Omaha, Neb. – A multidisciplinary team of physicians recently performed the first “ex utero intrapartum treatment” or “EXIT” procedure at The Nebraska Medical Center – successfully securing an airway for a baby girl with a benign tumor in her mouth before fully delivering the infant by Cesarean section.

 
EXIT is an innovative procedure developed to deliver infants with severe congenital abnormalities usually of the head and neck that may make breathing after delivery difficult or impossible. During EXIT, the newborn is partially delivered by a C-section, but the umbilical cord supplying oxygen from mother to baby is not immediately cut. Next, the baby is intubated – a breathing tube is inserted through the mouth or nose into the windpipe. Finally, the delivery of the infant is completed and the cord cut only after a clear airway has been established.

 
“The biggest challenge in this type of procedure is establishing an airway for the baby quickly and maintaining a steady supply of oxygen so that no neurological damage occurs,” said Teresa Berg, MD, maternal-fetal medicine specialist at The Nebraska Medical Center. “If you can’t successfully intubate on the first several attempts, a tracheotomy, without a secure airway, is required and that potentially increases the risk for both the baby and the mother.”

 
This is an uncommon procedure – only about 100 cases have been documented in the United States.

 
Ultrasound Discovery: Mass on Mouth Will Prevent Baby From Breathing
A prenatal ultrasound at 22 weeks delivered the frightening news. Dan and Megan Hanson of Denison, Iowa were told that their baby girl had a mass in her mouth and wouldn’t be able to breathe on her own after delivery.

 
“It was an extremely anxious and overwhelming pregnancy,” said Megan.

“Prenatal care saved this baby’s life,” said Ann Anderson-Berry, MD, neonatologist and medical director of the Newborn Intensive Care Unit (NICU) at The Nebraska Medical Center. “We have fascinating technology like fetal MRIs and ultrasounds to help us plan for high-risk deliveries like this. If we had not discovered the mass in an early ultrasound and the baby was delivered in a normal delivery room, the risk of death or at the very least severe neurological problems is very high.”

 
Because the EXIT procedure is a complex and delicate operation, it requires careful planning and coordination between the mother’s physicians, anesthesiologists and the neonatal and pediatric specialists charged with the care of the newborn. Before the actual operation, the medical center’s teams established protocols and contingency plans for the surgery.

 
Shahab Abdessalam, MD, pediatric surgeon at The Nebraska Medical Center and Children’s Hospital & Medical Center helped to coordinate the procedure in the days leading up to delivery – putting into action expertise learned through experience with previous EXIT procedures.

 
“We were all familiar with our roles, our equipment and what steps needed to be taken when. We prepared for the best and worst case scenarios,” said Dr. Anderson-Berry. “The EXIT procedure required tremendous collaboration, and the successful outcome speaks of the excellent teamwork.”

 
“This is a complex and highly synchronized operation that requires a great deal of medical collaboration. We’re bringing together a team of experts dedicated to mom and a team of experts dedicated to the newborn. Our ability to provide this lifesaving procedure in Omaha speaks volumes about the caliber of our medical community,” said Dr. Abdessalam.

 
The Day of the EXIT Procedure
July 29, 2010, more than 34 physicians, nurses and other health care professionals filled the operating room, prepared for the complex, high-risk delivery of Haylee Hanson.

“From ultrasounds, we had determined that Haylee has a mass in her mouth that would interfere with her ability to breathe on her own,” said Rodney Lusk, MD, airway consultant for The Nebraska Medical Center and pediatric ENT (ear, nose and throat) specialist at Boys Town National Research Hospital.

 
Dozens of doctors and nurses begin the EXIT Procedure to deliver Haylee
In addition to a mass blocking the baby’s airway, masses can lead to an accumulation of excess amniotic fluid. Before the procedure would begin, the maternal-fetal medicine specialists removed about two liters of excess amniotic fluid from Megan’s uterus through a process called amnio-reduction.

 
The EXIT procedure is an extension of the Cesarean section wherein an incision is made in mother’s abdomen and uterus. The baby is only partially delivered – her head, chest and shoulders are visible outside of the uterus while the rest of the body remains inside.

“This allows us to maintain volume in the uterus and prolong placental support, meaning mom is still breathing for baby through the umbilical cord,” said Dr. Berg. “It is optimal for there to be as much uterine relaxation as possible and this can be provided by anesthesia to the mother and by a medication to prevent contractions. If the uterus does not remain relaxed, the placenta will separate with the onset of maternal bleeding and the oxygen supply from the mother to baby would be stopped.”

 
The team has to move quickly. Placental support usually lasts for 30 minutes or less.

 
“At this point, the baby’s life is dependent on whether or not we can establish an airway in a short period of time,” said Dr. Anderson-Berry.
Dr. Lusk who is nationally known for pediatric airway management was in the “hot seat.” Using a laryngoscope (viewing instrument with a light), Dr. Lusk could see that Haylee’s mass was attached to the top of her mouth and down the back of her throat.

 
“The good news was I could see her larynx (voice box) so I believed I would be successful at placing a thin, plastic tube into her airway,” said Dr. Lusk.
A minute after delivering the baby’s head, an airway had been established. The tube was suctioned free of amniotic fluid and Dr. Anderson-Berry began hand ventilation until the baby could be hooked up to the ventilator machine.

 
“We were very fortunate to be able to establish an airway so quickly,” said Dr. Lusk. “We had several backup techniques with rigid and flexible scopes available if the initial intubation was not successful.”

 
Dr. Abdessalam was on standby in case intubation proved difficult, and an emergency tracheotomy (a hole made in the windpipe) would need to be performed. He also assisted in stabilizing the newborn.

 
Once physicians were confident that the baby’s breathing tube was secure and her heart rate stable, the medical team delivered Haylee completely, cut her umbilical cord and rushed her to a second operating room. Here Dr. Anderson-Berry did a complete physical exam of Haylee.

 
Before Haylee was safely transferred to the Newborn Intensive Care Unit (NICU), the doctors obtained a CT scan to better visualize the facial mass.
“It was determined that the mass was a teratoma, benign tumor that was relatively small,” said Dr. Anderson-Berry. This type of tumors often has teeth, bone, skin or even hair inside. “It’s essentially an error in development,” she said.

 
Successful Outcome
On Aug. 5, little Haylee went back into the operating room for a second time. Dr. Lusk and Jason Miller, MD, plastic and reconstructive surgeon at The Nebraska Medical Center, completely removed the mass.

 
“The mass came out very cleanly,” said Dr. Lusk. “However, because of the positioning of the mass, Haylee is left with a large cleft palette.” Another surgery at nine to 12 months of age will be required to reconstruct the palette.

“We are very blessed with the outcome,” said Haylee’s mother, Megan. “The first time I heard her cry was after she had her breathing tube removed on Aug. 9 and that was so thrilling to hear.”

 
Dr. Anderson-Berry does not predict any significant problems for Haylee.

“Because of her cleft palette, sucking is more difficult, so our goal now is to get her to nipple her feedings so she can be taken off the feeding tube.”
Once that happens, little Haylee can go home.

The following were the key physicians on the EXIT delivery team:
Maternal-Fetal Medicine – Dr. Teresa Berg, Dr. Serena Wu, Dr. Carl Smith
Anesthesia – Dr. Sheila Ellis, Dr. Joseph Kalamaja, Dr. Shawna Freeman-Ngau
Neonatology – Dr. Ann Anderson-Berry
Pediatric ENT (ear, nose and throat) – Dr. Rodney Lusk
Pediatric Surgery – Dr. Shahab Abdessalam, Dr. Robert Cusick

With a reputation for excellence, innovation and extraordinary patient care, The Nebraska Medical Center has earned J.D. Power and Associates’ Hospital of Distinction award for inpatient services for four consecutive years. It also received the 2009 Consumer Choice Award, a mark of patient satisfaction as selected by healthcare consumers and has achieved Magnet recognition status for nursing excellence, Thomson Reuters 100 Top Hospitals Performance Improvement Leader recognition, as well as the Award of Progress from the state of Nebraska’s Edgerton Quality Awards Program. As the teaching hospital for the University of Nebraska Medical Center, this 624 licensed bed academic medical center has an international reputation for providing solid organ and bone marrow transplantation services and is well known nationally and regionally for its oncology, neurology and cardiology programs. The Nebraska Medical Center can be found online at www.nebraskamed.com

Omaha, Neb – Ann Connealy lived her first 50 years without ever being a patient in a hospital. Her run of good luck ended with a diagnosis of cancer of the appendix in 2007. After an appendectomy and six rounds of chemotherapy, she was cautiously optimistic.

Three years later, the Pilger, Neb resident was back in the hospital. Her cancer had returned. But instead of feeling unlucky, Connealy said she felt fortunate to be in Nebraska, when her doctor in Norfolk referred her to Jason Foster, MD, a surgical oncologist at The Nebraska Medical Center who specializes in a new and emerging treatment for abdominal cancer.

“He does not give up,” Connealy said. “He operated on me for more than 12 hours. He did everything.”

Dr. Foster is one of a very small number of surgical oncologists in the United States practicing this approach.

During the operation, Dr. Foster removed all the visible cancer from Connealy’s organs. Then, using a process known as hyperthermic intraperitoneal chemotherapy (HIPEC) or hot chemo, he and the surgical team bathed her organs in a heated solution of chemotherapy to kill the microscopic cancer cells which almost certainly still remained.

“With this approach, we do the surgery and the chemo all at once,” Dr. Foster explained. “It complements the IV chemotherapy she received and allows us to treat the organ surfaces and inner abdominal walls which could have been exposed to the cancer.

The typical course or conventional approach for a patient like Connealy would be multiple surgeries to remove some of the tumors, followed by multiple rounds of chemotherapy each time her disease recured. Unfortunately, 65-80 percent of abdominal cancers like Conealy’s will recur, Dr. Foster said. And in Conealy’s case her tumor did recur 2-3 years after traditional therapy.

The hot chemo (HIPEC) approach is well-suited for treating cancer in the abdominal cavity since the organs and inner abdominal wall are at risk, and the cancer cells can spread from one area to another.

After removing the visible tumors, surgeons close the abdomen, and fill the abdominal cavity with the heated chemo and bathe all the organs with the solution.

The cancer-fighting benefit does not just come from the high dose chemo solution itself.

“Cancer cells do not dissipate heat well and can be killed by heat; we know that from research,” Dr. Foster said. “So for this to work, we had to find a temperature warm enough to kill the cancer cells, but not too hot to damage the healthy tissue inside the body.”

That temperature is 42 degrees Celsius, or 108 degrees Fahrenheit.

Hot chemo treatments can be used for some patients with ovarian and colorectal cancer, and is the primary treatment for cancer of the appendix and peritoneal mesothelioma.

“The exact treatment is different for each patient and depends on the type of cancer they have,” Dr. Foster said. “But the concept is generally the same.”

Patients who are candidates for hot chemo treatment are facing very steep odds. They are typically stage four cancer patients and in many cases have already experienced surgery and chemotherapy.

“Ideally we would like to see all patients at the time of diagnosis to avoid multiple surgeries but often patients are not aware of this option until they relapse”, said Dr Foster.

For some people, the treatment has the potential to save a life. In others, it is used to make the remaining months or years more tolerable.

“In some cases, it’s a quality of life issue,” said Dr. Foster. “A patient may be looking at spending what time they have left undergoing traditional chemo and the side effects that sometimes come with it. For the

right person, this can be a viable alternative; improving their quality of life

and potentially extending their survival.

  “There is more research to be done,” Dr. Foster said. “Can this approach work in other parts of the body? Maybe.”

Ann Connealy’s outlook is positive. Her surgery behind her, her future will hold at least a few traditional chemotherapy treatments.

“It’s just to be sure there’s nothing else still there,” she said. “But I have a good gut feeling this time.”

With a reputation for excellence, innovation and extraordinary patient care, The Nebraska Medical Center has earned J.D. Power and Associates’ Hospital of Distinction award for inpatient services for four consecutive years. It also received the 2009 Consumer Choice Award, a mark of patient satisfaction as selected by healthcare consumers and has achieved Magnet recognition status for nursing excellence, Thomson Reuters 100 Top Hospitals Performance Improvement Leader recognition, as well as the Award of Progress from the state of Nebraska’s Edgerton Quality Awards Program. As the teaching hospital for the University of Nebraska Medical Center, this 624 licensed bed academic medical center has an international reputation for providing solid organ and bone marrow transplantation services and is well known nationally and regionally for its oncology, neurology and cardiology programs. The Nebraska Medical Center can be found online at

www.nebraskamed.com

For Release:  September 17, 2010
Contact: Paul Baltes (402) 552-2282

The Nebraska Medical Center first to offer minimally invasive option
Omaha, Neb – It’s a space-age treatment for a life-threatening condition. For the first time, it’s available in Nebraska. Surgeons at The Nebraska Medical Center are now using robotic surgery techniques to remove cancerous tumors from patients’ throats.

 
Medical center surgeons performed the first such case in late August. The patient, Vickie Hebing of Council Bluffs, IA went looking for this specific treatment.

 
“After I was diagnosed, my daughter did a lot of research on the Internet,” Hebing recalled. “It sounded a lot better than chemotherapy and radiation, and certainly better than open surgery.”

 
Hebing’s primary care doctor discovered the tumor, a squamous cell carcinoma on her right tonsil during a routine check-up. From there, things moved quickly.

 
“I was referred to the med center,” Hebing said. “I knew I could have radiation and chemotherapy, but we found out about this robotic surgery. I wanted surgery and when I found out they could do it here, I knew this was the place.”

 
Hebing met with Russell Smith, MD, a head and neck surgical oncologist at The Nebraska Medical Center and associate professor at The University of Nebraska Medical Center. They decided robotic surgery would give Hebing a great option for recovering quickly and beating the cancer.

 
Robotic surgery for tumors like Hebing’s was approved by the FDA earlier this year.

 
“Using the robotic approach allowed us to incorporate surgery in a way we could not before,” explained Dr. Smith. “Had we seen Vickie before this was available, we would have recommended chemotherapy and radiation as her best primary treatment. And we did give her that treatment option in this case.”

An open surgical option exists as well, but it is a much more invasive treatment that could potentiallybring with it more complications.

 
“In some cases to surgically remove a tumor like Mrs. Hebing’s, instead of working through the mouth, we would have had to potentially do a surgery that splits the lip and breaks the jaw bone so that we could get to the tumor to remove it,” Dr. Smith said. “That can have a very negative impact on swallowing and speech function.”

The robotic surgery has a much quicker recovery, two to three days in the hospital; compared to the open surgery where a patient can spend a week or more in the hospital.

 
During the operation, Dr. Smith sat at the controls of the DaVinci Surgical Robot system. About five feet to his right, Hebing lay on the operating room table. Two visual ports transmitted the picture from the operating table to the control console, giving Dr. Smith a three-dimensional view of the anatomy of Hebing’s throat. The surgeon’s hands controlled the two instruments that removed the tumor. A surgical assistant sat next to Hebing during the entire operation providing another set of hands.
“That allows us to have a four-handed surgery inside someone’s mouth,” said Dr. Smith. “You couldn’t do that with traditional techniques.”

Assistant surgeon Robert Lindau, MD helps Dr. Smith during Vickie Hebing’s surgery

Hebing will still require radiation therapy. She expects to begin in the coming weeks.

 
“Our goal is, having done the surgery, we may be able to eliminate chemotherapy from her treatment and use a lower dose of radiation,” Dr. Smith said. “So hopefully, the side effects of those treatments will be lessened.” “I think I was probably a difficult case,” Hebing said. “But it went as well as I could have hoped. I think it’s a really favorable outlook at this point.”

 
With a reputation for excellence, innovation and extraordinary patient care, The Nebraska Medical Center has earned J.D. Power and Associates’ Hospital of Distinction award for inpatient services for four consecutive years. It also received the 2009 Consumer Choice Award, a mark of patient satisfaction as selected by healthcare consumers and has achieved Magnet recognition status for nursing excellence, Thomson Reuters 100 Top Hospitals Performance Improvement Leader recognition, as well as the Award of Progress from the state of Nebraska’s Edgerton Quality Awards Program. As the teaching hospital for the University of Nebraska Medical Center, this 624 licensed bed academic medical center has an international reputation for providing solid organ and bone marrow transplantation services and is well known nationally and regionally for its oncology, neurology and cardiology programs. The Nebraska Medical Center can be found online at www.nebraskamed.com

Omaha, Neb – For the second year in a row, The Nebraska Medical Center has earned the American Heart Association/American Stroke Association’s Get With The Guidelines® Stroke Gold Plus Achievement Award.

 
Get With The Guidelines is a hospital-based quality-improvement program designed to ensure hospitals consistently care for cardiac and stroke patients following the most up-to-date guidelines and recommendations. The program addresses coronary artery disease, heart failure and stroke. Currently more than 1,400 hospitals participate in the program.

 
Stroke is the leading cause of disability in the United States and the third leading cause of death.

 
The stroke team at The Nebraska Medical Center is poised to help patients seven days a week, 24 hours a day. The goal is to treat patients as soon as possible after the onset of stroke symptoms.

 
“Reducing stroke’s devastating effects and preventing it can only be achieved with the right dedication, staffing, organization, and treatment,” said Pierre Fayad, M.D., Director of the Stroke Center at The Nebraska Medical Center and Reynolds Centennial Professor & Chairman of Neurological Sciences at UNMC. “This recognition for our stroke center reassures our patients, their families and our community, that our staff and dedication allow us to deliver such complex care around the clock, and achieve similar results to the very best centers around the country.

 
To receive the award, The Nebraska Medical Center achieved 85 percent or higher adherence to all Get With The Guidelines-Stroke Performance Achievement indicators for two or more consecutive 12-month intervals and achieved 75 percent or higher compliance with six of 10 Get
With The Guidelines-Stroke Quality Measures, which are reporting initiatives to measure quality of care.

“This award is another demonstration of The Nebraska Medical Center’s commitment to being among the top hospitals in the country for providing the best proven and effective stroke care,” said Dr. Fayad. “We need to continue focusing on providing care according to the latest reliable scientific findings, and adapting them as quickly and efficiently as possible to treat stroke patients with evidence-based strategies.”

 
The Nebraska Medical Center and the other Get With The Guidelines® recipient hospitals will be recognized in a special advertisement in the upcoming “Best Hospitals” issue of US News and World Report.

 
“The American Heart Association is pleased to recognize its top Get With The Guidelines participants,” said. Lee Schwamm, M.D., national chairman of the Get With The Guidelines steering committee, associate professor of neurology at Harvard Medical School and Vice Chairman of Neurology at Massachusetts General Hospital. “Healthcare providers who use Get With The Guidelines are armed with the latest evidence-based guidelines and immediate access to clinical decision support, using a set of tools that have been shown to improve delivery of evidence-based care. The goal of this initiative is to improve the quality of life and help reduce deaths and disability among patients with heart disease and stroke.”

 
Schwamm added, “Published scientific studies are providing us with more and more evidence that Get With The Guidelines works. Patients are getting the right care they need when they need it. That’s resulting in improved survival.”

 
About The Nebraska Medical Center
With a reputation for excellence, innovation and extraordinary patient care, The Nebraska Medical Center has earned J.D. Power and Associates’ Hospital of Distinction award for inpatient services for four consecutive years. It is a US News & World Report 2008 “Best Hospital” for Cancer, Neurology and Neurosurgery. It also received the 2009 Consumer Choice Award, a mark of patient satisfaction as selected by healthcare consumers and has achieved Magnet recognition status for nursing excellence, Thomson Reuters 100 Top Hospitals Performance Improvement Leader recognition, as well as the Award of Progress from the state of Nebraska’s Edgerton Quality Awards Program. As the teaching hospital for the University of Nebraska Medical Center, this 624 licensed bed academic medical center has an international reputation for providing solid organ and bone marrow transplantation services and is well known nationally and regionally for its oncology, neurology and cardiology programs. The Nebraska Medical Center can be found online at www.nebraskamed.com

About Get With The Guidelines
Get With The Guidelines® is the American Heart Association/American Stroke Association’s hospital-based quality improvement program that empowers healthcare teams to save lives and reduce healthcare costs by helping hospitals follow evidence-based guidelines and recommendations. For more information, visit heart.org/quality.

An Omaha man is recovering well today after undergoing an historic operation at The Nebraska Medical Center on May 18. David Gildea was the first patient at the medical center to receive a combined heart and kidney transplant.

 
“This is an exciting milestone for our transplant program,” said John Um, M.D., heart transplant surgeon at The Nebraska Medical Center. “This is a vital treatment option for patients in our region who have advanced heart failure and renal disease.”

 
Before transplant, Gildea had end-stage heart disease and his kidneys were barely functioning, requiring daily dialysis.

 
“Medically speaking, he was about as sick as a person can get,” said Clifford Miles, M.D., nephrologist at The Nebraska Medical Center.

 
Even at a medical center which routinely handles complex cases requiring multi-disciplinary care, Gildea’s case necessitated a remarkable amount of highly specialized expertise; bringing together experts from five different medical specialties.

 
“Very few heart transplant programs in the world will perform a multi-organ transplant for an extremely sick patient, said Eugenia Raichlin, M.D., cardiologist at The Nebraska Medical Center. “The care for this patient required the skills of an experienced and sophisticated team of transplant surgeons, hematologists and renal and cardiovascular disease specialists.”
Dr. Raichlin adds that advanced renal disease in the presence of severe heart failure has traditionally been a reason to exclude heart failure patients from a heart transplant. “Patients in this particular condition have faced insurmountable odds,” said Dr. Raichlin. “With simultaneous heart and kidney transplantation, we are able to offer more of the high-risk heart disease patients a reason for hope.”

 
Surgery began at 5:30 p.m. on Tues., May 18 and continued until 1:00 a.m. the next morning. The patient’s heart was transplanted first, followed immediately by the kidney.

 
“Once we were confident that the new heart was working well, we knew the patient could tolerate the kidney transplant,” said Dr. Um.

 
An Uncommon Operation
A combined heart and kidney transplant is not a common procedure. Data from the United Network of Organ Sharing (UNOS) shows there were only a total of 60 combined heart and kidney transplants performed in the nation last year in comparison to 362 combined liver and kidney transplants and 16,831 isolated kidney transplants.

 
“This is not a technically difficult operation,” said Michael Morris, M.D., kidney transplant surgeon at The Nebraska Medical Center. “The reason these operations are relatively rare is because there are not many robust heart transplant programs in the nation. The fact that The Nebraska Medical Center can now perform these transplants is a huge credit to the growing success of our heart transplant program.”

 
The Nebraska Medical Center transplant team anticipates there will be a growing need for combined heart and kidney transplants. According to Dr. Miles, many patients who suffer from long-term heart failure also have significant renal disease. The two problems often co-exist because a weakened heart cannot pump blood sufficiently to the kidneys or because the kidneys have been damaged by other cardiovascular conditions such as hypertension or diabetes.

 
At age 61, David Gildea says he had been in great shape until recently, eating well and exercising every day since his teenage years.

 
“For more than forty years, I ran about two to three miles a day and lifted weights,” said Gildea. But one day, about a year ago, he says he couldn’t find the energy to run. “I was alarmed,” he said. He quickly got worse. “I had a hard time doing anything. It would take me a few hours to get dressed every morning.”

 
“He was exhausted just walking from the bedroom to the living room,” said Gildea’s girlfriend, Karen Rech. “It was to the point that every time he moved, I was in constant fear of losing him.”

 
A biopsy revealed amyloid (pronounced AM’-i-loyd) protein deposits in Gildea’s kidneys and heart. His physician suspected Gildea had amyloidosis, a rare blood disease affecting only eight of every one million people. People who have the disease have abnormal deposits of amyloid in their tissue or organs. Harm results when the deposits cause the organs to malfunction. The disease is rapidly disabling and life-threatening. In Gildea’s case, his heart and kidneys were affected.

 
“I had never heard of amyloidosis,” said Gildea. “I was told it was a very rare disease, and that most people don’t survive it.”

 
Dr. Raichlin had trained at the Mayo Clinic in Rochester, Minn., a center which specializes in amyloidosis, and knew about an aggressive treatment for the disease – a multi-organ transplant followed by a blood stem cell transplant.

 
“I knew our medical center had the expertise to help this patient,” said Dr. Raichlin. “Plus, we had to act quickly; David didn’t have a lot of time. I suggested this innovative treatment.”

 
Immediately following his heart and kidney transplant, Gildea said he felt like a new person. “I wasn’t short of breath when I went for a walk. I had stamina again.” His friends said they also noticed he could think more clearly.

 
Another Transplant to Come
As amyloidosis is normally a fatal disease, Gildea will require high-dose chemotherapy followed by an autologous blood stem cell transplant to halt the progression of the disease towards his transplanted organs. Edward Faber Jr., DO, MS, hematopoietic stem cell transplant specialist at The Nebraska Medical Center plans to prepare Gildea for this treatment over the next three months.

 
“Many patients with amyloidosis have advanced organ disease or are too old to benefit from this type of intensive treatment,” said Dr. Faber. “Usually, heart and kidney failure from amyloidosis are contraindications to this type of therapy, but Gildea is now eligible for the treatment due to the successful combined heart and kidney transplant.”

 
Gildea will receive an autologous blood stem cell transplant, which means that he will have his own blood stem cells collected and stored in liquid nitrogen. He then will receive high-dose chemotherapy to damage the blood stem cells which are causing the amyloidosis. After chemotherapy, Gildea’s stored blood stem cells will be reintroduced to replace the damaged blood stem cells.

 
Gildea Continues Positive Attitude
“Although I was deeply concerned when I was first diagnosed, a positive attitude has gotten me through the tough times,” said Gildea. “As the father of severely handicapped 29 year old twins, I have had a lot of hard days in my life. I know I still have a long road ahead with my treatment. My goal has always been to not complain.”

 
Before he went into the transplant operation, Gildea says he was asked, “How can you be so calm?” His response, “I know the outcome.” This is the kind of attitude that will help Gildea through the next steps of his treatment.

Published Feb 23, 2010
Published Tuesday February 23, 2010

Dr. Dave Mercer transplants a new liver into Thomas Martin of Sedalia, Mo., at the Nebraska Medical Center. Helping him are scrub tech Erin McLaughlin at left and medical student Mandy Byers at right. Music is playing from an iPod. Mercer likes to keep the atmosphere light during surgeries. At one point a scrub tech called him “sir” and he replied: “Sir? What’s with sir? I never get sir.”

By Rick Ruggles
World-Herald staff writer

 
ALYSSA SCHUKAR/THE WORLD-HERALD

Dr. Dave Mercer transplants a new liver into Thomas Martin of Sedalia, Mo., at the Nebraska Medical Center. Helping him are scrub tech Erin McLaughlin at left and medical student Mandy Byers at right. Music is playing from an iPod. Mercer likes to keep the atmosphere light during surgeries. At one point a scrub tech called him “sir” and he replied: “Sir? What’s with sir? I never get sir.”

Dr. Dave Mercer took a final glance at his BlackBerry and walked through the operating room doors.

For the next few hours, he would hold a man’s life — and liver — in his hands.

As a surgeon who performs transplants of the small intestine, liver, pancreas and kidney at the Nebraska Medical Center, Mercer had been summoned this afternoon to the operating room. A liver was available. A patient was ready.

For the moment, though, the talk in the operating room revolved around Mercer’s music.

“Did you bring your iPod?” a member of the operating team asked him.

“No,” Mercer said.

“Darn it.”

“I didn’t think we were going to be transplanting today,” Mercer said.

Mercer, 39, defies the stereotype of the brooding surgeon, perpetually irritated at his subordinates. Mercer likes to keep the atmosphere light. His orders come out more as questions, with a polite lilt. He’s Canada cool — he grew up just outside Edmonton, Alberta.

Thomas Martin lay on the operating room table, thoroughly anesthetized and with a ventilator tube down his throat. He and his wife, Penny, had rushed by car from Sedalia, Mo., to the med center when they learned this morning that a liver was available.

It had been a rough year for Martin, 52. His feet and stomach swelled with fluid because his liver had ceased breaking down foods and cleaning his blood. Sometimes over the past year he needed a needle in his belly to drain the fluid.

Dr. Lori Kautzman, a transplant-surgeon-in-training, would help Mercer on this operation. Already her value had been evident. She had her iPod, and it would provide the music through the surgery.

Placed on a platform just above and behind the operating area, the iPod began to quietly rumble out rap music, then a tune by Aussie rockers AC/DC. The anesthesiologist, Dr. Michael Fee, said AC/DC was more like it.

Nurses bathed Martin’s chest and stomach in yellow-orange iodine to sterilize the skin. They covered his head and body in blue drapes.

Mercer trimmed away part of the drapes to expose Martin’s stomach. Mercer tapped the stomach with his hands, then with his fingers. He figured this surgery would take from four to six hours.

“Everybody ready to go?” Mercer asked.

At 4:05 p.m., the left-handed Mercer took a scalpel and lined the area on the stomach that he would open. He handed the scalpel to the scrub technician and took an electrocautery device, which cuts away tissue with an electrical current. A bit of smoke rose from Martin’s stomach, and a dull smell of smoke and burning skin pervaded the air.

It took only seven minutes to open the stomach for a look at the liver. The surgical team suctioned 1½ gallons of fluid from the stomach.

A woman brought in a cooler containing Martin’s new liver. No information was divulged about its origins.

As Mercer cut, blood squirted on his gloves and then onto the front of his blue surgical gown.

The iPod seemed stuck for a moment. “Is that part of the song?” Mercer asked.

He had opened a large enough area for metal retracting devices to be connected to the abdomen. The abdominal wall was pulled back to leave a large cavity from which Mercer could remove the liver and put in the new one.

Mercer and Kautzman leaned over the stomach, peered in and began to tie off veins with silk thread so they wouldn’t gush blood. Mandy Byers, a third-year med student, also stood at Martin’s side.

“Never panic when something bleeds. When you panic, that’s when you jack things up,” Mercer said to Kautzman and Byers from the other side of the operating table.

“There’s an old saying — you operate slowly to finish quickly.”

Mercer asked that the music be turned up “just a teeny bit.” The Beastie Boys came through more clearly, suggesting that you fight for the right to party.

Mercer remembers the day he decided to become a physician. A doctor showed up at his third-grade class with a stethoscope. Mercer put it on and listened to people breathe. “That was the exact moment,” he said a few weeks ago.

He earned his medical degree and a Ph.D. at the University of Alberta, then became a fellow in surgical transplantation at the Nebraska Medical Center early last decade.

He joined the University of Alberta’s surgery department in 2004 but returned to the Nebraska Medical Center two years later. It’s a superb institution for transplantation, he said. More small intestine transplants are done there than anywhere in the country, he said, and no institution in a six-state region does more liver transplants.

He estimated that he does 30 transplants a year and 200 additional surgeries annually, typically fixing intestinal problems.

In a brief meeting with Mercer an hour and 45 minutes before the surgery, Martin talked about his extensive guitar collection.

“That’s pretty hip of you,” Mercer said. “Cool.”

The surgeon owns two guitars but doesn’t claim to be much of a player. He has a Kiss mouse pad in his office.

Mercer, who is married and has three young children, is tall and lean and plays men’s league hockey once a week. He often doesn’t tuck in his shirt. He talks rapidly and likes to laugh.

He believes it’s wise to never be too optimistic about a surgery. It’s when you think it went perfectly that they’re calling you back to the operating room at 2 a.m. because of complications, he said.

Nevertheless, he’s not the kind to get uptight and figures everyone performs better when they’re relaxed.

By 5:10 p.m., Mercer had snipped most of the connections that held Martin’s liver in place. He made sure the donor organ was available.

“OK,” he said. “I’m gonna cut the liver out.” Mercer made some more snips.

“Do we have some better scissors? These do kind of suck,” he said.

He had cut the bile duct, veins and artery. Out came the diseased liver, rough and hard, almost as big as a football. He held it in his right hand and placed it in a blue bowl.

He poured several small buckets of saline into the cavern where Martin’s liver had been. Kautzman used a suction device to drain it out. The saline washes away blood and helps the surgeon see where there is new bleeding.

“I’ve got to get the clamp on the kidney and then pull the kidney out of the way,” Mercer told Kautzman and Byers. “And we are going to need the liver up in about 20 seconds.”

He told Byers to hold the new liver, one hand under it, one on top. They placed it inside the hole and began threading it in with what is virtually fishing line.

The old liver weighed about 3 pounds and 5 ounces, the new one just a bit less.

Mercer was quiet and serious as he sewed for the next 25 minutes. Bon Jovi sang on the iPod: “It’s now or never. I ain’t gonna live forever.”

Erin McLaughlin, the scrub tech who had been handing Mercer the tools, turned that job over to Molly Gunter.

“Dr. Mercer, you’re getting Molly now,” McLaughlin said.

“Oh, thank God,” Mercer said facetiously.

Now it was time to unclamp a key vein into the liver, meaning cold preservative solution and waste products stored inside the organ would flush into the heart. This could overwhelm the heart and shut it down.

“You guys have the paddle in the room?” Mercer asked, referring to the paddles that could jolt the heart back to life. “Four minutes from unclamping. Four or five minutes.”

Then Mercer said again: “Paddles are up?”

“Yep,” said Gunter.

“OK. Is everybody ready?” He unclamped the new liver about 6 p.m. The heart kept pounding and the liver began to fill with blood. It pulsed like a little animal with the beating of the heart.

“That is nice,” Mercer said. “And we’re not bleeding very much.”

He poured a bucket of solution in and Kautzman suctioned it out. The blood flow made the liver turn from brownish to pinkish.

“That means the liver is happy,” the surgeon said.

The atmosphere lightened. “Is that ‘Funky Cold Medina’?” Mercer asked, referring to the absurd tune from the 1980s.

The heart’s pounding was evident against the diaphragm inside the open cavity. Mercer asked for a bucket of saline and Gunter handed it to him.

“Will you take that back?” he said of the bucket after he had emptied it into the hole in Martin’s stomach.

“Sorry, sir,” Gunter said.

“No worries. Sir? What’s with sir?” Mercer said. “I never get sir.”

He trimmed off the gallbladder, which looked like a long, fat minnow. Mercer’s favorite Pearl Jam song played, and he commented on it.

They took the retractors off and Kautzman started stitching up the huge wound. With the drying iodine turning light brown, the skin and cavern in Martin’s stomach looked a bit like a half-eaten Thanksgiving turkey.

Mercer and Kautzman sewed, and then Kautzman stapled the remaining flap of skin.

“When a case goes by quickly, I think, ‘OK, did we do everything?’’’ Mercer said. And this had gone quickly. They finished at 7:04 p.m. — just less than a three-hour transplant.

“Dr. Kautzman, thank you very much,” Mercer said. “A pleasure.”

He headed toward the waiting room with a spot of blood on his right knee from the surgery.

Lots of bad things could still happen, some involving blood clotting or blood leaking, but the surgery had gone smoothly.

He walked toward Martin’s wife.

“It went exactly as we would hope,” he told her. “We put the new liver in and sewed it up and it looks like it belongs there.”

Tears came to her eyes.

He told her that things could go awry. He said he would remain “paranoid” for a while and suggested they “hope for the best and plan for the worst.” He patted her on the knee.

“It’s surreal, isn’t it?” he said to her.

“Yeah,” she said.

Mercer walked out of the waiting room. He looked forward to watching the Winter Olympics on TV with his family.

Contact the writer:

444-1123, rick.ruggles@owh.com

“The answer was here, at The Nebraska Medical Center.  We are amazed with the advanced level of medicine and modern technology.  We thank God for his mercy and the doctors who took excellent care of Jana,” praised Mr. Mesfer Al Yami. 
The Al Yami family courageously flew half way across the world from the Kingdom of Saudi Arabia with poignant anticipation and high hopes to save the life of their beloved baby, Jana.  The transplant team and the International Healthcare Services (IHS) at the Nebraska Medical Center/the University of Nebraska Medical Center (TNMC/UNMC) held their hope for a successful treatment and triumphantly delivered.

 
Jana Al Yami, a 19-month baby from Riyadh, Saudi Arabia was born with a neuronal dysplasia causing intestinal failure that left her dependent upon total parenteral nutrition (TPN – tube feeding).  She then developed life threatening complications related to TPN.  For more than a year, the family relentlessly explored every option to save baby Jan’s life. Through IHS’s international relationships in Saudi Arabia, the Al Yami family learned of TNMC/UNMC’s transplantation services and excellence.  IHS assisted the family in making all the arrangements for the family to travel to Omaha for the expert medical treatment that couldn’t be offered at home. 

 
Jana is the 6th daughter of Mr.  & Mrs. Mesfer Al Yami. Jana underwent an intestinal transplant in November 2009.  Although Jana is still an outpatient staying in the Omaha area, she is being prepared by the Transplant Team to go home to be with her sisters and brothers who miss her very much.

 
 The Al Yami family credits Jana’s recovery to the staff who cared for her. “At the Nebraska Medical Center, we found a loving family that never spared any effort to make our stay as comfortable as possible. The humanity and emotional support have been unbelievable. We never felt like we were strangers among this group of friends and we are so happy that we came here!” 

 
Debb Andersen, Manager of the Liver/Intestinal Transplant Program states, “The transplant program has always embraced patients from other countries. The hospital community and the local community have also embraced our international patients by taking the extra time to communicate with them, respect their cultural diversity, provide interpretation and just to be understanding of what they are going through so far away from home. We have had the opportunity to learn so much about their cultures and in turn they have the chance to see our culture first hand, too. When we do this, we find that the rest of the world is not so large and different than us after all”.
Intestinal transplants have become an accepted treatment option for people with intestinal failure who also experience life-threatening complications related to total parenteral nutrition (TPN).  TNMC/UNMC program is one of the largest intestinal transplant programs in the world. The United Network for Organ Sharing, the department of Health and Human Services that oversees organ allocation, allows a program of up to 5% of their volume for the transplantation of non-US citizens.  

 
 The International Healthcare Department was created to support families like Jana’s during their lengthy medical stays in the Omaha.  “With the help of the dedicated staff at TNMC/UNMC, IHS has had the privilege to arrange for the treatment of hundreds of patients who choose TNMC/UNMC for treatment of complicated cases. Our international team of experts provides patients with all their needs – setting up appointments, assistance with billing, banking, visa, housing, interpretations, special meals, cultural and social needs, site seeing, and other concierge-type services”, said Nizar Mamdani, Executive Director of IHS.  “I have personally experienced how difficult it is to be thousands of miles away from home while receiving care. Receiving medical treatment for transplant patients can be both very exhausting and frustrating to the family as well as the patient. It is our mission in the IHS department to help ease all of these extraneous burdens that are inherent in any hospital care”.

 
Mr. Al Yami also expressed his appreciation by “thanking the authorities in Saudi Arabia who supported us through this difficult experience and gave us this life changing opportunity”.

 
 For any assistance with traveling patients and families, call International  Healthcare Services at 1-402-559-3656.

The findings appear in the March 1 issue of the Journal of Immunology.

“This could be a revolutionary means for Parkinson’s disease therapeutics,” said Howard Gendelman, M.D., chairman of the department of pharmacology and experimental neuroscience (PEN), who partnered with R. Lee Mosley, Ph.D., to lead the research. “It has been a long journey representing more than 10 years of hard work by our research team.”

UNMC researchers reversed the neurodegenerative effects of alpha synuclein by changing immune responses to it.

In mice with an experimental form of Parkinson’s disease, researchers found that the vaccine enabled T cells to migrate to the damaged area of the brain and triggered a neuroprotective response that reduced disease-linked reactions in the brain.

T cells are white blood cells that are key to immune response. They act like soldiers who search out and destroy the targeted invaders.

Other contributors:
Graduate students, Ashley Reynolds, Ph.D., David Stone and Jessica Hutter, contributed to the study.
 
 
Additional work is needed to determine how to safely translate the study results into a therapy for humans, Dr. Gendelman said.

Human studies are being conducted at the University of Alabama-Birmingham and within the next month at UNMC to determine if the immune deficits seen in mice also are present in humans with Parkinson’s disease. Such studies are required before vaccine trials are performed in humans, Dr. Gendelman said.

“Early results are encouraging,” said Dr. Mosley, an associate professor in the PEN department, who noted that the research could open new doors for treatment of Parkinson’s and other neurodegenerative disorders.

UNMC’s technology transfer company, UNeMed, has filed a patent application on the vaccine and soon will talk to commercial partners about bringing the vaccine to the clinical setting.

 
 
 
Date Published: Tuesday, March 2, 2010 

Chad Kimpel said it with a smile.

“I died. Multiple times.”

The 41 year old father of three from Farragut, IA first came to The Nebraska Medical Center on July 1, 2009. That was the day of the heart attack.

“My heart stopped before they got me on the life flight chopper to get here,” Kimpel recalled. “They shocked me and brought me back, but the doctor said I died several more times on the flight here. They kept bringing me back.”

Once at the medical center, Kimpel was diagnosed with heart failure. Treatments had him in and out of the hospital several times in the following months. When he returned to the medical center in January, his heart was working at just a fraction of its potential and his remaining arteries blocked. Kimpel’s cardiologists decided to place a stent in his artery.

A new type of heart pump allowed doctors to place the stents while Kimpel’s damaged heart continued to work. Instead of preparing for major heart surgery, Kimpel’s doctors placed the Impella 2.5 in his heart inside a cardiac catheterization lab at The Nebraska Medical Center. He was sedated, but awake during the procedure.

“The Impella acts almost like an artificial heart,” explained Ed O’Leary, MD, cardiologist at The Nebraska Medical Center. “Without this machine, his blood pressure would drop to dangerously low levels and he might not make it through the procedure.”

Dr. O’Leary inserted the Impella pump through the femoral artery in Kimpel’s left leg. He then guided it through his body into his heart. Once in place, the straw-sized pump assisted Kimpel’s heart by pulling blood out of the left ventricle and into the aorta. By keeping his blood flowing, the cardiology team was able to keep Kimpel’s blood pressure stable while placing the stents in his artery. Once the stents were placed, the Impella pump was removed and Kimpel’s heart was pumping blood through a newly cleared artery.

“Dr. O’Leary told me it was as close as I could get to having a new artery,” Kimpel said.

The Impella is designed to help the heart for short periods of time.

“There are machines that do the work of the heart,” Dr. O’Leary said. “Those bypass machines are used during open heart surgery. During those surgeries, the heart is stopped and the bypass machine does the work of the heart. Bypass surgery would have been very risky for Chad. With as weak as his heart was, it might have been very difficult to get his heart re-started after surgery.”

Instead of a long and risky open heart surgery, Kimpel’s angioplasty took only two hours. The Impella carried part of his heart’s workload for much of that time.

After the procedure, Kimpel was all smiles.

“I feel great,” he said with a laugh. “The technology is amazing. They put this little turbocharger in my heart and I feel great!”

Kimpel will have close follow up care with his cardiology team at the medical center. A carefully designed diet and exercise plan awaits him back home in Iowa.

“I’ve always been in good shape and kind of a health food nut,” he said. “But I’ll have to be extra careful about salt, and about doing too much exercise.”

The Impella was approved by the FDA in June of 2008.

Dr. Ed O’Leary (right) places the Impella 2.5 into the left femoral artery
of angioplasty patient Chad Kimpel

For the second year in a row, The Nebraska Medical Center has received the American Stroke Association’s Get With The GuidelinesSM–Stroke Gold Performance Achievement Award. The award recognizes the medical center’s commitment and success in implementing a higher standard of stroke care by ensuring that stroke patients receive treatment for at least 24 months according to nationally accepted standards and recommendations.

The Nebraska Medical Center will be recognized by the American Stroke Association in an advertisement in the July 21 “America’s Best Hospitals” issue of US News & World Report.

“This accomplishment signifies that The Nebraska Medical Center has consistently committed to and successfully implemented accepted standards, or guidelines, to improve quality patient care,” said Pierre Fayad, M.D., Director of the Stroke Center at The Nebraska Medical Center and Reynolds Centennial Professor & Chairman of Neurological Sciences at UNMC. “Rapid assessment, treatment and intensive acute care is vital for stroke patients to help them gain back as much of their lives as possible and prevent complications.”

View video: watch?v=bSPJ5oJI6to&feature=player_embedded

To receive the Get With The Guidelines-Stroke Gold Performance Achievement Award, The Nebraska Medical Center demonstrated 85 percent adherence in the Get With The Guidelines–Stroke key measures for 24 or more consecutive months. These include aggressive use of medications like tPA, antithrombotics, anticoagulation therapy, DVT prophylaxis, cholesterol-reducing drugs, and smoking cessation.

Dr. Fayad adds that the Get With The Guidelines-Stroke program addresses the important element of time. “With a stroke, time lost is brain lost,” said Dr. Fayad. The Nebraska Medical Center has developed a comprehensive system for rapid diagnosis and treatment of stroke patients admitted through the emergency department or transferred from other hospitals. The medical center ensures the prompt availability and coordination of medical professionals, personnel and equipment 24 hours a day, seven days a week. Highlights of its expertise include: rapid brain and blood vessel imaging; neurologists, neurosurgeons, emergency physicians, radiologists and pharmacists available to conduct acute patient evaluations; and use of clot-busting medications and interventional clot removal techniques when appropriate.

“The American Stroke Association commends The Nebraska Medical Center for its success in implementing standards of care and protocols,” said Lee H. Schwamm, M.D., Chair of the national Get With the Guidelines Steering Committee and Vice-Chair of the Neurology department and director of acute stroke services at Massachusetts General Hospital in Boston. “The full implementation of acute care and secondary prevention recommendations and guidelines is a critical step in saving the lives and improving outcomes of stroke patients.”

Get With The Guidelines–Stroke uses the “teachable moment,” the time soon after a patient has had a stroke, when they are most likely to listen to and follow their healthcare professionals’ guidance. Studies demonstrate that patients who are taught how to manage their risk factors while still in the hospital reduce their risk of a second heart attack or stroke. Through Get With The Guidelines–Stroke, customized patient education materials are made available at the point of discharge, based on patients’ individual risk profiles. The take-away materials are written in an easy-to-understand format and are available in English and Spanish. In addition, the Get With The Guidelines Patient Management Tool* provides access to up-to-date cardiovascular and stroke science at the point of care.

According to the American Stroke Association, each year approximately 795,000 people suffer a stroke — 610,000 are first attacks and 185,000 are recurrent. Every 40 seconds, someone in the United States is suffering from a stroke. This deadly condition accounts for 1 out of every 18 deaths in the United States. The number of acute ischemic stroke patients eligible for treatment is expected to grow over the next decade due to increasing stroke incidence and a large aging population.

The stroke center at The Nebraska Medical Center has also achieved recognitions from other organizations. The Nebraska Medical Center was Nebraska’s first and continues to be Omaha’s only stroke center to receive the “Gold Seal of Approval” from the Joint Commission for its dedication to the prevention and management of stroke. Dr. Fayad was also named the National American Heart Association Physician of the Year in 2009. He serves as the chairman of the American Stroke Association Advisory Committee.