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an online version of the magazine Fall 2007
Medical Rounds
Robert Bristow
Bristow, with the da Vinci


A Low-Impact Hysterectomy

Robotic assist brings “minimally invasive” to major procedure.


WHEN RENEE BURCIN met with a surgical oncologist last spring, the diagnosis of a cancerous tumor in her cervix was still new and ominous. What next?

If she wanted a shot at ridding herself of cancer, he counseled, Burcin needed to undergo a radical hysterectomy.

Burcin certainly wanted to reduce her cancer risks. And, at 46, she had two teens and no interest in enlarging her brood. But she’d heard enough about the effects of radical hysterectomy to know it was a trauma she’d just as soon minimize.

This was not a time for halfway measures, the surgeon advised, and the clock was ticking. Everything should come out, he said—the uterus, fallopian tubes, the ovaries. He was skilled in the open procedure, which required a large opening across her lower abdomen.

But Burcin was also inclined to second opinions and her search led her to the Hopkins office of Robert Bristow, whose group has made headway in adapting the newest robotic devices to minimize gynecological surgeries. Bristow assessed Burcin’s tumor and considered her eligible for radiation therapy, which could produce an equivalent cure rate to surgery but would also risk damaging the bowel and other surrounding pelvic tissues.

But Bristow also told Burcin that her profile made her an ideal candidate for the minimally invasive approach to radical hysterectomy—her tumor was caught early, and her trim figure allowed easy access to the tissues along with an ability to endure the optimal head-down operating position. He would just have to make five dime-sized slits in her abdomen for the entire operation.

Burcin opted for the four-hour procedure on May 28, in which Bristow operated from the controls of his department’s da Vinci robotic surgical assist system stationed a few feet away from his patient. Bristow selected and excised the troubled tissues within Burcin’s abdomen—including the 3.5 cm tumor itself—removing them intact through the small incisions while another operator assisted from a hands-on position.

Burcin was discharged the next day, three days ahead of open procedure patients. She returned to work in less than three weeks, half the traditional time. Burcin says the recovery to her hysterectomy has been surprisingly easy, leaving “little itty bitty scars.”

Bristow says Burcin’s not yet out of the woods on the cancer risk, but reports he removed 21 lymph glands in the procedure and they all came out clear.

This lower impact approach to hysterectomy continues to grow in his practice here, says Bristow. His group has performed more than 80 of the procedures, all with good outcomes.

The best part of the new procedure, says Bristow, is that it’s significantly easier on the patient’s quality of life. With hysterectomies currently at 650,000 per year and growing with the Boomer generation, says Bristow, it’s nice to have the robotic assist technology to reduce the burden on patients. Ramsey Flynn


Start Me Up, 2.0

Chief of Medicine upgrades AHA’s resuscitation guidelines



WHEN IT CAME time to reconsider the 50-year-old rules for saving people whose hearts had suddenly stopped, Mike Weisfeldt proceeded cautiously. Having faced his first major resuscitation test as a young resident in 1967, Weisfeldt knew better than most how the original guidelines had saved many lives.

His formative moment came with the report of a sudden cardiac arrest near the Hospital. Weisfeldt and a fellow resident raced to the scene and followed the breakthrough formula devised by a Johns Hopkins expert just a few years earlier: Clear the airway, induce breathing by mouth-to-mouth, then move to chest compressions.

After the patient remained lifeless for 30 minutes, the chief resident prepared to call it. But the younger residents pleaded for more time, eventually bringing the man back from certain death.

CPR had “an almost magical quality” on the patient—and on his young doctors—recalls Weisfeldt, now Hopkins’ chief of Medicine.

But nearly half a century later, Weisfeldt and other senior members of the American Heart Association shared a growing concern. Of the 200,000 people who still experienced sudden cardiac arrests each year, only 7 percent survived after traditional CPR techniques. Hoping to do better, the AHA tapped Weisfeldt and others to review the guidelines.

Lifesavers for years had memorized the “ABC” rule for cardiopulmonary resuscitation—Airway, Breathing, Compressions. But a lot had changed since Hopkins’ William Kouwenhoven and friends first devised their simple formula. The most pivotal of these was that defibrillation had been invented and then transformed into portable devices. Then, with the dawning of the 911 emergency calls in the late-1960s, everyday citizens could summon medical help by dialing three simple digits. Hospital code teams were also formed, along with rapid-response emergency medical technicians who could deploy to remote locations via ambulance.

And there was growing research showing patterns for successful CPR techniques, many of which highlighted the value of quick defibrillation. The studies showed that—regardless of whether defibrillation was delivered by everyday bystanders or medical specialists—over 30 percent of patients could be revived by a shock as long as it was administered within four minutes of the cardiac arrest.
Those findings only head up the new rules for CPR, which became AHA gospel in March:


1) A single shock within four minutes of onset is always the best first response if the arrest is witnessed. This assumes a defibrillator is nearby.

2) If a person is found unconscious and without pulse, perform two minutes of CPR first, then administer a single shock. This also assumes a defibrillation device is nearby.

3) If someone has suffered cardiac arrest and no defibrillator is near, perform chest compressions until medical help arrives. Thirty chest compressions should be administered for each breath—half the 15:1 ratio under the previous guidelines. (In fact, Weisfeldt says, the value of mouth-to-mouth ventilation is increasingly questioned, with growing consensus that properly executed chest compressions alone may be the most effective remedy for many minutes).

4) Make the chest compressions hard and fast. The optimal pace is 100 compressions per minute. Avoid interruptions.

Two additional tools are also gaining traction, says Weisfeldt. One is a manually operated breathing device that extends a catheter past the patient’s trachea (patented as the “ResQ-Valve”); the other is hypothermia therapy—which can be administered with a liberal application of ice to a patient’s torso—cooling down a patient’s metabolism to slow the advance of tissue damage until function is restored.

If widely applied, says Weisfeldt, the new guidelines can improve survival. But the word may not be reaching everyday people. “It’s been slow,” he says. “We’re still in the process of disseminating to people that there’s a better way to do this.” RF


To Sleep, Perchance to Diagnose

Team sees new friend to psychiatry in REM sleep.


CHarles Hong
> Hong sees promise in the dreaming brain.

Our waking mind may have far more in common with our sleeping one than previously suspected, according to a new study led by neuroscientist/psychiatrist Charles Hong.

That finding could offer scientists a new opportunity for examining major brain systems that go awry in psychiatric diseases—such as schizophrenia, depression, or Alzheimer’s disease—while patients are fast asleep.

Basically (and this understates the difficulty) Hong’s team videotaped the rapid eye movements of healthy volunteers who spent the night asleep in an exquisitely sensitive functional MRI (fMRI) scanner. They then synchronized the results to get a real-time snapshot of active brain areas. It wasn’t a stretch to expect that regions for eye movement would light up. And because Hong and earlier research had revealed that, in REM sleep, eyes apparently track what they “see” in dreams, the Hopkins team also anticipated activity in some cortical areas for sight. That was indeed the case.

Yet there was more. Unexpectedly, brain sites for hearing, smell, touch, and balance are turned on when rapid eye movements occur in sleep, they found, as well as motor areas that control body movements. They’re likely the same areas active in awake, fully conscious people looking at and perceiving something.

“Because so much is shared, we believe that consciousness in waking life and REM sleep dreaming are continuous,” says colleague James Harris. “During waking consciousness you’re seeing things in the real world. In dream consciousness, you’re also looking at images, but, it appears, they’re created internally by your brain.”

Now for the practical: Hong says many of the brain regions that light up under fMRI  function poorly in psychiatric disease. For example, language areas and the basal nucleus, both areas apparently active in eye-movement sleep, are profoundly affected in Alzheimer’s disease. Other REM-active regions—for sensory processing, for example—go awry in schizophrenia.

Additionally, Hong’s team found that healthy subjects have lowered activity in a dense serotonin-secreting neural network in the brain. Having a window into the workings of serotonin, closely tied to mood disorder therapy, could be a great benefit, he says.

The plan, Hong explains, would be to compare healthy people at sleep with those touched by psychiatric disorders. “An advantage is that they’re all asleep, so you can carry out accurate studies in uncooperative schizophrenia patients, in infants, or those with Parkinsonian tremors.”  Marjorie Centofanti

Taking the Pressure Off

Why a Wilmer ophthalmologist is warming to less invasive glaucoma surgery.


1 1 1
cardin & bush
> The Trabectome probe clears clogged tissues that block aqueous flow.

John Haddick took a certain pride in the eagle-eyed vision he’d enjoyed for 24 years as a Navy pilot. So, as an advancing case of glaucoma began to darken his right eye’s visual field on the eve of his 70th birthday last year, Haddick decided to make a move.

His ophthalmologist recommended one of the most common surgical solutions for adult glaucoma, a trabeculectomy, in which a hole is made in the sclera under a flap to release trapped intraocular fluid to the outer surface of the eye, relieving destructive pressure on the optic nerve fibers below.

Haddick knew he needed a fix, but the details of the procedure gave him pause. The procedure often fails over time, and the surgery put the eye at permanent risk of developing an infection, one that can be blinding. The details, he says, “didn’t really give me the most comfortable feeling in the world.”

Even an initial consult at Hopkins confirmed trabeculectomy as the logical answer. “Is that it, then?” Haddick pressed. “Do I have no other options?’’ Well, one of the Wilmer physicians answered, one faculty member was making headway with a new approach, and Haddick just might be eligible.
Wilmer surgeon David Friedman soon confirmed that other options are now available. In fact, he says, about one in five of the nation’s 2.5 million glaucoma patients may qualify for a growing procedure that he calls “elegant.”

Named after the new technology that makes it possible, the Trabectome approach allows eye surgeons to restore fluid outflow to over-pressured eyes without the more radical restructuring posed by traditional trabeculectomies. The technique employs a finely crafted probe with a gently curved, gold-plated tip that can precisely remove fine layers of clogged tissues that block aqueous flow.

“It all comes down to plumbing,” explains Friedman. With all glaucoma cases, he says, “we just need to make sure that either more fluid is leaving the eye or less is coming in.”

Friedman describes how the Trabectome probe uses an electrical pulse that passes through a gap in the device’s tip that spans less than 300 microns, nearly exactly the thickness of the trabecular meshwork, the area where  aqueous flow is usually slowed. With the patient’s afflicted eye numbed by anesthesia, the surgeon can place the probe into the front part of the eye, just anterior to the iris, and slowly sweep it through the affected layer of meshwork, much the way a seamstress strips away a restrictive bond.   

“You’re just ablating the tissue in between the gap,” explains Friedman. The unwanted material is then suctioned away by the probe. After the probe is withdrawn, “you put one stitch in where you entered the eye,” he says.

The Trabectome approach worked “perfectly” on Haddick, and Friedman has continued to extend the technology to dozens of new patients. He says about 70 percent of his Trabectome patients will need no further surgery. “You can’t perform the procedure on everybody,” Friedman says, explaining that patients with angle closure glaucoma are not good candidates, nor are those whose intraocular pressures must be brought lower. RF


Through the Looking Glass

Endomicroscopy is magnifying field of vision for GI cancers.


JUST A FEW short years ago, identifying and diagnosing esophageal cancers endoscopically was a hit-or-miss mission. “We could scope out large areas for biopsy,” says gastroenterologist Kerry Dunbar. “But, missing has been the ability to be more precise and selective about what we biopsy.”

That’s meant multiple biopsies and tissue samples being sent to pathology, and needle-in-the-haystack searches. It’s time-consuming and frustrating, especially when patients are anxious for immediate results.

That waiting game changed when Hopkins recently became the first facility in the United States to use confocal endomicroscopy to instantly diagnose patients with gastrointestinal cancer. Tipping the end of a traditional endoscope is a miniaturized microscope, which lets physicians view cellular, vascular, and connective structures in detail. Where the devil is in those details, doctors are seeing a more precise view of them than ever.

“We’re seeing the mucosa magnified about a thousand times,” says Dunbar. “And that’s letting us see in vivo differences between normal and precancerous cellular changes.”

While that’s helping to improve diagnosis of diseases of the esophagus and gastrointestinal tract, Dunbar is also using endomicroscopy specifically for Barrett’s esophagus, which carries a lifetime cancer risk of about 5 percent. What’s been tricky for doctors is identifying whether and to what degree dysplasia—that atypical change in cell nuclei or growth patterns—exists in Barrett’s.

“The idea is to be able to identify it early,” says Dunbar. Endomicroscopy may help that endeavor by not only magnifying the field of vision but allowing a more discerning tissue selection. “What that means is that we’re sending fewer tissue samples to pathologists and only those that have been identified as suspicious via endomicroscopy.” Mary Ann Ayd


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 Annals of Hopkins
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