Leading the Way Newsletter

LEADING THE WAY FALL 2020 • VOLUME 12, NUMBER 3 DEPARTMENT OF #MCWMedicalMoments @MCWSurgery SURGERY iHeartRadio: The Word on Medicine MCWSurgery www.mcw.edu/surgery From the Chair | Douglas B. Evans, MD This issue of Leading the Way represents the completion of eliminate the ability the 12th year of the Department of Surgery Newsletter – to make acid, but not and the authors keep coming! I hope you have time to review eliminate the hyper- every fantastic contribution, especially Tim Ridolfi’s announce- gastrinemia and the ment of the Edwin Ellison Surgical Society – the newly formed potential for liver me- alumni society for the graduates of our surgical residency as tastases from the gas- well as current and past faculty. Dr. Edwin H. Ellison is forever trinomas located in the known for the description of the Zollinger-Ellison Syndrome in pancreas and regional a presentation by Dr. Robert Zollinger at the American Surgical lymph nodes. We Association in 1955 (and subsequently published in the Annals stopped performing to- of Surgery). Zollinger and Ellison described two patients who tal gastrectomy for Z-E had persistent marginal or jejunal ulcerations despite repeated Syndrome many years operations and this appeared to be associated with a non-beta ago, but the legacy of cell pancreatic tumor (found at autopsy in one patient and at Drs. Ellison and Wilson the time of total gastrectomy in the surviving patient). Nine at MCW has carried on years later, Drs. Edwin Ellison (then Chair of Surgery at Mar- and their paper to the MCW Surgery Chief Residents 2020- quette University School of Medicine – MCW was not born American Surgical in 2021 (names listed on page 23). yet) and Stuart Wilson (who needs no introduction – an icon 1964 embodies the power of academic medicine – I can only of MCW surgery) presented a report of 260 patients with the imagine the number of hours they spent thinking about this Zollinger-Ellison Syndrome to the American Surgical Association disease and their study of acid secretion was just fascinating. in Hot Springs, Virginia in 1964 – almost hard to remember the Importantly, they remained so connected with their patients pre-COVID times when we had medical meetings – don’t worry, who formed the foundation for their investigations. those days are not lost forever. Ellison and Wilson were able The world was indeed different in 1964. At that time, Ruth to appreciate that in some patients, this syndrome was famil- Bader Ginsberg had just accepted a position at Rutgers Uni- ial (we now know that gastrinoma/Z-E Syndrome can occur in versity Law School as she could not get a job in corporate Multiple Endocrine Neoplasia type 1), it is often associated with America, despite an incredible academic record at Harvard and multiple tumors in the pancreas (which frequently involved re- Columbia as well as having clerked for U.S. District Judge Ed- gional lymph nodes), diarrhea was an important manifestation mund L. Palmieri. RBG was a passionate and powerful advocate of the syndrome (so important to listen to patients and take a for justice, gender equality and the promotion of women to good history) and, at that time, anything short of total gastrec- leadership positions across all of society – something we have tomy would not prevent ongoing hyperacidity and ulcer for- championed at MCW and in the Department of Surgery. Which mation. Gastrin (arising from the tumors in the pancreas and/ brings us to the picture on the cover of this issue of Leading or duodenum) would stimulate any remaining parietal cells in the Way – our talented chief residents who represent Dr. Stuart the stomach (if a total gastrectomy had not been performed) Wilson’s favorite class and the newest members of the Edwin to make tremendous amounts of acid and cause recurrent ul- Ellison Surgical Society when they graduate in June 2021. ceration. A total gastrectomy would remove the parietal calls, IN THIS ISSUE: Robotic Lung Cancer Surgery.................................................. 2 Evolving Therapies for Abdominal Aortic Aneurysms...............10 Trailblazing in Nepal: Building Bridges for International Surgical Introducing the Edwin Ellison Surgical Society......................... 4 Hepatotoxicity and Dietary Supplements...............................12 Collaboration........................................................................20 MCW Surgery to Begin Investigational Trial on Using Mechanical Complex Heart Problems: Choosing the Right Tool from a Very Leading the Way....................................................................22 Aortic Valve Without Warfarin................................................... 5 Large Toolbox........................................................................14 Faculty Listing.......................................................................23 Neighborhood Socioeconomic Deprivation and Health Radiographic Patterns of First Disease Recurrence Following MCW Surgery Disparities Among Trauma Patients.......................................... 6 Neoadjuvant Therapy...Pancreatic Cancer..............................16 knowledge changing & saving life Inoperable Mitral Valve: MCW Surgery Providing a Solution and Long-term American Impact on Quality of Care for Babies with Hope for Patients.................................................................... 8 Congenital Heart Disease in Slovakia.....................................18

Robotic Lung Cancer Surgery Mario Gasparri, MD Professor Division of Cardiothoracic Surgery Paul L. Linsky, MD Assistant Professor Division of Cardiothoracic Surgery Lung cancer remains a significant health risk and is the Figure 2: VATS Lobectomy. number one cancer killer worldwide. In the United States, there will be an estimated 228,000 cases in 2020 techniques. The percentage of lobectomies done using with an estimated 135,000 deaths. In fact, in the United VATS techniques has hovered around 25-30%. 4,5 There are States more people die from lung cancer than colon, breast, several reasons for this low adoption rate, but the most of- and prostate cancer combined. 1 ten cited are that standard VATS techniques can be difficult Surgical resection of a portion of the lung, most com- as using straight stick instruments can make fine dissection monly a lobectomy, remains the gold standard treatment challenging, especially when encountering complex anato- for early stage lung cancer. Historically, lung resection was my. Additionally, even when the case is started as a VATS, done via open thoracotomy, which involves division of mus- the conversion rate to an open thoracotomy (especially cles and spreading or removal of the ribs (Figure 1). While with less experienced surgeons) can be as high as 20%. 6,7 these incisions are still used today, especially for larger tu- mors, they are painful, lead to longer hospital lengths of In 2002, the use of the surgical robotic platform to per- stay and recovery times, and are associated with increased form a lobectomy was first reported. 8 The surgical robot morbidity. 2 consists of several small, fully articulating wristed instru- In the 1990’s, the first reports of minimally invasive lung ments and a 3-D camera which the surgeon controls while surgery using Video Assisted Thoracoscopic Surgery, or seated at a console (Figure 3). The instruments are inserted VATS, appeared. These techniques involve small incisions via several small incisions without rib spreading, similar without rib spreading utilizing a camera with straight stick to standard VATS techniques. However, the 3-D magnified instruments to resect the lung (Figure 2). Since the initial optics and fully wristed instruments (which translate every description of VATS lobectomy in 1992, numerous studies hand movement in real time) more closely mimic an open have been published showing the benefits of a minimally in- operation. This platform allows the best of both worlds, vasive approach. Specifically, this includes less pain, short- combining the advantages of minimally invasive surgery er length of stay, quicker recovery, and lower complication (small incisions and no rib spreading) with the natural feel rates. Of course, of open surgery (excellent dexterity and exposure). this was accom- plished without Since the initial description, numerous studies have been compromise in published showing the benefits of robotic lobectomy. They the efficacy of the have been shown to have all the benefits of a minimally in- operation as long- vasive approach, including less pain, shorter length of stay, term survivals quicker recovery, and lower complication rates. 9-11 When have been proven compared to VATS techniques, studies have suggested less equivalent. 3 De- blood loss, an increased ability to harvest lymph nodes, and spite these en- a lower risk of having to convert to an open thoracotomy. couraging results, 11-13 There has even been one large volume paper showing the majority of superior survival per stage in patients undergoing robotic lung resection lobectomy compared to predicted survival. 14 As a testa- continued to be ment to all of this, while the percentage of lobectomies done using open performed via VATS has remained at about 30%, the num- Figure 1:TraditionalThoracotomy. ber of robotic lobectomies performed has continued to rise. Over the last decade, the percentage of lobectomies performed robotically has risen dramatically from less than 1% to roughly 25%. 4 2 | Medical College of Wisconsin Department of Surgery

Here at the Medical REFERENCES College of Wisconsin, 1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA: we have performed hundreds of robotic A Cancer Journal for Clinicians. 2020;70(1):7-30. lung resections, includ- 2. Scott WJ, Allen MS, Darling G, et al. Video-assisted ing lobectomies, with outstanding results. thoracic surgery versus open lobectomy for lung cancer: The patient is admitted a secondary analysis of data from the American College the morning of surgery of Surgeons Oncology Group Z0030 randomized clinical and taken to the op- trial. J Thorac Cardiovasc Surg. 2010;139(4):976-981; erating room. We use discussion 981-983. a standard four-arm 3. Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus technique with a small MA. Surgery for early-stage non-small cell lung cancer: accessory port for re- a systematic review of the video-assisted thoracoscopic Figure 3: Robotic Instruments. moval of the specimen surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg. 2008;86(6):2008-2016; discussion (Figure 4). The procedure takes about two hours and at its 2016-2018. completion a chest tube is left through one of the port sites. 4. Subramanian MP, Liu J, Chapman WC, et al. Utilization The chest tube is typically removed the following morning Trends, Outcomes, and Cost in Minimally Invasive and most patients spend one or two nights in the hospi- Lobectomy. Ann Thorac Surg. 2019;108(6):1648-1655. tal. During the procedure, we use a variety of techniques 5. Abdelsattar ZM, Allen MS, Shen KR, et al. Variation to minimize pain and use a multimodal pain medicine strat- in Hospital Adoption Rates of Video-Assisted egy postoperatively. The majority of our patients go home Thoracoscopic Lobectomy for Lung Cancer and the without the need for narcotics and most are fully recovered Effect on Outcomes. Ann Thorac Surg. 2017;103(2):454- within one to two weeks. Our conversion rate is less than 1% 460. and there are very few tumors that are not candidates for a 6. Kim S-W, Hong J-M, Kim D. What is difficult about doing robotic approach. In fact, there are many tumors which are video-assisted thoracic surgery (VATS)? A retrospective now routinely approached using robotic techniques that we study comparing VATS anatomical resection and would not have attempted using standard VATS approaches conversion to thoracotomy for lung cancer in a university- and previously would have required open thoracotomy. based hospital. J Thorac Dis. 2017;9(10):3825-3831. The Divi- 7. Hendriksen BS, Hollenbeak CS, Taylor MD, Reed MF. sion of Tho- Minimally Invasive Lobectomy Modality and Other racic Surgery Predictors of Conversion to Thoracotomy. Innovations at the Medi- (Phila). 2019;14(4):342-352. cal College 8. Melfi FMA, Menconi GF, Mariani AM, Angeletti CA. Early of Wisconsin experience with robotic technology for thoracoscopic has the goal surgery. Eur J Cardiothorac Surg. 2002;21(5):864-868. of provid- 9. Agzarian J, Fahim C, Shargall Y, et al. The Use of ing the most Robotic-Assisted Thoracic Surgery for Lung Resection: advanced A Comprehensive Systematic Review. Semin Thoracic surgical tech- Surg 28:182–192 nologies to 10. Nguyen DM, Sarkaria IS, Song C, et al. Clinical and all aspects of economic comparative effectiveness of robotic-assisted, thoracic pa- video-assisted thoracoscopic, and open lobectomy. J thology and is Figure 4: Robotic Lobectomy Incisions. Thorac Dis. 2020;12(3):296-306. 11. Veronesi G, Novellis P, Voulaz E, Alloisio M. Robot- committed to minimally invasive strategies in an effort to assisted surgery for lung cancer: State of the art and decrease hospital stay, improve pain, and accelerate post- perspectives. Lung Cancer. 2016;101:28-34. operative recovery. Each patient is evaluated with these 12. Oh DS, Reddy RM, Gorrepati ML, et al. Robotic-Assisted, specific goals in mind and the best operation for each indi- Video-Assisted Thoracoscopic and Open Lobectomy: vidual patient and problem is offered. Propensity-Matched Analysis of Recent Premier Data. Ann Thorac Surg. 2017;104(5):1733-1740. FOR ADDITIONAL INFORMATION on this topic, visit 13. Reddy RM, Gorrepati ML, Oh DS, et al. Robotic-Assisted mcw.edu/surgery or contact Dr. Mario Gasparri at Versus Thoracoscopic Lobectomy Outcomes From [email protected]. High-Volume Thoracic Surgeons. Ann Thorac Surg. 2018;106(3):902-908. 14. Cerfolio RJ, Ghanim AF, Dylewski M, et al. The long-term survival of robotic lobectomy for non-small cell lung cancer: A multi-institutional study. J Thorac Cardiovasc Surg. 2018;155(2):778-786. Leading the Way | Fall 2020 | 3

Introducing the Edwin Ellison Surgical Society Timothy Ridolfi, MD, MS gery. The Society also hopes to facilitate communication Associate Professor and networking amongst members. This will initially take Division of Colorectal Surgery place through a closed Facebook page, which is under de- velopment. The Department of Surgery is excited to announce the Edwin Ellison Surgical Society. The idea of creating an Lifetime (Graduate and Fellow) membership to the alumni association for graduates of the Medical College of dues-free society will be conferred on successful comple- Wisconsin general surgery training program began in late tion of the MCW general surgery residency or fellowship 2019, to commemorate the 60th anniversary of the Carl programs within the Department of Surgery. Lifetime W. Eberbach Memorial Lectureship. Subsequently, a sev- membership will be retroactively granted to all previous en-member planning committee was formed by Dr. Tracy graduates of the MCW Surgery program, if they wish to re- Wang to develop the society. ceive it. Additionally, all current MCW Surgery faculty will become Faculty Members until departure from MCW. Hon- Several naming options were discussed, all of whom orary membership can be given to those who have made were amazing MCW surgeons with whom any of us would significant contributions to the Department of Surgery. To be proud to be associated. Ultimately, the committee facilitate societal communication, previous graduates will chose the surgeon who could best represent all who have be contacted by the Department of Surgery. Alternatively, graduated from the program. A surgeon who united all the previous graduates can register to be a part of the society residency programs in the Milwaukee area into one MCW at www.mcw.edu/surgery, selecting “Edwin Ellison Surgical program and developed the Department of Surgery into Society” under the “Education” tab, and completing the the foundation of MCW’s clinical practice, Dr. Edwin H. El- survey under “Join the EESS.” lison. Dr. Ellison was the distinguished Chairman of the De- partment of Surgery at MCW from 1958 until his untimely The Executive Committee of the Society consists of the death in 1970. We have reached out to Dr. Ellison’s son (E. Current and Past President(s), the President Elect, Secre- Christopher Ellison, MD, MCW Medical School Alumni, pre- tary, Alumni Representative, Faculty Representative, Resi- vious Chair of the Department of Surgery at the Ohio State dent Representative(s), Program Director, Program Manag- University, and current CEO of the OSU Faculty Group Prac- er, and Department Chair. The 2020 Executive Committee tice) and grandson (Jonathan Ellison, MD, current MCW Pe- was chosen by the planning committee. We hope that this diatric Urologist) and they are both excited to launch this new society can help all of us to stay connected as the sur- society. gical journey continues following residency. The intent of the society is to connect MCW surgeons 2020 EESS Executive Committee across subspecialties, practice settings and years of training through a collaborative network to provide support, men- President Resident Rep. torship and sponsorship to our esteemed faculty and alum- Timothy Ridolfi, MD Elizabeth Traudt, MD ni. To this end, the Society plans to hold an alumni event at ’05, GME ‘12, MS ‘16 MCW preceding the American College of Surgeons Clinical 2020-2022 2020-2022 Congress each time it is hosted in Chicago. We had hoped to have the inaugural alumni meeting this fall, however due President-Elect Resident Rep. to multiple COVID-19 related constraints, it simply was not Rachel Greenup, MD Jacqueline Blank, MD possible and will now set our sights on 2025. In the future, ‘04, MPH, GME ‘11 2020-2022 this CME event will be hosted at MCW on Friday night and 2022-2024 Saturday morning with a dinner reception. Symposia will allow alumni to share their accomplishments as well as ex- Secretary Program Director citing developments within the MCW Department of Sur- Betsy Appel, MD ‘11, Matthew Goldblatt, GME ‘16 MD ‘97, GME ‘04 2020-2022 Alumni Rep. Program Manager Chris Fox, MD ’98, Lisa Olson GME ‘04 2020-2022 Faculty Rep. Surgery Chair Tracy S. Wang, MD, Douglas B. Evans, MD MPH 2020-2022 4 | Medical College of Wisconsin Department of Surgery

MCW Surgery to Begin Investigational Trial on Using Mechanical Aortic Valve Without Warfarin Paul J. Pearson, MD, PhD Professor and Division Chief Division of Cardiothoracic Surgery Aortic valve replacement (AVR) is one of the most common cardiac surgical procedures in the United States. At Froedtert & the Medical College of Wisconsin, older patients are typically treated with transcatheter aor- tic valve replacement (TAVR). All of the currently available TAVR valves are constructed with animal tissue and do not require life-long anticoagulation with warfarin. The Achil- Even in the TAVR era, MCW surgeons perform many surgical les’ heel of tissue valves is limited durability, particularly aortic valve replacements, particularly in younger patients in younger patients. Two recent studies demonstrate a and in those with infected heart valves. survival advantage of mechanical heart valves in patients younger than age 60 years.1-2 The benefit of the mechani- cal valve without the need for the monitoring require- cal heart valve is unlimited durability. The drawback of the ments for Warfarin? The alternative anticoagulant used in mechanical valve is that all commercially available mechan- the study is the oral factor Xa inhibitor apixaban (Eliquis) ical heart valves require life-long anticoagulation with War- which is approved for stroke prophylaxis in atrial fibrilla- farin. Warfarin anticoagulation requires careful monitoring tion and the treatment of venous thromboembolism, but via regular blood testing for therapeutic effect and safety. not for anticoagulation following AVR. The Proact Xa Trial For many patients, this has a negative impact on their life- will allow patients to manage their anticoagulation by sim- style perceptions of personal freedom. ply taking daily pills without the INR monitoring required At Froedtert & the Medical College of Wisconsin, car- with Warfarin. diothoracic surgeons can implant the On-X valve if the pa- tient requests a mechanical prosthesis. The On-X valve has To be included in the study, patients need to be between the distinctive characteristics of being constructed of pyro- 18-70 years old, have an On-X mechanical heart valve in lytic carbon and is engineered to always have some blood the aortic position, and have been maintained on Warfa- flow across the valve — even in diastole. Because of these rin for at least three months following valve replacement. characteristics, Patients who had On-X mechanical heart valves placed at the On-X valve other institutions are eligible for entry in the MCW study. is the only com- If you have questions about the Proact Xa Study or wish to mercially avail- refer a patient for enrollment, please call the Division of able mechani- Cardiothoracic Surgery at (414) 955-7065. cal heart valve in the United FOR ADDITIONAL INFORMATION on this topic, visit States where mcw.edu/surgery or contact Dr. Paul Pearson at the therapeutic [email protected]. target of Warfa- rin therapy can REFERENCES ON-X mechanical heart valve. Two be dropped to 1. Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick leaflets constructed of pyrolytic carbon an International and a fabric sewing ring (valve open in WL, Fischbein MP, Woo YJ. Mechanical or Biologic photo). Prostheses for Aortic- Valve and Mitral-Valve Normalized Ra- Replacement. New Engl J Med 2017; 377:1847-1857. tion (INR) of 1.5 after several months at the typical INR of 2. Chiang Y, Mechanical versus biological prostheses 3.0. for surgical aortic valve replacement in patients MCW Department of Surgery is now part of the PROACT aged 50-70 (Commentary), The Annals of Thoracic Xa Trial (3). The PROACT Xa multicenter randomized trial Surgery (2020), doi: https://doi.org/10.1016/j. will aim to answer a long-standing question: Can patients athoracsur.2019.11.039. consider surgical aortic valve replacement with a mechani- 3. ClinicalTrials.gov, Identifier NCT04142658 Leading the Way | Fall 2020 | 5

Neighborhood Socioeconomic Deprivation and Andrew T. Schramm, PhD Recognition of the multiple layers that impact health and the need to improve ways of operationalizing these Assisant Professor variables gave rise to a new construct, known as the Area Division of Trauma & Acute Care Surgery Deprivation Index (ADI), a measure of neighborhood socio- economic deprivation.4-5 A unique contribution of the ADI is that it is based on census data and describes the level of socioeconomic deprivation geographically associated with Terri A. deRoon-Cassini, PhD, MS the zip code or block in which an individual lives. The index Associate Professor uses 17 poverty, education, housing, and employment in- Division of Trauma & Acute Care Surgery dicators, including percentage of adult population with less Director, MCW Comprehensive Injury than nine years of education, median home value, median Center gross rent, unemployment rate, percentage of households Increasingly throughout the last decade, researchers and without a motor vehicle, and percentage of households practitioners have highlighted the stark health disparities with more than one person per room.5 plaguing the United States. This work has shown that the burden of disease falls disproportionately on the shoulders Research to date has supported the conclusion that of racial and ethnic minority members of our communities.1 neighborhood socioeconomic deprivation contributes to In an effort to understand and ameliorate these health dis- social determinants of health. Kind et al. found that among parities, often referred to as social determinants of health, a sample of adults admitted for congestive heart failure, interdisciplinary research initiatives have assessed a host of pneumonia, or myocardial infarction, residence in a socio- factors that may explain them. Most of these efforts, how- economically disadvantaged neighborhood predicted hos- ever, have explored the impact of individual-level risk fac- pital 30-day rehospitalization rate to a magnitude compa- tors such as patient experiences of perceived discrimination rable to that of chronic pulmonary disease.5 A more recent by providers, access to health care, and modifiable health study with similar methodological approach found that risk behaviors, such as smoking or consuming alcohol. patients who lived in the most extremely socioeconomi- cally deprived neighborhoods were 70% more likely to be An important direction for this area of research is to readmitted to the hospital than those living in less disad- move beyond individual-level risk factors by considering vantaged neighborhoods.6 Patients admitted with trau- the role of systemic and social environmental contexts matic brain injury who discharge to socioeconomically dis- on patients’ wellbeing. This endeavor is consistent with a advantaged neighborhoods have also been shown to have widely cited theoretical conceptualization of the interact- poorer outcomes, highlighting the range of syndromes as- ing levels of ones’ world: the social ecological model (Figure sociated with disparate outcomes based on neighborhood 1).2 This model emphasizes the role of phenomena beyond characteristics.7 the individual, including interpersonal (e.g., social support, family systems), community (e.g., schools, neighborhoods, In the Division of Trauma and Acute Care Surgery, we unemployment rates), and societal (e.g., social norms, are currently undergoing research to evaluate the impact media) variables. The premise of this approach is that the of socioeconomic deprivation on outcomes of trauma sur- determinants of one’s health are complex and interactive vivors. This work includes the first ever study to utilize the within and between these four levels, all of which impact ADI in this population. We have found that greater levels one’s overall health.2-3 of socioeconomic deprivation significantly predict post- traumatic stress disorder (PTSD) six months following hos- pital admission, above and beyond well-known individual risk factors, such as type of injury. Given the high rates at which individuals ad- mitted for trauma go on to report mood and post-traumatic stress sequalae,8 our preliminary findings suggest that consid- eration of the contexts to which patients are discharged should weigh into our as- sessment of their risk for PTSD following injury. As many hospitals are integrating assessments of social determinants of health into their interdisciplinary treat- Figure 1: Socio-ecological model to evaluate multiple levels of one’s life that impacts ment approaches and electronic medi- health.3 6 | Medical College of Wisconsin Department of Surgery

Health Disparities Among Trauma Patients cal records, it is increasingly important to fully understand CONNTINUED FROM PAGE 13 (HEPATOTOXICITY) the impact that those social determinants have on health outcomes. However, to assess social determinants and 16. Orrin G, H.R., DSHEA “Six versions of Bill Number document them does not improve an individual’s health. S.784 for the 103rd Congress. 1994. To meaningfully respond to social determinants of health to combat health disparities, health care institutions, policy 17. Navarro V, A.B., Khan I, Verma M, Seeff L, Serrano J, makers, public health professionals, and communities will Stolz A, Fontana R, Ahmad J, The contents of herbal need to collaborate to increase equity of access to educa- and dietary supplements implicated in liver injury tion, employment, and economic opportunities. Providers in the United States are frequently mislabeled. will have to understand the multiple factors impacting their Hepatology Communications, 2019: p. 3(6):1-6. patients’ health to treat and even prevent disease as effec- tively as possible. 18. Medina-Caliz I, G.-C.M.G.-J.A., et al., Herbal and dietary supplement-induced liver injuries in the FOR ADDITIONAL INFORMATION on this topic, visit Spanish DILI Registry. Clin Gastroenterol Hepatol, mcw.edu/surgery or contact Dr. Andrew Schramm at 2018: p. 16(9):1495-502. [email protected]. 19. Park SY, V.M., Johnston D, et al, Acute hepatitis and REFERENCES liver failure following the use of a dietary supplement 1. Braveman, Paula, Susan Egerter, and David R. Williams. intended for weight loss or muscle building. MMWR Morb Mortal Wkly Rep, 2013: p. 62(40):817-9. “The Social Determinants of Health: Coming of Age.” Annual Review of Public Health 32, no. 1 (2011): 381- 20. Favreau JT, M.L., Braunstain G, et al., Severe 98. hepatotoxicity associated with the dietary 2. Kloos, Bret, Jean Hill, Elizabeth Thomas, Abraham supplement LipoKinetix. Ann Intern Med, 2002: p. Wandersman, Maurice J. Elias, and James H. Dalton. 136:590-5. Community Psychology: Linking Individuals and Communities. 3rd ed. Belmont, CA: Wadsworth, 2012. 21. Zheng EX, R.S., Fontana RJ, et al., Risk of liver injury 3. Centers for Disease Control. Violence Prevention: The associated with green tea extract in SLIMQUICK Social-Ecological Model. Available at https://www. weight loss products. Drug Saf, 2016: p. 39(8):749-54. cdc.gov/violenceprevention/publichealthissue/social- ecologicalmodel.html 22. Elinav E, P.G., Safadi R, et al., Association between 4. Singh, G K. “Area Deprivation and Widening Inequalities consumption of Herbalife nutritional supplements in Us Mortality, 1969-1998.” American Journal of Public and acute hepatotoxicity. J Hepatol, 2007: p. 4:231-3. Health 93 (2003): 1137-43. 5. Kind, A J H, S Jencks, J Brock, M Yu, C Bartels, 23. Araujo JL, W.H., Acute liver injury associated with a W Ehlenbach, C Greenberg, and M Smith. new formulation of the herbal weight loss supplement “Neighborhood Socioeconomic Disadvantage and 30- Hydroxycut. BMJ, 2015: p. 2015:1-4. Day Rehospitalization: A Retrospective Cohort Study.” Annals of Internal Medicine 161 (2014): 765-74. 24. Patel SS, B.S., Kearney DL, Phillips G, Carter BA, Green 6. Hu, J, A J H Kind, and D Nerenz. “Area Deprivation tea extract: a potential cause of acute liver failure. Index Predicts Readmission Risk at an Urban Teaching World J Gastroenterol, 2013: p. 19(31):5174-7. Hospital.” American Journal of Medical Quality 33 (2018): 493-501. 25. Aldyab M, E.P., Bui R, Chapman TD, Lee H, Kratom- 7. Braveman, Paula, Susan Egerter, and David R. Williams. Induced Cholestatic Liver Injury Mimicking Anti- “The Social Determinants of Health: Coming of Age.” Mitochondrial Antibody-Negative Primary Biliary Annual Review of Public Health 32, no. 1 (2011): 381- Cholangitis: A Case Report and Review of Literature. 98. Gastroenterology Res, 2019 p. 12(4):211-215. 8. deRoon-Cassini, Terri A., Anthony D. Mancini, Mark D. Rusch, and George A. Bonanno. “Psychopathology and 26. Sharma A, A.E., Njie A, Goyal S, Arsene C, Resilience Following Traumatic Injury: A Latent Growth Krishnamoorthy G, Ehrinpreis M, Acute Hepatitis due Mixture Model Analysis.” Rehabilitation Psychology to Garcinia Cambogia Extract, an Herbal Weight Loss 55, no. 1 (2010): 1-11. Supplement. Case Rep Gastrointest Med, 2018: p. 2018:1-4. 27. Neff GW, R.K., Durazo FA, et al., Severe hepatotoxicity associated with the use of weight loss diet supplements containing ma huang or usnic acid. J Hepatol, 2004: p. 41:1062–4. 28. Christl SU, S.A., Seeler D, Toxic hepatitis after consumption of traditional kava preparation. J Travel Med, 2009 p. 16(1):55-6. 29. Hillman L, G.M., Whitsett M, et al., Clinical features and outcomes of complementary and alternative medicine induced acute liver failure and injury. Am J Gastroenterol, 2016: p. 111(7):958-65. Leading the Way | Fall 2020 | 7

Inoperable Mitral Valve: MCW Surgery Paul J. Pearson, MD, PhD Professor and Chief Division of Cardiothoracic Surgery Michael Salinger, MD Professor Division of Cardiology Director, Structural Heart Interventions, Froedtert Hospital Surgical mitral valve replacement is the mainstay for Figure 1. Computerized Tomographic (CT) image of a mitral the treatment of calcific mitral stenosis. The narrowed valve with severe mitral annular calcification (MAC). or stenosed mitral valve obstructs the flow of oxygenated blood from lungs to the left ventricle. This causes dramatic removing the MAC (and potentially causing the left atrium increases in pressure in the lungs and symptoms of heart to disconnect from the left ventricle), suspending the pros- failure. In the current era, by replacing the obstructive mi- thetic heart valve to the wall of the atrium instead of the tral valve, patients are afforded a relatively low-risk and mitral valve annulus (risking valve dehiscence and an un- lifesaving procedure which dramatically improves their dersized prosthesis), or even creating an extra-anatomic quality of life. However, even in the current era, there is bypass between the left atrium and left ventricle. 3,4,5 While a subset of patients who are still deemed inoperable by these are all possible strategies to deal with severe MAC, most surgeons and are not offered life-saving surgery. The none are reliably reproducible with good clinical outcomes. distinctive feature of this group of patients is severe mitral annular calcification (MAC).1,2 Just as with all other heart It was these challenges that inspired MCW Surgery valves, the mitral valve is suspended in a “doorframe” physicians to use balloon-expandable stent-mounted (termed the annulus). The mitral valve annulus defines the heart valves to replace mitral valves with severe MAC. At junction of the left atrium and left ventricle. During surgi- Froedtert & the Medical College of Wisconsin, balloon-ex- cal mitral valve replacement, the leaflets of the native mi- pandable stent-mounted heart valves are one of the main- tral valve are removed from the annulus and the surgeon stays of our transcatheter aortic valve replacement (TAVR) places sutures into the annulus to anchor the prosthetic program. Unlike a conventional surgical prosthesis which heart valve. If there is calcium in the annulus, this must be has a rigid frame that needs to be secured in position with removed. sutures, balloon-expandable stent-mounted valves typi- In a sub- cally rely on calcium in the surrounding tissue and strong group of pa- radial force to anchor the prosthesis in place (Figure 2). tients needing With TAVR, the balloon-expandable stent-mounted valve mitral valve re- is positioned and deployed in the calcified aortic annulus, placement, the the heavy calcium being the only anchor for the prosthet- calcium com- ic aortic valve. MCW Surgery physicians, building on the pletely replaces experience of others, reasoned that in mitral valves with the annulus severe MAC, the rigid ring of calcium could be used to an- and can even chor the stent-frame of a balloon-expandable valve, just extend all the as with TAVR. After much research and collaboration with way through physicians from around the country, Froedtert & the Medi- Figure 2. Balloon-expandable stent- the wall of the cal College of Wisconsin is now one of the few programs in mounted tissue heart valve used in heart. In ef- the United States which can successfully offer mitral valve transcatheter aortic valve replacement fect, the native replacement in these high-risk or traditionally inoperable (TAVR). Edwards LifeSciences Sapien. patients with MAC. Newport Beach California. mitral valve In patients referred to MCW for treatment of mitral is completely surrounded by a ring of calcium (Figure 1). valve disease associated with MAC, along with the typical Many articles have been written to outline surgical strate- pre-operative tests such as echocardiography and coronary gies to deal with severe MAC. These include completely arteriography, special computerized tomographic (CT) im- ages are obtained of the heart. The data from the CT im- 8 | Medical College of Wisconsin Department of Surgery

Providing a Solution and Hope for Patients ages are utilized to construct a three-dimensional image of Figure 3. Steps for placing balloon-expandable stent-mount- the heart. Utilizing computer-assisted design, MCW imag- ed valve in mitral position. A,B,C-after removing the anterior ining specialists model how the balloon-expandable stent- leaflet of the mitral valve, everting sutures are placed in atrial mounted valve will interact in the heart, ensuring that the wall around circumference above the calcified annulus. D,E- stent frame will not obstruct the left ventricular outflow stent-mounted valve placed in mitral valve annulus and de- tract (LVOT). Based upon these findings, MCW heart valve ployed. E-previously placed sutures placed through base of specialists determine the valve size to implant and plan the stent-mounted valve to bring cuff of atrial tissue around base operation. of valve. For most of our patients, mitral valve replacement in FOR ADDITIONAL INFORMATION on this topic, visit patients with severe MAC is performed utilizing conven- mcw.edu/surgery or contact Dr. Paul Pearson at tional open-heart surgical techniques to directly expose [email protected]. the native mitral valve in the arrested heart (termed “di- rect atrial”).6 In a typical case, the anterior leaflet of the REFERENCES native mitral valve is surgically excised so that when the 1. Fox CS, Vasan RS, Parise H et al. Mitral annular stent-mounted valve is expanded, the stent frame will not push the anterior leaflet of the mitral valve into the LVOT calcification predicts cardiovascular morbidity and and cause a fixed left ventricular outflow tract obstruction. mortality: the Framingham Heart Study. Circulation For this procedure, we use a commercially available stent- 2003;107:1492-6. mounted heart valve which is used in our TAVR program 2. Abramowitz Y, Jilaihawi H, Charkravarty T, Mack MJ, (Edwards Lifesciences Sapien Heart Valve, Newport Beach, Makkar RR. Mitral annulus calcification. J Am Coll CA). Prior to implantation, the balloon-expandable stent- Cardiol 2015;66:1934-41. mounted valve is modified by adding a Teflon-felt collar 3. Carpentier AF, Pellerin M, Fuzellier JF, Relland JY. around the base to act as a seal between the valve and Extensive calcification of the mitral valve annulus: the mitral valve annulus. After the stent mounted valve is pathology and surgical management. J Thorac positioned and deployed, sutures are passed through the Cardiovasc Surg 1996;111:718-29;discussion 729-30. pliable wall of the left atrium and through the base of the 4. Feindel CM, Tufail Z, David TE, Ivanov J, Armstrong stent-mounted valve (Figure 3). When these sutures are S. Mitral valve surgery in patients with extensive tied, a collar of atrial tissue acts as a further seal around calcification of the mitral annulus. J Thorac Cardiovasc the valve to prevent leakage of blood around the valve Surg 2003;126:777-82. (paravalvular leakage). 5. Said SM. Schaff HV. An alternative approach to valve replacement in patients with mitral stenosis and In rare patients, the Structural Heart Team at MCW can severely calcified annulus. J Thorac Cardiovasc Surg replace the native mitral valve with the stent-mounted 2014;147-e76-8. valve using a percutaneous technique which does not re- 6. Russell HM, Guerrero ME, Salinger MH et al. Open quire an arrested heart, cardiopulmonary bypass, or surgi- atrial transcatheter mitral valve replacement in cal incision (termed “trans-septal”).7 To use this technique, patients with mitral annular calcification. J Am Coll the patient’s mitral valve must have three unique charac- Cardiol 2018;72:1437-48. teristics - the native mitral valve must have uniform circum- 7. Guerrero M, Salinger S, Pursnani A et al. Transseptal ferential MAC to securely anchor the stent-mounted valve, mitral valve-in-valve: A step by step guide from the size and shape of the annulus must be favorable for preprocedural planning to postprocedural care. circumferential sealing of the heart valve in the annulus, Cath Cardiovasc Interv 2017;00:1-12. https://doi. and computer-assisted modeling must demonstrate that org/10.1002/ccd27128. the expanded stent-mounted heart valve will not push the anterior leaflet of the mitral valve into the LVOT and cause Leading the Way | Fall 2020 | 9 obstruction. MCW Surgery is continuing to lead the way in the treat- ment of patients with heart valve disease. If you would like to refer a patient with mitral valve disease and MAC for consideration of this innovative treatment, or if you would like to refer a patient with any type of heart valve problem for an initial consultation or a second opinion, please call our multidisciplinary Structural Heart Team at (414) 955-7065 for an appointment.

Evolving Therapies for Abdominal Aortic Neel Mansukhani, MD Frank Veith, performed the first procedure in the United Assistant Professor States. This revolutionized the treatment of AAA and ush- Division of Vascular and Endovascular ered in the modern era of minimally invasive endovascular Surgery aortic repair (EVAR).3 The treatment of abdominal aortic aneurysms (AAA), a Since the first EVAR, multiple procedural improvements, disease that has humbled physicians for hundreds of technological advancements, and public health initiatives years, is at the forefront of clinical innovation, research, have been developed and implemented that have dramati- and technology at the Medical College of Wisconsin. Early cally improved and prolonged the lives of patients with unsuccessful therapies included ligation, external wrap- AAA. Free screening of qualifying patients offered by Medi- ping, and surgical coiling.1 In 1954, Dr. Michael DeBakey de- care and the recommendations to screen family members scribed the repair of AAA using a Dacron graft – a synthetic of AAA patients have proven effective in reducing AAA- material made of woven polyester. The first grafts were related mortality.4 Every generation of EVAR devices im- made from donated parachute material following World proves incrementally, akin to improvements in an annual War II by Dr. DeBakey, along with Dr. Edman (a textiles re- car model. Every generation has advanced design features searcher), using his wife’s sewing machine.2 The procedure such as improved fabric strength and porosity that increas- was refined and perfected, and it became the standard of es long term procedural success; decreased delivery sheath care for decades. However, it was and still is associated size for safer access through smaller arterial access vessels; with a high likelihood of cardiopulmonary complications in improved conformability to navigate and deliver endografts the immediate post-operative period, and an approximate- through tortuous blood vessels; and increased flexibility to ly five to seven day hospitalization duration even under the allow the treatment of patients with more complex anato- most optimal circumstances. mies. With the development of adjunctive technology and increased experience, procedural steps have evolved as In the early 90s, Dr. Juan C. Parodi developed a novel well. Previously, EVAR mandated surgical exposure of both method for treating AAA using a metal stent lined with common femoral arteries for device delivery. Today, the hand-sewn fabric, delivered with the aid of a large intro- procedure can be performed through percutaneous access ducer sheath passed through the common femoral arter- with two 2-5mm incisions. System-based improvements ies to reline the abdominal aorta to exclude the aneurysm including regionalization of care, improved inter-hospital from systemic flow and pressure. He first performed the transfer systems, permissive hypotension, and the use of procedure in Buenos Aires in 1990, and in 1991, with Dr. compliant aortic occlusion balloons have made EVAR the standard of care for patients who present with ruptured ab- Figure 1: 3D reconstruction of a thoracoabdominal aneurysm dominal aortic aneurysms as well.5 in a patient with a previous infrarenal endograft repair of an infrarenal AAA (A). Open repair of a thoracoabdominal For several years, patients with juxtarenal or paravis- aneurysm utilizing a multibranched graft and individual ceral aneurysms were not considered candidates for en- bypasses to visceral vessels (B). Endovascular repair of a dovascular therapy. These patients can now be treated paravisceral aortic aneurysm using a custom branched/ with minimally invasive endovascular techniques. Thanks fenestrated graft to visceral vessels (C). to the development of parallel grafting techniques, where 10 | Medical College of Wisconsin Department of Surgery stent grafts to the visceral vessels are placed in parallel with EVAR devices to “snorkel” blood flow from above the graft, and the development of fenestrated/branched endo- grafts with fenestrations to allow blood flow to the visceral vessels. Today, the frontier of minimally invasive complex endovascular therapies for the aorta include treatment of thoracoabdominal aneurysms and aortic arch aneurysms with custom fenestrated endografts built for each indi- vidual patient’s anatomy. In the near future, off the shelf branched endografts that can be applied to most patients, even in emergent situations when device customization is not feasible, will be an option. At the Medical College of Wisconsin, the Division of Vascular and Endovascular Surgery offers the complete spectrum of aortic reconstruction surgery. From traditional open surgery to minimally invasive EVAR, hybrid surgical

Aneurysms Furthermore, we are collaborating with surgeons and re- searchers from Dartmouth, Northwestern, and Cornell Uni- and endovascular repair options, management of failed or versities as a part of the Vascular Implant and Interventional infected endografts, parallel grafting techniques and cus- Outcomes Network (VISION). VISION is a collaboration be- tom branched/fenestrated endografts for paravisceral and tween the Society for Vascular Surgery Patient Safety Orga- thoracoabdominal aneurysms as well (Figure 1). The recent nization (SVS-PSO), the U.S. Food and Drug Administration, integration of intraoperative cone-beam CT angiography and the Medical Device Epidemiology Network (MDEpiNet). and 3D fusion imaging in the hybrid operating room has The VISION project links detailed peri-procedural device re- aided in reducing intravenous contrast use, radiation expo- lated data with long term mortality data to offer a longi- sure, and operative procedure time for aortic reconstruc- tudinal view of outcomes related to vascular procedures. tion procedures. In addition to utilizing novel technology, Currently, we are developing a study to investigate the long- MCW’s vascular surgeons are currently collaborating with term outcomes related to type 2 endoleak, the most com- researchers in the MCW Center for Advancing Population mon, and amongst the most puzzling post EVAR procedure Science to leverage novel machine-learning methods to related complications to manage. We believe this work is study local and national Vascular Quality Initiative (VQI) leading the way in the modern era of AAA therapies, and registry data, to improve local quality and develop quality will lead to improved outcomes, increased patient satisfac- improvement protocols that can be implemented and tai- tion, and dramatic cost savings for the healthcare system. lored to other centers’ individual needs as well. FOR ADDITIONAL INFORMATION on this topic, visit Currently, quality improvement efforts are aimed at mcw.edu/surgery or contact Dr. Neel Mansukhani at reducing the length of stay following elective EVAR. Af- [email protected]. ter identifying multiple contributing factors to prolonged length of stay through the VQI database, surveying multi- REFERENCES ple stakeholders including physicians, physician assistants, 1. Thompson JE. Early history of aortic surgery. Journal of nurse practitioners, ICU/floor nurses, and service line direc- tors, a bundled quality improvement (QI) initiative was im- vascular surgery. 1998;28(4):746-52. plemented. This QI bundle included multiple interventions 2. De Bakey ME, Cooley DA, Crawford ES, Morris GC, such as a preference for percutaneous access, avoidance of urinary catheter use and the timing of bladder catheter re- Jr. Clinical application of a new flexible knitted moval if it was deemed necessary, avoidance of general an- dacron arterial substitute. The American surgeon. esthesia, ensuring that patients have transportation home 1958;24(12):862-9. after surgery, setting patient expectations for a short hospi- 3. Parodi JC, Palmaz JC, Barone HD. Transfemoral tal stay, and many others. Since this intervention has been intraluminal graft implantation for abdominal aortic implemented, hospital length of stay for elective EVAR has aneurysms. Annals of vascular surgery. 1991;5(6):491-9 been reduced from an average of 3.3 days to less than 2 days (Figure 2). CONTINUED ON PAGE 21 Figure 2: Hospital stay after elective EVAR at Froedtert Hospital with quality improvement efforts implemented to reduce length of stay and enhance recovery. Leading the Way | Fall 2020 | 11

Hepatotoxicity and Dietary Supplements Francisco Durazo, MD not require to show to be safe or effective before they are Professor marketed. Section Chief of Transplant Hepatology Division of Transplant Surgery A prospective study by the DILIN studied 272 different supplements implicated in liver injury. They found that 51% The use of herbal remedies has been around for many were mislabeled; that is, to have chemical contents that centuries. However, their use in developed countries did not match the label. Appearance enhancement, sexual has increased over the years despite increased awareness performance, and weight loss products were most com- of their potential toxicities.1 Liver failure due to herbal monly mislabeled.17 and dietary supplements (HDS) has become widely recog- nized.2-5 By its strategic location, the liver is massively ex- In a study of 130 cases of liver injury caused by HDS, the posed to drugs and other compounds absorbed from the most common type of supplements involved were the ones gastrointestinal tract. During the first pass of portal blood used to change physical appearance. One third of the cases through the liver, uptake, biotransformation, transport and were attributed to body building supplements followed by excretion determine how much drug enters the circulation weight loss supplements, many of which contained multi- and its degree of bioavailability. Drug-induced liver disease ple ingredients. Multi-ingredient products have the poten- has replaced acute viral hepatitis as the most common tial to cause significant liver injury, given the multitude of cause of acute liver failure in the United States6 and hepa- potentially hepatotoxic ingredients, the unknown concen- totoxicity from HDS is being recognized more and more.7 trations, and possible mislabeling.18 Over $36 billion are spent every year in HDS in the Unit- HDS involved in hepatotoxicity include anabolic andro- ed States.8 Studies show that 52% of the adult population genic steroids7, OxyELITE Pro 19, Lipokinetics 20, SLIMQUICK take dietary supplements9-11 and 67% have used at least 21, Herbalife 22, Usnic Acid Industrial Strength 3, and Hy- one supplement in their lifetime.1,12 Thirty per cent of pa- droxycut 23 among others. Ingredients in dietary supple- tients attending hepatology clinics use HDS.12 People taking ments suspected to have induced liver injury include green HDS perceive them to be both effective and safe, and two tea extract 24, kratom 25, Garcinia cambogia 26, usnic acid 3, thirds of patients do not disclose their use of HDS to the ephedra 27 and kava 28, to name a few. attending physician.13 They are generally obtained without prescription and taken without specific medical advice or Diagnosis and Treatment monitoring. Hepatotoxicity from HDS is a more severe liver injury and has worse outcomes with a higher liver transplant rate The US Drug-Induced Liver Injury Network (DILIN) has compared with drug-induced liver injury from conventional reported that the proportion of liver injury caused by HDS drug use.29 The diagnosis of hepatotoxicity due to HDS is a has increased from 7% in 2005 to 20% in 2014, indicating diagnosis of exclusion and it is frequently delayed because that the prevalence of hepatotoxicity attributable to HDS is of lack of disclosure of HDS use and low suspicion from the increasing in the US population.14 treating physician. It is therefore essential that the attend- ing physician actively solicits such information. Patients and The Food and Drug Administration (FDA) regulates what their partners or housemates should be questioned about is considered a drug and a dietary supplement. This regu- possible ingestion of HDS. A basic work up of viral hepati- latory distinction, however, is not based on biologic data; tis, autoimmune, metabolic and biliary diseases should be rather it is a question of labeling. A drug is a product in- done to rule out other etiologies. Very helpful information tended to treat, prevent, cure, mitigate, or diagnose a about drugs and supplements causing liver disease can be specific disease. The Dietary Supplement and Health and found on-line at Livertox (livertox.nih.org). Livertox is pro- Education Act of 1994 defines a supplement as a “product duced by the that is intended to supplement the diet that bears or con- National Insti- tains one or more of the dietary ingredients: a vitamin, a tute of Diabetes mineral, an herb, an amino acid, a dietary substance for and Digestive use by man to supplement the diet by increasing total daily and Kidney Dis- intake, or a concentrate, metabolite, constituent, extract eases (NIDDK) or combination of these ingredients.”15, 16 Manufacturers and provides are prohibited from making medical claims for efficacy in up-to-date, treating diseases. They are, however, able to make nonspe- unbiased and cific claims of function, such as enhancing energy, wellness, easily accessed liver health, sexual enjoyment, or weight control, and do information on the diagnosis, Acute liver failure due to a weight loss 12 | Medical College of Wisconsin Department of Surgery cause, frequen- supplement (Pure Usnic Acid, Industrial StrengthTM)

cy, clinical patterns and management of liver injury attrib- REFERENCES utable to prescription and nonprescription medications 1. Kessler RC, D.R., Foster DF, Long-term trends in the use and selected herbal and dietary supplements. of complementary and alternative medical therapies in Causality adjudication (linking the injury to a specific the United States. Annals of Internal Medicine, 2001: drug or agent) can be challenging. Currently, there are no p. 135:262-8. definitive, objective criteria or a gold standard method for 2. Stedman, C., Herbal hepatotoxicity. Semin Liver Dis, establishing the diagnosis of drug-induced liver disease. 2002: p. 22:195-206. When facing a poten- 3. Durazo F, L.C., Han Steven HB, Saab S, Lee N, Kawano tial case of drug or HDS M, Saggi B, Gordon S, Farmer D, Yersiz H, Goldstein hepatotoxicity, I ask 5 D, Ghobrial M, Busuttil R, Fulminant liver failure due questions: to usnic acid for weight loss. American Journal of Gastroenterology, 2004: p. 99(5):950-952. 1. Has this type 4. Stolpman DR, P.J., Ham J, et al, Weight loss supplements of adverse re- and fulminant hepatic failure: A case series. Hepatology, action been 2002: p. 36(4):168A. observed previ- 5. Roytman MM, P.P., Lee CL, Huddleston L, Kuo TT, Bryant- ously? Greenwood P, et al, Outbreak of severe hepatitis linked 2. Was the tim- to weight-loss supplement OxyELITE Pro. American ing appropri- Journal of Gastroenterology, 2014: p. 109:1296-1298. ate between Usnic acid, an oxidative 6. Ostapowicz G, F.R., Schiodt FV, et al, Results of a the ingestion phosphorylation uncoupler used prospective study of acute liver failure at 17 tertiary of supplement as one of the ingredients in weight care centers in the United States. Annals of Internal and liver test loss supplements involved in Medicine, 2002: p. 137:947-54. abnormalities? hepatotoxicity. 7. Navarro VJ, B.H., Bonkovsky HL, Davern T, Fontana RJ, Grant L, et al, Liver injury from herbals and dietary 3. Does the problem improve with discontinuation of supplements in the US. Drug-Induced Liver Injury the drug? Network. Hepatology, 2014: p. 60:1399-1408. 4. Does the problem occur with re-exposure? We rare- 8. Lindstrom A, O.C., Lynch ME, Blumenthal M,Kawa A., ly do this except in cases where we have a low suspi- Sales of dietary supplements increase by 7.9% in 2013. cion and the patient needs the medication. HerbalGram, 2014: p. 103:52-56. 5. Were other likely causes of hepatitis excluded? 9. Timbo BB, R.M., McCarthy PV, Lin CT, Dietary supplements in a national survey: Prevalence of use The treatment of HDS liver injury is to stop the suspect and reports of adverse events. J Am Diet Assoc, 2006: drug. However, this doesn’t always happen because of the p. 106:1966-1974. delay in the diagnosis. Corticosteroids may be used if a hy- 10. Clarke TC, B.L., Stussman BJ, Barnes PM,Nahin RL, persensitivity reaction or drug-induced autoimmune hepa- Trends in the use of complementary health approaches titis is suspected. In patients with acute liver failure, liver among adults: United States 1002-2012. 2015: transplantation frequently is the only option. Hyattsville, MD. 11. Bailey RL, G.J., Lentino CV,Dwyer JT, Engel JS, Thomas Conclusion PR, et al, Dietary supplement use in the United States, Since HDS products are not subject to the same FDA 2003-2006. J Nutr, 2011: p. 141:261-266. 12. Seef LB, L.K., Bacon B, et al, Complementary and drug regulations as prescription medications, and are not alternative medicine in chronic liver disease. mandated to undergo investigational clinical trials to assess Hepatology, 2001: p. 34:595-603. safety and efficacy, it is imperative that the clinicians report 13. Eisenberg DM, K.R.R.M., et al, Perceptions about the post marketing adverse effects of HDS to the FDA. It is complementary therapies relative to conventional the only way to obtain information about these products therapies among adults who use both: results from and, hopefully, improve regulatory enforcement and con- a national survey. Ann Intern Med, 2001: p. 135:344- sumer guidance. Challenges for the future include the need 351. for appropriate reporting and regulatory systems to moni- 14. Navarro VJ, K.I., Bjornsson E, et al., Liver injury from tor adverse effects from HDS, identification of hepatotoxic herbal and dietary supplements. Hepatology, 2017: p. compounds and evaluate the potential benefits. 65(1):363-73. 15. Administration, F.a.D., Dietary supplements. Available FOR ADDITIONAL INFORMATION on this topic, visit at http://www.fda.gov/Food/DietarySupplements/ mcw.edu/surgery or contact Dr. Francisco Durazo at default.htm, Accessed February 2016. [email protected]. CONNTINUED ON PAGE 7 Leading the Way | Fall 2020 | 13

Complex Heart Problems: Choosing the Takushi Kohmoto, MD, PhD, MBA ogy, the Complex Professor Cardiac Case Re- Division of Cardiothoracic Surgery view Conference Surgical Director, Adult Heart is the perfect ven- Transplantation ue where a physi- Paul J. Pearson, MD, PhD cian can get clarity Professor and Chief and consensus as Division of Cardiothoracic Surgery to the best treat- ment strategy One of the greatest benefits of receiving care at an aca- with input from demic medical center is the breadth and depth of spe- every MCW sub- cialty care and the availability of cutting-edge and experi- specialty involved mental techniques to treat disease. However, when deal- in treating heart ing with input from many specialty areas, it can be a chal- disease. “Physi- lenge to choreograph the efficient work-up of a patient’s cians have long condition and quickly come to a consensus on the best practiced the con- Figure 2: Semi-circumferential peri- treatment strategy. The Medical College of Wisconsin’s De- cept of ‘curb-side aortic pseudoaneurysm extending from partment of Surgery (MCW Surgery) was in the forefront of consults’ where under mechanical heart valve to the embracing the concept of regular multidisciplinary, patient- outside of the prosthetic graft used to centered case conferences in oncology, neurosciences, and they informally replace the ascending aorta (red arrow). transplantation. In the past, multidisciplinary conferences discuss a complex patient’s condition with a specialist” in heart care were not routine because well-defined treat- states Michael Salinger, MD, Professor of Surgery and Med- ment guidelines for heart disease and limited therapeutic icine at MCW and Director of Structural Heart Interventions options resulted in straightforward treatment algorithms. at Froedtert Hospital. “Think of the Complex Cardiac Case However, with the explosion of technology available to Review Conference as the curb-side consult on steroids. In- treat the failing heart and with the rapid expansion of cath- stead of one physician’s input, imagine getting input from eter-based and minimally-invasive options to treat heart fifteen specialists in real-time and in an interactive setting.” valve disease, simple treatment algorithms became obso- Physicians submit the names of patients who they want lete. Based upon this reality, the multidisciplinary Complex discussed at the Complex Cardiac Case Review Conference Cardiac Case Review Conference at Froedtert & the Medi- through the Division of Cardiothoracic Surgery at MCW. cal College of Wisconsin was born. One of the most senior advanced practice providers in the Division administrates the conference. They develop an ab- Consisting of cardiothoracic surgeons with specialty stract of the patient’s medical history including important practices in heart failure, complex aortic diseases, and case-related factors, ensure the availability of non-heart structural heart disease, along with cardiologists specializ- care related specialists if needed for discussion, and create ing in imaging, complex percutaneous interventions, struc- a schedule for the conference. This schedule is sent out to tural heart interventions, heart failure, and electrophysiol- the entire heart care team prior to the conference. After many changes of venue, the conference finally Figure 1: Pre-COVID, attendings, residents, and fellows re- found a permanent home in the Interventional Cardiology view a case at the Complex Cardiac Case Conference. Conference Room in the Integrated Procedural Platform 14 | Medical College of Wisconsin Department of Surgery (IPP) at Froedtert Hospital. The IPP is home to Froedtert Hospital’s cardiac surgery operating rooms, hybrid proce- dure rooms, and cardiac catheterization laboratories. Be- ing centrally located and a short walk from the hospital in- patient units and out-patient clinics, the location provides an easily accessible location which promotes high atten- dance which includes not only staff physicians, but also the participation of fellows and residents (Fig 1). The confer- ence room provides high-definition video capabilities to re- view relevant imaging studies and information technology which allows physicians at locations from around the state of Wisconsin to participate in the conference. Thus, a phy- sician who wishes to discuss a complex patient can partici-

Right Tool from a Very Large Toolbox pate in the conference from their local hospital or medical Access Center at (414) practice office. 805-4700 or (877) 804-4700. One of the An example of how treatment strategies can develop nurses staffing the Ac- during the conference is exemplified by a recent patient cess Center will initiate presented. A cardiac surgeon who specializes in aortic re- a Shock Pager confer- construction presented imaging of a patient who previously ence call. Attending- had three cardiac surgical operations. At the final operation, level providers from the patient had his aortic root replaced with an artificial cardiology, critical care, heart valve suspended in a prosthetic graft. However, on cardiac surgery, car- surveillance imaging following the operation, the patient diology heart failure, Figure 3.: Utilizing transesopha- was found to have developed a pseudoaneurysm around cardiac anesthesia, the geal echocardiography and fluo- the aortic root. The entry point of blood into the pseudoa- Medical Director of the roscopic guidance, a sheath is neurysm was at the proximal aortic root suture line, below Mechanical Circulatory placed into the apex of the beat- the prosthetic heart valve (Fig 2). The aortic surgeon asked ing heart to deliver a 14mm Am- the structural heart cardiologist if he could close the defect platzer Plug II to close the pseudo- percutaneously. The structural heart cardiologist respond- Support (MCS) / Extra- anerym. ed that he could close the defect, but that he had no way to Corporeal Membrane access the defect. A heart surgeon who is a member of the Oxygenation (ECMO) Service of Froedtert Hospital, and a Structural Heart Team at Froedtert & the Medical College nurse coordinator for Flight for Life all respond to the call of Wisconsin said “I can get you there”. Thus, the follow- and discuss the patient as a group. If emergent transfer ing week, through a very small incision on the left anterior to Froedtert & the Medical College of Wisconsin is desired chest, an introducer sheath was placed into the apex of the by the referring physician, the Access Center working with patient’s beating heart, through which the structural heart Flight for Life arranges transportation and coordinates the cardiologist deployed a vascular plug to seal the pseudoan- hospital admission. “Our goal was to create a very high eurysm (Fig 3). The patient was discharged on post-proce- level, ‘one and done’ call for the referring provider” states dure day two. Through a multidisciplinary discussion and Lucian “Buck” Durham III, MD, PhD, Associate Professor of bringing together different skill-sets, the complex patient Surgery, Division of Cardiothoracic Surgery at MCW and underwent a well-tolerated minimally-invasive procedure Medical Director of the MCS/ECMO Service at Froedtert to treat his aortic leak. Hospital. “We know that referring doctors with a critical patient on their hands need a quick response and an action Common themes discussed at the Complex Case Re- plan. Not only can we arrange to get their patient to our view Conference include patients with cardiomyopathies cardiovascular intensive care unit ASAP, but we can assist and coronary artery disease or heart valve problems, heart them with advice on medical management until our trans- problems in very fragile or medically complex patients, port team arrives.” and patients who have developed new heart problems af- If you would like one of your patients presented at ter having had previous cardiac surgery. “I am sometimes the Complex Cardiac Case Review Conference, please call amazed at the unique problems and challenges which we the MCW Division of Cardiothoracic Surgery at (414) 955- are presented with at the conference”, states Lyle Joyce, 7065 and our staff will make all the arrangements. We MD, PhD, Professor of Surgery and Section Chief of Adult welcome your participation by phone or in person when Cardiac Surgery, Division of Cardiovascular Surgery at the case is discussed. MCW. “I am more amazed at the very creative treatment If you have an urgent or emergent case you would strategies we are able to engineer for these very complex like to discuss with our heart care physicians, please call patients.” the Froedtert Access Center 24 hours a day, seven days a week at (414) 805-4700 or (877) 804-4700 and we will ini- While the Complex Cardiac Case Review Conference is tiate our multidisciplinary Shock Page conference call. If the ideal venue to discuss non-emergent patients, some- you wish to emergently or urgently transfer the patient to times a physician requires an emergent multidisciplinary Froedtert & the Medical College of Wisconsin, the Access conference because a patient’s clinical condition is rapidly Center can arrange transportation through Flight for Life. deteriorating. For these situations, Froedtert & the Medi- cal College of Wisconsin established what is termed the FOR ADDITIONAL INFORMATION on this topic, visit Shock Pager system. The Shock Pager system can be acti- mcw.edu/surgery or contact Dr. Takushi Kohmoto at vated by physicians both in and outside the Froedtert & the [email protected]. Medical College of Wisconsin system. Referring physicians wishing to access this system call the 24-hour Froedtert Leading the Way | Fall 2020 | 15

Radiographic Patterns of First Disease Recurrence Following Mohammed Aldakkak, MD To answer this, we analyzed clinical data from 306 pa- Instructor tients with resectable or borderline resectable PDAC who Division of Surgical Oncology received neoadjuvant therapy and surgery between Janu- Susan Tsai, MHS, MD ary 2009 and March 2018. Of the 306 patients, 43 (14%) Associate Professor received chemotherapy, 98 (32%) received chemoradiation, Division of Surgical Oncology and 165 (54%) received both therapies. Of the 43 patients Director, LaBahn Pancreatic Cancer Program who did not receive preoperative chemoradiation, 29 (67%) Chad Barnes, MD received chemoradiation after surgery. Overall, 292 (95%) 2019-2020 Chief Resident, MCW Surgery of the 306 patients received either pre- or post-operative Fellow, City of Hope Cancer Center chemoradiation. All 306 patients had pancreatectomy and after surgery, surveillance CT imaging and CA19-9 levels Pancreatic ductal adenocarcinoma (PDAC) is the third were performed at 3-4 months intervals for the first two most common cause of cancer-related death in the years and at six months intervals thereafter. Recurrent dis- United States and it is projected to become the second ease was diagnosed radiographically but occasionally was cause of cancer-related death by 2031.1 Most patients with confirmed with a tissue biopsy. Recurrence was classified PDAC present with advanced, inoperable disease but a pro- as either local (pancreas, resection bed, or peripancreatic portion of patients can undergo upfront surgical resection. vasculature), regional (peritoneum or abdominal wall), or However, these patients are at high risk for disease recur- distant (liver, lung, bone). Early recurrence was defined as rence. In a large single institutional study, Groot et al.2 re- recurrence within one year from surgery. ported the timing and patterns of first recurrence in 692 patients with PDAC who had upfront surgery. Recurrence After a median follow-up of 27 months, 120 patients was documented in 531 (77%) patients with a median (39%) had no evidence of disease recurrence and 186 (61%) progression-free survival (PFS) of 15.9 months. First recur- had recurrent disease. The median PFS of all 306 patients rence occurred as metastatic disease in 307 (44%) patients, was 24 months. The most significant negative prognostic isolated local recurrence within the remnant pancreas or factors for PFS were N1 (HR:1.54; 95%CI:1.09-2.17) and N2 the surgical bed in 126 (18%) patients, and both local and (HR:2.62; 95%CI:1.61-4.28) disease status. Furthermore, in metastatic recurrence in the remaining 98 (14%) patients. a subset analysis involving patients who were CA19-9 pro- Although many patients with PDAC may develop meta- ducers (n=164), factors negatively associated with PFS in- static disease, a significant proportion of patients will also cluded elevated preoperative CA19-9 (HR:1.90; 95%CI:1.24- develop local tumor recurrence which may impact their 2.90) and N2 disease (HR:3.33; 95%CI:1.66-6.68). survival and quality of life.1 Figure 1 summarizes patterns of recurrence in all 306 Over the past decade, preoperative (neoadjuvant) ther- patients. Overall rates of any local, any regional, and any apy has been increasingly adopted for the management of distant recurrence were 16% (n=51), 13% (n=39), and 43% PDAC, as it is associated with downstaging of lymph node (n=132), respectively (patients with multisite recurrence metastases and potential eradication of occult distant mi- counted more than once). The liver was the most common crometastatic disease. While neoadjuvant treatment se- site of recurrence; 70 (23%) of the 306 patients developed quencing has gained acceptance, the optimal neoadjuvant liver metastases. Local recurrence occurred as the only site therapy regimen has yet to be defined, and the inclusion of first recurrence in 29 (9%) patients and as a multisite of chemoradiation, chemotherapy, or both remains con- recurrence in 22 (7%) patients. Local-only recurrence oc- troversial. In addition, other factors, such as stage of dis- curred in 4 (29%) of the 14 patients who did not receive ease and patient performance status may influence neo- adjuvant treatment sequencing. Therefore, we sought to understand how neoadjuvant therapy impacts patterns of disease recurrence in order to better understand how mul- timodality therapy may best be administered. 16 | Medical College of Wisconsin Department of Surgery

Neoadjuvant Therapy & Surgery for Patients with Resectable & Borderline Resectable Pancreatic Cancer chemoradiation as compared to 25 (9%) of the Our study has demonstrated that neoadjuvant therapy 292 patients who received pre- or postoperative is associated with decreased rates of recurrence as com- chemoradiation (p=0.01). The delivery of chemo- pared to a surgery-first approach. We have established a radiation was associated with 0.79-decreased odds multi-institutional collaboration with two institutions who (OR:0.21; 95%CI:0.06-0.77; p=0.02) of developing do not utilize chemoradiation as part of their neoadjuvant a local-only recurrence. approach to further assess the impact of chemoradiation on the patterns of recurrence. Our findings in the current Of the 186 patients with recurrence, early re- study and our ongoing collaborations may help to provide currence occurred in 103 patients (55%) vs. 83 the framework for current and future clinical trials. patients (45%) who developed late recurrence. Of the 103 patients with an early recurrence, the FOR ADDITIONAL INFORMATION on this topic, most common patterns of recurrence were liver- visit mcw.edu/surgery or contact Dr. Mohammed only (n=34, 33%) and multisite recurrences (n=33, Aldakkak at [email protected]. 32%). In contrast, of the 83 patients with a late recurrence, the most common sites of recurrence REFERENCES included lung-only (30, 36%) and local-only metas- 1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, tases (18, 22%). For the 103 patients who devel- oped early recurrence, the median overall survival (OS) was Fleshman JM and Matrisian LM. Projecting cancer 20 months as compared to 46 months for the 83 patients incidence and deaths to 2030: the unexpected with late recurrences (p<0.0001). The median OS (Figure 2) burden of thyroid, liver, and pancreas cancers in the for patients with lung-only recurrence, local-only, regional- United States. Cancer Res. 2014;74:2913-21. only, liver-only and multisite recurrences were 50, 34, 24, 2. Groot VP, Rezaee N, Wu W, Cameron JL, Fishman 23 and 23 months, respectively (p=0.0001). EK, Hruban RH, Weiss MJ, Zheng L, Wolfgang CL and He J. Patterns, Timing, and Predictors of Recurrence Our findings highlight several important implications re- Following Pancreatectomy for Pancreatic Ductal garding the use of neoadjuvant therapy for both local and Adenocarcinoma. Ann Surg. 2018;267:936-945. metastatic disease control. As compared to a surgery-first 3. Sperti C, Pasquali C, Piccoli A and Pedrazzoli S. approach, neoadjuvant therapy is associated with patho- Recurrence after resection for ductal adenocarcinoma logic downstaging of lymph node metastases (node posi- of the pancreas. World J Surg. 1997;21:195-200. tive 70-80% vs 40%, respectively). The median OS among 4. Van den Broeck A, Sergeant G, Ectors N, Van patients with node negative disease following neoadjuvant Steenbergen W, Aerts R and Topal B. Patterns of therapy and surgery approaches four years, suggesting that recurrence after curative resection of pancreatic pathologic downstaging associated with neoadjuvant ther- ductal adenocarcinoma. Eur J Surg Oncol. apy translates into a meaningful survival advantage. Taken 2009;35:600-4. together, the improvement in median OS and evidence of treatment response, including sterilization of lymph node metastases and normalization of CA19-9 levels, suggests that neoadjuvant therapy may be effective in controlling clinically occult micrometastatic disease. In addition, the high incidence of local recurrence with a surgery-first approach2-4 is likely related to the high rates of positive margins, perineural infiltration, and lymph node metastases. In contrast, we observed local-only recurrences in 9% of patients. Although, most patients with PDAC suc- cumb to metastatic disease, the significance of local-only recurrences should not be underestimated. It is very likely that patients who experience local-only recurrence may have been cured with a more meticulous operation, the use of pre- or postoperative chemoradiation, or both. Currently local-only recurrences account for a small proportion of re- currences, but as systemic therapies improve and distant metastatic disease control improves, local-only recurrences will become a more universally appreciated clinical concern. Leading the Way | Fall 2020 | 17

Long-term American Impact on Quality of Care for Viktor Hraska, MD, PhD American Help to Professor and Chief Slovakia Division of Congenital Heart Surgery After the fall of the Surgical Director communist system in Herma Heart Insititute 1989 in Eastern Eu- rope, USAID via Proj- ect Hope focused on Disclosure improving health care The author was working in Pediatric Cardiac Center at in central Europe. PCC Children’s Hospital in Bratislava, Slovakia between 1992 – successfully applied 2002. for grants and received On December 4, 2019, at a ceremony that took place at $2.5 million from US- the Embassy of Slovakia in Washington, the Ambassa- AID with the goal to dor of Slovak Republic in the USA Ivan Korčok appreciated establish a high level the outstanding work of Boston Children’s Hospital (BCH) of diagnosis and care From the left to right: Viktor Hraska; and Children’s Hospital in Bratislava, Slovakia that teamed for the children born John E. Mayer; Ivan Korcok. up in 1992 under the umbrella of the US Agency for In- with CHD. BCH was chosen as a proxy to foster care for CHD ternational De- in Slovakia. velopment (US- During the period of 1992-1994, the robust team of BCH AID) and Project (see acknowledgment) led by surgeon John E. Mayer, MD, Hope to save the and cardiologist Gil Wernovsky, MD, visited Slovakia mul- lives of thou- tiple times to work closely with their counterpart at PCC. sands of chil- Team approach and mentorship, maintaining close mentor/ dren born with scholar relationship during the life of the project and later congenital heart on appeared to be fundamental for success. Significant im- disease (CHD) in provement has been achieved in invasive and noninvasive Slovakia. diagnostic, patient care management, infection control Panorama of HighTatras. The leaders practice, problem-solving skills and capability to document from both sides, John E. Mayer, MD, and Viktor Hraska, and plan care, in promotion of family centered care. MD, were awarded the Golden Medal of the Minister of Apart from the investment for equipment and educa- Foreign and European Affairs of the Slovak Republic, for tional material, eleven physicians and nurses of the PCC their active contribution to the development of the Slovak team had participated in training programs of BCH. The – American relations. partnership proved to be effective and made dramatic It is fascinating that a project that happened more than changes in all aspects of treatment of children with CHD in 25 years ago, and lasted for only three years, even now has Slovakia. had enormous impact on the quality of care of babies born The most signifi- with CHD in Slovakia. cant impact was seen in operative man- Geopolitical background agement. Gradually Slovakia is a landlocked country in Central Europe. Slo- all complex opera- tions across the age vakia’s territory spans about 19,000 square miles (smaller spectrum had been than Lake Michigan), and contrary to Wisconsin, is mostly implemented, along mountainous. with improvement in myocardial pres- The population is over 5.4 million, which is fairly com- Josef Masura, MD; the chief ervation, cardiopul- parable with Wisconsin (5.8 mil). Annually, approximately cardiologist of PCC, happy with 300-350 patients with CHD need complex treatment. His- postoperative course of the 1st monary strategy and torically, pediatric cardiac services had been provided in arterial switch patient. perioperative care. two clinics with suboptimal quality of care. In 1992, the Slovak government stepped in and centralized care for Most importantly, the whole philosophy changed from pal- CHD, creating a two-tier system, to streamline care and liation to correction irrespective of age, including neonatal optimize resource utilization. The Pediatric Cardiac Center repairs. A typical example was introduction of the arterial (PCC) at Children’s Hospital in Bratislava has been estab- switch operation (ASO) for transposition of the great arter- lished as the only referral center for the whole country. ies (dTGA). In January 1993, a team led by Drs. Hraska and 18 | Medical College of Wisconsin Department of Surgery

Babies with Congenital Heart Disease in Slovakia Mayer operated on newborn treatment of CHD in Slovakia. Team approach and mentor- M.B., born with dTGA. This ship has become an inherited feature of PCC. Even today baby was the first successful every child treated for CHD benefits from BCH’s know- ASO not only in Slovakia, but legde, and mentorship. Overall, during the last 26 years, in all of central Europe. more than 8,500 children born with CHD have been oper- ated on in PCC and the vast majority are living a high qual- Now 27 years later, Mar- ity of life. Currently, the second generation of physicians tina is a college graduate and and nurses of PCC is offering high quality of care, pushing lives without any restriction. the “envelope” even further. Further Development In the following decade, Future there has been a dramatic in- In 2020 a new PCC will be opened. This new building crease of the number of op- Martina B. DOB: Jan 16th will be attached erated patients, completely 1993; the first ASO in to the currently central Europe. covering the country’s needs (Fig. 1). Mortality rates sig- standing Na- nificantly dropped down from nearly 10% to less than 2%, tional Institute despite increased complexity of the cases. Overall, 39 new of Cardiovas- surgical approaches had been introduced to clinical prac- cular Diseases tice including heart transplant; 95% of all patients under- dedicated to went primary correction, and 70% of babies were corrected acquired heart during the first year of life. Since 1997, a program for hy- lesions, provid- poplastic left heart has started with encouraging 80% mid- ing advanced in- term survival rate after stage one and two of palliation.1 frastructure and PCC has become one of the leaders in central Europe, offering better New Pediatric Heart Center (building in offering service to foreign countries (Yugoslavia, Russia, resource utiliza- the front). Ukraine, Kazakhstan, Libya, Kirgiz, etc.). A unique achieve- tion, while dealing with new challenges associated with ment was trans-state collaboration with Slovenia (previous treatment of adult patients with CHD as well. Acknowledgment I wish to thank the medical and nursing staff of the Car- diovascular program at Boston Children’s Hospital who participated on Project Hope (John E. Mayer Jr., MD; Dolly Hansen, MD; Gil Wernovsky, MD; Phil Spevak, MD; Scott Yaeger, MD; Paula Moynihan, RN; Jeanne Davis, RN; Ellen Begley, RN; John Thompson, RRT; Robert Lapierre, CCP; Bettina Alpert, CCP; Willis Geiser CCP). Figure 1: Surgical output 1992 - 2001. FOR ADDITIONAL INFORMATION on this topic, visit mcw. edu/surgery or contact Dr. Viktor Hraska at vhraska@ Yugoslavia), by merging activity for complex CHD, to elimi- mcw.edu. nate any “learning curves” in complex management strat- egies. Since 1995, most critical newborns from Slovenia, REFERENCES including dTGA, have been referred to PCC with excellent 1. Hraška V, Nosal M, Sykora P, Sojak V, Sagat M, Kunovsky results.2 Up until now this is a unique example of collabora- tion between small countries in Europe. As has been dem- P. Results of modified Norwood´s operation for onstrated, if the volume of patients is small due to the low hypoplastic left heart syndrome. Eur J Cardiothorac birth rate (Slovenia), institutions should consider merging Surg. 2000;18:214-219 activity to have enough patients to enable rapid learning. 2. Hraška V, Podnar T, Kunovsky P, Kovacikova L, Such centralization amplifies the experience to the benefit Kaldararova M, Horvathova E, Masura J, Mayer JE Jr. Is of the patients.2 a learning curve for arterial switch operation in small countries still acceptable? Model for cooperation in Project Hope and USAID via BCH has established a pro- Europe. Eur J Cardiothorac Surg. 2003 Sep; 24(3): 352-7. gram with long term impact on all providers involved in Leading the Way | Fall 2020 | 19

Trailblazing in Nepal: Building Bridges for Michael J. Malinowski, MD I spent the end Associate Professor of the day helping Division of Vascular and Endovascular with a trauma in a Surgery 9-year-old girl in Dean E. Klinger, MD the “shock room,” Professor during which I no- Department of Surgery ticed the patient in the next bed was also having an active arrest due to acute cor- What do we think about when it comes to the current onary syndrome. Broken cardiac catheterization lab state of surgical mission in the world, and all its un- He was deceased equipment unused since 2015. by the time we finished with the trauma since the cardiac catheterization lab had been destroyed in the 2015 earth- derserved areas and populations? Unfortunately, in past quake and never rebuilt. Many of the hospital capital invest- years the concept of surgical mission from the United States academic centers has meant a wide spectrum ranging from ment projects have strong footing in international charita- ble funds. The next day we found ourselves in the “OT,” the surgical tourism, to free surgical care without long-term re- operating theater. Dr. Klinger and Dr. Prem were taking the lationships, to a conquistador style of surgical crusades to remote villages. But the truth of the matter is that in the junior surgeons, Drs. Robin, Satish, and Amit, through redo and complex open cases. We had spent months preparing 21st century our hopes for surgical mission must be one of for the first endovascular intervention in the Dhulikhel Uni- lasting effects beyond the time of our trip and hopefully, if done well, beyond the time of our careers. This is easi- versity Hospital. The patient we chose for our first interna- tional case just happened to be the high priest of the Swan- er said than done. Early in my career, charitable mission yambhunath Temple, i.e. “Monkey Temple,” in Kathmandu. meant flying to a remote area for 7-10 days with all surgical equipment, doing a dozen surgeries a day and then flying Being one of the largest Buddhist Temples in the world and the largest in Nepal, this patient selection was essentially a back home. Collaborating with local surgeons was variable dignitary/VIP patient selection for the first case. The patient at best, and when we left, the surgical hospital closed shut- ters until the next came in with a dysfunctional brachiocephalic fistula with two tandem high grade venous stenosis. We were able to international surgi- treat both lesions successfully with a five-millimeter angio- cal group arrived. During our trip to plasty balloon and using a 15-year-old, portable Siemens C- arm. This was the first case of an endovascular salvage of a Nepal, I realized dysfunctional arteriovenous fistula in Nepal. However, this quickly that the current day success was only possible based on the goodwill and understanding of benefit given to the local population that allowed for this of surgical mission achievement. was based on years of prior work, pas- We then attended the International Vascular Conference organized by the Vascular Society of Nepal. Dean and myself sion, preparation, gave presentations along with surgeons from Nepal, Hol- Endovascular intervention with heartache as well international team. as success. Dean land, Indonesia Klinger had done the most crucial tasks of successful sur- and Germany. As we did, Dean gical mission years before I arrived, by showing the local Klinger present- surgical groups our good faith efforts for long-term inter- national collaboration, not crusading. We started off our ed awards to the recipients, most- trip by handing out chocolates to everybody in the operat- ly lecturers (ju- ing room and the outpatient clinic building, known as the “OPD.” In my first few days in Nepal, I spent time seeing pa- nior surgical fac- ulty), residents tients in clinic giving advice on surgical planning and ultra- and medical stu- sound technique. We also discussed the creation of a vas- cular lab and have personally given charitable assistance in dents with each the acquisition of the necessary equipment for the hospital. Dr. Dean Klinger in OT with Nepali one receiving a surgeon lecturer. 20 | Medical College of Wisconsin Department of Surgery

International Surgical Collaboration handwritten note about what they’ve done well as well Group photo of entire Nepali vascular group. as in areas to improve. Since that time, one of the young surgical staff, a faculty lecturer, has reached out to me in Intraoperative teaching to the Nepali surgical group. pursuit of an international membership in the Society of Vascular Surgery. He was the winner of the best vascu- FOR ADDITIONAL INFORMATION on this topic, visit lar surgery abstract for the conference and is currently at- mcw.edu/surgery or contact Dr. Michael Malinowski tempting to obtain vascular fellowship training within Asia. at [email protected]. REFERENCES CONTINUED FROM PAGE 11 (AORTIC) As I flew home during the Covid-19 outbreak, I won- 4. Olchanski N, Winn A, Cohen JT, Neumann PJ. dered if the trip had been a success or not. I was reminded of the beauty of surgical collaboration and the importance Abdominal aortic aneurysm screening: how many life of constructively contributing to the international surgical years lost from underuse of the medicare screening culture in the country of Nepal with a population of great- benefit? J Gen Intern Med. 2014;29(8):1155-61. er than thirty million people, most living below the pov- 5. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, erty line. The earthquake of 2015, the mudslides of 2017 Lee WA, Mansour MA, et al. The Society for Vascular and variable periods of financial recession have had seri- Surgery practice guidelines on the care of patients ous impacts on the country and healthcare. Only within with an abdominal aortic aneurysm. Journal of the past year has the government made insured health- vascular surgery. 2018;67(1):2-77 e2. care possible, with healthcare coverage of up to $1,000 of care per year per patient. These advances are mostly due to Nepal having a Prime Minister who has undergone two kidney transplants during his lifetime. Within a week of my return to the States, I was notified by the surgical team in Nepal of their first independent venoplasty done for graft salvage, including a treatment for central venous stenosis. I realized this endeavor was the farthest thing from surgi- cal tourism or surgical crusading. Instead it was truly build- ing a bridge of international collaboration to offer long- term goodwill and benefits in the surgical outcomes of the residents of Nepal. Our U.S. team of surgeons and physi- cians (Drs. Dean Klinger, Andrew Goelz, Matthew Madion, Leann Arcori and myself) had established the most critical role we can have in the international surgical community, which is reinforcing lasting relationships and collaboration together, regardless of differences in resource availability and the spectrum of practice that comes with variable na- tional funding and equipment. To refer a patient or request a transfer/consultation, please use the references below: ADULT PATIENTS Clinical Cancer Center PEDIATRIC PATIENTS All Non-cancer Requests Referrals: 866-680-0505 Referrals/Transfers/ Referrals: 800-272-3666 Transfers/Consultations: Consultations: 800-266-0366 Transfers/Consultations: 877-804-4700 Acute Care Surgery: 877-804-4700 414-266-7858 mcw.edu/surgery Leading the Way | Fall 2020 | 21

LEADING THE WAY NEW FACULTY DIVISION OF COLORECTAL SURGERY Wood Johnson Medical School and serves as the Evaluation Committee Chair for the fellowship program. He received his Jed F. Calata, MD medical degree from Jefferson Medical College in Philadelphia. He completed general surgery residency training at the University of Jed F. Calata, MD, will join the Department Illinois and a colon and rectal surgery fellowship at the University of Surgery faculty in October as Assistant of Illinois/Cook County. Dr. Calata will provide surgical clinical care Professor of Surgery. Dr. Calata is currently an to the patients on the Colorectal Surgery service at the Zablocki attending colorectal surgeon at JFK Medical VA Medical Center and the main campus. Center in Edison, New Jersey and at Overlook Medical Center in Summit, New Jersey. He is also a member of the Colorectal Surgery Fellowship Teaching faculty at Rutgers/Robert DIVISION OF PEDIATRIC SURGERY fellowship at the UW-Harborview Injury Prevention and Trauma Research Center and received an MPH degree in Epidemiology. Dr. Katherine Flynn-O’Brien, MD, MPH Flynn-O’Brien will provide clinical care to patients of the General and Thoracic Pediatric Surgery service with a special interest Katherine Flynn-O’Brien, MD, MPH, will join in pediatric trauma and burn surgery and will be the Associate the Department of Surgery faculty in October Medical Director of the Pediatric Trauma Program at Children’s as an Assistant Professor of Surgery. Dr. Wisconsin. She will also be a faculty member in MCW’s Institute Flynn-O’Brien completed a pediatric surgery for Health & Equity where her research will focus on pediatric fellowship at MCW and Children’s Wisconsin trauma prevention and health outcomes. We are delighted to in July of this year. She earned her medical have her remain in Milwaukee and join our department faculty. degree from the University of New Mexico Center in Nashville. While at Vanderbilt, he completed a T32 NIH School of Medicine and completed general Research Fellowship, studying neuroblastoma. Dr. Craig joins the surgery residency training at the University of Washington in laboratory of Michael Dwinell, PhD, where their collaboration will Seattle. While at the University of Washington, she completed a investigate the basic scientific mechanisms that drive recurrence and progression of high-risk neuroblastoma. In addition to his Brian Craig, MD research, Dr. Craig will provide clinical care to patients of the General and Thoracic Pediatric Surgery service with a special Brian Craig, MD, joins the Department of interest in pediatric surgical oncology. Surgery faculty as an Assistant Professor of Surgery. Dr. Craig completed a Pediatric Surgery fellowship at Lurie Children’s Hospital, Northwestern University in July of this year. He earned his medical degree from the University of Pittsburgh and completed general surgery residency at Vanderbilt University Medical DIVISION OF TRANSPLANT SURGERY her general surgery residency training at Lehigh Valley Medical Center in Allentown, PA, where she also completed a trauma/ Priyal Patel, MD surgical critical care fellowship. Dr. Patel will provide critical care management of transplant surgery patients in the Transplantation Priyal Patel, MD, joins the Department of Intensive Care Unit. She will also provide surgical care to all liver, Surgery faculty as Assistant Professor of kidney, and pancreas transplant patients at Froedtert Hospital Surgery following completion of a Multi-Organ and Children’s Wisconsin. Transplantation and Hepatobiliary Surgery fellowship at the University of California, Los Angeles (UCLA). Dr. Patel received her medical degree from the University of South Alabama College of Medicine in Mobile. She completed DIVISION OF TRAUMA & ACUTE CARE SURGERY Andrew T. Schramm, PhD Andrew T. Schramm, PhD, joins the University of South Carolina and completed a Clinical Psychology Department of Surgery faculty this month as pre-doctoral internship at Kansas University Medical Center. Dr. an Assistant Professor of Surgery following Schramm’s practice will be focused on Trauma and Acute Care a Postdoctoral Psychology fellowship in our Surgery patients. Division of Trauma and Acute Care Surgery. Dr. Schramm earned his doctoral degree in Clinical-Community Psychology at the 22 | Medical College of Wisconsin Department of Surgery

THE MEDICAL COLLEGE OF WISCONSIN DEPARTMENT OF SURGERY FACULTY BY SPECIALTY Bariatric & General Surgery, continued Surgical Oncology– Trauma/ACS, continued Minimally Invasive Surgery Kathleen Lak, MD* Hepatobiliary and Todd A. Neideen, MD Matthew I. Goldblatt, MD David J. Milia, MD* Pancreas Surgery Andrew T. Schramm, PhD Jon C. Gould, MD, MBA Patrick B. Murphy, MD, MSc, Kathleen K. Christians, MD Libby Schroeder, MD Rana M. Higgins, MD MPH Callisia N. Clarke, MD, MS Lewis B. Somberg, MD, MSS* Andrew S. Kastenmeier, MD Todd A. Neideen, MD Douglas B. Evans, MD* Jill R. Streams, MD Tammy L. Kindel, MD, PhD Philip N. Redlich, MD, PhD T. Clark Gamblin, MD, MS, MBA Colleen Trevino, MSN, FNP, PhD Kathleen Lak, MD Libby Schroeder, MD Karen E. Kersting, PhD, LCP Travis P. Webb, MD, MHPE Lewis B. Somberg, MD* Susan Tsai, MD, MHS Vascular & Endovascular Cardiac Surgery Jill R. Streams, MD Surgical Oncology– Surgery G. Hossein Almassi, MD Travis P. Webb, MD, MHPE Regional Therapies Shahriar Alizadegan, MD* Lucian A. Durham III, MD, PhD Kellie R. Brown, MD* Viktor Hraska, MD, PhD Pediatric General & Callisia N. Clarke, MD, MS Joseph P. Hart, MD, RVT, RVPI David L. Joyce, MD, MBA Thoracic Surgery T. Clark Gamblin, MD, MS, MBA Brian D. Lewis, MD Lyle D. Joyce, MD, PhD John J. Aiken, MD* Mona S. Li, MD* Takushi Kohmoto, MD, PhD, Casey M. Calkins, MD* Thoracic Surgery Michael J. Malinowski, MD* MBA* Brian T. Craig, MD Mario G. Gasparri, MD* Neel Mansukhani, MD R. Eric Lilly, MD* John C. Densmore, MD* David W. Johnstone, MD* Peter J. Rossi, MD* Michael E. Mitchell, MD* Katherine T. Flynn-O’Brien, MD, Paul L. Linsky, MD* Abby Rothstein, MD* Gary R. Seabrook, MD Paul J. Pearson, MD, PhD MPH Transplant Surgery Affiliated Institution Francisco A. Durazo, MD Program Directors Ronald K. Woods, MD, PhD* David M. Gourlay, MD* Calvin M. Eriksen, MD Gary T. Sweet Jr., MD Tammy L. Kindel, MD, PhD Johnny C. Hong, MD Aspirus Wausau Hospital Colorectal Surgery Dave R. Lal, MD, MPH* Christopher P. Johnson, MD James Rydlewicz, MD Jed F. Calata, MD Keith T. Oldham, MD* Joohyun Kim, MD, PhD Aurora–Grafton Kirk A. Ludwig, MD Thomas T. Sato, MD* Priyal Patel, MD Nicholas Meyer, MD Mary F. Otterson, MD, MS Jack G. Schneider, MD* Terra R. Pearson, MD Columbia St. Mary’s Hospital Carrie Y. Peterson, MD, MS* Sabina M. Siddiqui, MD Jenessa S. Price, PhD Joseph C. Battista, MD Timothy J. Ridolfi, MD, MS Kyle Van Arendonk, MD, PhD St. Joseph’s Hospital John G. Touzious, MD Community Surgery Amy J. Wagner, MD* Allan M. Roza, MD Waukesha Memorial Hospital Robert J. Brodish, MD Motaz A. Selim, MBBCh, MSC, Chief Advance Practice T. Clark Gamblin, MD, MS, MBA Research Faculty MD Providers Dean E. Klinger, MD Mohammed Aldakkak, MD Melissa Wong, MD Stephen W. Robischon, PA-C Kaizad Machhi, MD John E. Baker, PhD Stephanie Zanowski, PhD Kevin V. Moss, MD Young-In Chi, PhD Michael A. Zimmerman, MD Ambulatory Chief Eric A. Soneson, MD Mats Hidestrand, PhD Trauma/ACS Cynthia L. Schulzetenberg, PA-C Mark A. Timm, MD Gwen Lomberk, PhD Marshall A. Beckman, MD, MA* Angela J. Mathison, PhD Inpatient Chief General Surgery Aoy T. Mitchell, PhD Thomas Carver, MD Chief Surgical Residents Marshall A. Beckman, MD, MA* Kirkwood Pritchard, Jr., PhD Panna A. Codner, MD (2020-2021) Thomas Carver, MD Christopher S. Davis, MD, MPH Jacqueline Blank, MD** Kathleen K. Christians, MD Raul A. Urrutia, MD Marc A. de Moya, MD Kayla Chapman, MD Panna Codner, MD Terri A. deRoon-Cassini, PhD Kathryn Haberman, MD Christopher S. Davis, MD, MPH Surgical Oncology– Christopher Dodgion, MD, Elizabeth Traudt, MD** Marc A. de Moya, MD Breast Surgery MSPH, MBA K. Hope Wilkinson, MD, MS Christopher Dodgion, MD, MSPH, Chandler S. Cortina, MD Anuoluwapo F. Elegbede, MsC, MBA Amanda L. Kong, MD, MS* MD ** Administrative Chiefs Anuoluwapo F. Elegbede, MsC, Caitlin R. Patten, MD* Joshua C. Hunt, PhD, MA Tina W.F. Yen, MD, MS MD Surgical Oncology– Christina Megal, DNP, APNP, Matthew I. Goldblatt, MD Endocrine Surgery FNP-C, CWON-AP, CFCN Jon C. Gould, MD, MBA Sophie Dream, MD* David J. Milia, MD* Rana M. Higgins, MD Douglas B. Evans, MD* Rachel S. Morris, MD Andrew S. Kastenmeier, MD Tracy S. Wang, MD, MPH* Patrick B. Murphy, MD, MSc, Tammy L. Kindel, MD, PhD Tina W.F. Yen, MD, MS MPH LEARN MORE AT MCW.EDU/SURGERY | @MCWSurgery Leading the Way | Fall 2020 | 23 * Participates in Community Surgery/Off-Campus Locations.

Department of Surgery 8701 Watertown Plank Road Milwaukee, WI 53226 2020 SURGICAL Department of Surgery ONCOLOGY SYMPOSIUM Dedicated to Clinical Care, Research, and Education OCTOBER 23, 2020 AT 12:00 PM • Cardiothoracic Surgery Virtual Symposium • Colorectal Surgery • Community Surgery FEATURED TOPICS: Breast Oncology, Endocrine Neoplasias, Gastrointestinal • Surgical Education Oncology, Pancreatic Tumors, and Cutaneous Malignancies • Minimally Invasive & Gastrointestinal Featuring virtual keynote speaker: ‌Surgery Richard C. Wender, MD • Pediatric Surgery • Research Chair, Family Medicine and Community Health, Perelman School of • Surgical Oncology Medicine University of Pennsylvania; Past Chief Cancer Control Officer, • Transplant Surgery • Trauma/ACS American Cancer Society • Vascular & Endovascular Surgery REGISTER TODAY: www.ocpe.mcw.edu/surgery Leading the Way is published three times yearly by The Medical College of Wisconsin Email [email protected] for more information. – Department of Surgery, 8701 Watertown Plank Road, Milwaukee, WI 53226 ©2020 Check out our website for a current list of upcoming events! Editors: www.mcw.edu/surgery Rana Higgins, MD Heidi Brittnacher, 414-955-1831 or 24 | Medical College of Wisconsin Department of Surgery [email protected] Designer: Liz Chen, [email protected] Leading the Way is written for physicians for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient.