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Collins RA, Herman T, Snyder RA, Haines KL, Stey A, Arora TK, Geevarghese SK, Phillips JD, Vicente D, Griggs CL, McElroy IE, Wall AE, Hughes TM, Sen S, Valinejad J, Alban A, Swan JS, Mercaldo N, Jalali MS, Chhatwal J, Gazelle GS, Rangel E, Yang CFJ, Donelan K, Gold JA, West CP, Cunningham C. Unspoken Truths: Mental Health Among Academic Surgeons. Ann Surg 2024; 279:429-436. [PMID: 37991182 DOI: 10.1097/sla.0000000000006159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.
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Affiliation(s)
- Reagan A Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Tianna Herman
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Anne Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tania K Arora
- Department of Surgery, Augusta University at the Medical College of Georgia, Augusta, GA
| | | | | | - Diego Vicente
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cornelia L Griggs
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Srijan Sen
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Jaber Valinejad
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andres Alban
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - J Shannon Swan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Mohammad S Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Erika Rangel
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Karen Donelan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jessica A Gold
- Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Colin P West
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carrie Cunningham
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
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Xiang B, Heiselman JS, Richey WL, D’Angelica MI, Wei A, Kingham TP, Servin F, Pereira K, Geevarghese SK, Jarnagin WR, Miga MI. Comparison study of intraoperative surface acquisition methods on registration accuracy for soft-tissue surgical navigation. J Med Imaging (Bellingham) 2024; 11:025001. [PMID: 38445222 PMCID: PMC10911768 DOI: 10.1117/1.jmi.11.2.025001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/05/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024] Open
Abstract
Purpose To study the difference between rigid registration and nonrigid registration using two forms of digitization (contact and noncontact) in human in vivo liver surgery. Approach A Conoprobe device attachment and sterilization process was developed to enable prospective noncontact intraoperative acquisition of organ surface data in the operating room (OR). The noncontact Conoprobe digitization method was compared against stylus-based acquisition in the context of image-to-physical registration for image-guided surgical navigation. Data from n = 10 patients undergoing liver resection were analyzed under an Institutional Review Board-approved study at Memorial Sloan Kettering Cancer Center. Organ surface coverage of each surface acquisition method was compared. Registration accuracies resulting from the acquisition techniques were compared for (1) rigid registration method (RRM), (2) model-based nonrigid registration method (NRM) using surface data only, and (3) NRM with one subsurface feature (vena cava) from tracked intraoperative ultrasound (NRM-VC). Novel vessel centerline and tumor targets were segmented and compared to their registered preoperative counterparts for accuracy validation. Results Surface data coverage collected by stylus and Conoprobe were 24.6 % ± 6.4 % and 19.6 % ± 5.0 % , respectively. The average difference between stylus data and Conoprobe data using NRM was - 1.05 mm and using NRM-VC was - 1.42 mm , indicating the registrations to Conoprobe data performed worse than to stylus data with both NRM approaches. However, using the stylus and Conoprobe acquisition methods led to significant improvement of NRM-VC over RRM by average differences of 4.48 and 3.66 mm, respectively. Conclusion The first use of a sterile-field amenable Conoprobe surface acquisition strategy in the OR is reported for open liver surgery. Under clinical conditions, the nonrigid registration significantly outperformed standard-of-care rigid registration, and acquisition by contact-based stylus and noncontact-based Conoprobe produced similar registration results. The accuracy benefits of noncontact surface acquisition with a Conoprobe are likely obscured by inferior data coverage and intrinsic noise within acquisition systems.
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Affiliation(s)
- Bowen Xiang
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Jon S. Heiselman
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
- Memorial Sloan Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Winona L. Richey
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Michael I. D’Angelica
- Memorial Sloan Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Alice Wei
- Memorial Sloan Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - T. Peter Kingham
- Memorial Sloan Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Frankangel Servin
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Kyvia Pereira
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Sunil K. Geevarghese
- Vanderbilt University Medical Center, Division of Hepatobiliary Surgery and Liver Transplantation, Nashville, Tennessee, United States
| | - William R. Jarnagin
- Memorial Sloan Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Michael I. Miga
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
- Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
- Vanderbilt University Medical Center, Department of Neurological Surgery, Nashville, Tennessee, United States
- Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences, Nashville, Tennessee, United States
- Vanderbilt University Medical Center, Department of Otolaryngology–Head and Neck Surgery, Nashville, Tennessee, United States
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3
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Servin F, Collins JA, Heiselman JS, Frederick-Dyer KC, Planz VB, Geevarghese SK, Brown DB, Jarnagin WR, Miga MI. Simulation of Image-Guided Microwave Ablation Therapy Using a Digital Twin Computational Model. IEEE Open J Eng Med Biol 2023; 5:107-124. [PMID: 38445239 PMCID: PMC10914207 DOI: 10.1109/ojemb.2023.3345733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 12/04/2023] [Indexed: 03/07/2024] Open
Abstract
Emerging computational tools such as healthcare digital twin modeling are enabling the creation of patient-specific surgical planning, including microwave ablation to treat primary and secondary liver cancers. Healthcare digital twins (DTs) are anatomically one-to-one biophysical models constructed from structural, functional, and biomarker-based imaging data to simulate patient-specific therapies and guide clinical decision-making. In microwave ablation (MWA), tissue-specific factors including tissue perfusion, hepatic steatosis, and fibrosis affect therapeutic extent, but current thermal dosing guidelines do not account for these parameters. This study establishes an MR imaging framework to construct three-dimensional biophysical digital twins to predict ablation delivery in livers with 5 levels of fat content in the presence of a tumor. Four microwave antenna placement strategies were considered, and simulated microwave ablations were then performed using 915 MHz and 2450 MHz antennae in Tumor Naïve DTs (control), and Tumor Informed DTs at five grades of steatosis. Across the range of fatty liver steatosis grades, fat content was found to significantly increase ablation volumes by approximately 29-l42% in the Tumor Naïve and 55-60% in the Tumor Informed DTs in 915 MHz and 2450 MHz antenna simulations. The presence of tumor did not significantly affect ablation volumes within the same steatosis grade in 915 MHz simulations, but did significantly increase ablation volumes within mild-, moderate-, and high-fat steatosis grades in 2450 MHz simulations. An analysis of signed distance to agreement for placement strategies suggests that accounting for patient-specific tumor tissue properties significantly impacts ablation forecasting for the preoperative evaluation of ablation zone coverage.
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Affiliation(s)
- Frankangel Servin
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTN37235USA
- Vanderbilt Institute for Surgery and EngineeringVanderbilt UniversityNashvilleTN37235USA
| | - Jarrod A. Collins
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTN37235USA
| | - Jon S. Heiselman
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTN37235USA
- Vanderbilt Institute for Surgery and EngineeringVanderbilt UniversityNashvilleTN37235USA
- Department of Surgery, Hepatopancreatobiliary ServiceMemorial Sloan Kettering Cancer CenterNew YorkNY10065USA
| | | | - Virginia B. Planz
- Department of RadiologyVanderbilt University Medical CenterNashvilleTN37235USA
| | | | - Daniel B. Brown
- Department of RadiologyVanderbilt University Medical CenterNashvilleTN37235USA
| | - William R. Jarnagin
- Department of Surgery, Hepatopancreatobiliary ServiceMemorial Sloan Kettering Cancer CenterNew YorkNY10065USA
| | - Michael I. Miga
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTN37235USA
- Vanderbilt Institute for Surgery and EngineeringVanderbilt UniversityNashvilleTN37235USA
- Department of RadiologyVanderbilt University Medical CenterNashvilleTN37235USA
- Department of Neurological SurgeryVanderbilt University Medical CenterNashvilleTN37235USA
- Department of OtolaryngologyVanderbilt University Medical CenterNashvilleTN37235USA
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Merrill WH, Geevarghese SK. Genius is Largely a Matter of Making a Continuous Effort: A Reappraisal of the Contributions of H. William Scott, Jr., MD, A Surgeon Nonpareil. Ann Surg Open 2023; 4:e312. [PMID: 37746597 PMCID: PMC10513363 DOI: 10.1097/as9.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/16/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Walter H. Merrill
- From the Department of Cardiac Surgery, Vanderbilt University Medical Center, Medical Center North, Nashville, TN
| | - Sunil K. Geevarghese
- Section of Surgical Sciences, Vanderbilt University Medical Center, Medical Center North, Nashville, TN
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5
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Lillemoe HA, Hanna DN, Baregamian N, Solórzano CC, Terhune KP, Geevarghese SK, Kiernan CM. The use of an educational time-out in thyroid and parathyroid surgery to move the needle in periprocedural education. Surgery 2023; 173:84-92. [PMID: 36216620 DOI: 10.1016/j.surg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/19/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND As surgical training shifts toward a competency-based paradigm, deliberate practice for procedures must be a point of focus. The purpose of this study was to assess the impact of an educational time-out intervention on educational experience and operative performance in endocrine surgery. METHODS For 12 months, third-year general surgery residents used the educational time-out to establish an operative step of focus for thyroidectomy and parathyroidectomy procedures. Data were collected using the System for Improving and Measuring Procedural Learning application and post-rotation surveys. The Zwisch scale was used to classify supervision, with meaningful autonomy defined as passive help or supervision only. RESULTS Eight residents and 3 attending surgeons performed the educational time-out for a total of 211 operations (93% completion rate). At the end of each rotation, there was improvement in the frequency of goal setting. There was strong agreement (90%) that the intervention strengthened the educational experience. For most cases (52%), the residents were rated at active help. Residents performed a median of 3/6 thyroidectomy steps at meaningful autonomy and a median of 2/5 parathyroidectomy steps at meaningful autonomy. Review of the qualitative data revealed that optimal feedback was provided in 46% of cases. CONCLUSION The educational time-out strengthened educational experiences. Stepwise procedural data revealed the varying levels of supervision that exist within an operation. Broader implementation of this intervention could facilitate competency-based procedural education.
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Affiliation(s)
- Heather A Lillemoe
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX.
| | - David N Hanna
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naira Baregamian
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Carmen C Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kyla P Terhune
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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Wallace MW, Lyons EM, Grogan EL, Johnson J, Geevarghese SK. Histoplasma Empyema Appearing as a Diaphragm-Invading Colorectal Metastasis to the Liver. Am Surg 2022:31348221082274. [PMID: 35331019 DOI: 10.1177/00031348221082274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Eden M Lyons
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Eric L Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joyce Johnson
- Department of Pathology, Microbiology and Immunology, 12328Vanderbilt University Medical, Center, Nashville, TN, USA
| | - Sunil K Geevarghese
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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7
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Servin F, Collins JA, Heiselman JS, Frederick-Dyer KC, Planz VB, Geevarghese SK, Brown DB, Miga MI. Fat Quantification Imaging and Biophysical Modeling for Patient-Specific Forecasting of Microwave Ablation Therapy. Front Physiol 2022; 12:820251. [PMID: 35185606 PMCID: PMC8850958 DOI: 10.3389/fphys.2021.820251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/29/2021] [Indexed: 11/14/2022] Open
Abstract
Computational tools are beginning to enable patient-specific surgical planning to localize and prescribe thermal dosing for liver cancer ablation therapy. Tissue-specific factors (e.g., tissue perfusion, material properties, disease state, etc.) have been found to affect ablative therapies, but current thermal dosing guidance practices do not account for these differences. Computational modeling of ablation procedures can integrate these sources of patient specificity to guide therapy planning and delivery. This paper establishes an imaging-data-driven framework for patient-specific biophysical modeling to predict ablation extents in livers with varying fat content in the context of microwave ablation (MWA) therapy. Patient anatomic scans were segmented to develop customized three-dimensional computational biophysical models and mDIXON fat-quantification images were acquired and analyzed to establish fat content and determine biophysical properties. Simulated patient-specific microwave ablations of tumor and healthy tissue were performed at four levels of fatty liver disease. Ablation models with greater fat content demonstrated significantly larger treatment volumes compared to livers with less severe disease states. More specifically, the results indicated an eightfold larger difference in necrotic volumes with fatty livers vs. the effects from the presence of more conductive tumor tissue. Additionally, the evolution of necrotic volume formation as a function of the thermal dose was influenced by the presence of a tumor. Fat quantification imaging showed multi-valued spatially heterogeneous distributions of fat deposition, even within their respective disease classifications (e.g., low, mild, moderate, high-fat). Altogether, the results suggest that clinical fatty liver disease levels can affect MWA, and that fat-quantitative imaging data may improve patient specificity for this treatment modality.
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Affiliation(s)
- Frankangel Servin
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
- Vanderbilt Institute for Surgery and Engineering, Vanderbilt University, Nashville, TN, United States
| | - Jarrod A. Collins
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
| | - Jon S. Heiselman
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
- Vanderbilt Institute for Surgery and Engineering, Vanderbilt University, Nashville, TN, United States
| | - Katherine C. Frederick-Dyer
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Virginia B. Planz
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sunil K. Geevarghese
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Daniel B. Brown
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael I. Miga
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
- Vanderbilt Institute for Surgery and Engineering, Vanderbilt University, Nashville, TN, United States
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- *Correspondence: Michael I. Miga,
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Geevarghese SK, Pomfret EA. Peer support networks: A local approach to the global issue of moral injury in surgical training and practice. Can Urol Assoc J 2021; 15:S33-S35. [PMID: 34406929 DOI: 10.5489/cuaj.7300] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Sunil K Geevarghese
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Elizabeth A Pomfret
- Transplant Division, University of Colorado Anschutz Medical Campus, Denver, CO, United States
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9
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Lee SJ, Natour AK, Geevarghese SK. Fireside Chats: A Novel Wellness Initiative for Medical Students in the COVID-19 Era. Am Surg 2021; 88:1703-1707. [PMID: 33745289 PMCID: PMC9198670 DOI: 10.1177/00031348211003060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To supplement preexisting wellness programming for the surgery clerkship, a faculty surgeon at Vanderbilt initiated Fireside Chats (FC) in 2015. Inspired by Franklin Roosevelt’s Depression-era radio broadcasts, FC features small group sizes, off-campus excursions, and a reimagining of the mentor–mentee relationship that eschews hierarchy in favor of deep, mutualistic connections in both personal and professional domains. Here we describe the rationale and implementation of FC and present survey data that demonstrate the warm reception of FC and its efficacy in stewarding the mental health of medical students. Moreover, unlike large group activities such as “learning communities,” FC continues to meet in-person during COVID-19 and preserves social engagement opportunities that may alleviate pandemic-induced isolation and distress.
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Affiliation(s)
- Sean J Lee
- 12327Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Sunil K Geevarghese
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, 12328Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Ziogas IA, Martins PN, Alexopoulos SP, Matsuoka LK, Rauf MA, Geevarghese SK, Gorden LD, Karp SJ, Perkins JD, Montenovo MI. Effect of Donor Transaminase Levels on Graft Survival Following Liver Transplant: An Analysis of the Organ Procurement and Transplantation Network Database. EXP CLIN TRANSPLANT 2021; 19:250-258. [PMID: 33605200 DOI: 10.6002/ect.2020.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite data showing equivalent outcomes between grafts from marginal versus standard criteria deceased liver donors, elevated donor transaminases constitute a frequent reason to decline potential livers. We assessed the effect of donor transaminase levels and other characteristics on graft survival. MATERIALS AND METHODS We performed a retrospective cohort analysis of adult first deceased donor liver transplant recipients with available transaminase levels registered in the Organ Procurement and Transplantation Network database (2008-2018). We used Cox proportional hazards regression to determine the effects of donor characteristics on graft survival. RESULTS Of 53 913 liver transplants, 52 158 were allografts from donors with low transaminases (≤ 500 U/L; group A) and 1755 were from donors with elevated transaminases (> 500 U/L; group B). Group A recipients were more likely to be hospitalized (P = .01) or in intensive care (P < .001) or to have mechanical assistance (P < .001), portal vein thrombosis (P = .01), diabetes mellitus (P = .003), or dialysis the week before liver transplant (P = .004). Multivariable analysis (controlling for recipient characteristics) showed donor risk factors of graft failure included diabetes mellitus (P < .001), donation after cardiac death (P < .001), total bilirubin > 3.5 mg/dL (P < .001), serum creatinine > 1.5 mg/dL (P = .01), and cold ischemia time > 6 hours (P < .001). Regional organ sharing showed lower risk of graft failure (P = .02). Donor transaminases > 500 U/L were not associated with graft failure (relative risk, 1.02; 95% CI, 0.91-1.14; P = .74). CONCLUSIONS Donor transaminases > 500 U/L should not preclude the use of liver grafts. Instead, donor total bilirubin > 3.5 mg/dL and serum creatinine > 1.5 mg/dL appear to be associated with higher likelihood of graft failure after liver transplant.
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Affiliation(s)
- Ioannis A Ziogas
- From the Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Abstract
Melanoma is the deadliest malignancy of the skin with an estimated 91 000 new annual cases with 9300 deaths in 2018. Metastatic disease generally presents with identification of known primary lesion; however, in 3.2% of patients, metastatic disease is discovered with unknown primary lesion/site. Rarely, melanoma is diagnosed as a primary lesion in visceral organs. Suspected primary hepatic melanoma is exceedingly rare and described in only a few case reports. We present the case of a 69-year-old Caucasian male who was found to have a hepatic melanoma on final pathology after resection of suspected primary hepatic malignancy. After a thorough postoperative workup, a primary lesion was unable to be identified. As such, a visceral primary lesion is considered.
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Affiliation(s)
- Jesse P Wright
- Department of Colorectal Surgery, AdventHealth - Orlando, Orlando, FL, USA
| | - Sunil K Geevarghese
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Ziogas IA, Alexopoulos SP, Matsuoka LK, Geevarghese SK, Gorden LD, Karp SJ, Perkins JD, Montenovo MI. Living vs deceased donor liver transplantation in cholestatic liver disease: An analysis of the OPTN database. Clin Transplant 2020; 34:e14031. [PMID: 33427333 DOI: 10.1111/ctr.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/11/2020] [Accepted: 06/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) and donation after circulatory death (DCD) can expand the donor pool for cholestatic liver disease (CLD) patients. We sought to compare the outcomes of deceased donor liver transplant (DDLT) vs LDLT in CLD patients. METHODS Retrospective cohort analysis of adult CLD recipients registered in the OPTN database who received primary LT between 2002 and 2018. Cox proportional hazards regression models with mixed effects were used to determine the impact of graft type on patient and graft survival. RESULTS Five thousand, nine hundred ninety-nine DDLT (5730 donation after brain death [DBD], 269 DCD) and 912 LDLT recipients were identified. Ten-year patient/graft survival rates were DBD: 73.8%/67.9%, DCD: 74.7%/60.7%, and LDLT: 82.5%/73.9%. Higher rates of biliary complications as a cause of graft failure were seen in DCD (56.8%) than LDLT (30.5%) or DBD (18.7%) recipients. On multivariable analysis, graft type was not associated with patient mortality, while DCD was independently associated with graft failure (P = .046). CONCLUSION DBD, DCD, and LDLT were associated with comparable overall patient survival. No difference in the risk of graft failure could be observed between LDLT and DBD. DCD can be an acceptable alternative to DBD with equivalent patient survival, but inferior graft survival likely related to the high rate of biliary complications.
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Affiliation(s)
- Ioannis A Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lee D Gorden
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth J Karp
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA, USA
| | - Martin I Montenovo
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Lillemoe HA, Stonko DP, George BC, Schuller MC, Fryer JP, Sullivan ME, Terhune KP, Geevarghese SK. A Preoperative Educational Time-Out is Associated with Improved Resident Goal Setting and Strengthens Educational Experiences. J Surg Educ 2020; 77:18-26. [PMID: 31327734 DOI: 10.1016/j.jsurg.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/15/2019] [Accepted: 07/06/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the impact of a preoperative Educational Time-Out (ETO) with structured postoperative feedback on resident preoperative goal-setting and the educational experience of a clinical rotation. DESIGN A preoperative ETO was developed during which trainees and faculty jointly identified an operative goal and discussed the trainee's operative autonomy. Postoperative feedback with a smartphone application was encouraged. From November 2016 to October 2017, the intervention was piloted with 1 surgical service. Outcomes included ETO completion rate, goal setting rate, and subjects' perception of the impact of the ETO on identification of performance deficits, trainee autonomy, and receipt of feedback. Data were analyzed using descriptive statistics. SETTING This study was performed in an institutional hospital setting. PARTICIPANTS Third-year general surgery residents and surgical faculty in the Department of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center took part in the intervention. RESULTS Seven residents and 7 attending surgeons participated in this study. Residents performed a median of 15 procurements during an average of 6.5 weeks each on service. The ETO completion rate was 83%. Resident-reported preoperative goal setting increased after the intervention (from 36% to 78%, p = 0.015). Subjects reported a positive impact of the intervention, with high resident agreement that the ETO helped identify deficits (82% median agreement), increased autonomy (82% median agreement), and increased receipt of feedback (84% median agreement). Residents and attendings agreed that the educational experience was stronger due to the ETO (median 81% and 77%, respectively). CONCLUSIONS The ETO intervention improved rates of resident preoperative goal setting and strengthened perceived educational experiences. Resident participants also reported improvements in autonomy and rates of postoperative feedback. Broader implementation of this brief preoperative pause is an easy way to emphasize procedural education in the operating room.
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Affiliation(s)
- Heather A Lillemoe
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - David P Stonko
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mary C Schuller
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan P Fryer
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maura E Sullivan
- Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Kyla P Terhune
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil K Geevarghese
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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14
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Kaldas FM, Rocca JP, Bhati CS, Duan N, Evenson AR, Tan HP, Redfield RR, di Sabato DM, Yoshida A, Abt PL, Geevarghese SK. The Abdominal Transplant Surgery Workforce: Current state and future trends. Clin Transplant 2019; 33:e13659. [DOI: 10.1111/ctr.13659] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/21/2019] [Accepted: 07/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Fady M. Kaldas
- Ronald Reagan UCLA Medical Center Los Angeles California
| | | | | | - Ning Duan
- American Society of Transplant Surgeons Arlington Virginia
| | - Amy R. Evenson
- Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Henkie P. Tan
- University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Robert R. Redfield
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | | | | | - Peter L. Abt
- University of Pennsylvania Philadelphia Pennsylvania
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15
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Ford JS, Wise ES, Rehman SC, Jacomino KG, Maggart MJ, Izmaylov M, Geevarghese SK. Obesity in Liver Transplantation: A Risk Factor for Unplanned Reoperation and Prolonged Operative Time. Am Surg 2019. [DOI: 10.1177/000313481908500850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Selection of orthotopic liver transplantation (OLT) candidates is increasingly inclusive of patients with high BMI. We aim to characterize the influence of obesity on the surgical outcome measures of prolonged operative time and unplanned reoperation. We reviewed the records of obese and normal weight OLT recipients over a 10-year period from a single institution. Variables that trended ( P < 0.1) with endpoints on univariate analysis were put into multivariate logistic regression models to determine independent association ( P < 0.05). We included 195 obese and 171 normal weight OLT recipients in our study. On multivariate analysis, obesity was the only preoperative risk factor that trended with unplanned reoperation (odds ratio 2, P = 0.05). Similarly, only obesity remained independently associated with prolonged length of operation (defined as ≥275 minutes) on multivariate analysis (odds ratio 1.7, P = 0.04). In summary, obesity may make OLT more technically challenging and, thus, represents an independent risk factor for unplanned reoperations and prolonged operative time.
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Affiliation(s)
- James S. Ford
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric S. Wise
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland; and
| | - Saad C. Rehman
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | | | - Sunil K. Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Ford JS, Wise ES, Rehman SC, Jacomino KG, Maggart MJ, Izmaylov M, Geevarghese SK. Obesity in Liver Transplantation: A Risk Factor for Unplanned Reoperation and Prolonged Operative Time. Am Surg 2019; 85:927-933. [PMID: 31560314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Selection of orthotopic liver transplantation (OLT) candidates is increasingly inclusive of patients with high BMI. We aim to characterize the influence of obesity on the surgical outcome measures of prolonged operative time and unplanned reoperation. We reviewed the records of obese and normal weight OLT recipients over a 10-year period from a single institution. Variables that trended (P < 0.1) with endpoints on univariate analysis were put into multivariate logistic regression models to determine independent association (P < 0.05). We included 195 obese and 171 normal weight OLT recipients in our study. On multivariate analysis, obesity was the only preoperative risk factor that trended with unplanned reoperation (odds ratio 2, P = 0.05). Similarly, only obesity remained independently associated with prolonged length of operation (defined as ≥275 minutes) on multivariate analysis (odds ratio 1.7, P = 0.04). In summary, obesity may make OLT more technically challenging and, thus, represents an independent risk factor for unplanned reoperations and prolonged operative time.
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17
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Lillemoe HA, Stonko DP, Sullivan ME, Geevarghese SK, Terhune KP. Preoperative goal setting and perioperative communication in an academic training institution: Where do we stand? Am J Surg 2018; 217:318-322. [PMID: 30224073 DOI: 10.1016/j.amjsurg.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/12/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND We collected data regarding specific aspects of perioperative surgical education within our institution's Section of Surgical Sciences as a needs assessment. METHODS Categorical general surgery residents and attending surgeons were queried regarding their perceptions of resident preoperative planning and perioperative communication. RESULTS The overall response rate was 81%, with 35 resident and 54 faculty respondents. Residents reported selecting an operative learning objective a median of 50% (IQR 36-67) of the time, whereas attending surgeons perceived this to be the case a median of 26% (IQR 15-35) of the time (P < 0.001). The group reported median frequencies of 20% (IQR 9-31) for preoperative discussion of learning objectives, 12% (IQR 4-27) for preoperative discussion of competence and 27% (IQR 17-55) for postoperative debriefing. CONCLUSIONS This study demonstrates deficits in resident goal setting and perioperative communication within our program, which are targets for future intervention. We share these results as a potential tool for other programs.
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Affiliation(s)
- Heather A Lillemoe
- Vanderbilt University Medical Center, Department of Surgery, 1161 21st Ave, Nashville, TN, 37232, USA.
| | - David P Stonko
- Vanderbilt University School of Medicine, 1161 21st Ave, Nashville, TN, 37232, USA.
| | - Maura E Sullivan
- Keck School of Medicine at the University of Southern California, Department of Surgery, 1520 San Pablo St., Ste. 4300, Los Angeles, CA, 90033, USA.
| | - Sunil K Geevarghese
- Vanderbilt University Medical Center, Department of Surgery, 1161 21st Ave, Nashville, TN, 37232, USA.
| | - Kyla P Terhune
- Vanderbilt University Medical Center, Department of Surgery, 1161 21st Ave, Nashville, TN, 37232, USA.
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18
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Heiselman JS, Clements LW, Collins JA, Weis JA, Simpson AL, Geevarghese SK, Kingham TP, Jarnagin WR, Miga MI. Characterization and correction of intraoperative soft tissue deformation in image-guided laparoscopic liver surgery. J Med Imaging (Bellingham) 2017; 5:021203. [PMID: 29285519 DOI: 10.1117/1.jmi.5.2.021203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022] Open
Abstract
Laparoscopic liver surgery is challenging to perform due to a compromised ability of the surgeon to localize subsurface anatomy in the constrained environment. While image guidance has the potential to address this barrier, intraoperative factors, such as insufflation and variable degrees of organ mobilization from supporting ligaments, may generate substantial deformation. The severity of laparoscopic deformation in humans has not been characterized, and current laparoscopic correction methods do not account for the mechanics of how intraoperative deformation is applied to the liver. We first measure the degree of laparoscopic deformation at two insufflation pressures over the course of laparoscopic-to-open conversion in 25 patients. With this clinical data alongside a mock laparoscopic phantom setup, we report a biomechanical correction approach that leverages anatomically load-bearing support surfaces from ligament attachments to iteratively reconstruct and account for intraoperative deformations. Laparoscopic deformations were significantly larger than deformations associated with open surgery, and our correction approach yielded subsurface target error of [Formula: see text] and surface error of [Formula: see text] using only sparse surface data with realistic surgical extent. Laparoscopic surface data extents were examined and found to impact registration accuracy. Finally, we demonstrate viability of the correction method with clinical data.
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Affiliation(s)
- Jon S Heiselman
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Logan W Clements
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Jarrod A Collins
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
| | - Jared A Weis
- Wake Forest School of Medicine, Department of Biomedical Engineering, Winston-Salem, North Carolina, United States
| | - Amber L Simpson
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Sunil K Geevarghese
- Vanderbilt University Medical Center, Division of Hepatobiliary Surgery and Liver Transplantation, Nashville, Tennessee, United States
| | - T Peter Kingham
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - William R Jarnagin
- Memorial Sloan-Kettering Cancer Center, Hepatopancreatobiliary Service, Department of Surgery, New York, New York, United States
| | - Michael I Miga
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States.,Vanderbilt University, Vanderbilt Institute for Surgery and Engineering, Nashville, Tennessee, United States
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19
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Bonatti HJR, Corey MR, Taylor JT, Geevarghese SK. Bile leak from the gallbladder fossa after liver transplantation. Eur Surg 2017. [DOI: 10.1007/s10353-017-0505-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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DaVee T, Geevarghese SK, Slaughter JC, Yachimski PS. Refractory anastomotic bile leaks after orthotopic liver transplantation are associated with hepatic artery disease. Gastrointest Endosc 2017; 85:984-992. [PMID: 27623104 DOI: 10.1016/j.gie.2016.08.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Anastomotic bile leaks are common after orthotopic liver transplant (OLT), and standard treatment consists of placement of a biliary endoprosthesis. The objectives of this study were to identify risk factors for refractory anastomotic bile leaks and to determine the morbidity associated with refractory bile leaks after OLT. METHODS Consecutive adult patients who underwent ERCP for treatment of post-OLT biliary adverse events between 2009 and 2014 at a high-volume transplant center were retrospectively identified. A refractory leak was defined as a bile leak that persisted after placement of a plastic biliary endoprosthesis and required repeat endoscopic or surgical intervention. RESULTS Forty-three subjects met study inclusion criteria. Median age was 57 years, and 36 (84%) subjects were men. Refractory bile leaks were diagnosed in 40% of subjects (17/43). Time-to-event analysis revealed an association between refractory bile leaks and the combined outcome of death, repeat transplant, or surgical biliary revision (hazard ratio, 3.78; 95% confidence interval, 1.25-11.45; P = .01). Hepatic artery disease was more common with refractory compared with treatment-responsive bile leaks (53% vs 8%, P = .001). CONCLUSIONS Refractory anastomotic bile leaks after liver transplantation are associated with decreased event-free survival. Hepatic artery disease is associated with refractory leaks. Large-scale prospective studies should be performed to define the optimal management of patients at risk for refractory bile leaks.
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Affiliation(s)
- Tomas DaVee
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick S Yachimski
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Kauffmann R, Karp SJ, Wright JK, Geevarghese SK. Retroversus Implantation of a Situs Solitus Deceased Donor Liver into a Situs Inversus Totalis Recipient. Am Surg 2017. [DOI: 10.1177/000313481708300406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rondi Kauffmann
- Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - Seth J. Karp
- Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - J. Kelley Wright
- Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - Sunil K. Geevarghese
- Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee
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22
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Kauffmann R, Karp SJ, Wright JK, Geevarghese SK. Retroversus Implantation of a Situs Solitus Deceased Donor Liver into a Situs Inversus Totalis Recipient. Am Surg 2017; 83:e120-e122. [PMID: 28424114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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23
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Jeyarajah DR, Berman RS, Doyle MB, Geevarghese SK, Posner MC, Farmer D, Minter RM. Consensus Conference on North American Training in Hepatopancreaticobiliary Surgery: A Review of the Conference and Presentation of Consensus Statements. Am J Transplant 2016; 16:1086-93. [PMID: 26928942 DOI: 10.1111/ajt.13675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/29/2015] [Accepted: 11/29/2015] [Indexed: 01/25/2023]
Abstract
The findings and recommendations of the North American consensus conference on training in hepatopancreaticobiliary (HPB) surgery held in October 2014 are presented. The conference was hosted by the Society for Surgical Oncology (SSO), the Americas Hepato-Pancreatico-Biliary Association (AHPBA), and the American Society of Transplant Surgeons (ASTS). The current state of training in HPB surgery in North America was defined through three pathways-HPB, surgical oncology, and solid organ transplant fellowships. Consensus regarding programmatic requirements included establishment of minimum case volumes and inclusion of quality metrics. Formative assessment, using milestones as a framework and inclusive of both operative and nonoperative skills, must be present. Specific core HPB cases should be defined and used for evaluation of operative skills. The conference concluded with a focus on the optimal means to perform summative assessment to evaluate the individual fellow completing a fellowship in HPB surgery. Presentations from the hospital perspective and the American Board of Surgery led to consensus that summative assessment was desired by the public and the hospital systems and should occur in a uniform but possibly modular manner for all HPB fellowship pathways. A task force composed of representatives of the SSO, AHPBA, and ASTS are charged with implementation of the consensus statements emanating from this consensus conference.
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Affiliation(s)
- D R Jeyarajah
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | - R S Berman
- Department of Surgery, Division of Surgical Oncology, New York University, New York, NY
| | - M B Doyle
- Department of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO
| | - S K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - M C Posner
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL
| | - D Farmer
- Department of Transplantation, UCLA Medical Center, Los Angeles, CA
| | - R M Minter
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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24
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Jeyarajah DR, Berman RS, Doyle M, Geevarghese SK, Posner MC, Farmer D, Minter RM. Consensus Conference on North American Training in Hepatopancreaticobiliary Surgery: A Review of the Conference and Presentation of Consensus Statements. Ann Surg Oncol 2016; 23:2153-60. [DOI: 10.1245/s10434-016-5111-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 11/18/2022]
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25
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Affiliation(s)
- Clark D Kensinger
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Walter H Merrill
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil K Geevarghese
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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26
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Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306-16. [PMID: 24088092 PMCID: PMC3922401 DOI: 10.1056/nejmoa1301372] [Citation(s) in RCA: 1653] [Impact Index Per Article: 150.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. METHODS We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. RESULTS Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. CONCLUSIONS Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).
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Affiliation(s)
- P P Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, USA.
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27
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Yan W, Xu R, Ma LL, Han W, Geevarghese SK, Williams PE, Sciammas R, Chong AS, Yin DP. B cells assist allograft rejection in the deficiency of protein kinase c-theta. Transpl Int 2013; 26:919-27. [PMID: 23841454 DOI: 10.1111/tri.12143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/29/2013] [Accepted: 06/10/2013] [Indexed: 11/28/2022]
Abstract
We have previously shown that mice deficient in protein kinase C theta (PKCθ) have the ability to reject cardiac allografts, but are susceptible to tolerance induction. Here we tested role of B cells in assisting alloimmune responses in the absence of PKCθ. Mouse cardiac allograft transplantations were performed from Balb/c (H-2d) to PKCθ knockout (PKCθ(-/-)), PKCθ and B cell double-knockout (PBDK, H-2b) mice and wild-type (WT) C57BL/6 (H-2b) mice. PBDK mice spontaneously accepted the allografts with the inhibition of NF-κB activation in the donor cardiac allograft. Anti-B cell antibody (rituximab) significantly delayed allograft rejection in PKCθ(-/-), but not in WT mice. Co-transfer of PKCθ(-/-) T plus PKCθ(-/-) B cells or primed sera triggered allograft rejection in Rag1(-/-) mice, and only major histocompatibility complex class II-enriched B cells, but not class I-enriched B cells, were able to promote rejection. This, together with the inability of PKCθ(-/-) and CD28(-/-) double-deficient (PCDK) mice to acutely reject allografts, suggested that an effective cognate interaction between PKCθ(-/-) T and B cells for acute rejection is CD28 molecule dependent. We conclude that T-B cell interactions synergize with PKCθ(-/-) T cells to mediate acute allograft rejection.
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Affiliation(s)
- Wenwei Yan
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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28
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Geevarghese SK, Geller DA, de Haan HA, Hörer M, Knoll AE, Mescheder A, Nemunaitis J, Reid TR, Sze DY, Tanabe KK, Tawfik H. Phase I/II study of oncolytic herpes simplex virus NV1020 in patients with extensively pretreated refractory colorectal cancer metastatic to the liver. Hum Gene Ther 2010; 21:1119-28. [PMID: 20486770 DOI: 10.1089/hum.2010.020] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This multicenter phase I/II study evaluated the safety, pharmacokinetics, and antitumor effects of repeated doses of NV1020, a genetically engineered oncolytic herpes simplex virus, in patients with advanced metastatic colorectal cancer (mCRC). Patients with liver-dominant mCRC received four fixed NV1020 doses via weekly hepatic artery infusion, followed by two or more cycles of conventional chemotherapy. Phase I included cohorts receiving 3 × 10(6), 1 × 10(7), 3 × 10(7), and 1 × 10(8) plaque-forming units (PFU)/dose to determine the optimal biological dose (OBD) for phase II. Blind independent computed tomography scan review was based on RECIST (response evaluation criteria in solid tumors) to assess hepatic tumor response. Phase I and II enrolled 13 and 19 patients, respectively. Patients experienced transient mild-moderate febrile reactions after each NV1020 infusion. Grade 3/4 virus-related toxicity was limited to transient lymphopenia in two patients. NV1020 shedding was not detected. Simultaneous cytokine and grade 1 coagulation perturbations were dose-limiting at 1 × 10(8) PFU/dose, considered the OBD. All 22 OBD patients had previously received 5-fluorouracil; most had received oxaliplatin or irinotecan (50% had both), many with at least one targeted agent. After NV1020 administration, 50% showed stable disease. The best overall tumor control rate after chemotherapy was 68% (1 partial response, 14 stable disease); this did not correlate with baseline variables or chemotherapy. Median time to progression was 6.4 months (95% confidence interval: 2, 8.9); median overall survival was 11.8 months (95% confidence interval: 8.3, 20.7). One-year survival was 47.2%. We conclude that NV1020 stabilizes liver metastases with minimal toxicity in mCRC. It may resensitize metastases to salvage chemotherapy and extend overall survival. A randomized phase II/III trial now appears justified.
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Affiliation(s)
- Sunil K Geevarghese
- Department of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University, Nashville, TN 37232, USA
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Saab S, Chang AJ, Comulada S, Geevarghese SK, Anselmo RDM, Durazo F, Han S, Farmer DG, Yersiz H, Goldstein LI, Ghobrial RM, Busuttil RW. Outcomes of hepatitis C- and hepatitis B core antibody-positive grafts in orthotopic liver transplantation. Liver Transpl 2003; 9:1053-61. [PMID: 14526400 DOI: 10.1053/jlts.2003.50208] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of hepatitis B core antibody (HBcAb)- and hepatitis C virus antibody (HCV+) liver grafts for transplantation in selected populations has not affected patient and graft survival. We reexamined the clinical outcomes of using these HBcAb+ and HCV+ grafts at our institution, in addition to studying recipients of combined HBcAb+/HCV+ grafts. We identified 377 patients who underwent transplantation for either hepatitis B and/or hepatitis C, or received both HBcAb+ and HCV+ grafts. Patient and graft survival at 5 years posttransplantation was 73% and 71%, respectively, in the HBcAb+ grafts compared with 81% and 75% in the HBcAb- grafts (P =.65; P =.94). For HCV+ grafts, patient and graft survival at 5 years posttransplantation was 89% and 73%, respectively, compared with 69% and 59% in the HCV- grafts; (P =.22; P =.77). The 5-year patient and graft survival rate in those who received combined HBcAb+/HCV+ grafts was 74% and 69%, respectively, and there was no statistical difference compared with the HBcAb+ and HCV+ grafts (P =.76; P =.90). The 5-year patient and graft survival rate in patients who received dual HBV prophylaxis with hepatitis B immunoglobulin (HBIg) and lamivudine was 88% and 84%, respectively, which was significantly higher than for patients who received single prophylaxis or no prophylaxis (P <.01; P =.02). Our study supports previous observations that patient and graft survival is not affected with the use of HBcAb+ and HCV+ grafts, and that dual prophylaxis with HBIg and lamivudine offers substantial survival benefits. Furthermore, the use of combined HBcAb+/HCV+ grafts did not impact patient or graft survival. This provides a potential new pool of donor livers that can be used for transplantation in select patients.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, Division of Digestive Diseases, Dumont-UCLA Liver Transplant Center, University of California Los Angeles, 90095, USA.
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Abstract
BACKGROUND Polycystic liver disease (PCLD) is an autosomal dominant disease characterized by multiple macrocystic lesions throughout the liver. The association between PCLD and cerebral aneurysm is well documented, and approximately 20% of patients with PCLD have demonstrable cerebral aneurysms at autopsy. The prevalence reported from autopsy series, however, may not reflect the true prevalence in patients with PCLD. We undertook this study to evaluate the prevalence and diagnosis of cerebral aneurysms in screening cerebral studies in patients with PCLD. METHODS Patients were identified by searching the hepatobiliary surgical service data base and hospital medical records. Hospital charts were reviewed to confirm presence of PCLD and to identify screening studies for cerebral aneurysms. RESULTS Ten patients with PCLD received screening studies of the cerebral vasculature during a 10 1/2-year period. One patient was found to have an asymptomatic cerebral aneurysm. A 45-year-old woman with no other significant medical history was referred for evaluation of PCLD. Screening magnetic resonance angiography (MRA) revealed a 5 mm aneurysm extending anteriorly near the origin of the right ophthalmic artery, without evidence of rupture. Cerebral angiography confirmed these findings, and the aneurysm was clipped. CONCLUSIONS Because cerebral aneurysms can be an important source of morbidity and mortality in PCLD, we recommend screening by MRA or by computed tomographic angiography (CTA) of the cerebral vasculature in all patients who have PCLD.
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Affiliation(s)
- S K Geevarghese
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn 37232-4753, USA
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31
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Geevarghese SK, Bradley AL, Atkinson J, Wright JK, Chapman WC, Van Buren DH, Blair KT, Hutchins CH, Jabbour K, Phillips J, Williams PE, Pinson CW. Comparison of Arcuate-Legged Clipped versus Sutured Hepatic Artery, Portal Vein, and Bile Duct Anastomoses. Am Surg 1999. [DOI: 10.1177/000313489906500404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 ± 1.1 minutes and 13.3 ± 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.
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Affiliation(s)
- Sunil K. Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne L. Bradley
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Atkinson
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J. Kelly Wright
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C. Chapman
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David H. Van Buren
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - K. Taylor Blair
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. H. Hutchins
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kareem Jabbour
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Phillips
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Phillip E. Williams
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. Wright Pinson
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
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Geevarghese SK, Bradley AL, Atkinson J, Wright JK, Chapman WC, Van Buren DH, Blair KT, Hutchins CH, Jabbour K, Phillips J, Williams PE, Pinson CW. Comparison of arcuate-legged clipped versus sutured hepatic artery, portal vein, and bile duct anastomoses. Am Surg 1999; 65:311-6. [PMID: 10190352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 +/- 1.1 minutes and 13.3 +/- 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.
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Affiliation(s)
- S K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, S.R. Light Surgical Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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33
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Geevarghese SK, Flakoll P, Bradley AL, Wright JK, Chapman WC, Van Buren D, Sika M, Blair KT, Jabbour K, Williams PE, Hutchins CH, Phillips JL, Pinson CW. The effect of nutritional and hormonal supplementation on protein synthesis immediately after liver transplantation. J Surg Res 1999; 81:196-200. [PMID: 9927540 DOI: 10.1006/jsre.1998.5509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have previously shown that immediately after liver transplantation (LT) the porcine recipient exhibits elevated plasma glucagon, increased fractional synthetic rate (FSR) of fibrinogen, and decreased FSR of fixed or structural liver proteins. The purpose of this study was to evaluate the effect of nutritional and hormonal supplementation on these observations 24 h after LT. Two groups of nine pigs were studied 1 day after LT using radioisotopic and arteriovenous difference techniques. A control group underwent LT with saline infusion and a supplemented group underwent LT with infusion of glucose, amino acids (6 and 1.06 mg/kg. min, respectively), and intraportal insulin (0.6 mU/kg. min) and glucagon (1.3 ng/kg. min). Primed constant infusions of [3H]leucine were used to determine leucine flux, an estimate of whole body protein breakdown, and fractional synthetic rates (FSR). The following changes were noted with supplementation: elevated plasma insulin (6 +/- 1 versus 29 +/- 4 microU/ml, control versus supplemented, respectively, P < 0.05), decreased glucagon to normal levels (323 +/- 65 versus 102 +/- 12 pg/ml, P < 0.05), decreased fibrinogen FSR (108 +/- 15 versus 70 +/- 6%/day, P < 0.025), and increased fixed liver protein FSR (8 +/- 1 versus 13 +/- 2%/day, P < 0.05, respectively). Albumin FSR was unaltered by supplementation (8 +/- 2 versus 6 +/- 1%/day, respectively). Nutritional and hormonal supplementation immediately after LT restored the measured protein synthesis in the allograft to near normal levels 1 day after transplantation.
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Affiliation(s)
- S K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation and Section of Surgical Sciences, Vanderbilt University Medical Center. Nashville, TN, USA
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Abstract
BACKGROUND There is an increasing demand for outcomes analysis, including quality of life and financial analysis, following medical interventions and surgical procedures. We analyzed outcomes for 100 consecutive patients undergoing liver transplantation during a period of case management revision. METHODS Patient survival was calculated by Kaplan-Meier actuarial methods. The Karnofsky performance status was objectively assessed for surviving patients up to 6 years after transplantation and was evaluated by repeated measures analysis of variance and covariance. Subjective evaluation of quality of life over time was obtained using the Psychosocial Adjustment to Illness Scale. The correlations between time and scale were calculated. Financial data were accumulated from billing records. RESULTS Six-month, 1-year, 2-year, and 3- through 5-year survival was 86%, 84%, 83%, and 78%, respectively. Karnofsky performance status confirmed poor functional status preoperatively with a mean of 53 +/- 2, but significantly improving to 72 +/- 2 at 3 months, 80 +/- 2 at 6 months, 90 +/- 1 at 1 year, 92 +/- 1 at 2 years, 94 +/- 1 at 3 years, 96 +/- 1 at 4 years, and 97 +/- 1 at 5 years (P <0.001). Psychosocial Adjustment to Illness Scale scores demonstrated significant improvement following transplantation overall (r = -0.33), improving most in sexual relationships (r = -0.41), and domestic environment (r = -0.35; P <0.001). Median length of stay for the first half of the patients was 19 days declining to 11 days for the second half. Median hospital charges declined from $105,000 to $90,000. CONCLUSIONS Quality of life parameters assessed both by care givers (Karnofsky) and by patients (Psychosocial Adjustment to Illness Scale) improved dramatically following transplantation and over time, demonstrating that liver transplantation effectively restores a good quality of life. Outcomes can be improved while reducing length of stay and charges through modifications in case management.
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Affiliation(s)
- S K Geevarghese
- Division of Liver Transplantation and Hepatobiliary Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-4753, USA
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Abstract
Close to birth rat fetuses have lungs which are depleted in retinyl esters. Glucocorticoids administered to pregnant rats accelerate this process. We have investigated changes in fetal lung levels of retinol and retinyl palmitate and accompanying morphological changes after administration of dexamethasone to pregnant rats on day 18 of pregnancy. Here we show that this depletion temporarily coincides with prenatal morphological maturation of the lungs. The data presented support the idea that the maturational effect of glucocorticoids in the developing lungs is linked to vitamin A metabolism.
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Affiliation(s)
- S K Geevarghese
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-0146
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