UCSF’s bariatric surgery program offers care for obese patients.

Unless you weigh more than 400 pounds, it’s difficult to imagine walking a mile in James Dials’ shoes. In fact, for most of his life, he couldn’t do that either.

The gregarious 62-year-old limousine driver made friends easily, escorting musicians and athletes all over town. Sometimes they would shower him with choice tickets to concerts and sporting events.

Stanley Rogers (left) and James Dials

But Dials always had to turn them down.

Not because of a company policy or because he didn’t enjoy public events. Not too long ago, Dials weighed 434 pounds, and he couldn’t walk 10 feet without having to stop and catch his breath. The walk from the parking lot to the venue would have been a Herculean task for him to accomplish.

“I could only take about 20 steps and stop and catch my breath,” Dials said. “Then, 20 more steps and then stop.”

He says low self-esteem and his love of his native Southern down home cooking contributed to his gradual weight gain. Before he knew it, Dials passed the 400-pound mark.

“My life was very uncomfortable,” Dials said. “I was a diabetic and I injected insulin. I had high blood pressure, sleep apnea, and high cholesterol. I was on all kinds of medications.”

That’s when he discovered the UCSF Bariatric Surgery Center, a Level 1 accredited center for weight-loss surgery by the Bariatric Surgery Center Network of the American College of Surgeons, which means they provide complete bariatric surgical care. It is a nationally certified “center of excellence,” which offers a multidisciplinary approach to weight loss.

“James had relatively advanced obesity,” says Stanley Rogers, M.D., chief of minimally invasive surgery and director of the Bariatric Surgery Center and Liver Tumor Ablation Program at UCSF Medical Center. “And we know that weight loss either with or without surgery can significantly impact those medical problems, and can make these medical problems called co-morbidities go away as weight loss occurs.”

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Roughly half use social media to help market their business.

Reza Jarrahy, UCLA

Social media has revolutionized the way in which people and businesses interact, and it is taking on a growing role in the health care industry. A new UCLA study looking at the use of social media among plastic surgeons found that roughly half of these specialists use social media tools.

Plastic surgeons have been leaders among medical specialists in the development of interactive websites to promote their practices and educate patients, said the study’s principal investigator and senior author, Dr. Reza Jarrahy, an associate clinical professor of plastic and reconstructive surgery at Ronald Reagan UCLA Medical Center. But until now, there there had been surprisingly little information on whether and how they are using social media.

In the study, published in the May issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS), approximately 50 percent of plastic surgeons polled said they use Facebook, Twitter and other social media platforms to help market their professional practice.

“Social media platforms represent a dynamic and powerful tool to educate, engage, market to and directly communicate with patients and professional colleagues,” said Jarrahy, who is a member of ASPS and vice president of communications for the American Society of Maxillofacial Surgeons. ”However, for plastic surgeons, the potential benefits associated with using this tool must be balanced against its potential pitfalls.”

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UCLA working group helps Guatemalans.

High above a village of shanties in Guatemala, plastic and reconstructive surgeon Dr. Reza Jarrahy of UCLA hauls concrete bricks to make stoves to replace wood-burning ones that spread soot in people's homes.

UCLA plastic and reconstructive surgeon Reza Jarrahy realized that he was missing something when his young Guatemalan patient developed a mysterious infection after undergoing surgery. That puzzled the surgeon, who travels Guatemala twice a year to do pro bono surgery on people from indigenous communities.

“I knew these people were destitute, uneducated and medically unsophisticated, but I didn’t appreciate the deeper social context in which they were living and how that influenced surgical outcomes,” said Jarrahy.

The realization that caring for indigenous people in parts of the world like Latin America requires more than just medical knowledge and skills has brought physicians and public health experts together with anthropologists and others from across the campus to learn from each other under the auspices of the UCLA Latin American Institute.

Funded by a Title VI grant from the U.S. Department of Education, this UCLA working group, led by Jarrahy, a board-certified plastic surgeon specializing in pediatric plastic surgery and craniofacial surgery, and Bonnie Taub, a medical anthropologist who teaches anthropology as well as public health, met recently for the first of a series of three symposia hosted by the institute to discuss how Westernized health care can intersect with traditional healing practices and beliefs.

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Bleeding, transfusion, readmission, death more likely after taking SSRIs.

Andrew Auerbach, UC San Francisco

Selective serotonin reuptake inhibitors (SSRIs) – among the most widely prescribed antidepressant medications – are associated with increased risk of bleeding, transfusion, hospital readmission and death when taken around the time of surgery, according to a new analysis.

Researchers from UC San Francisco and Baystate Medical Center in Massachusetts looked at the medical records of more than 530,000 patients who underwent surgery at 375 U.S. hospitals between 2006 and 2008. Their results were published today (April 29) in JAMA Internal Medicine.

“There have been small studies that suggested there was a problem, but it has never been well-proven,” said lead author Andrew D. Auerbach, M.D., M.P.H., a UCSF professor of medicine. “With this huge data set, we feel confident in saying that SSRIs are associated with about a 10 percent increased risk for these adverse outcomes.”

The study authors noted that patients on SSRIs are more likely to have conditions that in themselves increase surgical risk, such as obesity, chronic pulmonary disease and depression.

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Minimally invasive technique part of clinical trial for higher-risk surgical patients.

Doctors at Ronald Reagan UCLA Medical Center have become the first on the West Coast to perform a new, less-invasive procedure to help clear plaque-ridden carotid arteries. The procedure, which is part of a clinical trial, took place on March 28.

Just as arteries to the heart can become clogged with plaque, causing a blockage, so can the two carotid arteries that supply blood to the brain. Every year, more than 300,000 people in the U.S. are diagnosed with such blockages, which, if left untreated, can reduce or even stop blood flow to the brain, causing a potentially disabling stroke.

Current treatment options include the traditional “open” surgery approach to clean out the carotid artery and a minimally invasive alternative that uses a stent to keep the artery open.

Each of these options has some limitations. Traditional surgery involves making a large incision along the neck and carries the risk of surgical complications. While less invasive, the stent procedure requires the insertion of a catheter through an artery in the groin to guide the stent into place, which can potentially dislodge plaque; loose plaque can travel through the bloodstream and cause a blockage. Some studies have indicated that the stent procedure carries a higher risk of stroke than the surgical procedure.

The new technique and device system being tested at UCLA is called transcarotid stenting with dynamic flow reversal, or the Silk Road Procedure, which allows physicians to deliver a stent directly into the carotid artery from the neck, offering a shorter, potentially safer route than the typical stent procedure.

A unique aspect of the new system is the ability to temporarily divert blood flow away from the plaque during the procedure to help ensure that a patient’s brain is fully protected from plaque debris at all times. Physicians redirect blood flow from the carotid artery where the team is working into tubing set up outside the body and then back into the body through the femoral vein, near the groin.

Ronald Reagan UCLA Medical Center is one of 25 centers around the world participating in the clinical study, called the ROADSTER trial, which is designed for high–surgical risk patients who may be older or have especially narrowed arteries.

“We’re always seeking new options for patients with the ultimate goal of treating these carotid artery blockages with the least procedural risk,” said Dr. Wesley Moore, UCLA study investigator and a professor emeritus of vascular surgery at the David Geffen School of Medicine at UCLA. “We look forward to contributing to this important research.”

The study is funded by Silk Road Medical, developers of the transcarotid stenting with dynamic flow reversal system.

For more information on the clinical trial at UCLA, please call (310) 206-1115.

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National treatment trends raise concerns about rise of kidney removals.

Ithaar Derweesh, UC San Diego

Researchers at the UC San Diego School of Medicine have released study results that show national treatment trends in the surgical management of patients with kidney disease.

The study found that partial and complete kidney removal (total nephrectomy) and energy-based techniques to destroy tumors are all on the rise. Surprisingly, the patients most in need of kidney-sparing surgery are still more likely to undergo total nephrectomy. The findings recently published online in BJU International.

“While the overall proportion of patients receiving kidney preserving treatments for localized kidney tumors continues to grow, the most significant, and perhaps unsettling finding was that patients with kidney insufficiency still undergo complete kidney removal – even though kidney preserving treatment may be indicated,” said senior author Ithaar Derweesh, M.D., urologic oncologist at UC San Diego Moores Cancer Center.

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Study will help physicians calculate risk of post-surgical venous thromboembolisms.

Robert Canter, UC Davis

New research from the UC Davis Comprehensive Cancer Center, published in the Journal of Surgical Research, may help clinicians determine which patients are at highest risk for post-surgical blood clots in the legs or lungs.

A team led by Robert Canter, UC Davis associate professor of surgery, studied the medical histories of more than 470,000 surgical patients to determine which factors increased their risk of blood clots, also called venous thromboembolism (VTE). The team then created a nomogram, a type of calculator, which can help clinicians predict an individual’s 30-day VTE risk. The results could change clinical practice by providing a more rational approach to preventing dangerous blood clots.

Blood clots are a critical safety and quality challenge for hospitals around the nation. While they can be prevented by administering blood thinners, such as heparin, these measures increase the risk of bleeding. To complicate matters, clinicians have had no way of determining which patients are at higher risk for blood clots, forcing them to adopt a one-size-fits-all approach to prevention.

“The standard preventive measure is heparin,” said Canter. “However, there are many questions surrounding its use: What type of heparin should be administered? What dosage? Should we give it to patients before or after surgery? By identifying patients who are at higher risk for VTE, we attempt to answer many of these questions and help to personalize treatment.”

Blood clots of the legs or lungs are a serious surgical complication, which can cause shortness of breath, longer hospital stays and, in rare cases, death. Successful treatment often requires patients to take the blood thinner Coumadin for three to six months after discharge.

The researchers combed through the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database to identify 471,000 patients who underwent abdominal or thoracic surgeries between 2005 and 2010. Their goal was to identify VTE events within 30 days of surgery, both in the hospital and after discharge (VTEDC). VTE includes deep vein thrombosis (clots in the legs) or pulmonary embolism (clots in the lungs).

The team considered many patient factors: age, body mass index (BMI), gender, race, pre-existing conditions, medical history, smoking and others. The group also factored in different approaches to surgery—abdominal, thoracic, laparoscopic, etc. — as well as the specific procedure type such as gastrointestinal, hernia, bariatric, splenectomy or lung. They also looked at post-operative complications, as these could affect both the length of stay and blood clot prevention efforts.

“There are a multitude of factors that go into whether a patient is at risk for VTE, as well as how to prevent it,” said Canter. “Prior to this study, no one had ever looked at so many of these factors so comprehensively.”

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Becker’s Hospital Review ranks health system in top 100 list for neurosurgery and spine care.

More than 30 neurosurgeons at UC San Diego Health System are dedicated to the care of complex neurological diseases.

UC San Diego Health System has been named among “100 Hospitals with Great Neurosurgery and Spine Programs” by Becker’s Hospital Review, a news publication for hospital and health system leadership.

According to the Becker’s Hospital Review editorial team, these hospitals offer outstanding spine and neurosurgical care, and were selected based on nominations, clinical accolades, quality care and other spine and neurosurgical proficiencies.

“The UC San Diego Neurological Institute is proud to have its neurosurgery program recognized as a leading program in complex brain and spine care,” said Bob Carter, M.D., Ph.D., professor of surgery at UC San Diego School of Medicine, and chief of neurosurgery at UC San Diego Health System. “We have been fortunate to attract an outstanding cadre of neurosurgeons to UC San Diego who specialize in every form of neurosurgery, from minimally invasive techniques to the most complex spine and brain surgery.”

These hospitals have been recognized for excellence in this specialty by reputable healthcare rating resources, including U.S. News & World Report, HealthGrades, Truven Health Analytics, Blue Cross Blue Shield Distinction Centers for Spine Surgery, Delta Group CareChex and the American Nurses Credentialing Center.

Carter, who was recruited from Harvard in 2010, noted that a special emphasis has been placed on developing programs that require a multidisciplinary team-based approach.

“We have been fortunate to partner with our colleagues in neurology and other specialties to create ‘Centers of Excellence’ in brain tumors, spine and peripheral nerve restoration surgery, stroke and aneurysms, Parkinson’s disease, pediatric neurosurgery and skull base/pituitary surgery. These centers mean that patients are offered all forms of treatment, both surgical and non-surgical, in one setting.”

The neurosurgery program has more than 30 neurosurgeons dedicated to the care of all forms of brain and neurological disease. In 2012, UC San Diego Health System became one of the first facilities in the country to be certified as a Comprehensive Stroke Center (CSC), the newest level of certification for advanced stroke care awarded by The Joint Commission.

Patients and families who would like to learn more about the neurosurgery program at UC San Diego Health System may visit: http://health.ucsd.edu/specialties/neuro/Pages/default.aspx.

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Memorial service at UCSF to honor his life on March 8.

Maurice Galante

The UC San Francisco community is mourning the loss of Maurice Galante, M.D., professor emeritus and a renowned surgeon at UCSF for more than 50 years, who passed away at his home on Feb. 5, 2013. He was 93.

UC San Diego neurosurgeon specializes in procedure to reverse muscle paralysis.

After four years of confinement to a wheelchair, Rick Constantine, 58, is now walking again after undergoing an unconventional surgery at UC San Diego Heath System to restore the use of his leg. Neurosurgeon Justin Brown, M.D., performed the novel 3-hour procedure.

“Following a car crash, Mr. Constantine had a brain stem stroke that caused paralysis on the right side of his body.  His leg muscles became so severely spastic that he could not walk,” said Brown, director of the Neurosurgery Peripheral Nerve Program at UC San Diego Health System. “Our team performed a delicate surgery to reduce input from the nerves that were causing the muscles to over contract to the point of disability.”

“After my injury, I was told I would never walk again. All I could to was move from my wheelchair to my bed or a chair,” said Constantine, a former NASCAR crew member. “After surgery with Dr. Brown, I could put my foot flat on the ground to walk. With physical therapy, everything just gets better and better. I’m a firm believer in never giving up.”

Prior to surgery, Constantine underwent botox treatments and physical therapy in an attempt to restore the use of his leg. The results were positive but minimal. An additional nerve conduction study, called an electromyogram (EMG), identified the muscles causing the dysfunction.

Justin Brown, UC San Diego

“When all other options did not produce satisfying results, we opted for surgery,” said Brown. “With the EMG, we identified the over-excited nerves that needed to be downgraded. Mr. Constantine had surgery on a Friday and within days was in physical rehabilitation. Two weeks later he was walking without a walker and has even completed a 1-mile race without assistance.”

The surgery, called a selective peripheral neurotomy, is a procedure performed under a microscope.  Brown makes an incision behind the knee to reach the tibial nerve. He then selectively trims back the troublesome nerve branches by up to 80 percent.  Cutting the nerve reduces the “noise” being relayed back to the spinal cord which causes the spasticity.

Brown, who also serves as co-director of the Center for Neurophysiology and Restorative Neurology at UC San Diego Health System, said the advantage to this approach is that the muscle is preserved and there is no need to cut or lengthen the tendon.

“Depending on the specific patient and their medical history, selective peripheral neurotomy may be appropriate for patients with brain and spinal cord injury from strokes or tumors, cerebral palsy or multiple sclerosis.”

No special post-operative care is required as the sutures are absorbable. Rehabilitation can begin 72 hours after the procedure.

Constantine underwent physical therapy at VIP NeuroRehabilitation Center in San Diego.

The surgery, seldom performed in the United States, is more common in France and Japan. Brown has performed this surgery on six patients. Patients requiring information on this procedure should call (858) 657-7000.

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UC San Diego’s Satniago Horgan is first surgeon in U.S. to implant the FDA-approved device.

Santiago Horgan, UC San Diego

A study published Feb. 21 in the New England Journal of Medicine (NEJM) provides clinical evidence of the safety and effectiveness of a new magnetic medical device to treat gastroesophageal reflux disease (GERD). Santiago Horgan, M.D., professor of surgery at the UC San Diego School of Medicine and study co-author, was the first surgeon in the United States to implant the FDA-approved device.

“What we found is that the LINX magnetic device can solve GERD’s underlying problem, a weak sphincter,” said Horgan, chief of minimally invasive surgery, UC San Diego Health System. “The device corrects an anatomical defect that allows acids to move up the throat. For my patients this has been an effective way to permanently treat this painful condition, improve their quality of life, and end the need for over-the-counter medications.”

The LINX system is composed of a series of titanium beads, each with a magnetic core, that are connected to form a ring shape. It is implanted at the lower esophageal sphincter (LES), a circular band of muscle that closes the last few centimeters of the esophagus and prevents the backward flow of stomach contents.

As reported in the study, after sphincter augmentation with the LINX System, the majority of patients were able to substantially reduce or resolve their reflux symptoms, while eliminating use of their reflux medications such as proton pump inhibitors. Severe regurgitation was eliminated in 100 percent of patients, and nearly all patients (93 percent) reported a significant decrease in the need for medication. More than 9 in 10 patients (94 percent) reported satisfaction with their overall condition after having the LINX System, compared to 13 percent before treatment while taking medication.

Horgan said the device is an alternative to Nissen fundoplication which involves irreversibly wrapping the stomach around the esophagus. The LINX System allows surgeons to leave the stomach intact and support the weak sphincter with a small device that can be removed.

More than 20 percent of the U.S. population experiences the painful burning symptoms of GERD. For these 20 million Americans, the first line of defense is medication. GERD can cause both pain and injury to the esophageal lining and may lead to a precancerous condition called Barrett’s esophagus. Symptoms of GERD include heartburn and regurgitation, often associated with the inability to sleep and dietary constraints.

The LINX system was studied in a controlled, prospective, multicenter trial involving 14 U.S. and European medical centers as part of the FDA approval process. The patients in the study reported suffering from reflux symptoms for a median of 10 years and taking reflux medications for a median of five years.

The LINX Reflux Management System is manufactured by Torax Medical, which funded the study.

To learn more about the LINX device, call (858) 657-8860.

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