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STAT

An MUSC blog
Keyword: surgery

MUSC is known for its expertise in colorectal surgery. Virgilio V. George, M.D., an associate professor of surgery and section head for colon and rectal surgery at MUSC Health, has performed more single-site colectomies than any other surgeon in the country. This high volume means Dr. George has the expertise to perform the safest, most effective surgery for patients—and that almost always translates to a minimally invasive approach.

The colorectal surgery team at MUSC Health uses the most advanced research-based treatment techniques, including minimally invasive surgeries. In fact, Dr. George uses a minimally invasive approach for nearly all surgeries he performs at MUSC Health, leading to an easier recovery.

But Dr. George says MUSC Health also prioritizes another aspect of colorectal care that has nothing to do with technology: personalized care. It’s the compassionate approach, but it’s also evidence based. With a patient-centered approach to care that starts before patients walk through their doors, patients experience less pain and recover faster.

Colorectal Surgery: Advanced Technology, Less Invasive Techniques

MUSC colorectal surgeons use cutting-edge technology and extensive expertise to push the boundaries of what “minimally invasive” means in colon and rectal procedures. Surgeons use a less invasive approach to treat a range of benign and malignant disease, from diverticulitis and prolapses to malignant disease such as colon and rectal cancer.

“Our area of expertise in colorectal surgery is based on a minimally invasive approach,” says Dr. George. “We use this approach to access the abdominal cavity for many of our surgeries. We can also use this approach for some rectal surgeries, where we access the diseased area from the abdomen and remove the colon cancer that way.”

MUSC uses a range of techniques and technologies in its minimally invasive colorectal surgery options, including robotic, laparoscopic, single-site laparoscopy and transanal surgery.

In single-site laparoscopy, MUSC surgeons offer similar oncologic results to open surgery with even fewer incisions than conventional laparoscopy. Using advanced robotic technology, Dr. George says he has seen improvements in colectomy surgery as well as rectal surgery.

How Patients Benefit From Minimally Invasive Surgery

Often, less invasive equals less pain and a faster recovery for patients. “We know patients who have a minimally invasive procedure have less pain, the same oncologic result, faster discharge home, less incidence of hernias and wound infections and faster recovery to daily activities,” says Dr. George.

More refined surgical techniques are also translating into fewer complications for rectal cancer patients, another key benefit. Due to cutting-edge minimally invasive techniques in a specialized transanal surgery (transanal total mesorectal excision), Dr. George says MUSC Health has seen a decrease in the number of permanent ostomies needed. That means patients can maintain normal GI function and enjoy a significantly improved quality of life.

Another less invasive approach that marries the MUSC Health colorectal surgery team with GI specialists is large polypectomy surgery using a combined approach of colonoscopy and laparoscopy. This approach benefits patients who have large polyps located in the colon or the rectum, who previously would have required a more invasive open surgery to remove a portion of their colon.

Colorectal Surgery: A Personalized Approach

From the time a patient is first referred to MUSC Health until follow-up after treatment, MUSC Health takes extra steps to ensure coordinated care with a team approach. That’s first illustrated in the communication between referring physicians and colorectal service coordinators, who gather all necessary lab and diagnostic tests and patient data prior to the first appointment.

Going one step further in an approach unique to MUSC Health, Dr. George meets weekly with radiology, pathology, oncology, nutrition and other specialists to discuss all new patient cases. This ensures timely, multidisciplinary care, but it also adds a convenience factor for patients. When a patient comes for the first appointment, Dr. George is already waiting with his treatment recommendations and can get to work on a plan that targets the disease and suits the patient’s needs.

That team approach follows patients as they undergo surgery. In the hospital’s colorectal pathology unit, several specialists work toward the end goal of ensuring a smooth recovery and transition back to normal activity. Patients experience less pain, faster discharge from the hospital and ultimately an easier recovery.

The post-surgical care all patients receive emphasizes our integrated approach, making our patients’ experience as seamless and comfortable as possible. The skilled post-surgical team includes:

  • Nursing staff, who tend to patients’ individualized post-surgery concerns, both large and small
  • Dietitians, who offer post-surgery nutrition recommendations
  • Physical therapists, who help patients safely get moving after surgery
  • Pain management specialists, who keep patients comfortable from the operating table until discharge

For more information, contact Dr. George at georgev@musc.edu.

Biliopancreatic diversion, more commonly known as the duodenal switch, can offer patients greater weight loss and other health benefits compared with more popular bariatric procedures, such as gastric bypass—if it’s performed by a surgeon experienced in the advanced laparoscopic techniques.

Duodenal Switch Procedure at MUSC Health

MUSC Health is currently the only site in South Carolina offering the duodenal switch procedure, according to Rana C. Pullattrana, M.D., an associate professor of surgery who specializes in general and gastrointestinal surgery at MUSC.

MUSC’s well-respected bariatric surgery program is the oldest in the region and includes bariatric surgeons, advanced practice practitioners, psychologists, dietitians and patient coordinators. Dr. Pullatt has performed more than 700 bariatric surgeries during his career, including nearly 20 duodenal switch procedures. From the success he’s seen thus far, he hopes that number continues to rise.

“It’s a cutting-edge procedure that very few centers in the country offer,” says Dr. Pullattrana. “Less than 1 percent of all bariatric procedures done in the United States right now are duodenal switch. That shows the rarity of the procedure and why it really needs to be performed by someone who specializes in it.”

Bariatric Surgery: Gastric Bypass vs. Duodenal Switch

In a gastric bypass procedure, surgeons create a smaller stomach by dividing it into two sections, one considerably smaller. They then rearrange the intestine to connect to both sections. As a result, patients need to limit the amount of food they eat at any given time.

In the duodenal switch method, surgeons create a smaller stomach but then remove the unused portion. They reroute the digestive tract, bypassing a portion of the intestine entirely. When using this approach:

  • The pylorus remains intact, so patients do not experience dumping syndrome.
  • The volume of the stomach stays a bit larger, so patients may be able to eat more.
  • Patients may experience fat malabsorption.

According to Dr. Pullattrana, the duodenal switch is a technically challenging procedure, which may be why it accounts for such a miniscule percentage of bariatric surgeries to date.

“The first portion of the duodenum [small intestine] is surrounded by a lot of blood vessels as well as very critical structures, including the bile duct,” he explains. “A surgeon needs to be proficient with advanced laparoscopic techniques. Because this is performed on people with very high BMI, it is even more challenging.”

Duodenal switch surgery can take some surgeons 3 to 4 hours. Through their experience and expertise, the MUSC team has shaved an hour off of that, generally finishing a surgery in 2 to 3 hours. “Performing this surgery required some degree of adapting our technique to get especially skilled at it, and now we are,” explains Dr. Pullattrana.

Most patients go home after 2 days in the hospital and follow up with their doctor at regular intervals for the first year (at 1 week, 1 month and then every 3 months). MUSC Health sees patients annually after the first year, to monitor weight loss progress and ensure adequate nutritional intake.

Bariatric Surgery: Duodenal Switch Benefits

So far, results point to very effective weight loss with the duodenal switch. As of March, MUSC patients had an average BMI of 60 kg/m2 with an average weight of 388 lbs at the time of duodenal switch surgery. Average BMI after surgery dropped accordingly:

  • 54 kg/m2 at 1 month
  • 49 kg/m2 at 3 months
  • 47 kg/m2 at 6 months
  • 39 kg/m2 at 12 months

Patients’ overall health also improved. Whereas gastric bypass resolved diabetes in roughly 80 percent of patients, that number is closer to 93 percent after duodenal switch surgery.

“This is the best operation that we have for bariatric surgery,” says Dr. Pullattrana. “Like any bariatric surgery, patients do need to follow lifestyle as well as dietary and exercise guidelines.”

While the duodenal switch has traditionally been reserved for patients considered super obese (characterized as a BMI greater than 50), current opinion amongst bariatric surgeons is that
many who are a fit for other bariatric surgeries would likely benefit from duodenal switch as well.

In general, Dr. Pullattrana says ideal candidates include anyone with a BMI of 35 or greater who has another health condition (such as uncontrolled diabetes) or anyone with a BMI greater than 50 who desires a drastic weight loss.

This surgery is also an option for patients who’ve previously undergone a sleeve gastrectomy without adequate success.

Bariatric Surgery: Managing Expectations and Follow-Up

Dr. Pullattrana says duodenal switch surgery offers similar complication rates to other bariatric procedures. The most common concern is malnutrition.

Because the surgery affects nutrient absorption, patients need to eat a high-protein diet and supplement with vitamins regularly. To best manage this potential complication, Dr. Pullattrana recommends patients keep in regular contact with their bariatric specialty team, especially their registered dietitians. This includes getting nutritional lab panels every 6 months for the first 2 years and annually thereafter.

Emphasizing these post-surgery management details to patients as they’re considering the duodenal switch can help manage expectations and prevent complications in the long term.

Still, he says the potential for health improvement with this surgery is not to be understated. “This is a life-changing, life-altering procedure. Truly, we can make a dramatic difference in an obese person’s general medical condition,” he says.

For more information, contact Dr. Pullattrana at Pullattr@musc.edu.
 

Screen Shot of New Medical Video Center

The MUSC Health Medical Video Center is now available online at MUSCHealth.org/medical-video. It profiles cutting-edge surgical procedures and innovative treatments available at MUSC Health and is intended for a health care audience. Its initial areas of focus are cardiology, oncology, neuroscience, and pediatrics. The site contains educational (and explicit) surgical video and photography.

 

Summary: Investigators at the Medical University of South Carolina report impressive 90-day outcomes in patients with large-vessel ischemic stroke who underwent thrombectomy using a direct-aspiration, first pass technique.

In an article published online April 16, 2016 by the Journal of Neurointerventional Surgery (doi: 10.1136/neurintsurg-2015-012211), investigators at the Medical University of South Carolina (MUSC) report promising 90-day outcomes for stroke patients with large-vessel clots who underwent thrombectomy or clot removal using the direct-aspiration, first pass technique (ADAPT).  Approximately 58% of stroke patients with a large-vessel clot removed using the technique achieved a good outcome at 90 days, defined as a Modified Rankin Score (mRS) of 0 to 2.

ADAPT aims to remove the clot in its entirety with a large-diameter aspiration catheter in a single pass. In contrast, stent retrievers, currently considered standard of care, frequently fragment the clot for removal and can require several passes.

ADAPT 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., all co-authors on the April 2016 Journal of Neurointerventional Surgery article. MUSC Health neurosurgery resident Jan Vargas, M.D., is first author on the article.

“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 it out of the head to reestablish flow in that blood vessel,” said Turk. If the first-pass attempt is unsuccessful, stent retrievers can still be used to remove the clot.

In the article, the investigators report the results of a retrospective study of 191 consecutive patients with acute ischemic stroke who underwent ADAPT at MUSC Health. In 94.2% of patients, blood vessels were successfully opened—by direct aspiration alone in 145 cases and by the additional use of stent retrievers in another 43 cases. Good outcomes at 90 days (mRS, 0-2) were achieved in 57.7% of patients who were successfully revascularized with aspiration alone and in 43.2% of those who also required a stent retriever. The average time required to reopen the blocked blood vessels was 37.3 minutes—29.6?minutes for direct aspiration alone and 61.4 minutes for cases that also required stent retrievers. Patients presented for thrombectomy on average 7.8 hours after stroke onset.

These results confirm the promise of ADAPT, which was first described by the MUSC Health team in a seminal 2014 article in the Journal of Neurointerventional Surgery. Since the publication of that article, 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 ADAPT using a large-bore catheter, suggesting that it could offer an alternative approach to stent retrievers for mechanical thrombectomy.

Stent retrievers have been considered standard of care for stroke patients since the publication in the October 2015 issue of Stroke of a scientific statement on thrombectomy by the American Heart Association. That statement recommended rapid clot removal in addition to tissue plasminogen activator (tPA), a clot-busting drug that can minimize stroke complications if administered in a tight time window. The recommendation was based on the promising findings of five large clinical trials comparing treatment with tPA alone versus treatment with tPA plus thrombectomy using stent retrievers in large-vessel clots: MR CLEAN, EXTEND-IA,  ESCAPE, SWIFT PRIME, and REVASCAT.

A definitive answer as to whether ADAPT could likewise become standard of care for stroke patients with large-vessel clots will require clinical trials comparing the efficacy of the direct aspiration technique versus stent retrievers in this population of stroke patients.

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.

Image Caption: Left: Frontal view of the skull showing occlusion of the right internal carotid artery (ICA) beginning at the level of the vertical petrous potion (arrow). Right: Frontal view of the skull after thrombectomy shows the revascularization of the ICA and the distal arteries supplying the right side of the brain.

Genetic Origin of Mitral Valve ProlapseAs part of a multi-center investigation recently reported in the journals Nature1 and Nature Genetics,2 researchers at the Medical University of South Carolina (MUSC) and Harvard/Massachusetts General Hospital as well as other international institutes have discovered genetic and biological causes for MVP. The investigators identify that MVP can be a result of heritable genetic errors that occur during embryonic cardiac development and progress over the lifespan of affected individuals.

Mitral valve prolapse (MVP) affects 1 in 40 individuals making it one of the most prevalent human diseases. Many individuals with MVP develop potentially life-threatening cardiac arrhythmia and heart failure.

In MVP, one or both flaps of the mitral valve bulge backward into the left atrium causing it to close improperly upon termination of atrial systole. Mitral valve prolapse is often detected as a heart murmur and is usually asymptomatic, but in roughly 10% of cases mitral valve regurgitation intensifies to a clinically severe stage. In severe cases, arrhythmic heartbeats develop, which increases the risk of stroke, heart failure and sudden cardiac death. In fact, the risks are high enough in MVP to make it the leading indication for mitral valve surgery.

In the Nature article,1 investigators used linkage analyses and capture sequencing technology to examine protein-coding genes on chromosome 11 in four members of a large family segregating non-syndromic MVP. They discovered a missense mutation in the DCHS1 gene, which codes for the protein dachsous homolog 1, a member of the calcium-dependent cell-cell adhesion family of cadherins. Another DCHS1 mutation was found in additional families segregating deleterious MVP. Both mutations reduce DCHS1 protein stability in mitral valve interstitial cells (MVICs), a finding corroborated with the discovery of the original mutation in MVICs in a human patient with MVP that underwent mitral valve repair surgery. Dchs1 mutant mice displayed similar pathology, along with scattered migration of MVICs during growth, suggesting that protein stability is essential to maintaining cues for cell polarity during mitral valve development.

In a subsequent manuscript published in Nature Genetics,2 the investigators performed a genome-wide association study (GWAS) to identify genetic variants in a population of  more than 10,000 subjects.  Single nucleotide variants (SNPs) with genome-wide significance were identified in the patient cohorts and genes surrounding these SNPs were functionally evaluated in multiple in vivo models. 

The results from both studies highlight a potential unifying biological cause for MVP in the population.

“We have found a genetic and biological reason for one of the most common diseases affecting the human population," says MUSC researcher Russell A. (Chip) Norris, Ph.D., who was a co-senior author on the studies. "This is a critical initial step as we transform this discovery into new remedial therapies to treat the disease.”  Roger R. Markwald, Ph.D.,  and Andy Wessels, Ph.D. both of the Department of Regenerative Medicine and Cell Biology at MUSC, were also co-authors.

If you are interested in supporting medical research, visit donorscure.org, an MUSC-affiliated 501(c)(3) nonprofit organization that allows you to fund biomedical research projects led by researchers across the United States.

References

1 Durst, et al. Mutations in DCHS1 cause mitral valve prolapse. Nature. 2015 Aug 10 [Epub ahead of print]. Available at http://dx.doi.org/10.1038/nature14670

2 Dina C, et al. Genetic association analyses highlight biological pathways underlying mitral valve prolapse.
Nat Genet. 2015 Aug 24.  [Epub ahead of print] Available at http://dx.doi.org/10.1038/ng.3383.

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