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an online version of the magazine Fall 2009
Medical Rounds
Medical Rounds
Increasingly, says Rosson, breast reconstruction patients want to preserve sensation.
Photo by Keith Weller


Dawn of the Sensitive Surgeon

After mastectomy, reconstruction options now include "sensate preserving" procedures.


During his seven years in breast reconstruction, Gedge Rosson has worked with the assumed priorities of most breast cancer patients. First, save the patient’s life; second, restore her bust-line; and third, maybe, preserve physical sensation in the reconstructed breast.

But increasingly Rosson is seeing patients who would rank physical sensation equally with appearance, if not above it. The more fluid hierarchy, he adds, rests on how each patient defines her "emotional quality of life." Is it more important to look better in clothes, or is it more important to retain some aspect of physical sensation?

One of Rosson’s recent patients, an attractive broadcast producer from Denver who faced a double-mastectomy at 48, thinks it’s high time both goals were given equal footing. "I actually would say that sensation is at least as important to me," she says. "I’d rather feel good than look good."

Rosson, who directs Johns Hopkins’ four-surgeon breast plastic surgery unit, says the trend toward sensate-preserving reconstructions has become more prominent as surgeons have made gains in both nerve-sparing and nerve-connection techniques. Though his group offers the full range of approaches for post-mastectomy patients, his younger patients are increasingly inclined to ask for an approach that can retain feeling.

His group sometimes succeeds in preserving sensation, says Rosson, but he’s quick to adjust expectations. Even in the best outcomes, he says, patients who retain breast sensation do not experience a full return of erogenous feeling. Many do, however, often retain a sense of physical contact on the surface of the reconstructed breast, a sensation much preferred over no sense of touch at all. He says the preservation of erogenous sensation is a worthy goal still on the horizon.

The progress in sensate-preserving techniques builds on advances made in maintaining the motor nerve systems that underlie patients’ abdominal muscles. Many surgeons still offer procedures that harvest tissue from a patients’ abdomen in a technique that also takes portions of the underlying muscle tissue and its associated nerves. Patients are generally happy with the improved figure that results from a trimmer waist and restored bust-line, but it also "messes up their belly," says Rosson. The loss of abdominal muscles means poor torso control, requiring patients to use their arms just to sit up.

To answer that challenge, Rosson’s group most prefers an approach called the deep inferior epigastric artery perforator flap procedure, or DIEP. With DIEP, he explains, his group harvests the patient’s belly tissue in a way that completely preserves her abdominal muscles and nerve tissue. This growing mastery for preserving motor nerves, says Rosson, also now extends to preserving the sensory nerves in skin.

In general, Rosson says, sensate-preserving techniques can be accomplished in one of two ways—by preserving as much of the natural breast tissue as possible in a skin-sparing or nipple-sparing mastectomy technique, or by connecting nerve tissues in the transplanted surface skin of the reconstructed breast. Through various approaches, Rosson estimates his group succeeded in restoring sensation in about one-fourth of their 300 breast reconstruction procedures over the past year.
Ramsey Flynn

Owning Up to Errors

What patients hear is often more important than what doctors say.



Although patients may react more favorably to physicians who admit harmful medical errors and apologize for them, they may be no less likely to sue them for malpractice, according to a study led by Hopkins patient safety researcher Albert Wu.

The report, which appeared in September in The Journal of General Internal Medicine, recorded the reactions of 200 adult volunteers from Baltimore to videos of actors representing doctors who were revealing medical errors to their "patients." After each viewing, volunteers completed a survey that recorded their emotional responses, their evaluations of the erring physician, and the likelihood that they would pursue a lawsuit.

The vignettes depicted doctors admitting to a year’s delay in noticing a malignant-looking lesion on a mammogram, to a chemotherapy overdose, and to a slow response to pages that caused a pediatric patient to undergo emergency surgery. The degree to which doctors admitted responsibility and apologized varied in the videos— full responsibility and apology, incomplete responsibility and apology, and neither responsibility nor apology.

By most measures, viewers gave higher ratings to those doctors who apologized and took full responsibility for their errors. For example, 81 percent reported trusting these physicians, versus 52 percent for incomplete disclosures and 38 percent when physicians neither took responsibility nor apologized. However, such charitable thoughts did not keep viewers from considering legal action. Although they were more apt to sue those physicians who offered incomplete apologies or who did not admit their errors, they were only slightly less likely to sue the physicians they rated most highly, the researchers found.

Although Wu had hypothesized that the likelihood to sue would be significantly less when physicians offered apologies and full disclosures, he says these findings may result, in part, from the severity of the errors depicted. The vignettes were filmed as part of an educational video project supported by MCIC Vermont, Inc., the malpractice insurer for Hopkins, and the Agency for Health Care Research and Quality. A 25-minute video, "Removing Insult From Injury: Disclosing Adverse Events," has been distributed to all hospitals in Maryland.

"We wanted to help doctors understand how one should talk to patients about mistakes," says Wu, a professor at the Johns Hopkins Bloomberg School of Public Health.

He suggests that patients’ perceptions of what physicians say may be more important than what is actually said. Along with study co-author Peter Pronovost of the School of Medicine, Wu offers strategies "to make sure the patient knows you really mean it," such as repeating the message, using body language that shows contrition, and asking questions of the patient to make sure they understand. Linell Smith


Less is More

With Fuchs dystrophy, replacing the entire cornea is no longer necessary.


Less is More
Jun’s procedure offers faster visual recovery.

Sometimes in medicine, you can do more with less. At least that’s the conclusion of Wilmer ophthalmologist Albert Jun, who has refined a new surgical technique for treating Fuchs dystrophy. The condition, which results in vision loss and painful eye blisters, affects only about 1 percent of the population, but is responsible for half of all corneal transplants—which for 40 years was the only way to treat the disorder.

Jun has spent his MD/PhD career seeking a better way. He notes that corneal transplants have a long recovery period—often one to two years—and a lifelong risk of rupture because of weakness at the attachment site. The profile of the new cornea is problematic as well, often changing the shape of the eye and creating astigmatism or presenting a bull’s-eye of foreign tissue to be attacked and rejected by the immune system.

Jun’s work has shown that replacing the entire cornea isn’t necessary to treat Fuchs. He became fascinated with findings that came out of the Netherlands about 10 years ago, which looked at ways of transplanting just the lower two layers of the cornea, including the endothelium—the layer "about one-twentieth the thickness of a sheet of paper," he says—that degenerates in Fuchs. Instead of the standard transplant, which involves punching out a round piece of tissue and sewing it into the place of the removed cornea, the new procedure, called endothelial keratoplasty, makes a far smaller groove at the edge of the cornea. The diseased Fuchs tissue is removed through this groove, and the new tissue is inserted like a folded contact lens that then springs into place and is secured.

"It’s like sliding a pizza into a wood brick oven," says Jun. "Only it’s in a space of two and a half millimeters." This new procedure, which Jun has refined, "offers much faster visual recovery—as little as three months—and you don’t compromise eye shape or strength," he notes.

Jun admits that the tight space makes for difficult work, but he’d like to squeeze it even more. "The diseased endothelium is like the bottom piece of bread in a sandwich," he says. "That’s all we’d like to replace. Yet now we’re forced to transplant that bread and part of another layer—the inner meat, if you will—of the cornea."

That extra tissue bulks up the cornea by 20 percent and affects vision, something that might be eliminated if Jun and his colleagues can perfect a way to just swap endothelium. They’re working on it.

Meanwhile, Jun is ensuring that more people can benefit from the existing procedure. He’s consulted with national eye banks to help them properly prepare donated corneal tissue for efficient transplantation, and he’s written a seminal paper on the topic that shows the method is valid.

Eventually he hopes his lab research on the genetic and molecular changes that lead to Fuchs will create therapies that eliminate the need for surgery. Mat Edelson

MrBot Will Test You Now

Making prostate biopsies more precise than ever.


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Stoianovici and MrBot
Photo by Keith Weller

Consider the typical prostate biopsy: Using an ultrasound probe as a guide, a urologist inserts a needle into the patient’s rectum and removes about a dozen prostate tissue samples. Because the ultrasound can’t see the tumors, the urologist is effectively selecting biopsy location without accurate guidance within the gland. Perhaps not surprisingly, the present technique often misses cancers.

In the world’s only urology robotics lab, Johns Hopkins engineers have designed a solution: MrBot, a plastic, air-motored robot that works with magnetic resonance imaging to pinpoint suspicious tissue for biopsy. In animal tests, MrBot successfully probed within 1 millimeter of a target identified by physicians on an MR image.

"It’s certainly more precise than any other technique," says Dan Stoianovici, director of the URobotics lab. "The reason is that it makes a closed-loop digital system: The robot is a digital device, which means it has better communication with the image, which is also digital."

The most descriptive views of the prostate come from MR images, but they usually can’t help with biopsies, not least because the urologist can’t fit inside the small, constrictive MRI machine with the patient. What’s more, because the MRI machine is powered by strong magnets and reads the image using sensitive electromagnetic signals, it won’t function properly in the presence of steel and electrically powered devices.

MrBot—made entirely of nonmagnetic and dielectric materials such as plastic, ceramic, glass, and rubber—fits snugly around the patient while he’s lying inside the MRI machine. The robot’s motor is powered by puffs of pressurized air.

In addition to cancer diagnosis, MrBot could be used for treatment of prostate cancer, including thermal ablations or localized radiation therapy.

After almost four years of tweaking, MrBot is now ready for real patients. A stage-1 clinical trial on 20 patients at high risk of prostate cancer began last summer, says Mohamad Allaf, director of minimally invasive and robotic surgery here. Allaf, who is leading the trial, expects that MrBot will soon get FDA approval. Virginia Hughes

Moving the Goal Post

Cardiac surgeons here are increasingly pushing the boundaries for seniors. A case in point …


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A recovered Howe on his rowing machine.
Photo by Keith Weller

When Nick Fortuin sized up the cardiac patient who stood before him in the early spring of 2009, he held his skepticism in check. The man was 94. "But my goal," the man said, "is to make it to 100." The patient had survived a multivessel cardiac bypass in 1988. When his retooled heart began to give out in 2008, he was hospitalized twice, emerging with two new stents aimed at restoring lost flow.

But he still couldn’t walk across the room without gasping for breath. Physicians near his home in the nation’s capital said that at 94, he was clearly not a surgical candidate. Most patients in such a circumstance might have packed it in. But most patients are not Fisher Howe.

A career diplomat, he’d graduated from Harvard, served in naval intelligence during World War II, and ascended the ranks in the State Department to a position as deputy head of intelligence, later becoming the deputy chief of mission to both Norway and Holland. He followed that up with a turn as an assistant dean at Hopkins’ Nitze School of Advanced International Studies, and finally "retired" as a management consultant. In his spare time, Howe took up tennis. Well into his 90s, Howe had placed third in his U.S. age group.

To the physicians who had encouraged Howe to settle for the shorter lifespan, Fortuin took exception. "I respectfully disagree with them," he told Howe. "I think you’ve got the stuff to do it." After a further assessment with heart surgeon Duke Cameron, the obvious risks were at least enough to give Howe pause: up to a 4 percent risk of death, and up to a 10 percent risk of stroke. And, added surgeon Cameron, there would be an arduous recovery period.

Despite the well-intentioned skepticism of family and friends, Howe made the leap. "I really wanted to hit that 100 mark," he says. "My valve would deteriorate if I didn’t do something."

Cameron found the surgery difficult. Howe’s trileaflet aortic valve was heavily calcified. The surgeon replaced it with an animal valve, and re-bypassed a badly narrowed coronary vessel. Howe needed a balloon pump to sustain him through the procedure, and required a second intubation in response to bleeding in his lung cavity.

Howe spent 13 days in acute care, followed by 10 days on a rehab floor, followed by a month in a local rehab facility near his Washington home. But to Howe, the cost was worth it. He feels good again. He exercises daily, on the rowing machine, the treadmill, the elliptical unit.

As the population ages, Fortuin and and other cardiologists are seeing more patients with age-related aortic stenosis who have been rejected because of their age. "I’ve seen three 90-plus patients in the past year who were turned down elsewhere," he says, "all of whom had great surgical results here."
Ramsey Flynn

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