for the patient,” said Lena. “It was a single pass, and that was it, and it went very well.”

Mechanical thrombectomy using stent retrievers is now considered standard of care for patients with large-vessel clots. In 2015, the American Heart Association issued a scientific statement, published in October issue of Stroke, recommending rapid thrombectomy in addition to tissue plasminogen activator or tPA, a clot-busting drug that must be given within the first few hours of a stroke, on the basis of the promising findings of five large clinical trials comparing treatment with tPA alone vs treatment with tPA plus thrombectomy using stent retrievers in large-vessel clots: MR CLEAN, EXTEND-IA,  ESCAPE, SWIFT PRIME, and REVASCAT. Two MUSC Health faculty— Bruce I. Ovbiagele, M.D. MSCR, Chair of the Department of Neurology, and Edward C. Jauch, M.D., Director of the Division of Emergency Medicine—were among the authors of the guideline, issued on behalf of the American Heart Association Stroke Council.

Since the publication of the seminal 2014 article by the MUSC Health team, a number of single-center series studies have reported impressive recanalization times (the time it takes to open the blood vessel) and good neurological outcomes with the ADAPT technique using a large-bore catheter, suggesting that it could offer an alternative approach to stent retrievers for mechanical thrombectomy. To determine whether this alternative approach could become standard of care, clinical trials are needed comparing it to stent retrievers in stroke patients with large-vessel clots. The MUSC Health neuroendovascular surgery team is currently running the COMPASS trial (COMParison of ASpiration vs Stent retriever as first-line approach; Clinicaltrials.gov identifier NCT02466893) in conjunction with colleagues Dr. J. Mocco of Mount Sinai and Dr. Adnan Siddiqui of the University of Buffalo. The trial is randomizing patients to either ADAPT or a stent retriever as the initial thrombectomy technique. The trial, scheduled to enroll 270 patients, has enrolled 90 patients in the past year at ten sites in the United States.

ADAPT Technique

 

a) Neuron Max is placed in the distal cervical internal carotid artery.  The ACE 68 catheter is advanced over the 3 Max catheter telescoped with a Fathom 16 wire to the clot occluding the middle cerebral artery (MCA). 

 

 

 

 

 

b)  The ACE 68 catheter advanced to the face of the clot in the MCA and 3 MAX and wire being removed. 

c)  Clot ingested through the ACE 68 catheter under aspiration.

Marking site for surgical incision for revision hip replacement

For a transcript of the April 26 virtual grand rounds by Orthopaedics Chair Dr. Vincent Pellegrini on hip revision  on the free case-sharing app Figure 1, search @MUSChealth or #muscrounds on the Figure 1 app (iOS and Android) or at figure1.com.

To view (graphic) surgical photographs of the surgery, click here for a pdf of the Progressnotes article on revision hip replacement.

 

Of the approximately 350,000 hip replacements performed each year in the U.S., about 10% will eventually require revision surgery—typically, 15-20 years after the original surgery—due to infection, wear, instability, or component loosening.

Because revision hip replacements are more challenging and typically performed in an older population, they are best done at high-volume centers with robust critical care and advanced anesthesia services. At such centers, revision hip replacements are now commonly performed in patients older than 80 years of age, enhancing their mobility and enabling them to preserve an active lifestyle.

Vincent D. Pellegrini, M.D., Chair of the Department of Orthopaedics at MUSC Health, and the other surgeons on the joint replacement team—Harry A. Demos, M.D., Jacob M. Drew, M.D., and Richard J. Friedman, M.D.—perform more than 650 hip and knee replacements annually, more than a quarter of which are revisions. In 2014, the program was awarded Joint Commission specialty certification for total hip, knee, and shoulder joint replacement.

Report of a Case
An 80-year-old man, who had undergone primary cemented hip replacement 16 years previously, presented with “start-up” thigh pain. Each time he stood or initiated gait, he experienced thigh pain for the first few steps that resolved in a dozen steps. Radiographs revealed that the cement had loosened from the femur, resulting in the cycle of pain that repeated every time the patient stood up and the femoral stem sank to a stable position in the bone. The cement loosened due to bone loss, resulting from a foreign body reaction to microscopic particles that were generated as the plastic liner of the replacement wore.

Revision hip replacement was advised and involved removal of the femoral component, the associated cement, and the plastic liner, with implantation of a new plastic liner and a cementless femoral component. Bone from which cement has been extracted tends to be smooth and does not provide reliable fixation for new cement; for this reason, cementless femoral stems, which have a roughened surface texture to which bone can attach, are preferred for hip revision surgery.

Often in hip revision surgery, the greater trochanter and the attached muscles must be cut to allow access to the femoral canal for cement removal. In this case, an anterolateral approach provided good femoral access without the need for trochanteric osteotomy and the patient was able to begin exercise immediately after surgery. He will use a walker or cane for only three to four weeks, much less than would have been required after trochanteric osteotomy.

A pathologist was on hand to analyze tissue samples for infection. Had infection been detected, all components would have been removed, the patient would have received several weeks of intravenous antibiotics, and a second surgery would have been scheduled to implant the new components.

Want to learn more about this case and see more than a dozen surgical photographs? Ask Dr. Pellegrini questions in real time during his virtual grand rounds (a live event) on April 26 at 8:00 pm on the free Figure 1 app (iOS and Android).

Follow more surgical cases on the MUSC Health profile (@MUSChealth) on the free Figure 1 app (iOS and Android).

To consult with an MUSC Health joint replacement surgeon or to refer a patient, contact nurse navigator Kathleen Case at casek@musc.edu.

kidney donor with Give Life tattoed on knuckles

Search #muscrounds on the free case-sharing app Figure 1 (http://figure1.com) to view the annotated photographs and associated comments from the MUSC Health virtual grand rounds on kidney transplant.

Kristy Hokett (pictured at left) has the words “Give Life” tattooed on her knuckles. She was moved to get the tattoo when she saw the good that came from her aunt’s decision to donate her organs upon her death. A few years later, when her father tried to donate a kidney to his former colleague Thomas House, but was not a good candidate, Kristy offered to step in. In the past, all of these acts of generosity would have come to nothing when it was determined that Kristy was not a good match for Thomas. Today, with the availability of the kidney chain program, Kristy was able to give her kidney to another well-matched recipient, ensuring Thomas in turn received the kidney he needed. 

Three MUSC Health transplant surgeons (see photo below) were involved in this series of transplants—Satish N. Nadig, M.D., Ph.D.Charles F. Bratton, M.D.; and Prabhakar Baliga, M.D., Chair of the Department of Surgery at MUSC Health. Using surgical photos from this series of transplants, Nadig led a virtual grand rounds on the free case-sharing app Figure 1 (Android and iOS) on January 27, 2016. To view the annotated photographs and comments from the virtual grand rounds, search #muscrounds on Figure 1 (http://figure1.com). To see all posts of surgical photographs from MUSC Health, search @MUSChealth.

The Need for Living Donation

There are currently more than 100,000 people waiting for life-saving kidney transplants in the United States. Four out of five patients in need of a kidney go without one, many of whom must in the meantime rely on dialysis. Extended times on dialysis are associated with worse outcomes after transplant and place a huge economic burden on the health care system.

Living donors are crucial to reducing these statistics. An organ from a living donor lasts twice as long and provides the highest quality at the lowest cost. Living donor organs both reduce wait times and begin to function faster after transplant.

The MUSC Health Kidney Transplant Program, which began in 1968, numbers among the nation’s leading academic transplantation programs. MUSC Health is also South Carolina’s only Living Donor Transplant Center, kidney transplant surgerywhere more than 800 organs have been donated by living donors. 

Kidney chains remove the constraint of compatibility from living donation, expanding the pool of patients who can benefit. In effect, they unleash the power of generosity inherent in the decision to donate.

MUSC Health initiated its first kidney chain in 2013 (read story here) and participated in the longest chain the NKR has ever done—35 transplants—in 2015. The January 2016 chain involving kidney donor Kristy Hokett was MUSC Health’s twelfth, and the seventh that it originated. Hokett’s surgery was featured on the Figure 1 app to help build awareness among physicians and medical students about the importance of this revolutionary approach to kidney transplant.

How the Chain Works

Using a sophisticated algorithm, the National Kidney Registry (NKR) helps identify donors and recipients who would likely be good matches, though they may live in distant parts of the United States. More than 70 institutions, including MUSC, participate in the registry.  

The chain of kidney transplants is set off with an altruistic donation. A good Samaritan donor offers up a kidney without designating a recipient. The incompatible donor of the first recipient in turn “pays it forward” by donating his or her kidney to a recipient that is a good match for that kidney (View Figure), and the process continues on until a kidney comes back to the institution where the good Samaritan donation occurred or is given to a patient enrolled in the Children and High Panel-Reactive Antibody (PRA) Program (CHIP).

Paying It Forward

Good Samaritan donor Candace Potter initiated the January 2016 chain involving Kristy Hokett. She was a match for Thomas, enabling Kristy to donate her kidney to a well-matched recipient in the Charleston area.

“Your donor can give to the NKR list and it expands your options,” says Sara Parker, R.N., MUSC’s NKR coordinator. “A patient with a living donor is not bound to that one donor—that donor is a ticket into an exchange where there is greater genetic diversity and a greater chance of a good match.” In short, having a living donor, albeit an incompatible one, gains one right of entry into the NKR, where the right kidney might await.

By helping solve the problem of incompatibility, the kidney chain makes more living donations possible. For the donor, the kidney chain offers an opportunity to magnify the impact of their good deed. Instead of helping one, the donor is instrumental in helping many.

 For more information on the availability of kidney chains at MUSC, contact Sarah Parker, R.N., NKR coordinator, at burbages@musc.edu

For more information on innovation at MUSC Health, see Progressnotes, MUSC's medical magazine (MUSChealth.org/pn).

The Living Donor Institute

The MUSC Living Donor Institute is striving to create a nationally recognized program to serve as a leading resource for transplant patients and live donors through the pursuit of innovation. Its goals are to improve living donation education and access, improve transplant quality, and support research into high-tech alternatives to transplant.