VOLUME 1 NUMBER 3 SPRING 2003 Insidesurgery

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VOLUME 1 NUMBER 3 SPRING 2003insidesurgeryL A PA R O S C O P I C S U R G E R YWith the advent of better instrumentation and imaging tools, surgeons aretaking a laparoscopic approach to complex procedures traditionally performedwith an open incision. This shift towards minimally invasive surgery has dramatically reduced hospital stays and postoperative complications, allowingpatients to resume their normal activities much more rapidly. Laparoscopicsurgical techniques, many of which were developed by UCSF surgeons, canCONTENTSbe used to treat both cancerous and benign conditions.L A PA R O S C O P I CS U R G E RY1LETTER FROM THECHAIR2B A R I AT R I C C E N T E R4C O L O N A N D R E C TA LS U R G E RY6QI REPORTINGSYSTEM7NEW GENERALS U R G E RY C H I E F8APPOINTMENTS,HONORS8Laparoscopic AdrenalectomyLaparoscopic adrenalectomy is currently theprocedure of choice for most adrenal diseases requiring surgical treatment, includingpheochromocytomas, adrenal corticaltumors causing Cushing’s syndrome or primary hyperaldosteronism. This complexlaparoscopic technique can also be used toremove large adrenal tumors that are discovered incidentally and some cancers withlimited spread to the adrenal gland,according to Quan-Yang Duh, MD, sectionchief of Endocrine Surgery at UCSF, whichis a referral center for this operation. Dr. Duhhas performed more than 250 laparoscopicadrenalectomies—one of the largest seriesin the world—with excellent results. Goodoutcomes are the result of close collaboration between surgeons, endocrinologistsand anesthesiologists experienced in thetreatment of adrenal disease.Patients who undergo the laparoscopic procedure have less pain from the surgical sitethan those recovering from the large incision required by open surgery. They arealso able to eat and return to normalactivity within days instead of weeks oftheir surgery. Most patients are dischargedhome after a one- or two-day hospital stay.Minimally InvasiveParathyroidectomyA minimally invasive surgical approach isalso appropriate for up to two-thirds ofpatients with primary hyperparathyroidism.To be eligible, the patient must have a definitive finding of a single parathyroid adenomaby preoperative localization studies, usuallyultrasonography and sestamibi scan. This isbecause the minimally invasive approach,which involves small incisions ranging from1.5 to 3 cm, permits only limited explorationfor additional parathyroid tumors.C O N T I N U E D O N PA G E 3

Videoscopic training programThe Department of Surgery offers an extensive training program for community surgeons through its Videoscopic SurgeryCenter. Since its inception in 1992, theUCSF program in videoscopic surgery hastrained approximately 3,000 surgeons in thetechnical aspects of laparoscopic and thorascopic surgery. Formal training coursesinclude lectures, videotapes, a completesyllabus and lengthy periods of supervisedhands-on animal work. The UCSF trainingprogram is the most extensive of its type inthe United States. Courses cover not onlybasic and advanced general surgery but alsospecialized urologic, pediatric, cardiac andhernia repair procedures. The UCSF program has served as a model for the ACSCommittee on Emerging SurgicalTechnology and Education.Precise anatomical knowledge enables the surgeon to perform neck operations with small incisions.CONTINUED FROM FRONT PAGELETTER FROM THE CHAIRThis issue of Inside Surgery reflects how busy we have been, both in terms of faculty recruitment and clinical innovation.Several approaches to minimally invasiveparathyroidectomy are currently being performed at UCSF, some of which involve theuse of a videoscope, according to Duh.With appropriately chosen patients, theresults of minimally invasive parathyroidectomy are comparable to those of the traditional open approach.Esophageal Motility DisordersThe Department has been actively recruiting new faculty to meet our increasing clinicalneeds. We are fortunate that Dr. Hobart Harris, pictured on the back page of this newsletter,has accepted the important role of chief of the Division of General Surgery at UCSF. Dr.Harris has an impressive clinical and research background and is highly respected as aneducator. Under his leadership, the Division will continue to integrate surgery with other disciplines to provide comprehensive care for patients with complex diseases.Dr. Julio Garcia-Aguilar, the new chief of Colorectal Surgery, has expanded clinical serviceswithin this specialty and has developed a research program to investigate the optimal useof chemoradiation in the treatment of rectal cancer. Dr. Tom Karl, the new chief of PediatricCardiac Surgery, brings to UCSF his international reputation for providing excellent care tochildren with complex heart problems.Other new faculty recruits round out our current strengths in vascular, pediatric, endocrine,colorectal, plastic and reconstructive, adult and pediatric cardiothoracic, and breast surgery.Our new appointments also include faculty from the UCSF-East Bay Surgery Program. Thissurgical residency training program, previously affiliated with UC Davis, is based at AlamedaCounty Medical Center. This affiliation, which will complement our existing resident education and clinical programs, offers residents valuable surgical experience with a diversepatient population.This issue highlights clinical innovations in minimally invasive (laparoscopic) surgery. Lessinvasive techniques have been incorporated into virtually every surgical discipline; in thesepages we explore laparoscopic approaches to endocrine, bariatric and colorectal surgery.When performed by a highly skilled surgical team, these new approaches can greatly reducemorbidity and recovery times for patients.Nancy L. Ascher, MD, PhDProfessor and Chair, Department of SurgeryFor more than a decade UCSF has providedlaparoscopic treatment for a range of benignesophageal motility disorders. These includelaparoscopic fundoplication for gastroesophageal reflux disease (GERD) andlaparoscopic myotomy for the treatment ofachalasia. Gastrointestinal surgeons MarcoPatti, MD, and Lawrence W. Way, MD, carefor these patients through UCSF's multidisciplinary Center for the Study ofGastrointestinal Motility and Secretion.UCSF has extensive experience withlaparoscopic fundoplication, a procedure inwhich the stomach is wrapped around thelower esophagus to control acid reflux. Thesurgery is offered to patients who do notrespond to medical therapy for the condition,and to younger patients who elect to havethe condition surgically repaired rather thanundergo long-term medical therapy.UCSF has more experience than any institution in the world in the use of laparoscopicsurgery (Heller myotomy) for achalasia, adisorder in which the lower esophagealsphincter fails to open properly. Resultshave been so successful that it is now considered the treatment of choice for achalasia,having supplanted balloon dilatation andbotox injection.Technical InnovationsThe UCSF surgical team is responsible fortechnical advances that have affected howlaparoscopic surgeries are performed in thewider surgical community.Drs. Duh and Way, for example, developedthe most commonly used method for performing laparoscopic gastrostomies andjejunostomies. The team also developed thesurgical methods for laparoscopic removalof giant liver cysts and was the first toreport a large series of cases using thetechnique. The UCSF team has devised aninnovative intragastric method for performing laparoscopic cystgastrostomy forpancreatic pseudocysts. The approach usesa novel radially expanding trocar, now beingmarketed by industry as a safer alternativeto conventional cutting trocars. UCSF surgeons also authored a series of articles onlaparoscopic trocar injuries, showing thatthe occurrence of retroperitoneal vascularinjuries can generally be avoided by following principles of safe insertion.The Department of Surgery has also servedas the clinical testing arm for the development of a laparoscopic robotic device (thede Vinci robot marketed by IntuitiveSurgical). The UCSF Videoscopic SurgeryCenter has recently acquired two of therobots, one for training purposes in theanimal lab and the other for surgery in theoperating rooms.C O N S U LTAT I O N S A N DREFERRALSFor more information, please contact QuanYang Duh, MD, Lawrence W. Way, MD, orMarco Patti, MD, at 415/353-2161.Minimally invasive surgery for esophagealmotility disorders typically involves a 23hour hospital stay. Patients are usually ableto eat the evening following surgery andmost return to work within two weeks.Laparoscopic operation showing use of ultrasonic scissors and laparoscope connecting toa camera.2Excised pancreas showing a 1-cm insulinoma in the bodyof the pancreas.Magnetic resonance imaging (MRI) of the abdomen showing alarge right adrenal pheochromocytoma behind the liver and abovethe right kidney. This was resected successfully using laparoscopictechnique.3

Follow-UpB A R I AT R I C C E N T E R O F F E R S L A P A R O S C O P I CWEIGHT LOSS SURGERYPatients are seen in the office two and six weeks postoperatively. Appointments are then scheduled every three months during the first year, and every six months during the second and thirdyear. Monthly support groups are held to bring together pre- and postoperative patients. Aguest speaker is often present, ranging from a nutritionist who can discuss dietary questions toa plastic surgeon who can field questions about surgery to remove excess skin after majorweight loss.For carefully selected, highly motivated patients, weight loss surgery may offer agood treatment option for morbid obesity. The UCSF Bariatric Surgery Centercombines the expert skills of gastrointestinal surgeon Marco Patti, MD, andgastroenterologist James Ostroff, MD, who serve as surgical and medical directorsof the Center, respectively. The comprehensive, multidisciplinary program helpspatients decide if surgery is the right option for them, and provides ongoingsupport for those who choose to take this step.A Major Health ConcernThe incidence of morbid obesity reached epidemicproportions in the United States in the last decade,rising from 12% in 1991 to 18% in 1998. A steadyincrease has been observed in both sexes, andacross age groups, races, and educational levels,although the largest increases have occurred in 18to 29 year-olds, those with college education, andthose of Hispanic ethnicity. Defined as a body massindex (BMI) equal to or greater than 30 Kg/m2, obesity is caused by a complex interplay of genetic,environmental and psychosocial factors.Conditions associated with morbid obesity includepulmonary dysfunction, sleep apnea, diabetes mellitus,hypertension, venous stasis, degenerative joint diseaseand urinary incontinence. These conditions impairquality of life and contribute to increased mortality.Most morbidly obese patients repeatedly attempt dietand exercise regimens, only to regain their lostpounds at a discouragingly quick pace. The discoveryof the obese (ob) gene and its protein product leptinopened new doors for research into the pharmacological treatment of obesity, but as yet research has notbeen translated into clinical applications.In 1991 the National Institutes of Health called for aconsensus conference to define the role of surgeryin the treatment of morbidly obese patients andestablished criteria for the creation of Centers forBariatric Surgery. The UCSF program, created in1998, adheres strictly to the NIH guidelines. Surgeryis offered only when non-surgical treatments such asdiet and exercise have failed, and after patients havebeen thoroughly screened by a multidisciplinary,highly experienced team that provides long-termfollow-up.In addition to the expertise of Drs. Ostroff and Patti,the UCSF bariatric surgery program draws on the talents of cardiologists, endocrinologists, psychiatrists,4intensivists, radiologists, nurses and nutritionists.Karen Bagatelos, RN, NP, regularly assists in the preoperative screening of patients.The EvaluationPatients are initially seen in Dr. Ostroff’s office where acomplete history and physical evaluation are performed. All patients must be evaluated preoperativelyby a cardiologist and a psychiatrist and undergo anabdominal ultrasound to screen for gallbladder stones.Additional consultations may be arranged based onthe patient's history and physical findings. These supplementary evaluations can be performed by UCSFspecialists or by physicians in the patient’s hometown.Test results are discussed with the consulting andreferring physicians, and eligible patients arereferred to Dr. Patti. Patients are also required tolose 10% of their initial body weight prior tosurgery, a requirement that helps select patientswho have a full understanding of the rationale forthe operation and the mechanism of weight loss.Patients remain in the hospital for two to three daysafter a laparoscopic bypass, and three to five daysafter an open bypass, according to Dr. Patti. Theyare discharged with medications to control pain,reduce gastric acid secretion, and prevent the formation of est45%68%DJD/OA62%87%Sleep Apnea30%83%GERD38%89%Asthma19%93%CHANGE IN BMI7060505246404540Excellent ResultsBetween December 1998 and April 2002, 170patients underwent a Roux-en-Y gastric bypass atUCSF: 24 men and 146 women, whose mean agewas 42 years (ranging from 21 to 66). The averagepreoperative BMI was 48 Kg/m2 (ranging from 35 to76). Seventy-three operations (43%) were performedthrough a laparotomy, and 97 operations (57%)laparoscopically (including most of those performedduring the last 12 months). There was only oneanastomotic leak (0.6%) and one death (0.6%),according to Dr. Patti.Most patients tended to reach or closely approachtheir ideal body weight within 12 to 18 months, particularly those who exercised regularly. Preoperativecomorbid conditions were strikingly reduced. Mostpatients, for example, were able to stop medicationsfor diabetes or hypertension or sleep well and feelrested for the first time in years.BMI383531333035333131303027New Offices, Additional Staff70Given the program's statistical success and theincreasing number of patients interested in this procedure, UCSF is expanding support for the bariatricsurgery program. The center will move to a newoffice suite at 350 Parnassus Avenue in early fall, onethat will be equipped with furnishings such as chairsand examining tables that comfortably accommodatelarger patients. Patients will be able to obtain allnecessary consultations in this office. To ensure thatqualified patients do not experience long waits toschedule their surgery, the department is recruitingtwo additional surgeons with expertise in minimallyinvasive bariatric surgery.60C O N S U LTAT I O N S A N D R E F E R R A L S50For more information, please call 415/353-2161.20100PREOPThe OperationThe UCSF program uses the Roux-en-Y gastricbypass, a gastric restriction procedure. A small gastric pouch is isolated from the rest of the stomach,and connected to a loop of jejunum through a small(1 cm) anastomosis. The gallbladder is also removedif stones are detected by the preoperative ultrasound.The operation can be performed laparoscopically inmost patients. Very large patients (BMI 60) or thosewho have undergone previous operations requireopen surgery through a mid-line incision.COMORBIDCONDITIONS61224 Lap OpenMonths of Follow-up90EFFECTOF ofRYGBIN 020100NDDMPreopHTNDJD/OASAGERDPostop5

Proposed pathophysiologyof colorectal cancerNormal EpitheliumAPCSonia L. Ramamoorthy, MD, Julio Garcia-Aguilar, MD, PhD, andMadhulika G. Varma, MD.DysplasticC O L O N A N D R E C TA L S U R G E R YThe Section of Colorectal Surgery has recently expanded its staff and services toprovide the highest quality treatment for colorectal diseases. Section Chief JulioGarcia-Aguilar, MD, PhD, a nationally recognized expert in the field of colon andrectal cancer who joined the faculty this year from the University of Minnesota,leads a collaborative approach to basic science research, clinical research andpatient care. Section members include Madhulika G. Varma, MD, Sonia L.Ramamoorthy, MD, and Theodore R. Schrock, MD. Together they provide treatmentfor cancers of the small intestine, colon, rectum and anus; diverticular disease;inflammatory bowel disease such as ulcerative colitis and Crohn’s disease; defecation disorders, including constipation, pelvic floor prolapse and fecal incontinence;and anorectal problems such as hemorrhoids, fissures, and complex fistulas.Colorectal CancerImproved understanding of the pathophysiologyof colorectal cancer has led to a number ofadvances in the treatment of this disease.Cancer staging has been improved with the useof endorectal ultrasound, an area in which Dr.Garcia-Aguilar has particular expertise.Ultrasound staging allows physicians to moreaccurately plan multimodal therapy with medicaland radiation oncology. Surgeons are also nowable to preserve sphincter function in many rectalcancer patients, thanks to an improved understanding of cancer pathology and advances insurgical techniques. Sphincter-saving operations allow patients to maintain normal bowelfunction and eliminate the need for a permanentcolostomy. Treatment of patients with colorectalcancers is coordinated through the UCSF MountZion Clinical Cancer Center, which offers multidisciplinary expertise and the opportunity forselected patients to participate in clinical trials ofinnovative therapies.Laparoscopic SurgeryAnother faculty addition, Sonia Ramamoorthy,MD, recently completed a colon and rectalsurgery fellowship at Washington University, St.Louis, where she obtained advanced training inlaparoscopic surgery for colorectal diseases.Under her leadership, UCSF offers laparoscopiccolectomy for benign polyps, diverticular disease, inflammatory bowel disease, constipationand prolapse. This minimally invasive approachto intestinal surgery reduces the patient's hospital stay and need for pain medication. In the6future, Dr. Ramamoorthy plans to develop anadvanced laparoscopic colorectal surgery continuing medical education course for community-based surgeons.At this time, UCSF does not offer laparoscopicsurgery for colorectal cancers. Although earlyresults of a multicenter, NIH-funded trial comparing laparoscopic colectomy to open surgeryfor colon and rectal cancer are encouraging,long-term recurrence and survival data are stillpending. “We feel it is important to have thislong-term data before we substitute laparoscopic procedures for open surgery in colorectalcancer,” said Ramamoorthy. “However, we arein the process of developing a protocol to studythis issue at UCSF.”Early AdenomaK-RASIntermediateAdenomaDCC/DPC4/JV18The Center also provides a multidisciplinaryapproach to patients with complex pelvic floordisorders, which includes counseling, medicalmanagement, surgery and biofeedback.Urogynecologic evaluation with urodynamicswill also be available. Innovative surgical treatment options for fecal incontinence includeradiofrequency ablation, artificial sphincters andsacral stimulation for those patients who havefailed more conventional treatments. Moreeffective surgical treatments have also beendeveloped to treat severe constipation causedby rectal prolapse, rectocele and Hirschsprung's disease.Ulcerative ColitisThe development of the ileo-anal pull-throughprocedure has enabled ulcerative colitis patientsto avoid a permanent ileostomy following resection of the colon and rectum. Instead, therectum is replaced with a "J pouch" made ofsmall intestine to maintain intestinal continuity.This can be particularly beneficial to the qualityof life of younger patients with a severe form ofthe disease. Treatment is coordinated with othermembers of the UCSF Center for InflammatoryBowel Disease, which offers medical and surgical t

good treatment option for morbid obesity. The UCSF Bariatric Surgery Center combines the expert skills of gastrointestinal surgeon Marco Patti, MD, and gastroenterologist James Ostroff, MD, who serve as surgical and medical directors of the Center, respect