OPENING CEREMONY
5:00pm, Wednesday, September 9, 2009
HONORARY CHAIR PRESENTATION
The Development of Laparoscopic Surgery in Guatemala and Central America
Roberto Gallardo Diaz, M.D.
This will be a presentation of the facts of how the laparoscopic surgery was initiated in Guatemala and the rest of Central America, where and when the first cases were done, and also a brief history of the events that took place before it really started.
There will also be a complete detail report of what is going on in Guatemala and every country in Central America and how the Laparoscopic Surgery has change some of the old concepts of traditional medicine in our societies.
There will be a full report of how is the procedure is learn and showed in our countries and also what are the needs and improvements that must be done in order to make it a method for all the people and the effect of the procedures in our societies and communities.
We will be able to show and compare the results of some of our surgeons compare with some the top surgeons around the world and therefore I will show that Laparoscopic Surgery is the answer to many illness in our countries.
We will see how the procedure has developed in our countries almost as fast as in the rest of the world.
HONORARY CHAIR PRESENTATION
The Evolution of Minimal Access Surgery in Gynecology in Singapore
Suresh Nair, MD
Laparoscopy in Singapore began as a diagnostic intervention in mid 70s through the introduction of single port through the umbilicus. This gradually developed to include tubal sterilization and simple procedures like ablation of endometriosis using unipolar and bipolar coagulation and later on application of Falope rings and Filshie clips which became popular in the 80s.
Thereafter, Professor Steptoe demonstrated the use of the laparoscopic ovum pickup in the early 80s culminating in Singapore’s first IVF baby a few years later in 1983. At this time and for a few years after that, procedures done via a laparoscope involved the surgeon peering through the laparoscope and performing only limited procedures e.g. simple adhesiolysis, simple cystectomy.
In the 90s with the advent of the single chip endoscopic camera, the surgeon could perform laparoscopic procedures for longer periods and with participation of the whole surgical team. With the popularization of laparoscopic cholecystecomy and the rapid development of both disposable and reusable instruments, more complex procedures were carried out.
Laparoscopic minimal access surgery actually took off in a big way mainly in the private sector first. A group of doctors set up the MIS club in 1991 and invited Professor Charles Koh from Milwaukee, USA in the proctoring of surgeons through a series of workshops. Only in the mid 90s did laparoscopic minimal access surgery did a quantum leap. For e.g., in the largest women’s hospital in Singapore, ectopic pregnancies were removed in about 5% of cases in 1993. Thereafter, in 1995 nearly 80% of ectopic pregnancies were treated laparoscopically.
The need for an accreditation and credentialing programme became critical in order to maintain a good safety record of laparoscopic surgery. A description of the implementation of accreditation and training programs resulting in substantial penetration of laparoscopic surgery in all the hospitals in Singapore will be described culminating in the introduction of robotic surgery.
BEST OF LAPAROSCOPY UPDATES
7:30am Thursday, September 10, 2009
MULTISPECIALTY COMMITTEE
Office Cosmetic Procedure
Duncan Turner, MD
In these challenging financial times, we are all looking for additional ways to serve our patients well and to make ends meet. Cosmetic procedures are becoming increasingly popular for gynecologists most of us having a captive audience of a large number of women interested in such services.
The introduction of cosmetic procedures into the gynecologist’s office will be discussed. The procedures will include injectables as well as body sculpting techniques utilizing laser and ultrasound-based liposuction.
Sclerotherapy for spider veins and endovenous laser treatments for severe varicose veins are also within the skills of the gynecologist.
Some of these procedures are covered by insurance and some are elective, but the gynecologist’s patients are very appreciative of having these opportunities. Training equipment and expenses will all be discussed.
MULTISPECIALTY COMMITTEE
Pediatric
Urology Laparoscopy Update
Thomas
S. Lendvay, MD
Historically, pediatric urology has lagged behind in the adoption of MIS techniques because of the strong open surgery voice, but with the evolving face of the average pediatric urologist changing to one who has trained in a residency where MIS is commonplace, MIS pioneers are pediatric urologists. This year we have seen a rapid increase in the applications of robotic reconstructive procedures in children whether they are for the most common procedure, robotic pyeloplasty, or for more complex procedures such as robotic augmentation cystoplasties and catheterizable channel creation. In addition to the expansion of robotics, single incision surgery is gaining traction, especially in adolescents where the single port incisions are well tolerated and do not increase the total incision length that would have normally been placed for standard laparoscopy. Using only the umbilicus appeals to children who are most conscious of there body image- teenagers.
All MIS advances in pediatric surgery have not been high fidelity, however. Surgeons have demonstrated the benefits of augmenting MIS capabilities by using some very simple off-the-shelf technology. Intraoperative urinary stent confirmation using basic regional anesthesia ultrasound equipment and assist ports using 14G angiocatheters with existing cystoscopic instrumentation are examples of low cost improvements that minimize operative time and potentially patient morbidity. Such innovations are helpful to defray costs as the overall MIS technology becomes more sophisticated and expensive.
GYNECOLOGY COMMITTEE
The Use of Mesh for Stress Incontinence and Pelvic Organ Prolapse
Steven
Minaglia, MD, FACS, FACOG
The purpose of this presentation is to review pelvic anatomy, summarize current surgical approaches to pelvic organ prolapse and urinary incontinence, and enable the participant to make informed decisions when considering mesh augmentation versus native tissue repairs. Mid-urethral slings such as the tension free vaginal tape, transobturator tape, and single incision sling systems will be discussed. In addition, vaginal native tissue repairs, vaginal repairs augmented with mesh, and minimally invasive abdominal repairs (including robotically assisted repairs) for pelvic organ prolapse will be compared.
GYNECOLOGY COMMITTEE
Pediatric Gynecology
Robert K. Zurawin, MD
Advances in technology, coupled with better understanding of the unique pathology seen in the pediatric and adolescent patient have led to exciting developments in minimally invasive gynecologic surgery.
Fertility
preservation
Pediatric
cancers are increasingly amenable to treatment, but the chemotherapy and/or
radiation involved frequently obliterates germ cells. Developments in ovarian and oocyte cryopreservation and
ovarian transposition can maintain fertility. Important ethical questions and informed consent issues must
now be raised in children undergoing cancer treatment.
Vaginal
agenesis – Vechietti and Davydov procedures
Previously,
corrective surgery for congenital defects of the female genital tract required
open surgery or skin graft techniques.
New surgical devices and procedures now allow for the laparoscopic
creation of a neovagina. These
will be demonstrated in a video presentation
Robotic
surgery
Still
in its early stages of utilization in this population, robotic surgery has been
useful in the surgical management of congenital anomalies, cancer surgery, and
endometriosis, much the same as in the adult population. Challenges still exist in the pediatric
population because of the scale of the instrumentation.
Single
Port Access
The
most common procedures in the adolescent population involve benign ovarian
cysts and torsion. These
conditions are amenable to the single port approach.
MULTIDISCIPLINARY PLENARY SESSION
8:30am-9:45am, Thursday, September 10, 2009
IMAGE GUIDED SURGICAL PROCEDURES. WHAT A SURGEON SHOULD KNOW ABOUT NON-SURGICAL APPROACHES
The Surgeon's Responsibility for Imaging Utilization during Minimally Invasive Procedures
Pat Fox Fulgham, M.D.
Surgeons are increasingly performing diagnostic and therapeutic procedures using imaging for guidance and confirmation. The appropriate use of imaging requires the operator to understand the physical characteristics of the specific imaging modality. These characteristics have direct and significant implications for image quality and for patient and operator safety.
Ultrasound has proven valuable for location of renal and hepatic lesions and for monitoring ablative procedures. A foundational understanding of ultrasound physics enhances the accuracy and efficiency of ultrasound for this purpose. The surgeon should understand how to optimize imagine quality with the adjustment of user-directed machine functions.
CT and fluoroscopy are valuable for many minimally invasive procedures. Surgeons must understand the potential for radiation exposure to the patient, the operating room staff and themselves. The concept of effective radiation dose is discussed. The use of shielding, equipment position and selective adjustment of kV to reduce radiation exposure is considered.
This presentation addresses the technical aspects of ultrasound and CT with an emphasis on the responsibility of the surgeon in directing imaging during minimally invasive procedures.IMAGE GUIDED SURGICAL PROCEDURES. WHAT A SURGEON SHOULD KNOW ABOUT NON-SURGICAL APPROACHES
MRI-guided focused ultrasound surgery (MRgFUS) for Uterine Fibroids
Elizabeth A. Stewart, M.D.
In the past quarter century, the gynecologic surgery approach has evolved from laparotomy to laparoscopy, hysteroscopy and a wide range of minimally invasive therapies. This is especially true for treatment of uterine leiomyomas (fibroids or myomas), which are benign myometrial neoplasms and the primary indication for hysterectomy in the United States. The use of magnetic resonance guided focused ultrasound (MRgFUS) however, is the first noninvasive surgical treatment.
MRgFUS provides real time monitoring of both the leiomyoma and other pelvic structures to maximize safety. Temperature mapping provides confirmation of the efficacy of thermoablative treatment and the process of coagulative necrosis allows outpatient therapy and early return to work even when large lesions are treated.
Clinical trials and case series of women treated in commercial series have established MRgFUS as an effective non-invasive treatment for symptomatic uterine fibroids. Early reports of pregnancies following MRgFUS are encouraging. Clinical trials are underway to assess whether MRgFUS is able to optimize pregnancy outcomes in women with unexplained infertility and a fibroid which distorts the endometrial cavity.
IMAGE GUIDED SURGICAL PROCEDURES. WHAT A SURGEON SHOULD KNOW ABOUT NON-SURGICAL APPROACHES
Stereotactic Radiosurgery (SRS): Is It Surgery; Is It Radiation Therapy; Why Should I Care?
Ronald T. Davis, MD and Paul M. Goldfarb, MD, FACS
Computers and robotics are transforming the methods by which ablative doses of radiation can be safely delivered to internal tumors in less than a week’s time. Physicians can use graphical user interfaces within the planning phase to delineate the volumes to be included in high dose areas based on compiled radiographic images showing highly detailed anatomic structures. Iterative virtual operations can then be evaluated for dose distributions to the tumor and to normal structures. Quantitative determination of these distributions, called dose-volume histograms, allow estimations of likelihood of tumor control as well as normal tissue injury and the areas where complications might be expected. Based on tumor biology and surgical anatomy, an optimal plan can be developed prospectively by the treating physicians before it is then carried out on the patient. This carries the idea of simulation to routine use and allows further refinement of the technique of treatment based on results obtained from executed plan. Thus participating physicians, usually radiation oncologists and surgeons may both extend their training and intellectual skills to patient treatment that is often quicker, safer and less expensive than other techniques confined to either specialty alone.
With
simulation set to play a greater role in surgical training there may be a
common path that would allow surgical training to assist in radiation dose
delivery as well. There will be a common path that will allow surgical
participation in treatment planning and patient management for patients treated
with these new modalities. It will require surgeons to become more familiar
with radiation physics and patient selection.
Since the plan development is done hours or days prior to any dose delivery, networked computer systems allow for collaboration at a distance allowing the physicians to work remotely and at a time convenient to all parties.
MULTIDISCIPLINARY PLENARY SESSION
10:30am-11:30am, Thursday, September 10, 2009
CANCER AND LAPAROSCOPY - WHAT TO DO AND WHAT NOT TO DO
Cancer
and Laparoscopy: Pearls and Pitfalls
Stephen
Kavic, MD
There
has been a division in training between surgical oncology and those pursuing a
career in minimally invasive surgery. In addition to separate fellowship
tracks, the nature of the two surgical practices is vastly different. As a
result, there has been some professional distance between laparoscopists and
surgical oncologists.
The typical practicing general surgeon or gynecologist is more of an incidental oncologist, dealing with unexpected operative findings or common oncologic problems on an infrequent basis. Here, we review some of the more typical problems encountered during laparoscopic examination. Additionally, we will discuss some of the data underlying the recommendations on whether or not laparoscopic techniques are appropriate in the management of patients with cancer diagnoses.
CANCER AND LAPAROSCOPY - WHAT TO DO AND WHAT NOT TO DO
The Role of Robotics in Gynecologic Oncology : the Good, the Bad and the Ugly
Farr Nezhat, MD, FACOG, FACS
Cervical cancer is the most common gynecologic cancer in the world, and has been diagnosed in approximately 11,070 women in 2008 in the United States. Nearly 4,000 individuals will succumb to the disease in the same year. Laparoscopy has been used in the management of both early and advanced stages of cervical cancer in a number of different applications. In early cervical cancer, laparoscopy has been utilized to perform pelvic and para-aortic lymphadenectomy along with a laparoscopic-assisted radical vaginal hysterectomy, total laparoscopic radical hysterectomy or a radical vaginal trachelectomy. In advanced stages, pre-treatment surgical staging with pelvic and para-aortic lymphadenectomy has become a useful way to direct treatment. Laparoscopy has also been applied prior to a pelvic exenteration, laparoscopic ovarian transposition, and laparoscopically guided interstitial radiation implant placement, although the data is limited in these clinical scenarios.
Early
Stage Cervical Carcinoma
Laparoscopic
Radical Hysterectomy
The
first total laparoscopic radical hysterectomy with pelvic and para-aortic
lymphadenectomy was performed by Nezhat et al in June 1989 and was
published in the early 1990s.[1] The
technique has be described previously in the literature.[2] Since then, numerous authors have
reported their experience with the laparoscopic radical hysterectomy. One cohort study between laparoscopy
and laparotomy is published by Zakashansky et al.[3] There were a total of 60 women in the
study, 30 individuals underwent a laparoscopic radical hysterectomy, 30
patients underwent laparotomy.
Compared to the laparotomy group, the laparoscopic group had less blood
loss (200 vs 520mL), more nodes retrieved (31 vs 21.8 pelvic nodes), and a
shorter hospital stay (3.8 vs 5.6 days).
Intra- and post-operative complications and recurrence rates were similar in both groups and not
statistically significant. These
findings illustrate that laparoscopy leads to superior surgical outcomes when
compared to traditional laparotomy.
There is currently a multicentered, international, randomized study done by Obermair et al, comparing laparoscopy and robotic techniques to laparotomy.[4] If completed, the study will be the first blinded randomized clinical trial comparing laparoscopy and robotic assisted laparoscopy versus laparotomy.
Robotic
Radical Hysterectomy
Enhanced
robotic technology has been utilized to complete more radical cases in patients
with cervical cancers than any other gynecologic malignancy. Much of the literature is in the form
of case series and reports. The
largest studies comparing robotic assisted radical hysterectomy to laparoscopy
were conducted by Nezhat et al and Magrina et al. Nezhat et al prospectively compared robotic assisted
laparoscopy to traditional laparoscopy in patients with early stage cervical
carcinoma in a fellowship program.[5]
His group found that the robotic technique was equivalent to the
laparoscopic approach. No
statistical difference was observed regarding operative time (323 vs 318
minutes), pelvic lymph node retrieval (24.7 vs 31 nodes), estimated blood loss
(157 vs 200 mL), or hospital stay (2.7 vs 3.8 days) between the robotic
assisted laparoscopy and traditional laparoscopy groups, respectively. None of the robotics or laparoscopic
procedures required conversion to laparotomy and postoperative complications
were comparable.
Magrina et al compared three groups, robotic assisted laparoscopy, traditional laparoscopy, and laparotomy and concluded that the robotic and laparoscopic groups were very similar in their surgical outcomes, and were preferable over laparotomy.[6] The blood loss and length of hospital stay were similar for laparoscopy and robotics and reduced significantly when compared to laparotomy. The blood loss was 133mL vs 208mL vs 443.6mL between the robotic, laparoscopy, and laparotomy groups respectively. The hospital days were 1.7 vs 2.4 vs 3.6 days respectively. There were no significant differences in complication rates among the three groups.
Laparoscopic
Lymphadenectomy
Laparoscopic
lymphadenectomy has been performed in cervical cancer patients as an adjunct to
surgical staging, and has been proven to be a safe and accurate procedure in
multiple reports. Not only does
laparoscopy provide magnification of the operative field, but the
pneumoperitoneum decreases venous bleeding and assists in identification of
small accessory vasculature leading to better visualization of the surgical
field. Whether or not laparoscopic
lymphadenectomy has an established role in cervical cancer patients is
debatable, but it should be considered given the low morbidity, fast recovery,
and potential useful information obtained.
A recent study by Tillmans et al summarized findings of laparoscopic retroperitoneal lymphadenectomy, and found that the procedure had an overall detection rate of 13% of occult metastasis in the aortic lymph nodes in the 299 reported cases in the literature.[7] They performed their surgery as an outpatient procedure, and reported median blood loss to be 25mL, with an average operating time of 108 minutes.
Gynecologic Oncology Group (GOG) protocol 9207 examined laparoscopic pelvic and para-aortic transperitoneal lymphadenectomy in women with Stages IA, IB, and IIA cervical cancer.[8] There were 67 patients in seven institutions that were enrolled, with an average of up to 70 pelvic lymph nodes and up to 37 para-aortic lymph nodes retrieved. The complication rate was 1.4% for ureteral injury and 10% for major vascular injury. The study concluded that laparoscopy is a feasible alternative method of obtaining lymph nodes in indicated patients.
Trachelectomy
Laparoscopic
assisted vaginal trachelectomy has been an attractive alternative to those
desiring preservation of fertility.
The procedure combines laparoscopy and vaginal surgical approaches. This technique has been described in
the literature.[2]
There are certain criteria for consideration of a laparoscopic trachelectomy, including: (1) childbearing age with the desire to preserve fertility, (2) reasonable ability to conceive, (3) FIGO Stage IA2 to IB, with lesions less than 2cm, (4) limited endocervical involvement on colposcopy, (5) no positive lymph nodes, (6) no lymphovascular space invasion, (7) adequate understanding and comprehension of the procedure.
Multiple case reports and series have been published regarding laparoscopic lymphadenectomy along with radical vaginal trachelectomy, and more recently, total laparoscopic lymphadenectomy and trachelectomy. The latest review has been published by Milliken & Shepherd, who reported that a total of 709 patients had a radical vaginal trachelectomy between 1994 and 2008. There have been 29 cases of recurrence (4%) and 16 reported deaths from recurrence (2%).[9]
In the last few years, there have been case reports for total laparoscopic assisted trachelectomies or robotic assisted trachelectomies, but it is not a routinely performed procedure.
Advanced
Cervical Carcinoma
In
advanced stage cervical carcinoma, the standard therapeutic options include
chemoradiation and the exenteration, a radical procedure associated with a high
morbidity and mortality. In this
setting, laparoscopy has been utilized in ways to optimize treatments. Although limited data is available to
support these applications, it is clear that laparoscopy offers novel ways to
tailor and improve care for the oncologic patient.
Pretreatment
surgical staging with pelvic and para-aortic lymphadenectomy
Cervical
cancer is considered a clinically staged cancer, with additional information
obtained through cystoscopy, sigmoidoscopy, and imaging studies. However, there have been several
studies that report pre-treatment laparoscopic lymphadenectomy is beneficial,
and that there is a role for surgical staging as well. It has been shown that the removal of
bulky pelvic and/or para-aortic lymph nodes is associated with a longer
survival time. In addition, it can
help to plan the range of radiation therapy if any of the harvested lymph nodes
is positive for metastatic cancer. [10]
Laparoscopic
ovarian transposition
In
patients who are younger and still have desires for future fertility, the
ovaries can be transposed prior to the initiation of radiation therapy to
minimize damage from necessary therapy.
The largest series reported is by Pahisa et al looking at 28 patients[11] Ovarian preservation was demonstrated
in 64% of those receiving radiation, and 93% of the patients receiving no
radiation. Laparoscopy has been
shown to lead to shorter recovery times, decreased hospitalizations, all of
which is beneficial to a patient facing additional steps in her treatment
plans.
Laparoscopy
prior to pelvic exenteration
Pelvic
exenteration is a radical procedure that is offered to patients with centrally
recurrent, locally advanced cervical carcinoma. It is done with the intent to cure whatever residual
carcinoma is present. Laparoscopy
is a useful tool used to examine the intra-abdominal cavity prior to embarking
on this radical procedure to ensure that the cancer is resectable, and has no
upper abdominal disease. More
research needs to validate this application in the appropriate patient
population.
Laparoscopically
guided intersititial radiation implant
In
selected patients, particularly those with advanced stage disease, interstitial
brachytherapy offers an alternative to intracavitary therapy. Traditionally, placement of
interstitial needles is performed without the vizualization within the pelvic
cavity. This treatment is associated with high complication rates (5-48%). Laparoscopy may provide verification
and guidance of needle placement thus decreasing treatment related morbidity.
CANCER AND LAPAROSCOPY - WHAT TO DO AND WHAT NOT TO DO
Advanced Robotic Technique as a Surgical Treatment Option for Prostate Cancer
David Samadi, M.D.
Contrary to popular belief, laparoscopic radical prostatectomy is not a new technique. Initially described in 1997, it was largely abandoned in the United States (although it became popular in Europe) due to its difficulty. Following the development of the da Vinci surgical robot in 2001, however, robotic-assisted laparoscopic prostatectomy (RALP) has become widely prevalent. In 2008, it is estimated that over 70% of prostatectomies in the United States were performed in robotic-assisted, laparoscopic fashion. Historically, this rapid dissemination of a new surgical technology is second only to the laparoscopic cholecystectomy in terms of its adoption rate.
Radical prostatectomy is a technical tour de force, consisting of both exenterative and reconstructive procedures: the prostate is removed, then the bladder is reanastamosed to the urethral stump. Lying deep within the true pelvis, the prostate is surrounded by important structures, all of which must be carefully preserved to avoid complication and maximize post-operative functional outcomes.
The laparoscopic approach offers several benefits. Pneumoperitoneum tamponades venous bleeding, substantially decreasing blood loss. Lighting and magnification improves visualization of the delicate cavernous nerves that control erection. Smaller incisions may result in the traditional benefit of laparoscopic procedures in terms of pain and convalescence. In addition to these benefits, robotic-assistance adds wristed technology and more degrees of freedom, greatly facilitating suturing deep within the pelvis.
In our lecture, we will briefly discuss the treatment options for localized prostate cancer, then focus on the evolution of the advanced RALP technique, highlighting important modifications in the standard procedure. We will also discuss our outcomes in over 1400 RALPs performed to date at Mount Sinai.
CANCER AND LAPAROSCOPY - WHAT TO DO AND WHAT NOT TO DO
The Role of Laparoscopy in Pediatric Abdominal Malignant Tumors
Gustavo Stringel, MD, MBA
The
role of laparoscopy in the treatment of pediatric malignant tumors has
increased significantly over the last few years. Laparoscopy and thoracoscopy
have been important tools in the
diagnosis and removal of tumors in children. We have used both techniques
extensively to obtain tissue and in some occasions to remove the lesion. The
inability to feel the extent or fixation of tumors has been evoked as a
disadvantage when approaching the tumor for resection or biopsy. This
potential drawback is balanced by the superior visualization with magnification
of the field. The fear of seeding or spillage of the tumor has also been
quoted as a possible disadvantage, however there is no firm evidence to justify
this possibility as a contraindication to the use of laparoscopy or
thoracoscopy in the removal or biopsy of these lesions.
MULTIDISCIPLINARY PLENARY SESSION
11:30am-12:30pm, Thursday, September 10, 2009
THE US HEALTHCARE SYSTEM IS BROKEN WHAT CAN WE DO ABOUT IT?
The US Health Care System Is Broken: Facts and Figures
Michael S. Kavic, MD
There
is a problem with the US health care system and that problem is money. We are
spending a lot of money - 2.8
trillion dollars per year at last year’s count or about $8 000 per person in
the United States. Thirty percent of those dollars were spent just for
administration of the system. Whether that amount is too little, just right, or
too much needs to be determined.
It is said that part of the problem lies with the uninsured. Many feel that the uninsured are an excessive burden on the system. The uninsured consume health care dollars and only contribute a small amount to sustain the system. There were about 47 million uninsured persons in the US in 2008. In that same period, there were about 38 million people or 13% of our population existing at the federal poverty level.
However, the number of uninsured is elusive as estimates suggest that about 10 million of these persons are illegal immigrants. To further compound the complexity of the issue, it is thought that 18 million uninsured have household incomes in excess of $ 50 000 per year. And about 19 million of the uninsured are between the ages of 18 – 34 years. Perhaps up to one-half of uninsured were uninsured for only a few months of the year.
Other money issues that will ruin us: insurance company greed, malpractice litagation, drug industry costs, decreased reimbursement, and excessive paperwork.
THE US HEALTHCARE SYSTEM IS BROKEN WHAT CAN WE DO ABOUT IT?
Obstacles to Providing "Universal Care" to the Undeserved - a Urologic Perspective
Richard K. Babayan, MD
The Commonwealth of Massachusetts embarked on an ambitious experiment in health care reform, aimed at providing all of its citizens with some form of health insurance. The aim was to eliminate need for the “free care pool” and to provide necessary preventive care measures, which would ultimately lead to lower health costs. Although some of the goals have been achieved, namely more citizens with health insurance in 2009 than 2008, the costs of this experiment have been grossly underestimated and under-funded. The poor and underserved patients continue to have difficulty accessing the system and those physicians and institutions, which serve this population, have been denied the resources needed to provide universal care.
I shall attempt to review and dissect the good, the
bad and the ugly facts surrounding health care reform in a time of financial
crisis. How can we achieve a noble
goal under the current health system in the USA? Do we need mere reform or does the system need to be rebuilt
from the ground up? How can
physicians, who have only a minority input on the health care dollar, battle
the special interest groups (eg. insurance and pharmaceutical companies) supporting the status
quo?
THE US HEALTHCARE SYSTEM IS BROKEN WHAT CAN WE DO ABOUT IT?
Disparity in Healthcare: Target-Heart Disease
William A. Cooper, MD
Introduction
Racial
disparities in clinical medicine have been noted for some time. In 1999, the United States Congress
requested the Institute of Medicine (IOM) to study the extent to which such
disparities existed throughout healthcare in America. These findings along with factors contributing to the
inequities and recommendations for their elimination were published in the IOM
report: “Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care”, published in March of 2002 [1].
The report found a number of disparities in access, treatment and outcomes for minorities related to cancer, diabetes and heart disease. In particular, African-Americans (AA) were less likely to receive recommended treatment for coronary artery disease or myocardial infarction and were less likely to be referred for percutaneous coronary interventions (PCI) and bypass surgery. These findings have been substantiated and highlighted in several publications prior to and subsequent to the IOM report [2-8]. Two studies from large database registries have confirmed that race is an independent risk factor for adverse events and mortality after CABG. [3-4].
As a means of reducing the morbidity and mortality associated with the use of cardiopulmonary bypass (CPB) required for performance of conventional CABG, beating heart or off-pump coronary artery bypass (OPCAB) was introduced in the U. S. in the mid-1990’s [9]. In 2007, approximately 20% of all isolated CABG operations were performed with off-pump techniques (www.STS.org) [10]. Off-pump coronary artery bypass has been shown to be beneficial for patients at increased risk of stroke, diabetic patients and women [11-15]. In particular, we have previously demonstrated a significant early mortality and morbidity advantage for women and equal 10-year survival compared to men [12]. Specifically, among OPCAB patients, we have previously reported the mitigation of adverse events and equalization of outcomes in women compared to men [14]. The present study seeks to determine whether the disproportionate advantage of OPCAB observed in one high-risk demographic group (women) may also be present for another identifiable high-risk demographic group (African-Americans).
Race has been shown to be an independent risk factor for operative mortality following coronary artery bypass grafting (CABG). This study sought to determine the extent to which race is a risk factor for adverse events and long-term mortality following CABG and whether off-pump surgery (OPCAB) modifies that risk.
Methods
The
STS Adult Cardiac Database at Emory Healthcare Hospitals and
Wellstar-Kennestone Hospitals was queried for all primary isolated CABG patient
records from 1997-2007. A propensity score was formulated based on 49
pre-operative risk factors to balance the patient groups with respect to
treatment assignment (OPCAB or CABG on CPB). Multivariable logistic regression
was used to assess the impact of African-American (AA) race and OPCAB on
in-hospital outcomes (death, stroke, myocardial infarction, and their
composite, (MACE). A Cox proportional hazards regression model and Kaplan-Meier
curves determined whether AA race impacted long-term all-cause mortality.
Interaction terms were constructed to test whether OPCAB surgery influences
surgical results differently in AA patients than in Caucasians (CAUC) patients.
Results
There
were 12,874 consecutive CABG patients, including 2033 (15.8%) AA and 10,841
(84.2%) CAUC patients. AA patients
had higher baseline rates of hypertension, diabetes, and renal failure, and
suffered higher risk-adjusted incidence of death, stroke and MACE than Caucasian
patients. Risk-adjusted survival at 3, 5, and 10 years for AA (87.5%, 81.4%,
63.8%) was significantly lower than for CAUC (90.7%, 85.2%, 67.1%, p<0.001).
Both AA patients (AOR 0.77, Cl 0.44-1.36) and CAUC patients (AOR 0.72, Cl
0.53-0.99) who had OPCAB had lower risk-adjusted odds of MACE than their racial
counterparts who had CABG on cardiopulmonary bypass. No interaction terms were
significant, suggesting that OPCAB has the same effect in AA as it does in
CAUC.
Conclusions
Short and long-term outcomes are significantly worse in AA than
Caucasian patients undergoing primary, isolated CABG. OPCAB is similarly
beneficial to both groups in reducing perioperative morbidity. However, OPCAB does not narrow the
disparity in outcomes between African-Americans and Caucasians.
SLS EVENING WITH FACULTY FEATURING THE EXCEL AWARD PRESENTATION AND LECTURE
6:30pm-9:00pm, Thursday, September 10, 2009
EXCEL AWARD PRESENTATION AND LECTURE
Staring Into The Murky Abyss: The Future of Minimally Invasive Surgery
James "Butch" Rosser, Jr. MD, FACS
The lecture of the 2009 EXCEL award recipient, James "Butch" Rosser, Jr. MD FACS will give an "inside out" critique of the current state of the union of minimally invasive surgery from the vantage of a reflective participant of the laparoscopic revolution. In the afternoon of his career, Dr. Rosser will give his thoughts on 1) Procedure Adoption Rates and Training 2)Technique Evolution 3) The Medical/Surgical Industrial Complex 4) Government and Corporate Influence and Control. Finally, he will offer suggestions on how we as surgeons can re-seize the initiative and restore balance to the minimally invasive surgery universe.
MULTIDISCIPLINARY PLENARY SESSION
7:30am-8:30am, Friday, September 11, 2009
NOTES, SPA & MICROBOTS--A CONTROVERSY DEBATE
Single Port Access (SPA) Surgery: In Search of the Critical View
Paul G. Curcillo, II, MD
Some of the first laparoscopies (or celioscopies) that were performed in the early 20th century were, in fact, Single Port Access Procedures. A scope as inserted into the abdomen in order to explore the patient for disease. Over the next one hundred years laparoscopy has evolved to now be routine for most general surgery cases, and in its application to advanced procedures as well.
We are now entering an exciting time in the development of the next phase of laparoscopy, Minimal Access Surgery. NOTES has clearly demonstrated our desire to take this next step, albeit perceived often times as a “leap”. The advent of Single Port Surgery has now perhaps laid the groundwork for the “bridge” to NOTES or whatever path down which we proceed.
Paramount to the development of any new procedure is a focus on advancing safely and with caution. Single Port Access surgery has been developed with an eye to safety as we move forward. The “critical” view is the hallmark of Laparoscopic Cholecystectomies, and focusing on this gold standard during the development of Single Port Access Surgery has resulted no only in the successful application of this novel access technique to gallbladder surgery, but to more advanced procedures as well. In addition, it has prompted the development of a safe and effective method of training and adapting this technique into a surgeon’s practice across general surgery, gynecology and urology.
Although there will always be controversy with advances, there should be NO controversy with respects to safety.
NOTES, SPA & MICROBOTS--A CONTROVERSY DEBATE
Transvaginal NOTES: Culdolaparoscopy
Daniel S. Tsin, MD
Culdoscopy, this term is commonly used for transvaginal pelvic endoscopy and was published in 1944. Culdolaparoscopy is operative culdoscopy that goes beyond the pelvis into the abdominal cavity, and this was published in 2001.
NOTES is a revolutionary new surgery that focuses
on transgastric peritoneoscopy and also includes transvaginal endoscopy for
performing surgery that leaves no scars on the abdomen. Innovations in flexible technology,
magnets and robots are introduced in this surgery.
For an experienced laparoscopist it can be easy to
learn a transvaginal Minilaparoscopy Assisted Natural Orifice Surgery (MANOS),
hybrid form of NOTES. Hybrid culdolaparoscopy is MANOS, which combines
operative culdoscopy with minilaparoscopy. This approach uses a sealed vaginal port that avoids the
problem of losing the pneumoperitoneum. The port is placed under
minilaparoscopic surveillance. The vaginal port serves for insufflation,
visualization, and to place large instruments and endoscopic bag. The
endoscopic bag could be easily introduced and extracted via the vaginal port,
and when needed, the pneumoperitoneum reinstated. Pure culdolaparoscopy is done
via colpotomy with no abdominal ports.
Transvaginal endoscopy is less complicated for
entrance into the peritoneal cavity in comparison to the transgastric
approach. Yet, it is limited to
females with no obliteration of the pouch of Douglas or the vaginal fornix. Meanwhile, till flexible instruments,
robots, and magnets become available and affordable for NOTES, hybrid
procedures like culdolaparoscopy MANOS could benefit our patients and better
prepare us for the advances to come.
BREAKFAST WITH KEYNOTE SPEAKER/FUTURE TECHNOLOGY SESSION
7:30am, Saturday, September 12, 2009
FROM THE INFINITESIMAL TO THE INFINITE--MOLECULES, ENERGY AND SPACE FOR SURGEONS
Keynote Address
The Development of Space Robotics: Implications for Medicine
Tim Reedman, BASc, MEng
For over forty years, robots have been an integral part of the exploration of Space. From the early pioneering Moon landings to the assembly and construction of the International Space Station to the exploration of Mars, robots have been used to extend mankind’s reach through the Solar System. This talk will describe the evolution of the robots used for Space exploration and will illustrate interesting and exciting parallels with the development of robotics in medicine.
FROM THE INFINITESIMAL TO THE INFINITE--MOLECULES, ENERGY AND SPACE FOR SURGEONS
Plasma Medicine-Why Energy is Important to Surgeons
Michael R. Wertheimer, Ph.D., FCAE
When energy is provided to a solid material, the solid successively undergoes phase transitions, first to the liquid, then to the gaseous states. When still much more energy is introduced into the gas, the latter becomes ionised (i.e. some of the gas molecules are stripped of electrons and become positively-charged ions), a state known as “plasma”. Therefore “plasma” (the term first used in this context in 1929 by the Nobel-laureate physical chemist, Irving Langmuir) is often referred to as “the fourth state of matter”.
Plasma from a given gas can
have unique, unusual (but useful) properties, very different from those of the
parent gas molecules. For this reason it is being used during several decades
in a wide variety of technological applications, for example in the manufacture
of the ubiquitous integrated circuit “chips” found in our computers and cell
phones. In recent years, however, the plasma state has been recognised for its
very great potential in medicine, the focal issue of this talk. For example,
so-called “cold” plasmas (there is also a very “hot” variety, electric arcs),
where the ionised gas remains close to room-temperature, is extremely effective
in deactivating pathogenic microorganisms (bacteria, bacterial spores, even
proteins such as prions). This has given rise to a flurry of research activity relating
to the “plasma sterilisation” of medical devices and biological systems, even
living tissues such as skin and open wounds. Wound healing and tissue
regeneration can be enabled and greatly accelerated by plasma treatments for
ever-increasing varieties of pathologies, while leaving healthy tissues
unharmed.
This lecture will introduce the audience, first, to some desirable characteristics of the plasma state, then to a selection of medical applications of interest to surgeons.
FROM THE INFINITESIMAL TO THE INFINITE--MOLECULES, ENERGY AND SPACE FOR SURGEONS
Near-infrared photobiomodulation is neuroprotective in a transgenic mouse model of Parkinson’s disease
Harry T.
Whelan, MD, Michele M. Henry, BS, Ellen V. Buchmann, BS,
Margaret Wong-Riley, PhD, Kristina
DeSmet, MS, Janis T. Eells, PhD
Parkinson’s disease (PD) is a neurodegenerative movement disorder characterized by the loss of dopaminergic neurons in the substantia nigra and the accumulation of fibrous protein deposits consisting primarily of a-synuclein. Although most cases of PD are sporadic, there are inherited forms of PD that result from mutations in genes that code for α-synuclein. PD has also been associated with exposure to environmental toxins. Despite the diverse causes of Parkinson’s disease the pathogenesis of PD appears to be converging on a tightly linked common mechanistic pathway involving mitochondrial dysfunction, protein mishandling and oxidative stress leading to the death of dopaminergic neurons in the substantia nigra. Photobiomodulation by far-red to near-infrared (630-1000 nm) light [NIR-PBM] has been shown to improve recovery from ischemic injury in the heart, attenuate degeneration in the injured optic nerve and protect against mitochondrial dysfunction in the retina. Mechanistic studies have shown that NIR light interacts with the mitochondrial enzyme cytochrome oxidase triggering signaling mechanisms that result in improved energy production, antioxidant protection and cell survival. The present studies were undertaken to examine the potential neuroprotective actions of NIR-PBM in an animal model of PD. These studies were conducted in a transgenic mouse model of PD that expresses the A53T mutation of α-synuclein. These transgenic mice develop a Parkinson’s-like syndrome characterized by neurodegenerative changes in the basal ganglia and severe motor dysfunction. Two therapeutic protocols were tested, a prevention protocol and a treatment protocol. For the prevention protocol, animals received 670nm LED PBM (5 minute duration; 8 J/cm2) or sham treatment 3 times per week beginning at 2 months of age and extending for 20 months. For the treatment protocol, 670nm LED PBM treatment (5 minute duration; 8 J/cm2) was initiated at 8 months extending for 20 months. The onset of Parkinsonian motor symptoms was significantly delayed in both therapeutic protocols. Striatal dopamine concentrations were also significantly greater in the NIR-PBM treated mice compared to sham-treated mice. NIR-PBM also increased striatal concentrations of the anti-apoptotic factor (Bcl-2) and decreased concentrations of pro-apoptotic factors (BAX, Caspase-9) in the prevention protocol mice. These data document the neuroprotective actions of NIR-PBM in an experimental model of PD and support the potential of NIR-PBM in the treatment of Parkinson’s disease.
