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First Best Hope: Teamwork, Innovation and Efficiency in the Operating Room

Conquest - Fall 2009

By Mary Brolley

Linda Ferrante’s job in the OR command center is rarely dull. As coordinator of clinical care in M. D. Anderson’s Main Building operating rooms, she might be compared to an orchestra conductor.

Her charge is to assemble and schedule the teams that fill the 31 surgical suites and are responsible for nearly 11,000 procedures a year. These are complex surgeries, often requiring more than one team of surgeons, plus anesthesiologists, nurses, mid-level providers and technicians.

Linda Ferrante is coordinator of clinical care in the OR.

“It’s a challenge,” Ferrante says. “You have to know what’s going on everywhere. It’s a puzzle that — when all the pieces fit — is very satisfying.”

After an orientation class 20 years ago, she was instantly “hooked” on surgical nursing. Even in her administrative role, she has a soft spot for fellow surgical nurses, who must quickly become familiar with an ever-evolving slate of technology and equipment.

“With all of the equipment to set up, you’re almost an engineer,” she says.

When she trains new nurses, “I ease them in there. I want them to come back the next day,” she says with a laugh. “Our nurses are wonderful — we have some of the best. The doctors really depend on them.”

Passion, teamwork and technology

Variously described as a village, a city and an anthill, the 31 gleaming operating rooms showcase the skills of hundreds of surgeons and care team members using the latest techniques and equipment.

Despite incredible growth in the importance of chemotherapy and radiation therapy, effective surgery is still of paramount importance, says Raphael Pollock, M.D., Ph.D., head of the Division of Surgery. “For solid tumors, there’s usually no curability without surgical intervention.”

Even so, Pollock champions collaboration among surgeons, radiation oncologists and medical oncologists at the institution. “Our shared mission allows us to act together for patients. The biggest ego in the room is the tumor.”

In Pollock’s view, the Division of Surgery is successful because of a confluence of factors, beginning with surgeons who are “students of the disease,” passionate about learning how best to treat individual patients. Other factors are the use of the latest equipment and techniques in superb facilities and a reliance on collaboration between surgeons in all specialties.

One “student of the disease” is Jean-Nicolas Vauthey, M.D., professor in the Department of Surgical Oncology.

His 15 years of training include a residency in general surgery, a fellowship in surgical oncology and a specialization in the hepatobiliary (liver, gallbladder and bile ducts) system. His extensive knowledge has led him to discoveries in technology, technique and research. He has developed and uses a protective “sling” to hold the liver during surgery, increasing accuracy and reducing the chances of damage to the vena cava (the vein that carries blood to the heart’s right atrium) or rupture of the tumor.

A study, conducted by M. D. Anderson and Mayo
Clinic and published in the Journal of Clinical
Oncology, showed that among nearly 50,000
patients treated for metastatic colorectal disease
between 1998 and 2006, there was a significant
increase in the five-year survival of those who
underwent surgical liver resection compared to
those who did not.

Vauthey also has worked with medical oncology colleagues to track which chemotherapy drugs may do more damage to the liver, reducing a surgery’s success.

If liver surgery, or hepatectomy, is possible, he says, “it offers a chance of long-term remission to patients who might otherwise be guaranteed a poor outcome.”

Since he came to M. D. Anderson, liver surgeries have quadrupled. And a retrospective review published in May 2009 in the Journal of Clinical Oncology showed that liver resection to treat metastatic colorectal cancer has had a dramatic impact on five-year survival rates.

Teamwork pays off for patients

As a head and neck surgeon, Ann Gillenwater, M.D., can’t imagine not working as part of a team. Nearly every time she operates, she navigates a narrow, concentrated space with an anesthesiologist, a plastic surgeon and a dentist. A professor in the Department of Head and Neck Surgery, she recalls a recent example.

“I was sharing a patient’s airway with the anesthesiologist. Dr. Matthew Hanasono (plastic surgeon) was working on the leg to prepare the fibula bone to mold into the jaw. Dr. Jack Martin (dentist) was coming in to bend the reconstruction plate to attach the bone segments. It’s great collaboration,” she says. “It’s like a dance.”

There are 30,000 cases of oral cancer in the United States every year, and 8,000 people die from it. Worldwide, it is one of the 10 most common types of cancer.

Ann Gillenwater's Operating Room 6: It takes a
coordinated team of surgeons, anesthesiologists,
nurses and technicians to perform an intricate
head and neck surgery.

Gillenwater’s willingness to collaborate and contribute to research extends beyond the institution. She is working with Rebecca Richards-Kortum, Ph.D., professor of bioengineering at Rice University, and her students to develop an optical device that can detect and diagnose oral cancer at premalignant and early stages. Once the optical device is perfected, patients could be screened for these deadly cancers by their own dentists during regular checkups.

“If we can catch these oral cancer lesions earlier, treatment is likely to be less disfiguring, less debilitating and more successful,” Gillenwater says.

Plastic surgery ‘remarkably extends what we can do’

If surgery is the cornerstone of cancer treatment, plastic surgery has become an ever-increasing part of the equation.

Many multi-team surgeries in the Main Building OR involve a team of plastic surgeons, Pollock says. “They remarkably extend what we can do.”

“Plastic surgery allows the oncologic surgeon to be aggressive — not concerned about the extent of the operation — to achieve negative margins,” says Geoffrey Robb, M.D., professor and chair of the Department of Plastic Surgery. “We work to restore the physical body contours and to maintain or restore functional elements, such as the restoration of a disfigured or abnormal body part. Often we will need to address loss of function caused by the cancer and treatment.”

Plastic surgeons are experts in microsurgery, using a surgical microscope to aid in the careful removal and reapplication of a patient’s own vascular tissue to help restore normal contours and function.

Robb is proud of his 16 plastic surgeons, the largest and most productive team devoted to cancer in the world. Team members have pioneered a post-mastectomy approach that uses tissue expanders to develop and maintain natural breast contours before and after a patient undergoes radiation therapy.

They also have developed the integration of digital 3-D imaging to construct surgical models of the mid- and lower face that have revolutionized reconstructive strategies. And they have changed the standard of care in the surgical management of esophageal cancer, using leg tissue for throat replacement.

“Function is not a separate but rather an intrinsic goal,” Robb says. “We’ve helped develop a multidisciplinary process that augments the effects of oncologic surgery and allows better overall quality-of-life outcomes for patients.”

‘Combining our brainpower’

The institution has increasingly embraced minimally invasive surgical techniques because of the benefits to patients.

With these techniques, which include endoscopy, image-guided surgeries, robotic surgeries and those using real-time MRIs, patients have decreased blood loss, shorter hospital stays, decreased pain and need for postoperative pain medications, and quicker recoveries and returns to normalcy.

“We’ve quadrupled our minimally invasive cases since 2001,” says Surena Matin, M.D., associate professor in the Department of Urology, who leads MINTOS, or Minimally Invasive and New Technology in Oncologic Surgery, program at
M. D. Anderson. “It’s a growing trend as cancers are detected earlier. The techniques also are used for diagnostic purposes.”

He says that the majority of radical prostatectomies are done with minimally invasive techniques. Other procedures that lend themselves to these techniques are partial nephrectomies (surgical removal of a kidney) and robotic cystectomies (surgical removal of the bladder).

“Of course, there will always be a role for open surgeries because many patients come to us with more advanced disease,” Matin says.

He relishes the chance to work with experts in other specialties and recalls a recent surgery when he asked for assistance from colleague Pedro Ramirez, M.D., associate professor in the Department of Gynecologic Oncology.

“There’s an acknowledgement that it’s hard to keep up, even within your specialty. Working together — combining our brainpower — gives us the chance to interact outside of our silos.”

To have the safest ORs in the world

Raphael Pollock, M.D., Ph.D. (left), with Garrett
Walsh, M.D.

Over the last three years,
M. D. Anderson has begun a comprehensive process to identify best practices in scheduling staff, purchasing and maintaining essential equipment, all while keeping an eye on costs in its operating rooms.

“It’s a focus on the processes necessary to ensure the best outcome for our patients — which instruments we use for a particular procedure, how rooms are prepared,” says Garrett Walsh, M.D., head of Perioperative Enterprise and professor in the Department of Thoracic and Cardiovascular Surgery.

A crusader for efficiency, Walsh instituted a multidisciplinary value analysis team that reviews and assesses all products for safety and compatibility. They carefully consider input from all members of the surgical staff, then evaluate products in a systematic way.

To streamline procedures and eliminate waste and duplication, the team has reviewed and made suggestions about which instruments are to be used for certain surgeries.

“Though an individual surgeon may prefer a certain instrument, the committee has the final decision — and ultimate responsibility — for the outcomes,” he says.

In addition to his administrative and teaching roles, Walsh continues to enjoy his practice as a thoracic surgeon.

“Besides giving me an understanding of the frontline issues, it’s the most relaxing time of my week,” he says. “The only time that things are completely under my control.”

Changing the landscape

The legacy of surgery at the institution is not only within its operating rooms.
M. D. Anderson-trained fellows and residents have gone on to lead surgical programs in hospitals and medical centers around the country, Pollock says.

In the 27 years he has been here, he says, “we have evolved from being the surgical department of a state cancer hospital to one of the best surgical oncology units in the world — all by working as a team.”

Pollock, himself a former fellow at M. D. Anderson, gestures proudly at a list of 154 M. D. Anderson-trained surgeons who’ve made their mark in the field after leaving the institution.

“One-fifth of them are now either chairs of departments of surgery or heads of surgical oncology sections at major medical centers all over the United States and abroad,” he says. “Between 1984 and 2009, we’ve changed the landscape of American surgery.”

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© 2015 The University of Texas MD Anderson Cancer Center