Medical Update (2002)

Volume1/2002_WinterPatients Welcome Less Invasive Techniques U Surgeons Expand Laparoscopy to Major Operations University of Utah Hospital is among a handful of medical centers where surgeons are expanding the use of laparoscopy, or minimally invasive surgery, from relatively simple operations on the gall bladder or appendix to more complex procedures on the colon, kidney and liver. Surgeons Robert E. Glasgow, M. D., assistant professor of surgery at the U of U School of Medi-cine, and Sean J. Mulvihill, M. D., professor and chair of the Department of Surgery, recently per-formed what may be the first such laparoscopic procedures in Utah. For patients such as Janet Bell, whose colon was removed on September 28, the result is a quicker and less painful recovery from major surgery. " I had surgery on Friday and went home on Tuesday," Bell said. " I was never in a lot of pain from the operation." The Pocatello, Idaho, woman came to Glasgow after a yearlong bout with ulcerative colitis had left her unable to eat and so weak she couldn't walk on her own. Glasgow, who specializes in laparoscopic surgery, removed her colon. Instead of a lengthy scar and recovery from the conventional operation, Bell received five small incisions in her abdomen, the longest one being about two inches. Through those cuts, Glasgow removed her diseased colon. A laparoscope is a small, telescope- like device attached to a miniature video camera. The instru-ment is inserted through a small incision in the abdomen to give doctors a look at organs needing surgery to remove tumors, drain fluid collections and correct other problems. Patients who undergo laparoscopy, even for major operations such as Bell's, typically go home in two or three days, compared with one or two weeks after traditional surgery. " Patients get back to their lives more quickly," Glasgow said. Glasgow gained his expertise in laparoscopy through special fellowship training in Portland, Ore., with Lee Swanstrom, M. D., one of the world's leading laparoscopic surgeons. Mulvihill, who specializes in gastrointestinal cancer surgery, brought Glasgow to the U to help shape a state- of- the- art laparoscopic program and teach the technique to other surgeons. Sean J. Mulvihill, M. D., chair of the U medical school Department of Surgery, believes laparoscopy, or minimally invasive surgery, will become increasingly important. Laparoscopy shows promise in many areas of surgery, according to Mulvihill. It can be used to cut out or burn tumors in the liver and pancreas, or deliver chemotherapy directly to a tumor. In vascular surgery, surgeons can use laparoscopy to repair abdominal aortic aneurysms through a small incision in the groin, with the patient leaving the hospital in a few days. The traditional technique for that operation leaves a long scar on the torso and requires several weeks of recuperation. The U's program is well- established in this area. The U is going to stay at the forefront of laparoscopy, according to Mulvihill. " Our goal is to provide the most cutting- edge technology for the citizens of this state and region," he said. The surgery couldn't have come too soon for Bell. The colitis had destroyed her colon, leaving her unable to eat properly and causing her to lose 45 pounds. Her physician in Pocatello had identified the problem but was unable to treat it, so Bell started searching for a solution herself. She was aware of the U's reputation for medical care and contacted the hospital, which led her to 2 Glasgow. By the time she came to Salt Lake City, Bell had spent the previous three weeks hospitalized and had been so sick for a year that she'd lost muscle mass and barely walked. Yet, within a day of the surgery she started feeling better. She got stronger each day and regained the ability to walk, first with the aid of a walker and then on her own. Perhaps most importantly, she said goodbye to her companion of a year- pain. If she'd been less sick at the time of surgery, Bell said she would have recuperated even faster. As it was, she recuperated much more quickly than if she'd undergone traditional surgery. " I thought it was such a blessing that I got in touch with Dr. Glasgow and he was able to do that," she said. Along with its medical benefits of less pain, fewer complications and speedier recovery, laparoscopy can save the health- care system money in the long term, Mulvihill and Glasgow said. Although the equipment and training for surgeons are expensive, those costs can be offset by reduced hospital stays and people returning to their jobs more quickly after the operation. But for all its potential, laparoscopy can't be used in every operation. Some large hernias, for Robert E. Glasgow, M. D., specializes in laparoscopic surgery and says besides being less painful, laparoscopy helps patients return to their lives more quickly. Janet Bell, who battled ulcerative colitis for a year, returned to her job just a few weeks after surgeon Robert Glasgow removed her colon through laparoscopy. example, are better approached through traditional surgery. Repeat surgery on an organ or other body part often works better through the traditional technique as well. Still, the horizon for minimally invasive surgery is vast. " This really is the future of surgery," Mulvihill said. For more information, call the Department of Surgery, 801- 581- 7304. University of Utah Hospitals & Clinics toll- free referral and consultation numbers: in Utah 1- 800- 662- 0052 outside Utah 1- 800- 453- 0122 uuhsc. utah. edu 3 " It's My Sinuses. . . " Endoscopic Surgery Rates High in Improving Symptoms Stuffy nose, postna-sal drip, yellow-green discharge, throat clearing, headache between the eyes. It all adds up to the commonly heard complaint: sinus infection. More than 40 million Americans suffer from the condition. Chronic sinus disease is, in fact, more prevalent than hypertension and arthritis combined, according to Richard R. Orlandi, M. D., assistant professor of otolaryngol-ogy at the University of Utah School of Medicine. It seriously affects quality of life and day- to- day well- being and, from this standpoint, is considered to have a more negative effect on daily living than congestive heart failure, the U specialist said. The sinuses are located below and above the eyes, between the eyes, and behind the nose. " Sinuses are actually air- filled cavities within the facial bones. No one knows why we have sinuses, but they do provide a mucus production reservoir to help cleanse the nose," said Orlandi. There are several theories about the evolution of the sinuses. One On the cover. . . Richard R. Orlandi, M. D., is specially trained to do endoscopic sinus surgery, which is highly successful in improving symptoms. Kaye Watkins, Salt Lake City, who recently had endo-scopic sinus surgery to remove polyps, says it's wonderful to be able to breathe freely. holds that if the sinus cavities were bone, the skull would be very heavy; another speculates that they provide a " crumple" zone for the brain and the eyes, to offer some protection against injury. A recent idea, Orlandi said, is that a gas ( nitric oxide) that may regulate lung function, is produced in these cavities. Sinuses are large chambers lined with a mucus membrane, which drain through miniscule openings. When the lining swells with inflam-mation caused by colds or allergies, the mucus can't get out and the sinus cavities become a reservoir for bacteria. Acute sinusitis results. An acute sinus infection often starts out as a cold and, about 10 days later, symptoms include throbbing pain in the head and green mucus in the nose. This condition is treated with deconges-tants, and, if necessary, with antibiotics. With appropriate treatments, symptoms rarely last longer than two weeks. If a patient with chronic sinus symptoms is treated with medications, such as a topical steroid spray and antibiotics or antihista-mines, and symptoms, including facial pain, continue more than four weeks, then he or she is considered a candidate for sinus surgery. " It is not clear, with our current understanding of these diseases, that acute actually turns into chronic sinusitis," said Orlandi. " Many think chronic sinus disease develops insidiously over the course of months." Chronic sinus disease is not seen as much in children as in adults, but can affect adults at any age. Individuals who never have had sinus problems may have a situa-tion that triggers the condition, Orlandi said. Orlandi's specialty is endoscopic sinus surgery, a procedure first used in the United States in 1985. " Not much has changed with that procedure; it has become the standard of care for the disease," the U specialist says. He cautions that it is not a cure, but it is the best treatment available so far. There is about an 85 percent improvement in symp-toms. Patients have to stay on medications like nasal sprays and antihistamines afterward. " It's a matter of plumbing. By widening the drainage pathways of the sinuses, surgery helps to decrease the frequency, severity, and dura-tions of infections, and the medica-tions are much more effective," said Orlandi. Kaye Watkins had endoscopic sinus surgery in October and says it's been " wonderful" since. Her longstanding problem, which had been treated twice before with surgery, was nasal polyps. " Dr. Orlandi's goal is to not have the polyps come back, as they did before," she said. A benefit of endoscopic surgery is that it permits accurate removal of polyps using suction cutters, with minimal postoperative discomfort. Watkins' condition has been a gradual one, but " came on strongly" the past three years. Prior to having the surgery, she couldn't breathe, was totally congested and, when she blew her nose, there was no dis-charge. " My sinus condition interfered with my sleep. In addition I have allergies which reacted to various irritants and I also have asthma, so I was desperately looking for some help. When my physician said he thought he had the answer in Dr. Orlandi, I was thrilled, and I feel wonderful now," she said. Little is known about how or why nasal polyps develop. They obstruct the nasal passages, result-ing in stuffiness and nasal drainage. Individuals with chronic symptoms of nasal obstruction, should seek a medical evaluation to determine whether polyps are causing the problem, Orlandi said. Patients at University Hospital have the benefit of image guidance surgery, Orlandi explained. A CT scan is done prior to the operation and used to assess the patient's anatomy and identify diseased areas. During the surgery, the computer can tell the physician, in three dimensions, where his endoscope is and guide the surgeon. The endo-scope uses lighted fiberoptic glass rods which provide superior visualization. The procedure is almost always done on an outpatient basis, and although patients have the option of local or general anesthetic, most choose general. Work loss may be from three to 10 days. During recuperation, patients may feel like they have a cold and the nose will be somewhat swollen. Most patients say there is very little pain associated with the surgery. Post- operative care includes seeing the surgeon fairly frequently to be sure the nose is healing properly and that excessive scarring is not developing. " The surgery was very easy with no pain to speak of," Watkins said. Watkins believes that she inherited the problem from both sides of her family. Orlandi said that people who have sinus inflammation tend to have children who also have the problem. Occasionally, Orlandi does repair work to the paper- thin bone which separates the sinuses from the eyes and also from the brain. It's a rare occurrence, but this injury is sometimes a surgical complication, the surgeon said. Only the sinuses that are affected with disease are treated, but, generally, chronic sinus disease affects all the cavities, Orlandi said. When only one appears to be affected, physicians consider the possibility of a tumor, but such cases are exceedingly rare. Endoscopic sinus surgery is sometimes called ESS or FESS, for Functional Endoscopic Sinus Surgery, to distinguish this proce-dure from conventional surgery. FESS was made possible by the development of fiberoptic endoscopes, which allow a thorough examination of the nose. Previously, it was believed that once the mucosa, the lining, was chronically inflamed, it had to be removed because it was irreversibly damaged. The technique for this surgery required incisions between the eyes and nose, over the top of the head, ear- to- ear, and between the lip and gums. This radical operation resulted in scars, bruising and discomfort and also caused numb teeth. With FESS, scars are avoided and there is no damage to the nerve supply of the teeth. The procedure can be used successfully in patients who have had previous surgery, said Orlandi. Orlandi is one of 15 specialists who trained at the University of Pennsylvania with David Kennedy, M. D., who brought the procedure to this country. He completed a fellowship in rhinology and sinus surgery at the University of Penn-sylvania. He served on the faculty there and was associate director of the Michigan Sinus Center at the University of Michigan Center for Specialty Care before joining the U of U faculty about a year and a half ago. Aside from Orlandi, the nearest similarly trained specialists for this surgery are at Stanford, in Portland and in Nebraska. ® For more information, call Richard R. Orlandi, M. D., 801- 581- 7515. U Cardiologists Implant Device Pacemaker- Defibrillator Saves Lives of Heart Patients For a man whose heart has stopped three times recently, Terry Fox looks pretty healthy. That's because a small device in his chest, like the one Vice Presi-dent Richard Cheney received, shocked the West Valley City man back to life after his heart started fibrillating, or beating too fast, and then stopped. Without the device, a combination defibrillator and pacemaker, Fox, 60, would have become a statistic- one of 400,000 Americans who die every year from Sudden Cardiac Death ( SDC), according to John D. Day, M. D., Fox's doctor and an assistant professor of cardiology at Univer-sity of Utah School of Medicine. SCD kills more Americans each year than AIDS, breast cancer and lung cancer combined. Yet, the public is largely unaware of it, said Day, who specializes in abnormal heart rhythms. " It's a public health issue," he said. Many people are familiar with defibrillators shocking patients back to life on TV shows such as " ER" and " Mash". But the use of defibrillators goes beyond the world of hospi-tals. Heart problems are prevalent enough that defibrillators now are carried on commercial airplanes and also are available in casinos and sports stadiums, among other places. That's for good reason, according to Day. When someone's heart fibrillates and stops, the chances of survival diminish about 10 percent every minute that the heartbeat remains out of rhythm. With those odds, having a defibrillator at hand can save lives. In the past, many deaths attributed to massive heart attacks, or even natural causes, actually were SCD, according to Day. Anyone who has had a heart attack, has an abnormal rhythm or heart failure potentially could die of SCD and may benefit from a pacemaker- John D. Day, M. D., a University Hospital cardiologist who implanted the pacemaker- defibrillator in Fox, says Sudden Cardiac Death ( SDC) kills 400,000 Americans annually. defibrillator, said Day, who implanted one in Fox last July. He and two other University of Utah cardiolo-gists- Richard C. Klein, M . D , professor of cardiol-ogy, and Roger A. Freedman, M . D , professor of cardiology- implant up to 150 of the devices a year, Day said. Smaller and thinner than a pager, the device easily fits in the palm of a hand, weighs about an ounce and is implanted through minor surgery. A computer inside it monitors and records heart activity. When the heart starts beating too fast, the defibrillator shocks it into a normal rhythm, or, as in Fox's case, gives it a jump- start to get beating again. Conversely, if the heart is beating too slowly, the pacemaker speeds it up. Fox received his just in time. A week after the implant, he was puttering around his garage when his heart started beating so fast that it stopped. He woke up on the floor, not knowing what happened. Afterward, he went to see Day, who passed a wand over his chest, where the device is implanted. The wand downloaded the recent history of Fox's heart function onto a laptop computer. The computer record revealed that Fox's heart had started beating at a rate of 300- 400 times a minute. A heart beating that fast can't fill with blood, so it stops beating altogether. Fox's heart stopped for 15- 20 seconds before the defibrillator zapped him back to life, Day said. Fox's heart fibrillated two other times. The second time he was in University Hospital, and, again, he woke up on the floor not knowing what happened. The third incident occurred while he was undergoing a medical procedure. But that time Fox didn't lose consciousness and he felt the electrical charge that normalized his heart rhythm. He wasn't ready for the jolt he got. " It was like a mule kicked me in the chest," he said. Fox's heart problems stem from rheumatic fever that damaged his heart valve when he was a child. He'd lived a normal life, including working as a construction crane operator in California, until his heart condition worsened and he returned to Utah, his home state, a few years ago. No longer able to work, Fox needs a heart transplant, and he's been on the waiting list for three years. But a couple of factors have made it difficult to find a suitable donor heart for him. At 6 feet tall and 231 pounds, he needs a heart that is physically big enough to support him; so far he's had no luck getting one. He also has 0- positive blood, which limits the number of potential donor hearts his body can accept with a reasonable chance of avoiding rejection. But for someone whose heart has stopped three times, and who's lived to tell the tale, hope is not easily surrendered. Fox is confident he'll get a donor heart. " Give up hope and you might as well pull in the dirt after you," he said. " You've already dug your grave." SCD most commonly occurs because of ventricu-lar tachycardia or fibrillation, and for those at the highest risk of SCD and who have a medical indica-tion for a life- saving defibrillator, only 20 percent actually receive one, according to Day. Implanting the device involves minor surgery with a two- inch incision in the chest. An electrical wire runs from the device through a vein to the heart. Because it runs on Terry L. Fox, of West Valley City, says a pacemaker-defibrillator like the one implanted in Vice President Richard Cheney, saved his life by shocking his heart when it stopped beating. Fox is awaiting a transplant. a battery, the device must be replaced every five to six years, but insurance companies cover the cost, said Day. As Fox waits for a transplant, he is being assisted by another bit of technology he received at Univer-sity Hospital- a Left Ventricular Assist Device ( LVAD). The LVAD boosts the function of the left ventricle in his heart, and Fox said he's feeling better than he has in years. He expects the LVAD and the defibrillator- pacemaker to sustain him until he gets a new heart. All in all, Fox has developed a soft spot in his heart for University Hospital. " I'll tell you what, the University of Utah is keeping me alive," he said. For more information, call John D. Day, M. D., 801- 581- 7715. Visit uuhsc. utah. edu The new health sciences center Web site has comprehensive medical resources, and a list of all the University of Utah Health Sciences Center experts. 7 University of Utah School of Medicine Continuing Medical Education March 17- 22: Advances in Internal Medicine The Lodges at Deer Valley Chairs: Malcolm M. Berenson, M . D , Merle A. Sande, M . D , Barry M. Stults, M. D. 25 AMA Category 1 hours Contact: Jessica Kuo, 801- 581- 7606 jessica. kuo@ hsc. utah. edu March 25- 27: Family Practice Refresher Course 2002 Salt Lake Sheraton Hotel Chair: Stephen Ratcliffe, M . D , M. S. P. H. 24 AMA Category 1 hours 1 Contact: Kristin Christensen, 801- 581- 7914 kchristensen@ dfpm. utah. edu I I March 8: Ophthalmology Residents/ Alumni Day Conference John A. Moran Eye Center, University of Utah Chair: Paul L. Zimmerman, M. D. 7 AMA Category 1 hours Contact: Kim Nalewaja, 801- 585- 3719 kim. nalewaja@ hsc. utah. edu March 14- 16: Administration for Physician Executives- Leadership, Negotiation, and Organizational Structure: Managing the Organization C. Roland Christensen Center, University of Utah Chair: Brad Vierig Up to 72 AMA Category 1 hours; 6 hours graduate credit for completion of entire program Contact: Brad Vierig 801- 581- 5577 Execbv@ business. Utah, edu University of Utah Hospitals & Clinics Office of Public Affairs 50 N o r t h Medical Drive Salt Lake City, Utah 84132 March 2- 5: 4 7 c Annual Postgraduate Course in Anesthesiology: New Directions in Pain Management Cliff Conference Center, Snowbird, Utah Chair: Theodore H. Stanley, M. D. 20 AMA Category 1 hours Contact: Patricia Earl, 801- 581- 2707 patricia. earl@ hsc. utah. edu March 3- 9: 4 3 r d Annual OB/ Gyn & Maternal- Fetal Medicine Update Olympia Marriott, Park City, Utah Chair: Kirtly P. Jones, M. D. 29.5 AMA Category 1 hours Contact: Dora A. Thompson, 801- 581- 5501 dora. thompson@ hsc. Utah. edu MEDICAL UPDATE is published quarterly by the Office of Public Affairs for physicians and other health- care providers and educators in the Intermountain West. Editor: Mary Chachas, Contributing writer: Phil Sahm. Photographer: Brad Nelson