A Second Opinion on Gastric Banding


As a group of concerned bariatric surgeons and leaders in our field, in our communities, in our states and in the national societies, we would like to share our perspective on adjustable gastric banding (AGB), a misunderstood surgical procedure for weight loss that has helped hundreds of thousands of patients since its original introduction in 1993.

To start, we would like to offer some clinical background: Obesity is a chronic disease in need of long-term, often lifelong, treatment. To date, bariatric surgeons have been unable to identify any single surgical procedure that, without resulting in lifelong nutritional deficiencies, would offer durable results beyond the first few years after surgery. If such an operation existed, we would perfect the technique and offer it to all of our patients at a young age, and that would be all the patients would ever need. However, much like treatment of other chronic diseases—such as coronary artery disease and osteoarthritis—multiple interventions during the life of a patient are needed. And the most prudent approach would start with least invasive interventions and extend to more invasive surgical procedures, in an orderly fashion.

The article in General Surgery News is based on a report published in JAMA(2017 May 17. [Epub ahead of print]). This report simply suggests that it costs a lot of money when AGB patients undergo subsequent surgical interventions. What the authors have failed to offer is a reasonable comparison between cost of subsequent operations after initial AGB versus after other primary bariatric operations, such as sleeve gastrectomy or gastric bypass surgery.

In fact, the report has left us with more questions than much-needed answers:

The JAMA article suggests that 81.5% of all patients who underwent AGB since 2006, with a mean follow-up of more than four years, required no further surgical interventions whatsoever. These results are the most impressive among all published data in the English language and are unparalleled when compared with results for all other bariatric interventions. We wonder why such incredibly positive results are published with a negative undertone.

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We question the entire premise of the JAMA report. The motives for this investigation remain unclear to us. Imagine what would happen if the legitimacy of coronary artery angioplasty with stent placement were to be judged by the cost of future additional endovascular interventions and/or open-heart surgery. Using the logic offered by the investigators, we should stop offering angioplasty and stents to all cardiac patients and proceed to coronary artery bypass grafting (open-heart surgery) from the start.

The data presented remain unclear and ambiguous to us. The authors reported that among the 18.5% of patients who underwent additional interventions following AGB, the mean number of procedures was 3.8, and some patients had as many as 12 subsequent operations. Since the patients of most proponents of AGB often undergo either only one additional operation (removal of the band with or without simultaneous conversion to an alternative bariatric procedure) or two (removal and conversion to another operation at a later date, or revision and subsequent removal of the original band at a later date), we can only speculate on the reasons for the highly unusual data:

  • assignment of inaccurate International Classification of Diseases, Ninth Revision codes during subsequent hospitalizations for patients who were initially coded as an AGB patient;
  • inclusion of procedures to address post-stapling complications in patients who had their bands removed and were subsequently converted to a stapling procedure;
  • performance of multiple operative interventions on AGB patients by surgeons who have no familiarity with the gastric band and its aftercare; and
  • inadvertent billing for up to 12 surgical procedures when indeed such procedures were never performed.

Without similar data presented for other primary bariatric procedures, we believe the publication of the report in JAMA was entirely premature and misleading. Imagine how different our conclusions would have been had we looked at cost of follow-up interventions for Medicare recipients undergoing gastric bypass surgery with no similar results available for patients undergoing sleeve gastrectomy or AGB.

Is there any doubt that subsequent surgical procedures on AGB patients are costly? Absolutely not. Should we, therefore, conclude that AGB should not be reimbursed by Medicare and other payors? Absolutely not. AGB remains one of the safest and most effective bariatric interventions that is both adjustable and easily reversible due to its anatomy-preserving nature. It would be a great disservice to dissuade the self-educating public through publication of such inflammatory reports based on inaccurate and misinterpreted data.

In summary, we are disappointed by the misleading report and the misguided conclusions of the paper. We are equally disappointed with JAMA for accepting this report for publication without paying attention to the details of the data presented. And we are grateful for General Surgery News for having given us the opportunity to provide a much-needed second opinion on the utility of one of the most effective surgical procedures for treatment of morbid obesity.

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A 31-Year-Old Man to Undergo World’s First Human Head Transplantation


Throughout the last century, there were many significant advances in the medical field that could have been easily considered miracles in the past. With the development of antibiotics, advanced surgical procedures, and other medical treatments, life expectancy has increased exponentially. Though we are still far from gaining the knowledge and medical expertise to treat all diseases, we are on a path towards that goal as the first human head transplant is planned to take place in December this year.

In 2015, Dr. Sergio Canavero, an Italian neurosurgeon, has said that with improved technology and the ability to more accurately supply the neural tissue with fluids, it should be possible to successfully perform a head transplant by the end of 2017. In December he intends to perform the surgery. 

Dr. Sergio Canavero

According to Dr. Canavero, the surgery would take around 36 hours to perform and involve 150 members of medical support staff. After spending 30 years on research, he has devised a two-part procedure for the transplant. He calls the procedure “HEAVEN” (HEad Anastomosis VENture) and “GEMINI” (subsequent spinal cord transplant). The surgery would be performed on the recipient Valery Spiridonov, and a brain-dead donor who matches Spiridonov’s height, build, and immunotype. The donor will be screened beforehand to assure the absence of active systemic and brain disorders.

A 31-year-old Russian programmer Valery Spiridonov who suffers from Werdnig-Hoffmann disease, a highly debilitating and degenerative muscle atrophy disease,  has volunteered to undergo the head transplant surgery. In December 2017, he will become the first ever human to do so. 

Valery Spiridonov

The Werdnig-Hoffmann disease is a type 1 spinal muscle atrophy (SMA) and the most severe form of SMA. It is most commonly seen in newborn babies. It causes the death of motor neuron cells and progressive muscle wasting, eventually leading to death. The disease has left Spiridonov confined to a wheelchair and dependent on other people to help him every day in various tasks. He has stated in an interview that,

“Today my life is pretty tough, I need to rely on people to help me every day – even twice a day because I need someone to take me off my bed and put me in my wheelchair. It makes my life pretty dependent on other people. If there is a way to change this, I believe it should be tried and used.”

First, the muscles and the blood vessels in the neck are cut after freezing the head to avoid damage to brain cells. Then, the spinal cord is cut using a diamond nanoblade. Finally, the spinal cords will be fused, and the blood vessels and muscles are connected to those of donor’s body. 

Carotid Arteries and Cervical Spine of a Human
Image Source: Henry Grey’s Anatomy of Human Body

During the first phase of the surgery, two teams will work together to make deep cuts in the neck exposing the carotid and vertebral arteries, jugular vein, and the spine. A few more cuts will be made to give access to the trachea and esophagus. The muscles will be color-coded so that they could be attached correctly later. After that, the spinal cords of both the patient and the donor will be cut simultaneous using a $200,000 diamond nanoblade. All of this has to be done within an hour to minimize any brain damage.

The head is then immediately transferred to the donor’s body and the spinal cords are adjusted and fused within one or two minutes. In the next fifteen to thirty minutes, the blood vessels would be connected using chitosan-PEG (polyethylene glycol) glue to start circulation and theoretically warm up the head. The layer surrounding the spinal cord, the dura, will then be stitched, and the trachea, esophagus, vagi and phrenic nerves will also be connected. Finally, the muscles will be connected and the skin sewn by a plastic surgeon.

Once the surgery is done, the recipient will be kept in a coma for three to four weeks in order to avoid any ruptures of the sutures. Immunosuppressants will also be given to avoid rejection, just like for other transplant patients. 

Transplanting a head has been attempted a few times in the past on dogs and monkeys. Recently, a team led by Dr. Xiaoping Ren of Harbin Medical University of China has conducted a head transplant on a monkey based on the research of Dr. Canavero. However, the surgery did not include connecting the spinal cord and only the blood vessels were connected. According to Dr. Canavero, the monkey fully survived and suffered no neurological damage. It regained consciousness within three to four hours and was kept alive only for twenty hours due to ethical reasons. Though many people have expressed skepticism about medical technology advancing enough to make the surgery a success in humans, Dr. Canavero and Spiridonov believe it is not impossible.

Denmark Doctors Declare Circumcision Of Healthy Boys ‘Ethically Unacceptable’


Except within the small Muslim and orthodox Jewish communities, people in Denmark wonder why on Earth any parents would want to have their precious newborn child held down to have a part of his healthy, yet immature, penis cut off. According to a nationally representative poll from the summer of 2016, 87 percent of Danes favor a legal ban on non-therapeutic circumcision of boys under the age of 18 years. So far, politicians have been hesitant, but increasingly willing to listen.

Doctors and medical organizations in Denmark, the other Nordic countries and, with one notable exception, elsewhere in the Western world agree that circumcision of healthy boys is ethically problematic. It is considered an operation seriously and patently at odds with the Hippocratic oath (”first do no harm”) and one that is in conflict with a variety of international conventions, most notably the U.N. Declaration of the Rights of the Child.

The one Western country that is out of sync with its international peers is the United States, whose federal health authorities and national associations of pediatricians, obstetricians, family physicians and urologists endorse and perform most of these medically unnecessary operations in the country. Amputation of healthy infant foreskins constitutes the single most common surgical procedure in the United States ― a several hundred million dollars a year industry.

Internationally, several medical associations have issued policies and recommendations that contradict the popular belief in the United States that infant male circumcision is a harmless, health-promoting procedure. In fact, not one medical association in the whole world recommends circumcision of healthy boys.

In December of 2016, the Danish Medical Association published its revised policy on circumcision. Speaking on behalf of its 29,185 members, the new policy came out in an unusually clear voice. Its central passage goes like this (my unofficial translation):

Circumcision of boys without a medical indication is ethically unacceptable when the procedure is carried out without informed consent from the person undergoing the surgery. Therefore, circumcision should not be performed before the boy is 18 years old and able to decide whether this is an operation he wants.

Many Americans, who grew up in a culture whose medical authorities and mass media promote the view that an intact penis is dangerous, prone to infection, ugly and difficult to keep clean, may wonder what the penile health situation would be like in a country like Denmark, where few boys undergo circumcision. Of course, occasional intact men will encounter penile problems during their lifetime, just like people with natural teeth or appendices may develop cavities or appendicitis at some point later on. However, removing such healthy body parts on every child to prevent rare conditions in adulthood, that may be easily and effectively treated if and when they occur, is outright bad medical practice and ethics. So, why remove a healthy, functional and sensitive part of a child’s penis?

Indeed, a study published in Pediatrics in 2016 documented that only around one in 200 intact boys will develop a medical condition necessitating a circumcision before the age of 18 years. In other words, the chance is around 99.5 percent that a newborn boy can retain his valuable foreskin throughout infancy, childhood, and adolescence and enter adulthood with an intact penis. Simple information like this should urge parents to abstain from unnecessary infant surgery and let their sons decide for themselves about the size, sensitivity, functionality and appearance of their manhoods once they get old enough to understand the consequences.

In the fairytale The Emperor’s New Clothes by Danish author Hans Christian Andersen, a child too young to understand the desirability of keeping up the pretense that the emperor is wearing costly, elegant clothes when, in fact, he has nothing on, blurts out that the emperor is wearing nothing, and the cry is taken up by others. By speaking out frankly and without the usual diplomacy of such position papers, the Danish Medical Association impersonates that uncorrupted child shouting out against the falsehood, vanity and greed that has upheld the Empire of Circumcision for far too long.

In 2015, I urged U.S. parents to reconsider the moral acceptability of cutting a healthy, erogenous part off their sons’ penises. Now, at the beginning of 2017, I expand my call, and urge health professionals and payers, such as health insurers and Medicaid, to discourage circumcision of healthy boys and work to end the practice. No individual too young to provide informed consent to elective surgery should be subjected to an irreversible procedure that is painful, comes with risks, alters a natural, functional body part, has no relevant health benefits during childhood, causes pathological narrowing of the urethral opening in 5 percent -20 percent of boys, and – as stated by the Danish Medical Association – is ethically unacceptable.

 

Triplet babies make medical history after all braving procedure for rare skull condition


The surgeries were performed when they were just 11 weeks old.

Surgeons in New York have performed skull surgery on tripletinfants for the first time ever.

Amy Howard gave birth to Jackson, Hunter, and Kaden in October 2016. She and husband Michael are first-time parents and Ms Howard she “was terrified [of having triplets]. It took me a little bit of time to get used to the idea, to be honest.”

The babies were born on time but were soon diagnosed with craniosynostosis, a rare disorder when the bones in a baby’s skull fuse together too early.

Only one in 2,500 children are born with the disorder so for all three infants to have it is even rarer.

Dr. David Chesler, a pediatric neurosurgeon at the hospital, said in a statement that children’s brains were “put under pressure…That can be detrimental to the brain, the vision, the life of the child. It’s not imminently life-threatening, but it can cause real consequences down the road.”

The surgeries were performed in January 2017 when the babies were just 11 weeks old. According to the hospital, the required surgery had never been performed on triplets ever before.

Mr Chesler said that it was an endoscopic surgery, meaning it was done with smaller incisions rather than a more invasive open-skull surgery and it allowed them to return home within a few days.

The children are required to wear special helmets for up to 23 hours a day over six to nine months in order to shape their skulls as they grow.

Now five months old reported that the babies’ skulls are growing into a normal shape and they are hitting their developmental targets.

Mr Howard told Today that life is “a little chaotic. It’s awesome, I wouldn’t change it for the world.”

How doctors are reducing opioid use after surgery


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Opioid addiction is now a national crisis, and doctors worry that abuse too often begins when surgical patients are given prescriptions for large numbers of pain pills.  Orthopedic teams are rethinking how they manage pain, often employing a cocktail of drugs designed to reduce pain and inflammation in the crucial first days after surgery.  If patients can keep opioid use to a minimum then, the thinking goes, they’ll use fewer of the pills in total and switch to less dangerous medications faster.

While waiting in the pre-op area, Zeller took doses of Tylenol and gabapentin, an anti-seizure drug also used for nerve pain, with a sip of water.

 Just before surgery, anesthesiologist Nabil Elkassabany threaded a catheter the diameter of fishing line between nerves in Zeller’s neck with the help of ultrasound imaging.  The catheter would bathe the nerves around her shoulder with ropivacaine, a local anesthetic that would numb her arm so completely that she could stay awake during surgery if she wanted to.  (She did, but only long enough to see just how badly her muscles were torn.)

Glaser would also inject some numbing medicine directly into the surgical site.

The catheter for the regional pain block went home to Rumson, N.J. with Zeller, keeping her shoulder and arm numb for 2½ days.  She was instructed to take Tylenol, gabapentin, and ketorolac  for the first few days.

 She also got a prescription for low-dose oxycodone — an opioid — and was told she could take it if needed, but she didn’t have to.   For longer-term pain, she was to take over-the-counter drugs such as Tylenol or ibuprofen.

Two days after her surgery, Zeller’s pain was well under control.  The pump was still working and she had taken only a few of the 5 mg oxycodone pills.  Her goal matched her doctors’: to take as few opioids as possible.  “My best friend died because she became addicted to this kind of stuff,” said Zeller, 53, a home companion who was hurt during a fall in February.  “I miss her every day, so this stuff scares the living daylights out of me.”

Zeller’s care was typical of a trend sweeping surgery: “multi-modal” pain control that de-emphasizes opioids. Orthopedic surgeon Richard Rothman, founder of Philadelphia’s Rothman Institute, now also injects a combination of Marcaine, an anesthetic; ketorolac; and epinephrine, which controls bleeding, directly into the surgical site after he replaces a knee or hip. That “greatly improves” pain after surgery, he said.  Lewis Kaplan, section chief for surgical critical care at Philadelphia’s Michael J. Crescenz VA Medical Center, said intravenous Tylenol is commonly used during surgery at his hospital.  Spinal-numbing agents are also helpful in abdominal surgery.

Using small doses of several medicines that work in different ways allows some surgical patients to avoid opioids altogether. Doctors are also prescribing fewer opioid pills at a time, so patients are not left with dozens of unused pills or given the idea they should finish all those Percocets as if they were antibiotics. Doctors are resetting expectations, telling patients how  many pills most people need —  not very many — and they are asking more questions when patients want to take opioids  for weeks instead of days.

At the Philadelphia VA, all surgical patients meet with a pharmacist before picking up their medicines at the pharmacy and going home.  Richard Bright, 66, of Ardmore, talked with pharmacist Andrew Rogalski after surgery to clean and repair blood vessels needed for dialysis. Bright had prescriptions for Tylenol and oxycodone.  Rogalski told him he could break the oxycodone pills in halves or quarters. “Use only what you need, because the more you take, the more side effects you get,” he said. He pointed out that Bright could put any unused pills in a drop box near the VA Center’s police office.

Richard Bright, left, talks with Pharmacist Andrew Rogalski, right, at the VA Hospital in Philadelphia, Thursday, March 23, 2017. At the VA Hospital every patient who gets a prescription for opioids after surgery receives one-on-one time for questions and information with a pharmacist.

Doctors are also talking about pain itself differently. Many pain experts now think it was a mistake to call pain a “vital sign” and lead patients to think they could avoid it entirely. That led to greater use of addictive medicines.  Doctors now are more likely to tell patients to expect some pain, but also to expect that the worst of it will be gone within a few days.

Kaplan finds it helpful to talk to patients about how pain is affecting them, not whether they’re having it.   He has had multiple surgeries himself.  “I wake up with a pain score of six,” he said.  “This is an acceptable pain score for me.”  If it reaches eight,  he said, he takes a Tylenol.  At nine, he soaks in a hot tub.  His patients may not be that hard-core, but talking this way dramatically changes the discussion. “Your expectation will not be zero pain,” he said.

When he was a resident in the early 1990s, patients whose colons were removed would go home with 45 to 60 oxycodone pills.  Now they get about 15.

Eugene Viscusi, director of pain management at  Thomas Jefferson University, said American surgeons are “generous” with opioids compared with doctors in the rest of the world.  Elsewhere, he said, “you will not get a big bottle of opioids when you leave.”  Patients do fine with Tylenol and  anti-inflammatory drugs such as ibuprofen or Alleve.  “Their pain control is not inferior,” he said.

Like other pain specialists, he said that some drugs are better than opioids for many kinds of pain. Patients should not think they’re being  “shortchanged” if doctors don’t give them opioids. Some think over-the-counter medications are weak.  “Most patients still want the good stuff,” he said. “There’s still this pro-opioid bias.”

 Ira Kirshenbaum, chair of orthopedic surgery at Bronx Lebanon Hospital, has encountered that reaction, too. “Some of this good stuff is other stuff,” he tells patients.

His knee was replaced last year, and he took a total of three 10 mg oxycodones. “I saw firsthand. I was very well-controlled with anti-inflammatories and Tylenol,” he said, “and I was not being a hero.”

Over the last five or six years, many hospitals have begun making greater use of regional blocks such as the one Zeller got, both in surgery and after patients go home, Elkassabany said.   Ed Mariano, an anesthesiologist based at the VA in Palo Alto, Calif., says he thinks the blocks, which reduce opioid use, and allow patients to sleep better and start physical therapy faster, have proven their value and should be used more often.  Insurance coverage of home pumps, which cost about $400, is spotty, a problem he and Elkassabany say should be remedied.

“It is really important for hospitals to think much more broadly, beyond the cost of a pump,” Mariano said.  “For the cost of a readmission [for pain], you can buy a lot of pumps.”

Elkassabany said that if he had shoulder surgery, he would want the nerve block at home for four or five days.  “I’m not taking anything else,” he said.

Zeller took oxycodone during the first six days after surgery, but was doing fine on Tylenol and gabapentin after that.  Her biggest problem was boredom. She’d been ordered to keep injured arm completely still and was eager to get out and  enjoy the spring weather.

Source:http://www.philly.com

Fluorescence-guided surgery of peritoneal carcinomatosis: Safe and feasible.


Patients with peritoneal carcinomatosis of colorectal origin depend on an optimal cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) as a curative treatment – and, until now, surgeons have depended on visual inspection and palpation for tumor detection. There is room for improvement in this area, say Dutch surgeons at the renowned University of Groningen, and the technique to make it happen may be molecular fluorescence-guided surgery. The advantages of this approach could be twofold – one, an improved detection of tumor tissue to attain a complete cytoreduction of metastatic lesions, and two, the prevention of overtreatment by avoiding resection of benign lesions. The results of the (small) study are certainly promising: Molecular fluorescence-guided surgery was deemed safe and feasible.

The authors enrolled seven patients with colorectal peritoneal metastases scheduled for cytoreductive surgery and HIPEC. Two days before surgery, the patients were given 4.5 mg i.v. of the near-infrared fluorescent tracer bevacizumab-IRDye800CW. The primary endpoints were safety and feasibility, i.e. “safe” if no allergic or anaphylactic reactions or serious adverse events occurred that were linked to bevacizumab-IRDye800CW, and “feasible” if bevacizumab-IRDye800CW enabled detection of fluorescence signals during surgery.

–        The safety results:

o   Two patients developed serious adverse events, but both were attributed to the surgical cytoreductive surgery and HIPEC procedure.

o   By contrast, there were no serious adverse events related to bevacizumab-IRDye800CW.

–        The feasibility results:

o   Fluorescence was seen intraoperatively in all patients.

o   In two patients, the fluorescence-guided surgery managed to spot additional tumour tissue initially missed by the surgeon.

o   29 areas were ‘non-fluorescent’, all of these were found to contain only benign tissue

o   51 areas were fluorescent, 27 of which contained tumor tissue.

Using molecular fluorescence-guided surgery with the near-infrared fluorescent tracer bevacizumab-IRDye800CW is safe and feasible, conclude the authors, and might improve patient selection as well as optimizing cytoreductive surgery. As this was a small, single-center study, the authors now call for a multicenter phase 2 trial to confirm the diagnostic accuracy and to investigate the effect of this technique on clinical decision making.

Source:www.medperts.com

World’s First Head Transplant A Success After ninteen hour operation.


Johannesburg, South Africa — A 36-year-old man has undergone the world’s first successful head transplant. The ground-breaking operation took a team of surgeons nineteen hours to complete and has allowed the patient to be cancer-free.

Paul Horner, who was diagnosed with bone cancer five years ago, was on the verge of death when he was approved for the controversial and possibly deadly operation.

Doctor Tom Downey, who was part of the South African team who carried out the operation, told CNN he is thrilled about the results.

“It’s a massive breakthrough,” Downey said. “We’ve proved that it can be done – we can give someone a brand new body that is just as good, or better, than their previous one. The success of this operation leads to infinite possibilities.”

Surgeons at Charlotte Maxexe Johannesburg Academic Hospital inJohannesburg carried out the operation in February but waited until they could confirm it was successful before they made any public statement.Downey spoke to reporters about the complexity behind the first ever head transplant.

“This procedure is another excellent example of how medical research, technical know-how and patient-centered care can be combined in the quest to relieve human suffering.”

The operation was led by Professor Myron Danus and took place on February 10th of this year.“Our goal is for Horner to be fully functional in two years and so far we are very pleased by his rapid recovery,” said Danus. “Before the operation, Horner’s body was riddled with cancer and he had less than a month to live. We were fortunate enough to find a donor body; a 21-year-old man who has been brain dead from a serious car accident that happened in 2012. The boys body worked just fine, but his brain was not functioning whatsoever, and there was absolutely no chance of recovery.” Danus continued, “We received approval from the young man’s parents to use their sons body to do the operation. They were extremely happy their son could save a life even in the vegetated state that he was in.”

Doctors say Horner has made an 85% recovery; walking, talking and doing the normal things a healthy individual does.

WATCH THE VIDEO:


The Charlotte Maxeke Johannesburg Academic Hospital, nicknamed Joburg Gen is an accredited general hospital in Parktown, Johannesburg, Gauteng, South Africa. It has 1,088 beds. The hospital’s professional and support staff exceeds 4,000 people.

Even though Horner lives in the United States, the first-of-its-kind operation had to be done overseas in a location where the medical guidelines are not as strict.

Cutting-edge theatre: world’s first virtual reality operation goes live.


Medical experts hope surgery live-streamed in VR will make healthcare fairer and boost training

 Dr Shafi Ahmed performs the operation which could be watched online by the public.
Dr Shafi Ahmed performs the operation which could be watched online by the public. 

Stretched out on a table in a large, bright operating theatre at the Royal London hospital, a patient is awaiting Shafi Ahmed’s first incision in a procedure that will remove cancerous tissue from his bowel. Around the table a team dressed in blue scrubs and face masks are gathered, exchanging the odd word, while cumbersome machines bearing bundles of wires hum gently in the background. Everyone is focused on the task in hand, getting ready to play their part. Except me.

Scrubless and without so much as a scalpel to pass to the surgeon, I am a mere spectator to this intricate event, a bystander gazing around the room in fascination while others labour at a life-changing task.

Not that the surgeons are bothered. Because although I feel like I am standing at the edge of the operating table, in reality I am sitting in my office chair.

On Thursday afternoon I witnessed the world’s first operation to be streamed live in 360-degree video, allowing medical students, trainee surgeons and curious members of the public like me to immerse themselves in the procedure in real time via the Medical Realities website. A one-minute delay was incorporated into the broadcast in case of any complications in the surgery.

A cancer surgeon at Barts Health NHS Trust, Ahmed said before the operation that he believed the approach could make healthcare more equitable, improving the training of surgeons worldwide. With internet connections becoming better, smartphones getting cheaper and only a pair of lenses and some cardboard needed to make a virtual reality headset, the costs, he said, paled in comparison to the expense of students travelling abroad to train. “It is actually quite cost-effective.”

Shot using two 360-degree cameras and a number of lenses arranged around the theatre, the operation could be viewed through the “VR in OR” app, using a virtual reality headset that can be paired with a smartphone. Those who did not have a headset could watch the feed live online.

It takes a while to get the app up and running so while I wait for the VR experience to start I watch the procedure begin via the website.

The lights are dimmed and, wielding an intimidating device, Ahmed begins to remove a hernia. “This is called a harmonic scalpel,” he says as he gets to work.

A hush descends, punctured only by beeping. Peering down I spot some odd-looking scissors I hope no one will ever use on me. Two large screens on either side of the table show views from the camera inside the patient – a device that resembles an enormous knitting needle. The team prepares to tackle the cancer. “OK let’s have a look, here we go,” says Ahmed.

Fortunately the app boots up. And I am in the room too. “There is a tumour just here,” says Ahmed. “This is what cancer looks like in reality.”

While videos showcasing surgical procedures have been around for years, Ahmed believes the new approach is more than a mere gimmick. The technology, he has argued, brings a valuable new feature to education, allowing viewers to focus not just on what the surgeon is doing, but also on what other members of the team are up to: “There will be noise, there will be the immersive factor – so that will add different layers of educational value.”

George Hanna, professor of surgical sciences at Imperial College, London was cautiously optimistic about the benefits of the approach. “If this technology allows the transfer of knowledge and skills [over] a wider range and in an easier way that would be very beneficial,” he said.

But he was quick to add that, compared with existing approaches for sharing scenes from the operating theatre, the new technology offered more of an upgrade than a revolution. “It is a good video and wide broadcast with interactive [opportunities],” he said, stressing that the operation itself was real rather than virtual.

The procedure continues. Despite my loathing of all medical TV dramas, I am hooked. Suddenly the entire theatre goes dark, except for a spotlight. Someone is making an incision. They pull out a pink, fleshy mass. “Scissors,” says someone. A bundle that I assume is the tumour is removed and dropped into a bowl. The operation has been a success.

It was not the first time Ahmed had led the way in embracing modern technology in healthcare. He co-founded the healthcare company Medical Realities, which streamed the operation in partnership with Barts Health and 360-degree video experts Mativision.

Ahmed said he believes virtual reality, augmented reality and games could all play a role in training medical students. Two years ago he streamed a live operation using the “augmented reality” system, Google Glass, allowing viewers to see the procedure from a surgeon’s point of view.

But the new 360-degree video, Ahmed said, offered a new approach, allowing users to see beyond what the surgeon was looking at. Among future developments he has envisaged, Ahmed said he was keen to add graphics to the raw footage to provide additional information during the operation, as well as taking questions from those viewing the procedure.

“[During an operation] I am teaching people, talking to them, there is communication going on – so it’ll be just an extension of that,” he said. In three to five years, haptic devices – which work off physical contact between the user and computer – could boost the experience further: “Companies are really working on various gloves or bodysuits and devices so that it can replicate touch and feel.”

Such technologies, said Ahmed, could be a boon to healthcare. But, he added, the role of patients in agreeing to take part should not be forgotten. “Ultimately, it is about the operation, about [the patient], about his cancer care and that has to be the priority for everybody.

“The fact that patients have agreed to do this before – with the Google Glass – and again, it is quite reassuring and quite humbling.”

Source:www.theguardian.com

Taking Statins May Boost Heart Surgery Outcomes.


Heart surgery patients taking statins should keep taking those cholesterol-lowering drugs, even on the day of their operation, because doing so may improve their chances of survival, a new study suggests.

“Based on our findings, we would advise patients to continue taking their statin medication all the way up to and including the day of surgery,” said study author Dr. Wei Pan.

Statins are one of the most widely prescribed drugs in the United States. One in four Americans 40 or older takes a statin, according to the U.S. Centers for Disease Control and Prevention.

In the new study, Pan’s team looked at more than 3,000 patients who underwent coronary artery bypass graft surgery. Pan is a cardiovascular anesthesiologist at the Texas Heart Institute in Houston.

The findings showed that the rate of death from all causes within 30 days was about 2 percent for those who took statins 24 hours or less before their operation.

In those who took statins 24 to 72 hours before their operation, the rate of death was nearly 3 percent. And, for those who never took statins or who took statins more than 72 hours before the surgery, the death rate was just under 4 percent, the researchers said.

The study was published online March 16 in The Annals of Thoracic Surgery.

“Patients frequently forget to take their pills on the day of surgery, or they’ve been told to stop certain medications,” Pan said in a journal news release.

“This study shows that not taking your statin for even one day before cardiac surgery may increase your risk of death after surgery,” he said.

“Statins are ubiquitous today, so this study is especially important as it highlights that a patient simply adhering to his or her already prescribed statin medication and not stopping it prematurely could be lifesaving,” Pan said.

The researchers noted that they believe this is the first study to look specifically at the timing of statin medication before surgery.

Dr. Todd Rosengart is a cardiothoracic surgeon at Baylor College of Medicine in Houston who wasn’t involved in the study.

He said in the news release that “this is an important study that clearly extends our understanding of the growing importance of statins in benefiting patients with cardiovascular disease.”

Although the study found a link between regular statin use and increased survival rates in these patients, it did not prove a cause-and-effect relationship.

Source:www.drugs.com

Physician Invents Reconstructive Surgery For Female Genital Mutilation.


There is new hope for the hundreds of millions of women worldwide who have been subjected to genital mutilation.

A surgeon in Penn Medicine’s Center for Human Appearance has developed a reconstructive procedure that can increase sexual function and, patients’ early experiences suggest, help heal the emotional and psychological wounds associated with the mutilation. Ivona Percec, an assistant professor of Surgery in the division of Plastic Surgery, reports on her use of the technique in three patients this month in the Aesthetic Surgery Journal. She also calls for greater awareness of this human rights issue in support of women who’ve suffered these experiences across the world.

 “Plastic surgeons have a crucial role to play in this recovery, and it’s important for physicians to be informed and prepared to address the surgical and emotional needs of women who seek care for this,” Percec said. “Our procedure is simple yet effective and can help victims restore their physical and psychological sense of well-being.”

The World Health Organization (WHO) defines Female Genital Mutilation (FGM) as, “any procedure that intentionally alters or causes injury to female genital organs for non-medical reasons and with no health benefits.” An estimated 200 million women have been subjected to FGM around the world, usually between the first week of life and adolescence, and often by their caregivers. It is a cultural ritual in parts of Africa, the Middle East, and Asia to encourage female sexual fidelity. It is internationally recognized as a violation of human rights.

FGM can also have long-term consequences, including severe pain, post-traumatic stress disorder, cysts, recurrent infections, and even death.

All three women were between the ages of 30 and 33 and had recently immigrated to the United States from Sierra Leone. In each case, the women were married but had not told their husbands they had undergone FGM as children.

“These women were embarrassed that they were subjected to this procedure, in particular since relocating to the United States,” Percec said. “All of them were able to have intercourse, but without pleasure – usually with pain.”

The patients wanted to know if there were any surgical options available to help them look and feel more normal. After Percec’s research turned up little in the way of established procedures, she used her knowledge of other reconstructive techniques in hopes of restoring appearance and function.

With an average follow up of almost a year, all three patients reported improved sexual function and decreased embarrassment with their partners. All three women said they would recommend this procedure to others who have suffered FGM.

“Female genital mutilation is a violation of the basic rights of women and children,” Percec said. “As nations around the world work to eliminate this custom, plastic surgeons can play an important role in the physical, emotional, and psychological recovery of women everywhere.”