Surgery Commons^™

Successful Management Of Severe Liver Failure On Venoarterial Extracorporeal Membrane Oxygenation Using Molecular Adsorbent Recirculating Systeme., Shigeki Tabata, Nicholas Cavarocchi, Hitoshi Hirose

Department of Surgery Faculty Papers

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy.

Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on …

Venoarterial Extracorporeal Membrane Oxygenation (Ecmo) For Support During Whole Lung Lavage For Pulmonary Alveolar Proteinosis., Hitoshi Hirose, Julie Monteagudo, Nicholas C. Cavarocchi, Boyd Hehn, Naveed Hasan

Department of Surgery Faculty Papers

INTRODUCTION ECMO as support during whole lung lavage (WLL) for pulmonary alveolar proteinosis is reserved for severe cases where oxygenation is inadequate to support the patient using the ventilator alone. While most publications describe a venovenous cannulation with variable results we present a successful case using venoarterial cannulation and discuss the potential benefits of this mode of ECMO support. CASE PRESENTATION We present the case of a 44 year old female with a past medical history of Behcets disease and a BMI of 37 who was diagnosed with pulmonary alveolar proteinosis (PAP) on a lung biopsy after presenting with dyspnea. …

Novel Approach To Monitoring Renal Perfusion With The Use Of Continuous Renal Oximetery In The Setting Of Aortic Dissection, Hitoshi Hirose, Philip Batista, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

INTRODUCTION: Aortic dissections commonly extend beyond the renal arteries with varying effects ranging from asymptomatic to renal failure. We report a case of aortic dissection with initial renal compromise, which was continuously monitored utilizing direct renal oximetry for evaluation of real-time renal perfusion and function. CASE PRESENTATION: A 65 year-old female with a long history of uncontrolled hypertension presented with acute retrosternal chest pain radiating to the back for 12 hours. She was in stable condition except for a serum creatinine of 1.6mg/dl. Magnetic resonance angiography (MRA) demonstrated a type A dissection extending from the aortic root to the left …

Sternal Pain After Rigid Fixation: A Pilot Study Of Randomization Rigid Vs Conventional Wire Closure., Hitoshi Hirose, Hong Mun Kong, Shigeki Tabata, Kentaro Yamane, Margaret Lusardi, Linda J. Bogar, James Diehl

Department of Surgery Faculty Papers

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among …

Fate Of The Lower Extremity In Patients With Va-Ecmo Via Femoral Cannulation, Hitoshi Hirose, Kathleen Lamb, Neil Moudgill, Paul Dimuzio, Megan Mccullough, Pawel Karbowski, Atul Rao, Nicholas Cavarocchi, Joshua Eisenberg

Department of Surgery Faculty Papers

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Femoral cannulation is associated with limb complications including ischemia, limb loss, arterial infections and wound infections. This study aims to evaluate these complications and management related to successful outcomes. Methods: A retrospective review was conducted in 17 patients requiring VA- ECMO support via femoral cannulation from 1/ 2010 till 4/2012. After cannulation, all patients had near infared spectroscopy (NIRS) monitoring after cannula placement and most had placement of distal arterial perfusion catheters (DPC). At decannulation, all patients had femoral cutdown with closure of arteriotomies …

Percutaneous Gastrostomy (Peg) Tube Placement In Patients With Continuous Flow Left Ventricular Assist Device. (Lvad)., Hitoshi Hirose, Chris Rizzi, Linda Bogar, Jay S. Jenoff, Nicholas Cavarocchi

Department of Surgery Faculty Papers

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD). CHRIS RIZZI, BS, Linda Bogar, MD, Jay Jenoff, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Thomas Jefferson University, Philadelphia, PA. Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. The LVAD patients with complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 …

Successful Liver Failure Management Using Molecular Adsorbents Recirculating System During Complicated Veno-Arterial Extracorporeal Membrane Oxygenation As A Bridge To A Left Ventricular Assist Device Placement, Hitoshi Hirose, Shigeki Tabata, Nicholas Cavarocchi

Department of Surgery Faculty Papers

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement. SHIGEKI TABATA, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Division of Cardiothoracic Surgery Thomas Jefferson University Hospital, Philadelphia, PA Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the patients with cardiogenic shock. We present a patient who developed severe complications while on ECMO. Case presentation: A 49-year-old female presented with severe heart failure and was placed on veno-arterial ECMO for bridge to decision. While on ECMO, the patient developed massive …

Recovery Of End-Organs And Improved Mortality In Adult Patient On Ecmo., Hitoshi Hirose, Joshua Wong, Vei Shaun Siow, Thomas N. Smith, Harrsion Pitcher, Linda Bogar, Nicholas C. Carvarocchi

Department of Surgery Faculty Papers

Title: Recovery of End-Organs and Improved Mortality in Adult Patients on ECMO Joshua K Wong, BS1, Vei Shaun Siow, BS1, Thomas N Smith, BS1, Harrison Pitcher, MD2, Linda Bogar, MD2, Hitoshi Hirose, MD2 and Nicholas C Cavarocchi, MD2. 1Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States, 19107 and 2Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States, 19107. Body: With increasing use of ECMO in adults, we seek to objectively measure End-Organ recovery and correlate intensive care mortality scores and complications with patient survival. This is a retrospective review of patients who were placed on …

Efficacy Of Miniaturized Imacor Trans-Esophageal Echocardiografm (Tee) Prove In Mechanical Circulatory Support., Hitoshi Hirose, Christopher Y. Kang, Joshua K. Wong, Harrison T. Pitcher, Caitlyn M. Johnson, Konrad Sarosiek, Linda J Bogar, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

Application of the miniaturized ImaCor Trans-Esophageal Echocardiogram (TEE) probe in Heart Transplant/Mechanical Cardiac Support Patients In the surgical cardiac care unit (SCCU), therapeutic interventions often need to be done at the bedside, necessitating the need for a rapidly employable diagnostic tool for the cardiac intensivist. We report the clinical utility of the miniature ImaCor TEE-probe in guiding management of post heart transplant (H-Txp) and mechanical cardiac support patients (MCS) and describe the economic benefit of such a device. This is an IRB approved retrospective review of MCS/H-Txp patients who had ImaCor TEE monitoring in the SCCU of our institution in …

An Old Problem With A New Therapy: Gi Bleeding In Vad Patients And Deep Bowel Enteroscopy (Double Balloon. Spiral Enteroscopy)., Hitoshi Hirose, Konrad Sarosiek, Linda Bogar, Pitcher Harrison, Barbara Ebert, Nicholas Cavarocchi

Department of Surgery Faculty Papers

An old problem with a new therapy: GI Bleeding in VAD patients and deep bowel enteroscopy (Spiral and Double Balloon Enteroscopy) Purpose: Evidence suggests that patients treated with non-pulsatile ventricular assist devices (VAD) are at an increased risk for gastrointestinal bleeding (GIB) beyond what is expected from routine anticoagulation. Diagnostic and treatment algorithms are currently undefined. We reviewed our experience of GIB in VAD patients and propose a new algorithm utilizing deep bowel enteroscopy (DBE) aimed to speed diagnosis and limit transfusions. (471) Methods & Procedures From 2004 to 2011, we studied 62 patients who received a non-pulsatile VAD at …

Quantitative, Spectrally-Resolved Intraoperative Fluorescence Imaging, Pablo A. Valdés, Frederic Leblond, Valerie L. Jacobs, Brian C. Wilson, Keith D. Paulsen, David W. Roberts

Dartmouth Scholarship

Intraoperative visual fluorescence imaging (vFI) has emerged as a promising aid to surgical guidance, but does not fully exploit the potential of the fluorescent agents that are currently available. Here, we introduce a quantitative fluorescence imaging (qFI) approach that converts spectrally-resolved data into images of absolute fluorophore concentration pixel-by-pixel across the surgical field of view (FOV). The resulting estimates are linear, accurate, and precise relative to true values, and spectral decomposition of multiple fluorophores is also achieved. Experiments with protoporphyrin IX in a glioma rodent model demonstrate in vivo quantitative and spectrally-resolved fluorescence imaging of infiltrating tumor margins for the …

T-Cell Activation Is Enhanced By Targeting Il-10 Cytokine Production In Toll-Like Receptor-Stimulated Macrophages, Ryan Walk, Steven Elliott, Felix C. Blanco, Jason A. Snyder, Ashley M. Jacobi, Scott Rose, Mark Behlke, Aliasger Salem, Stanislav Vukmanovic, Anthony D. Sandler

Surgery Faculty Publications

Toll-like receptor (TLR) agonists represent potentially useful cancer vaccine adjuvants in their ability to stimulate antigen-presenting cells (APCs) and subsequently amplify the cytotoxic T-cell response. The purpose of this study was to characterize APC responses to TLR activation and to determine the subsequent effect on lymphocyte activation. We exposed murine primary bone marrow-derived macrophages to increasing concentrations of agonists to TLRs 2, 3, 4, and 9. This resulted in a dose-dependent increase in production of not only tumor necrosis factor–alpha (TNF-α), a surrogate marker of the proinflammatory response, but also interleukin 10 (IL-10), a well-described inhibitory cytokine. Importantly, IL-10 secretion …

Foleys Protection Caps: Inexpensive Alternative In Ilizarov Fixation, K Abbas, H Rashid

Section of General Surgery

No abstract provided.

John Y. Templeton Iii: Pioneer Of Modern Cardiothoracic Surgery., Jing Li, B.S., Herbert E. Cohn, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

John Young Templeton III was born in 1917 in Portsmouth, Virginia, and graduated from Jefferson Medical College in 1941. He completed his residency training under Dr. John H. Gibbon, Jr., and was the first resident who worked on Gibbon's heart-lung machine. After his training, he remained at Jefferson as an American Cancer Society fellow and Damon Runyon fellow and went on to become the fourth Samuel D. Gross Professor and Chair of the Department of Surgery in 1967. Dr. Templeton was the recipient of numerous grants and published over 80 papers in the field of cardiothoracic surgery. As a teacher …

Initial Experience With Imacor Htee-Guided Management Of Patients Following Transplant And Mechanical Circulatory Support., Christopher Kang, Hitoshi Hirose, Harold Hasting

Department of Cancer Biology Faculty Papers

We reviewed an initial experience using a miniaturized transesophageal echocardiography (TEE) probe (ImaCor, Garden City, NY) with 3 patients in whom Imacor hTEE intervention was used as a point of care device to manage extracorporeal membrane oxygenation cannula placement, cardiac hemodynamics, and post-op cardiac pathophysiology. The management of transplant or mechanical circulatory support (MCS) patients is especially challenging: transplanted hearts pose unique pathophysiological challenges, and MCS significantly alters pressure-volume-flow relationships. Real-time “hemodynamic” TEE (hTEE) can help provide effective management by direct visualization of cardiac filling and function and help guide hemodynamic management. In our initial experience, hTEE can provide point-of-care …

Knowledge Attitude And Practices Among Urban Women Of Karachi, Pakistan, Regarding Breast Cancer, Zain-Ul-Abedeen Sobani, Zeb Saeed, Hafiza Noor-Ul-Ain Baloch, Amina Majeed, Sana Chaudry, Adil Sheikh, Jalal Umar, Hira Waseem, Murtaza Mirza, Irfan Qadir

Department of Surgery Docs

Objective: To determine the knowledge,attitudes and practices of urban women regarding breast cancer and its available screening modalities.Methods: The cross-sectional, questionnaire-based, descriptive study was conducted in the urban population of Karachi in November 2010. Female attendants (n=373) visiting a tertiary care centre and four of its urban outreach centres during the study period were administered a questionnaire. The answers were then scored with regard to their knowledge. Frequencies and percentages were computed through SPSS 17, and analysis of variance was used to confirm significance.Results: Of the 373 participants with a mean age of 32.4+/-10.9 years, 293 (78.6%) were married, and …

Knowledge Of Patients' Visual Experience During Cataract Surgery: A Survey Of Eye Doctors In Karachi, Pakistan, Mohammad Zain Tauqir, Tanveer Anjum Chaudhry, Sehreen Mumtaz, Khabir Ahmad

Department of Surgery Docs

Abstract

BACKGROUND:

Several recent studies have recommended that ophthalmologists must be aware of the visual sensations (and their associated anxiety/fear) experienced by patients undergoing cataract surgery. We assessed the knowledge of a group of eye doctors in Pakistan regarding these phenomena.

METHODS:

This was a cross-sectional survey. Eye doctors (ophthalmologists, residents and medical officers) attending the Ophthalmological Society of Pakistan Annual Conference 2011, in Karachi were invited to participate in the study. A self-administered structured questionnaire was used to examine their knowledge of visual sensations and their associated anxiety/fear experienced by patients during cataract surgery. Simple frequencies and proportions were …

Association Between Tumour Volume And Recurrence Of Squamous Cell Carcinoma Of The Head And Neck, Faraz Nasim Kazmi, Amina Adil, Shehzad Ghaffar, Farhan Ahmed

Section of Otolaryngology, Head & Neck Surgery

Objective: To evaluate the prognostic significance of computerized tomography derived tumour volume for squamous cell cancers of the head and neck, treated primarily by surgery.Methods: The retrospective review study comprised 72 patients with head and neck malignancies who were treated primarily by surgery at Aga Khan University Hospital, Karachi, with/without adjuvant. It was done from May 2007 to November 2008. Each patient was followed up for a minimum of one year to check for recurrence. For statistical analysis SPSS 17 was used. Frequencies, cross-tabulations with chi square tests to find associations, binary logistic regression analysis, Cox regression analysis and receiver …

Successful Management Of Bleeding Complications In Patients Supported With Extracorporeal Membrane Oxygenation With Primary Respiratory Failure., K Lamb, Sw Cowan, N Evans, H Pitcher, T Moritz, M Lazar, H Hirose, Nc Cavarocchi

Department of Cancer Biology Faculty Papers

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. METHODS: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. RESULTS: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. …

Enhancing Resident Education By Empowering The Learner Through The Creation Of Smartphone Applications, Christine W. Du Md, Dale A. Dangleben Md, Judith A. Olenwine Ms, C-Tagme, Michael M. Badellino Md

Department of Surgery

No abstract provided.