University of Florida College of Medicine Department of Surgery Progress Report

u n i v e r s i t y o f f l o r i d a c o l l e g e o f m e d i c i n e d e pa r t m e n t o f s u r g e r y   |  2014 progress report

milestones in surgery

Patient Michael Gracy is back to doing what he loves — golfing.

TA B L E O F C O N T E N T S

Letter from the Chairman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Section 1: Milestones in Surgery General Surgery

Pancreatic Surgery Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5

Rib Fracture Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7

Thoracic and Cardiovascular Surgery

Aortic Valve Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9

Vascular Surgery and Endovascular Therapy

Spinal Cord Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11

Heart and Vascular Care

Hybrid Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-13

Plastic and Reconstructive Surgery

Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15

Pediatric Surgery

Congenital Diaphragmatic Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-17

Transplantation Surgery

Genetic Liver Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-19

Section 2: Milestones in Patient Care, Education and Research Patient Care

Rosalie Youngerman, TAVR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23

Michael Gracy, Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27

Chelsey Hoyle, Pediatric Liver Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29

New Surgery Practice and UF Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31

Science with Impact

Science for Survival, Pancreatic Cancer Research . . . . . . . . . . . . . . . . . . . . . . . 32-33

UF Sepsis and Critical Illness Research Center . . . . . . . . . . . . . . . . . . . . . . . . . . 34-35

Liver Disease and Recovery Research NIH Grant . . . . . . . . . . . . . . . . . . . . . . . . 36-37

Math and Medicine, Vascular Biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38-39

Skin Regeneration Research, AFIRM II Grant . . . . . . . . . . . . . . . . . . . . . . . . . . 40-41

Training our next Generation

Resident Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42-43

Research Residency Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4-45

Physician Shadowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46-47

Plastic Surgery Residency Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48-49

Reaching Out

Volunteering Abroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50-51

Florida-Georgia Vascular Study Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52-53

Giving

John and Betty Payne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-55

Research Milestones

Grant Funding by Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56-57

Educational and Clinical Milestones:

Physician Visits, OR Cases, Resident Graduates . . . . . . . . . . . . . . . . . . . . . . 58-59

What's Next?

WRITER AND EDITOR

Laura Mize

CONTRIBUTING WRITER AND EDITOR

Katrina Ciccarelli

CONTRIBUTING WRITER

Rebecca Burton

CREATIVE DIRECTION AND DESIGN

Mary Cecelia

Letter from the Chairman

Welcome to our first edition of the UF College of Medicine Department of Surgery progress report. We are excited to bring you up-to-date on the many milestones our faculty, residents and staff have achieved.

Our 61 faculty work in multidisciplinary teams across six divisions and three sections to achieve our primary goal of delivering high-quality care that exceeds patient expectations.

Our commitment to improving the quality of care for our patients is our top priority each and every day. However, marked improvements in care will only occur if we integrate clinical translational research programs that seek novel approaches to the treatment of surgical diseases and to health care delivery systems.

We are proud of our achievements over the last five years: • A 28 percent increase in outpatient visits • An increase in operative volume of greater than 13 percent • A dramatic 85 percent increase in funding from the National Institutes of Health • First-time pass rates of 96 percent and 95 percent on the American Board of Surgery qualifying and certifying examinations, respectively, and • An increase in the size of each class of categorical surgical residents from five to six In this progress report, we highlight the accomplishments of our superior faculty, who work hand-in-hand with our trainees and staff to set the standard of care in many disciplines. Furthermore, we outline the synergies that evolved between our clinical, research and education missions as we committed to two years of research training for all our general surgery residents. Our goal is to enhance the maturation of our trainees by developing an integrated model of clinical and research training that will produce academic leaders in surgery.

We are indebted to our faculty, residents and staff, who have committed their time and energies to continual improvement in our clinical, research and education missions. We also recognize our colleagues across University of Florida Health who have graciously supported our aspirations and provided inspiration.

Kevin E. Behrns, MD Edward R. Woodward Professor and Chairman UF College of Medicine Department of Surgery UF Health

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Section 1:

milestones in surgery

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Every year in the UF College of Medicine Department of Surgery, each of our six divisions achieves milestones in patient outcomes, education and research. Our trauma team helped set a new standard of care for treating

multiple fractured ribs, in hopes that it will be used at

medical centers across the country. Our vascular surgeons

are exploring ways to prevent and treat spinal cord ischemia in aortic surgery patients. Our division of pediatric surgery released record survival rates for infants with congenital

diaphragmatic hernia. These accomplishments just scratch

the surface of the progress our divisions have made over the past few years.

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PA N C R E AT I C S U R G E R Y P R O G R A M

a quiet but deadly cancer

Because most cases of pancreatic cancer do not cause symptoms until the disease is advanced, five-year survival rates among pancreatic cancer patients are abysmally low. From 2003 to 2009, only 6 percent of people with pancreatic cancer were alive five years after their initial diagnosis, according to the National Cancer Institute. For some patients, treatment with the intent to cure is not practical and oncologists recommend a palliative approach, which focuses on alleviating discomfort. In other cases, aggressive treatment — surgery accompanied by chemotherapy, radiation or both — is necessary to give patients the best chance of beating cancer or extending life expectancy. That’s where UF Health excels.

Steven Hughes, MD, UF’s chief of general surgery, is one of a few surgeons nationwide who performs a high volume of the laparoscopic Whipple procedure. This procedure is a complex, demanding surgery that involves removing about 60 percent of the pancreas, portions of the bile duct and small intestine, and sometimes part of the stomach. The surgeon then connects the remaining sections of the pancreas, bile duct and stomach to the small intestine to allow the digestive system to function.

Hughes also performs this operation through the traditional, open method for some patients, depending on how much cancer is present, the patient’s surgical history, tumor proximity to nearby blood vessels and whether the organ is inflamed.

The laparoscopic method requires inserting long, slender tools through five small incisions in the abdomen. This approach eliminates the need for a large incision and, according to Hughes’ research, is just as effective as the open Whipple procedure in removing tumors.

Hughes says he does this operation an average of five times per month and has completed nearly 150 since 2008. He performed his 100th at UF Health in the summer of 2014. He began performing the Whipple procedure 14 years ago and has completed nearly 400 total.

“I guess I am considered one of the pioneers of the laparoscopic Whipple,” he says. “I taught

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myself how to do it while talking to the only two other people in the world, at the time, who were doing it. Since that time, I’ve helped other high-volume pancreatic surgeons begin to do the laparoscopic Whipple. Others now use the surgical robot. I tried the robot for a while, but ultimately abandoned using it. It just wasn’t helpful for me.”

The surgery carries significant risks and in the past had a high mortality rate, around 25 percent. Today, patient deaths from the Whipple procedure are far less common. But for a good outcome, the surgeon’s experience and collaboration with a panel of other surgical and cancer specialists is still of utmost importance.

Hughes emphasizes the need for “a multidisciplinary approach to the disease process, which includes a team that’s devoted to pancreatic disease, including gastroenterologists, radiation oncologists, medical oncologists, interventional radiologists, anesthesiologists and surgical intensivists.

“If you’re at a hospital that doesn’t have the volume that can support a team like that — that’s devoted to these types of surgeries — quality is going to be affected,” he says.

“We’re one of the highest-volume centers in the nation, but most importantly, we are among the best when it comes to our results,” Hughes explains.

General Surgery

Steven Hughes, MD, performs a laparoscopic Whipple procedure.

about the program: In addition to being leaders in the Whipple procedure, UF Health pancreatic surgeons are investigating the causes of pancreatic cancer.

Kevin Behrns, MD, chair of the Department of Surgery and the Edward R. Woodward professor; Jose Trevino, MD, an assistant professor of general surgery; and Ryan Thomas, MD, also an assistant professor of general surgery; are involved in this research.

“Our research group is dedicated to determining the molecular pathways that are responsible for pancreatic tumor initiation, development and progression,” says Thomas, who joined the department in 2013 after completing clinical and administrative fellowships at the University of Texas MD Anderson Cancer Center’s Department of Surgical Oncology. He sees patients primarily at the Malcom Randall VA Medical Center.

“I am personally interested in the initiation of pancreatic cancer from precursor lesions that start out benign or in the setting of pancreatitis, and how to slow or stop this progression.

“Coupled with the great work of Dr. Trevino looking at the cellular signals responsible for pancreatic cancer progression and metastasis, we really are focused on the whole gamut of pancreatic cancer pathophysiology, not just the surgical treatment,” he continues. “When patients come to UF Health for their pancreatic surgery, not only will they receive exceptional surgical care, but also they are playing a larger role in our understanding of diseases of the pancreas.”

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R I B F R A C T U R E T R E AT M E N T

setting a new standard of care

For most patients in the United States with several broken ribs, recovery is a monthslong journey full of immense pain, difficulty breathing and a high risk of serious complications. But a consensus report from trauma care experts —including a UF Health trauma surgeon — strives to change that by promoting a technique called surgical rib fixation, or rib plating.

This technique shortens recovery time, decreases the risk of complications and can reduce pain by as much as 80 percent in patients, the experts say.

The report, published online in the September 2013 issue of General Surgery News, aims to increase the use of rib plating in patients with multiple rib fractures at medical centers across the country.

In June 2013, 11 surgeons from several different countries came together at a consensus meeting about rib fractures. The rib plating procedure involves attaching flexible metal bars to the broken bones to stabilize them and help them heal correctly.

Lawrence Lottenberg, MD, an associate professor of surgery and anesthesiology at UF and a member of the acute care surgery team until his retirement in the fall of 2014, represented UF Health at the meeting to share UF Health surgeons’ experiences with and protocol for rib plating procedures. He handed leadership of the rib plating program over to Chasen Croft, MD, an assistant professor of surgery at UF and a member of the acute care surgery team, before retiring.

Croft, like Lottenberg, says the benefits of rib plating are so profound he believes the procedure should be adopted as a standard of care for certain patients.

“We’ve had experiences where patients who otherwise didn’t look like they would come off the ventilator got their ribs plated and, within a matter of one to two days, are off the ventilator,” Croft says.

Rib plating allows patients to breathe on their own more easily, enabling them to be free of a

Chasen Croft, MD

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ventilator sooner than they otherwise would, and drastically reducing their pain. Lottenberg has estimated the procedure cuts pain by about 80 percent for patients with the highest levels of discomfort from their broken ribs. It also decreases their chances of developing pneumonia, lung collapse and other potential complications, and significantly shortens recovery time.

“If somebody’s on the ventilator and they’ve got significant chest wall injuries, and one of their reasons for being on the ventilator is because of significant pain, then once we stabilize their chest wall, typically we are able to get them off the ventilator quicker after surgery,” Croft explains.

“In patients who are not on the ventilator preoperatively, and have significant pain, we often can better manage their pain once their chest is reconstructed and prevent them from being on the ventilator postoperatively.”

Croft and other UF Health trauma surgeons have performed about 115 rib fixation procedures to date. The acute care surgery team is working on a retrospective study to document outcomes among these patients. Some UF Health thoracic and cardiovascular surgeons also perform rib fixation at times.

Although surgeons at many medical centers have adopted the practice, most hospitals in the U.S. still do not offer rib plating or offer it only in extreme cases, according to the report from last year’s consensus meeting. That means every year thousands of people who would benefit from the procedure remain in a prolonged, dangerous and extremely painful state. Croft says limited existing

General Surgery

research on the procedure likely explains its lack of popularity nationwide.

In past decades, specialized equipment for fixating broken ribs did not exist, so some surgeons used plates, wires or screws meant for other surgical procedures. That has biased some surgeons against the procedure, the consensus report states. Plates designed especially for this procedure, which have been available for several years, make rib fixation today simpler and more effective.

Currently, the standard of care in the U.S. for patients with multiple broken ribs focuses on pain management through medication.

The consensus report outlines guidelines for when and how rib plating should be done. It stipulates that rib fixation should be considered for patients with three or more fractured ribs who have uncontrolled pain, an impaled lung, worsening pulmonary status or other specific clinical requirements. The report also emphasizes the importance of postsurgical therapies for patients who undergo rib plating, including anesthesia, pain catheters and good pulmonary care.

Another important step, Croft says, will be “to identify the subset of patients who will benefit from this operation."

“I don’t think that every patient who has rib fractures necessarily needs this operation, but certainly those whose pain is not controlled, who cannot do their activities and daily living, those who are on the verge of needing mechanical ventilator support or those who are already on a ventilator, may benefit.”

The plate is positioned on the rib over the fracture to allow a minimum of three screws on each side of the fracture.

Screws are inserted through the plate to the broken rib and tightened until secure.

division milestones • UF Health Breast Center reaccredited by the National Accreditation Program for Breast Centers and recognized for “best practices” in quality improvement efforts and patient enrollment in clinical trials.

• University HealthSystem Consortium ranks UF Health 4th in pancreatic resection mortality.

• University HealthSystem Consortium ranks UF Health 7th in esophageal resection mortality.

Diagrams: © DePuy Synthes CMF, a division of DOI 2013. All rights reserved.

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A O R T I C VA LV E P R O C E D U R E S

transcatheter aortic valve replacement to florida sleeve

UF Health thoracic and cardiovascular surgeons offer one of the most extensive slates of aortic valve procedures in the state.

“The division of thoracic and cardiovascular surgery at UF Health has a long history of handling the toughest and most difficult cases from around the state of Florida," says Thomas Beaver, MD, MPH, "including aortic valve reoperations and valve disease from dissections and aneurysms."

The TAVR Procedure TAVR is a treatment for symptomatic severe aortic stenosis, a condition in which the aortic valve is narrowed.

The manufacturer of the replacement valve created just for this procedure named UF Health one of the first facilities initially approved to perform the procedure.

Edwards SAPIEN Transcatheter Heart Valve.

Diagram provided by Edwards Lifesciences LLC.

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Beaver is a professor and chief of thoracic and cardiovascular surgery, and part of UF Health’s aortic valve surgical team. In addition to traditional, fully open surgical procedures, UF Health thoracic and cardiovascular surgeons also offer procedures that are less invasive and allow for smaller incisions in the chest or even access to the heart through the vascular system without major incisions. Each procedure has different benefits, degrees of risk and requirements for patients who undergo it, and our surgeons help patients determine which is right for them.

The minimally invasive aortic valve replacement, commonly called a mini AVR, is much like a fully open aortic valve replacement.

Both procedures require open access to the heart and removal of the faulty valve leaflets. However, surgeons perform this procedure through a smaller opening in the breastbone rather than one that extends the length of the breastbone.

A heart-lung machine takes over the function of those organs for the patient, and the surgeon cuts open the aorta and removes the malfunctioning valve leaflets. A new valve is stitched into place and the surgeon removes the patient from the heart-lung machine and closes the incision.

UF Health surgeons began performing another form of valve replacement — transcatheter aortic valve replacement — in March 2012. Called TAVR for short, this treatment is for symptomatic, severe aortic stenosis, a condition in which the

aortic valve is narrowed.

The manufacturer of the replacement valve created just for this procedure named UF Health one of the first facilities initially approved to perform the procedure. Attaching the valve to a catheter allows it to travel through the body to the site where it's needed, without a large incision required. Surgeons guide a tool carrying the replacement valve through an artery in the leg and up to the heart. Patients undergoing TAVR do not require a heart-lung machine.

This treatment is another option for patients unable to undergo more extensive surgery and who previously had to depend on medication alone. To be a candidate for TAVR, a patient should "be free of other conditions that would severely limit the quality and quantity of life improvements we anticipate following the TAVR," says Charles Klodell, MD, professor of surgery and one of the UF Health surgeons who performs TAVRs. Open replacement remains the gold standard for this procedure and should be performed on patients who can tolerate it.

But Beaver says the procedure "has revolutionized the field, making even the most frail and sickest patients candidates for this new therapy."

"Our TAVR program is one of the busiest in the Southeast and we see only further growth in this area,” he adds.

For patients with healthy valves, a Florida

Thoracic and Cardiovascular Surgery

Sleeve procedure, created by surgeons at UF Health, or a “David” procedure may be appropriate.

The Florida Sleeve procedure leaves the aortic tissue around the valve and coronary arteries entirely intact. The surgeon places a sleeve of Dacron tubing around the root of the aorta, completely encasing the aorta and valve inside the tubing. The tubing returns the aortic root to relatively normal size and stabilizes the valve’s suspension mechanism and annulus, a collagen ring that provides structure and support.

“One of the key elements when treating aneurysms of the aortic root is making every effort to 'spare' or save the natural valve rather than replace it," Beaver says. "All valve replacements are susceptible to either wear or clot formation. Nature knows best, so we always try to spare your own valve."

With many years of experience in complex aortic procedures, UF Health thoracic and cardiovascular surgeons are ready to handle any cases that come their way.

“We have a very unique team of talented aortic valve surgeons that you could not find in many other places in the country," Beaver says. "Because we are so used to taking care of the most difficult cases, we have years of experience that help make all of our aortic valve procedures safer for our patients.”

The surgeons also have another vital resource for helping patients.

UF Health now has "a new ShandsCair helicopter that can reach the entire state of Florida, from Pensacola to the Florida Keys, to bring aortic emergencies back to UF."

thomas beaver, md, mph Thomas Beaver, MD, MPH, has been named the new chief of the division of thoracic and cardiovascular surgery at UF Health.

Beaver, who has worked at UF Health since 2000, is a professor of thoracic and cardiovascular surgery, holds an endowed chair position in the Department of Surgery and has a joint appointment in the department of anesthesiology’s division of cardiovascular anesthesia.

He earned his medical degree at the University of Wisconsin - Madison, completed his general surgery residency at the University of Colorado, and completed his fellowship in thoracic and cardiovascular surgery and a Master of Public Health degree at the University of Florida. He is board-certified in general surgery and thoracic surgery. Beaver was a lieutenant colonel in the U.S. Army Reserve medical corps from 1992 to 2005 and served in Iraq and Afghanistan in 2004. He and his wife, Michelle, have two children.

division milestones • Long-time UF surgeon Thomas Beaver, MD, MPH, named new chief.

• Leader in the Southeastern U.S. for TAVR procedures, with 150 performed in 2013.

• Selected for the PARTNER trial, Thomas Beaver, MD, MPH

allowing access to the latest valves for TAVR.

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Full recovery from SCI is possible, and understanding the factors that lead to recovery is another goal for the vascular team.

Robert Feezor, MD

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Vascular Surgery and Endovascular Therapy

SPINAL CHORD ISCHEMIA

stacking the deck

Why do some people who undergo aortic surgery suffer from spinal cord ischemia, a debilitating side effect that can cause paralysis, while others do not? UF Health vascular surgeons are working hard to find an answer, along with innovative ways to detect, prevent and treat spinal cord ischemia, SCI for short. The condition causes neurological problems in the lower half of the body, ranging in severity from mild movement impairment to paraplegia.

“Spinal cord ischemia is a devastating complication of aortic repair and can be associated with a very poor prognosis,” says Adam Beck, MD, an assistant professor of vascular surgery and endovascular therapy and the department’s lead researcher on the disease.

“Anything we can do to mitigate the severity of SCI will be a major advance in treating aortic diseases.”

SCI occurs when blood flow to the spinal cord is disturbed during aortic surgery, but the specifics of this cause are largely unknown. The spinal cord relies on blood flow from multiple sources, which vary from patient to patient. Not everyone has an obvious connection between the spinal cord and a specific artery, says Robert Feezor, MD, an assistant professor in the division of vascular surgery and endovascular therapy.

“Any time that we perform aortic surgery in the chest, we know that the blood supply to the spinal cord will be altered,” he explains. “The question is: How much blood supply does the spinal cord need? It probably varies with each person.”

Although SCI can occur with any type of aortic procedure, thoracic aortic procedures pose the greatest risk, Feezor says. As a part of one of the busiest centers in the country performing thoracic aortic repairs, UF Health vascular, thoracic and cardiovascular surgeons have extensive experience with patients suffering from SCI. Questions also remain about long-term outcomes for people who develop SCI. Full recovery from SCI is possible, and understanding

the factors that lead to recovery is another goal for the vascular team. Their recent analysis, published in the September 2013 issue of the Journal of Vascular Surgery, detailed the outcomes for UF Health patients with SCI, and the probability of each outcome.

UF Health researchers are seeking innovative ways to predict and diagnose SCI. Beck and Gerry Shaw, PhD, a professor emeritus in UF’s Department of Neuroscience, are leading a clinical study examining recently discovered biochemical markers found in the blood and in the fluid surrounding the spinal cord (cerebrospinal fluid) of patients with SCI. The goal is to learn whether the biomarkers will allow for earlier detection of SCI, or shed light on why it occurs.

Some current methods for treating SCI include draining some of the patient’s cerebrospinal fluid to reduce pressure on the spinal cord, the use of steroids and elevating blood pressure through medication. But Beck, Feezor and their colleagues want to be able to do more.

Feezor describes it as “trying to stack the deck” for their patients.

That includes “things like putting a spinal drain in and trying to do some adjunctive surgical maneuvers during the procedure, carefully managing their blood pressure postoperatively and getting everyone acutely aware of the need for good neurological assessments,” he explains.

“We know that if you detect their spinal cord ischemia symptoms very rapidly, you have a better chance of correcting them and improving outcomes.”

division milestones • Selected for NIH’s BEST trial, the largest vascular clinical trial in the U.S.

• Leading enrolling center for Hemodialysis Fistula Maturation Consortium study

• Became one of the first centers in the country with branched and fenestrated devices available for thoracoabdominal aortic aneurysm treatment.

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UF Health plans to open a new heart and vascular hospital in 2018, which will include five state-of-the-art hybrid ORs.

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Working Together: Heart and Vascular Care

H Y B R I D O P E R AT I N G R O O M

more flexibility for surgeons, decreased x-ray and contrast exposure for patients

A new hybrid operating room, the second at UF Health Shands Hospital for vascular and cardiovascular procedures, opened in September 2013. It accommodates minimally invasive procedures performed with the help of radiology machines for visualization, as well as procedures requiring an open approach.

“Having a hybrid OR really improves our ability to do minimally invasive operations efficiently and quickly,” says Adam Beck, MD, an assistant professor of vascular surgery and endovascular therapy, who was extensively involved in planning the room. UF Health surgeons performed their first procedure in the room in September 2013.

X-ray imaging equipment called a fluoroscopy machine gives surgeons detailed views of the patient’s anatomy during minimally invasive procedures involving the arteries and other blood vessels. The machine creates real-time “video” of what’s happening inside the patient without the need for large incisions, as well as three-dimensional reconstructions of the vessels intraoperatively, Beck says.

As a result, some of the most difficult procedures are notably shorter than when performed in a regular operating suite.

“For our complex endovascular aortic repairs, the new room has taken one to two hours off of operations that would usually take five or six hours,” Beck says.

Endovascular procedures require inserting catheters and tools through small incisions into a major blood vessel in the body, then navigating them through the blood vessels to the area that needs repair. These procedures pose less risk of infection, heal faster and cause less bleeding than traditional open procedures. Beck also notes that the equipment in the new room reduces the

need for contrast dye during such procedures by about half.

Contrast dye, which is injected into the blood vessels to make them visible via radiology imaging equipment, may cause kidney problems for patients. Shorter operations and decreased exposure to radiographic contrast dye lead to better outcomes, Beck says.

Hybrid ORs are also fully outfitted for open surgeries.

“Because the room is fully equipped for both endovascular and open vascular surgery, we can do some procedures that require both a minimally invasive and open component at the same time,” Beck says.

All these advantages add up to increased flexibility for patients and surgeons and a surgical experience that’s tough to beat.

Thanks in part to facilities such as this hybrid OR, UF Health is a premier destination for endovascular treatment of aortic aneurysms and dissections.

Some repairs, such as thoracic and thoracoabdominal aneurysms and abdominal aneurysms extending above the level of the kidney arteries, are especially complex are performed only at specialized centers, such as UF Health. These procedures often require customized devices.

UF Health is one of the busiest hospitals in the nation for these types of procedures, Beck says.

The hybrid OR helps reduce surgery time and decreases patient exposure to radiation and contrast dyes.

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Fat grafting involves removing fat from one part of the body to add tissue to another area in need of more fat.

FAT G R A F T I N G

improved appearance, relief from pain Some patients undergoing facial rejuvenation procedures or breast reconstruction at UF Health get an extra bonus from the treatment: liposuction.

That’s because UF Health plastic and reconstructive surgeons sometimes inject fat removed from another part of a patient’s body to add tissue to areas that need filling or smoothing, a technique known as fat grafting.

“It’s used to do a lip enhancement,” says Bruce Mast, MD, UF’s chief of plastic and reconstructive surgery and the Maurice J. Jurkiewicz professor of reconstructive plastic surgery. “It’s also used to fill in some deep lines and wrinkles in the face — furrows — or to provide augmentation of some areas, like the cheeks or sometimes in the junction between the lower eyelid and the cheek, to soften that transition.”

In rare cases, UF Health plastic surgeons have used fat grafting to aid in facial reconstruction.

For patients who have suffered traumatic facial injuries, for example, the technique can help to eliminate or reduce indentations in softtissue areas.

The same is true for breast reconstruction patients.

“We can do reconstruction with either a tissue flap or with an implant,” Mast explains. “After that, if the patient has areas that still are deficient in shape or contour in the chest, we can add to the

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reconstruction by fat grafting and sort of fine tuning it to shape the breast better.”

Mast says fat grafting provides a significant improvement in such cases and is simpler to employ than other methods.

In addition to facial and breast surgery patients, people with painful scars also may benefit from fat grafting. Injecting fat underneath the surface of such scars sometimes reduces pain substantially.

Extra cushioning over irritated nerves or in bony areas may explain the effect, Mast notes In addition, stem cells naturally found in the harvested fat may contribute to the success of fat grafting procedures performed anywhere in the body.

“There may be an effect of the stem cells helping to regenerate the tissue,” he says.

UF Health plastic surgeons are planning a clinical trial to further explore fat grafting’s therapeutic powers.

“We’re going to look at post-mastectomy neuritis, which is a chronic chest wall pain after mastectomies, and see if fat grafting is effective in treating these patients,” Mast says.

Plastic and Reconstructive Surgery

Fat grafting may be used to fill in deep lines and wrinkles.

Fat grafting may be used to help smooth areas of the face after trauma.

Fat grafting may benefit people with painful scars.

division milestones • New integrated plastic surgery residency established.

• New aesthetic surgery fellowship established.

SEC TION 1: PLASTIC AND RECONSTRUC TIVE SURGERY | 1 5

C O N G E N I TA L D I A P H R A G M AT I C H E R N I A

record survival rate for infants with cdh

UF Health pediatric surgeons published results from nearly 20 years of treating children with congenital diaphragmatic hernia, showing the highest published survival rate for a large-group study. The findings also present new data for determining when a baby’s hernia should be surgically repaired.

Baby Eva’s parents came from Russia to have her treated for CDH by Dr. Kays.

Watch a video of her story: bit.ly/1asauv0

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Congenital diaphragmatic hernia occurs when one of the diaphragm muscles does not develop fully during gestation. Abdominal organs migrate into the chest, crowding the heart and lungs and impeding lung development. Infants born with CDH have life-threatening breathing problems. Most cases of diaphragmatic hernia are diagnosed before birth.

The best modern estimate of survival at U.S. centers that treat CDH patients is 67 percent.

However, this estimate may be high, in part because it does not include data on babies born at hospitals that don’t routinely treat CDH. In the period from 1992 to 2011, 88 percent of CDH babies treated at UF Health who did not have lethal associated defects, often cardiac or neurological defects, lived to be released from the hospital. An article in the October 2013 issue of the Annals of Surgery describes the UF Health team’s methods and results, achieved under the leadership of David Kays, MD, chief of pediatric surgery. Kays and his team at UF Health Shands Children’s Hospital have treated children with CDH from across the world.

Kays began UF Health’s CDH program in 1992 after studying at Columbia University under Jen-Tien Wung, MD, a pioneer in ventilation for newborns, and pediatric surgeon Charles Stolar, MD, a specialist in CDH treatment. Since the program’s start, Kays has consistently employed gentle ventilation techniques to avoid further damage to babies’ lungs, a treatment that has gradually become mainstream.

He and his team also have worked diligently to determine the best time to surgically repair a baby’s diaphragmatic hernia. Analysis of their data from nearly two decades of treatment shows the answer depends on specifics about the baby’s condition.

“Up until now, all the studies that looked at questions of how we should care for diaphragmatic hernia babies lumped all

diaphragmatic hernia babies together,” Kays notes. “Our data indicate that the optimal therapeutic plan is not the same across the entirety of the CDH spectrum, and we have to begin to think about what plan is best based on the patient’s markers of severity. CDH is one disease, but the spectrum of severity is wide and one treatment plan doesn’t necessarily fit all.”

In babies with a hernia on the left side of the body, which is much more common than a rightside hernia, physicians should determine when to operate based in part on whether any portion of the liver juts through the hernia into the chest.

Those with a left-side hernia and protruding liver have the most threatening cases and the worst outcomes, the study results show.

“For those babies with less severe diaphragmatic hernia, we found that they benefited from delay of surgery. They had good survival rates and showed less need for heartlung bypass, also called ECMO (extracorporeal membrane oxygenation), if we delayed surgery beyond 48 hours,” Kays explains. “However, babies with anatomically more severe diaphragmatic hernia who ultimately need ECMO appear to benefit from a more aggressive surgical plan, getting the repair done in the first day or two.”

The next step in the team’s research will be to determine even more precisely when to operate on infants with the most serious cases of CDH, Kays says. To do this, the team will analyze gases in the blood of the sickest babies, as well as how much of the liver protrudes into the chest, for clues.

In addition, Kays says he hopes other surgeons will consider their own surgical timing approaches for babies with CDH, as well as the messages they give parents.

Institutions that treat CDH should “continue to work toward better survival rates, because they are achievable,” he says.

Pediatric Surgery

“Institutions that treat CDH should continue to work

toward better survival rates, because they are achievable.”

— David Kays, MD

division milestones • Published record survival rate for infants with congenital diaphragmatic hernia: 88%.

• UF Health Shands Children’s David Kays, MD, and CDH survivor Caleb Burton participate in a CDH Awareness Parade held at UF Health Shands Hospital in 2013.

Hospital: In 2014, recognized

by U.S. News & World Report as one of the nation’s best hospitals for children in seven medical specialties.

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GENETIC LIVER DISEASE

working toward a cure

Imagine a cure for hemophilia that could grow healthy new liver cells inside the patient’s liver, where the defective cells that should produce a blood-clotting protein reside.

That’s exactly what Jeffrey Fair, MD, UF’s chief of transplantation surgery, is trying to achieve with his research team. The group’s goal is to find a safe cure for genetic liver diseases that can be used for patients who do not yet have widespread liver damage, or who have diseases such as hemophilia that originate in the liver but do not damage the organ. Genetic liver diseases affect a wide variety of body functions, and some can be fatal.

Such diseases could currently be cured by a liver transplant, but the procedure and antirejection medications it requires are considered too risky. Many patients with hemophilia, for example, receive regular infusions of bloodclotting protein to manage the disease. Still, the risk of serious, even life-threatening, complications remains for some people.

Fair’s work to find a cure starts with induced pluripotent stem cells, also called iPSCs. “They’re your own cells and you can differentiate them into whatever cells you want — so liver cells of a particular type, of a particular age,” Fair explains.

Fair and his team have been producing and experimenting with iPSCs from both mice and humans with the help of Naohiro Terada, MD, PhD, an expert in iPSCs and a UF professor of pathology, immunology and laboratory medicine, and Bryon Peterson, PhD, a UF professor of pediatrics. Creating them requires taking cells from the body and manipulating them with gene therapy and drugs. Scientists can start with any of several types of cells. Unlike embryonic stem cells, which also can differentiate into any type of body cell desired, iPSCs do not require the use of embryos.

The team’s latest work with the human cells focuses on creating liver cells that are at just the

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right stage of development to thrive inside a patient’s liver — not an easy task.

“It has been known for 30 years that the liver is a very inhospitable place to park new cells. The liver doesn’t want those cells and it tends to shut them down," Fair says. They either don’t survive or they don’t expand in a meaningful way.

“We found a version of that cell within what we call the ‘liver lineage,’ that will, for a period of time, proliferate inside the liver. It will sort of force its way in, like an unwanted houseguest, and then fill up a usable amount of that liver’s biomass.”

Fair says the work with mouse liver cells created from iPSCs has shown that, at least in mice, the cells can grow inside the organ to take up as much as 10 percent of it. That could be enough to pave the way for a type of genetic therapy not yet performed in the liver.

First, the team must prove they can do the same with human cells, starting in specially designed mouse livers. Then, they must confirm in the laboratory that gene therapy would, as believed, cause defective liver cells to function fully. In the case of hemophilia, the group would work with Tung Wynn, MD, a pediatric hematologist/oncologist and an assistant professor in the Department of Pediatrics.

“If someone has a genetic defect and you could take their cells out and then repair the gene, hopefully instead of doing a liver transplant, you just put the cells back in the liver,” Fair says.

Though much work remains before the method can be tested in humans or made available for patients, Fair is optimistic.

“This has a lot of indications for particular pediatric liver diseases for which transplantation is the only potential treatment at this time,” he says.

Transplantation Surgery

"We found a version of that cell within what we call the ‘liver lineage,’ that will, for a

period of time, proliferate inside the liver."

— Jeffrey Fair, MD

division milestones • Established systemwide quality assessment and performance improvement groups.

• Delayed graft function rate for deceased donor recipients down to a low of 10% and 0% in living donor recipients.

• Performed first kidney-paired donation transplant at UF Health.

• Mortality rate below 1% for liver resections.

S E C T I O N 1 : T R A N S P L A N TAT I O N S U R G E R Y | 1 9

Section 2:

milestones in patient care, education and research

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The UF College of Medicine Department of Surgery focuses

on providing compassionate and personalized patient care,

educating the surgical leaders of tomorrow and conducting basic and translational research to improve treatments and outcomes. The department is part of UF Health, the most comprehensive academic health center in the Southeast.

Over the past few years, we have reached numerous milestones in each of these areas.

In collaboration with UF Health cardiologists, our

cardiovascular surgeons performed their 100th transcatheter aortic valve replacement, greatly improving quality of life for an 89-year-old woman. The first UF surgical residents admitted under our two-year research requirement are

now all engaged in their research projects, which will make

them more competitive as they seek clinical fellowships. Our

inflammation biology and surgical science research team and acute care surgery team, along with other UF researchers, were instrumental in securing an $11 million grant to

establish a comprehensive sepsis research center. And these accomplishments just scratch the surface.

S E C T I O N 2 : M I L E S T O N E S I N PAT I E N T C A R E , E D U C AT I O N A N D R E S E A R C H   |   2 1

ROSALIE YOUNGERMAN'S STORY

heart patient back to volunteering

For Rosalie Youngerman, the chance to get a new aortic valve without open-heart surgery was literally a lifesaver. In July 2013, Youngerman became the 100th person at UF Health Shands Hospital to undergo a transcatheter aortic valve replacement, a procedure that allows surgeons to replace valves in patients who are not good candidates for open-heart surgery.

Youngerman, an 89-year-old from Fort White, Florida, learned in April 2013 that the valve allowing her heart to pump oxygenated blood to the aorta — the large artery that delivers blood to the rest of the body — was not functioning well and had been narrowed by plaque and calcium buildup. As a result, blood flow throughout her body was diminished.

“I felt like I wanted to pass out all the time,” Youngerman says.

Her advanced age and a slew of other recent health problems made open-heart surgery, the traditional method for replacing aortic valves, a dangerous option. But she was a candidate for transcatheter aortic valve replacement.

The procedure allows a team of collaborating surgeons and cardiologists to replace a dysfunctional aortic valve with an artificial one through a small incision in the groin or side of the chest. They use a catheter to insert the new valve and maneuver it to the right place inside the body. The old valve remains in place, but the new one pushes it harmlessly against the wall of the aorta.

Before the TAVR procedure, patients who could not endure open surgery had to rely on medications for treatment.

Youngerman said she could tell immediately after the procedure that the new valve was doing its job. After four days of recovery, she left UF Health Shands Hospital to stay in a rehabilitation facility and regain strength she’d lost due to her myriad health problems. In August 2013, Youngerman returned home, and soon resumed one of her favorite activities — visiting residents at a nursing home in the area.

“Our patient outcomes have been good, and this milestone really just represents how well our team functions,” says R. David Anderson, MD, an associate professor in the UF Department of Medicine’s division of cardiovascular medicine.

“It makes us one of the busiest centers in the southeastern United States.” Anderson and Anthony Bavry, MD, MPH, an assistant professor of medicine in the division, perform TAVR procedures in collaboration with two UF Health cardiothoracic surgeons: Thomas Beaver, MD,

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MPH, a professor and chief of thoracic and cardiovascular surgery, and Charles Klodell, MD, a professor of thoracic and cardiovascular surgery.

The team began offering TAVR in early 2012 and since then, about 215 patients at UF Health have undergone the procedure. UF Health Shands Hospital was one of several in the United States initially selected by the manufacturer of the valve and catheter used in the procedure.

The FDA approved TAVR in November 2011 for use only in patients with severe aortic valve narrowing who were unable to have open-heart surgery but has since expanded its guidelines.

High-risk surgical patients suffering from severe valve narrowing also are now eligible to undergo TAVR. Such patients include those with liver disease, lung disease, too much plaque buildup in the heart or anatomical features that can prevent open-heart surgery, such as an abnormally shaped sternum, Anderson says. People of advanced age or those who are especially frail also may qualify as high-risk patients.

“You can save them the risk of complications associated with open valve surgery, such as being on a respirator a long time, prolonged hospitalization, possibly inpatient rehab or time in a nursing home,” he says. “If your 89-year-old patient is less functional than you’d like her to be but you can get her through the catheter procedure, she can still go home in four or five days.”

UF Health cardiothoracic surgeons and cardiologists are participating in a series of trials, called the PARTNER trials, to test the newest versions of the artificial valve used in the procedure. The new iterations of the original valve include larger and smaller versions to fit the various sizes of patients’ heart anatomies, as well as other developments.

In the meantime, TAVR is already changing the lives of patients such as Youngerman.

“It’s revolutionary technology, being able to treat patients who could not previously be treated, and in an entirely new way,” Klodell says.

“It represents a completely new way of thinking about aortic stenosis patients.”

Patient Care

S E C T I O N 2: R O S A L I E YO U N G E R M A N'S S TO RY | 2 3

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Patient Centered Patient Care Care

"Patient centricity defines UF surgery. Patients are the focal point of all our missions. Every advance is critically dependent on patient confidence in

our capabilities. Similarly, every idea we conceive, investigate, implement or teach must be directed at safe and innovative patient care."

— Kevin E. Behrns, MD, UF Department of Surgery chairman

PAT I E N T C A R E | 2 5

MICHAEL GR AC Y’S STORY

defying the odds, motorcycle accident survivor returns to the life he loves

Michael Gracy’s life nearly ended one Friday afternoon in November 2010. Then 68, Gracy had just left work at his Gainesville office of the financial services company for which he works, and was headed home on his motorcycle.

A young woman pulled out in front of him just before he entered an intersection, leaving him no time to stop. He crashed into her vehicle at about 40 miles per hour.

“The highway patrol came out and took many photographs of the accident scene, thinking that I wasn’t going to live and it was going to be a vehicular manslaughter case,” Gracy says.

Paramedics rushed him to the hospital.

“Thank God for the Shands surgical trauma unit,” he says. “They took me there and I was given the best care imaginable. They saved my life.”

When Gracy arrived at UF Health Shands Hospital, he was just barely clinging to life, says Lawrence Lottenberg, MD, then an associate professor of surgery and anesthesiology at UF. Lottenberg, a renowned trauma surgeon, has since retired.

“Our trauma team performed a ‘miraculous’ resuscitation on Mr. Gracy,” Lottenberg says. “It is those first five to 30 minutes which trauma centers exist for, and they make the difference between life and death.”

Gracy’s injuries included many broken or crushed bones and a right leg that nearly required amputation. He underwent several surgeries.

“My right leg and my right arm and shoulder got the worst of the impact,” he explains. “They normally put a rod in the leg where the femur was just in shreds, but they didn’t have enough (bone left) to put a rod in. They had to put a plate from my knee to my hip, which I have in there today. With my arm, they had it all bandaged up and wrapped up and there was a big hunk of it missing.”

During Gracy’s extensive recovery at UF Health Shands Hospital, UF Health surgeons also

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operated on his face to insert plates where his cheekbones had been. For several months, he was dependent on a ventilator. He remained in the hospital through December 2010, much of the time unaware of his surroundings, and he suffered several setbacks in his recovery.

“I died a half dozen times, literally, and was brought back,” Gracy says. “Different things would happen. I’d be coming along and my lung would collapse, or I had a heart attack at one time, and they had to run me down to cardiology.”

By early January 2011, Gracy was more stable and moved into an extended-stay acute care hospital. But he worsened there and returned to the intensive care unit at UF Health Shands Hospital in early February 2011. After improving, he transferred to UF Health Shands Rehab Hospital, where he remained for a month. In early April 2011, Gracy left to go home. He required a wheelchair and in-home therapy to help him walk again, followed by outpatient physical therapy.

He was back at work for his regular four-days-aweek schedule sometime in the fall of 2011, Gracy recalls. Since then, he has continued to excel in his career. He earned honors from his company and was ranked 24th out of about 3,000 financial professionals. Gracy also has returned to hobbies he loves, such as working in his yard and golfing.

Some of his abilities have not returned, including his once-praised singing voice, or the strength and dexterity to run or jog. He can’t lift his right arm past about a ninety-degree angle.

But Gracy is just glad to be alive.

“I’ll never be back 100 percent normal, like I was before, but just to be here talking to you is good enough for me,” he says.

Patient Care

“Thank God for the Shands surgical trauma unit. They took me there and I was given the best care imaginable. They saved my life.”

— Michael Gracy

Almost four years later, Michael Gracy is back to doing what he loves — golfing.

SEC TION 2: MICHAEL GRACY’S STORY | 2 7

C H E L S E Y H OY L E ’ S S T O R Y

child thriving after pediatric liver transplant

Now that Chelsey Hoyle is rid of her scarred, dysfunctional liver, she can really get down to the business of being a kid.

Since receiving her new liver in 2012, Chelsey Hoyle has continued to grow happily. Chelsey started walking not long after and is a prolific talker, her mother says, and has not shown signs of rejecting her new liver. Chelsey and her family and friends celebrated her second birthday in December 2013 with a Minnie Mouse-themed party.

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Chelsey received part of an adult liver during a transplant operation in early November 2012, less than a month before her first birthday. The operation was UF Health’s first pediatric liver transplant since the program’s seven-month hiatus and its reactivation in April 2012. The program is one of only two in Florida.

UF Health voluntarily suspended its liver and pancreas transplant programs in August 2011 after several transplant surgeons moved to more urban areas. With the addition of two transplant surgeons, both programs were reactivated in 2012.

Between the program reactivation in early 2012 and mid-February 2014, UF Health surgeons performed 12 pediatric liver transplants, including Chelsey’s. Her donated partial liver came at just the right time.

“She was within days of dying,” says Jeffrey Fair, MD, chief of the Department of Surgery's division of transplantation surgery. “She had complete cirrhosis. Her liver was just a little gnarly knot and nothing like a liver at all.”

Chelsey developed cirrhosis, or scarring, of her liver due to biliary atresia. The condition occurs when liver ducts that transport bile and other fluids to the gallbladder are malformed and blocked. The resulting backlog causes inflammation and permanent liver damage and hardening. Children with the disease often become malnourished and develop swollen bellies. They all eventually require a liver transplant.

To keep Chelsey going while she awaited transplant, UF Health’s pediatric intensive care team performed a procedure known as plasma exchange, which involves withdrawing blood from the body, replenishing its clotting properties, and filtering out unwanted substances

— as the liver normally does — and returning the blood to the body.

When it came time for surgery, the transplant team accommodated the donated liver portion’s adult size by leaving her abdomen partly open and covering the opening with a patch, “to give the liver time to shrink a little bit,” Fair says.

After a while, the team closed the opening in her abdomen entirely. A few months posttransplant, Chelsey was back home in Zephyrhills with her mother, Kaylee Alford; her father, Nick Hoyle; and her grandparents, Donna Alford and Terry Alford.

“She is a new baby,” Kaylee Alford said shortly after her daughter returned home. “She was happy before, but now she’s no longer hurting, so she’s just super excited and laughs for no reason.

She eats a lot more and she’s doing great. I am more than thankful for how great she’s doing.”

Le Jones, RN, CCTC, program manager of UF Health's adult and pediatric liver transplant programs, says Chelsey began "rapidly acquiring all the developmental stages that a child that age would,” after being delayed because of her illness.

Fair emphasized the strength of the pediatric liver transplant program, with its team of committed and reputable surgeons. He says the program also has enhanced collaborations with UF Health’s medical and anesthesia teams. The UF College of Medicine’s Department of Pediatrics (led by Scott Rivkees, MD) and the department’s division of gastroenterology, hepatology and nutrition (led by Christopher Jolley, MD) also are integral to the care and recovery of pediatric liver transplant patients at UF Health.

Jackson Memorial Hospital in Miami has Florida’s only other pediatric liver transplant program. The next closest such program is in Atlanta.

Patient Care

SEC TION 2: CHELSEY HOYLE’S STORY | 2 9

surgery practices move to uf health springhill UF Health Springhill is a four-story, 108,000-square-foot building in Northwest Gainesville that is home to a variety of UF Health clinical practices, including cardiology, dermatology, women’s health, diagnostic imaging, adult psychiatry and pain medicine.

Recently, the Department of Surgery’s outpatient practices for plastic surgery, vein surgery and breast, melanoma and endocrine surgery moved to the facility. The new location for these practices provides easier access for patients in the community and offers multidisciplinary and coordinated care in one location.

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Patient Care

uf&shands is now university of florida health If you haven’t heard the news, UF&Shands is now University of Florida Health (UF Health). The new “umbrella” name encompasses all our hospitals, physician practices, colleges, centers, institutes, programs and services across northeast and north central Florida. The new name reflects our health system’s strong ties to UF — a key part of what distinguishes our academic health center — with a focus on excellence in research, teaching and patient care.

The moniker also represents the next stage in our evolution as one of the nation’s most successful academic health centers. Broader name recognition will help attract and retain the most talented physicians, nurses, faculty, staff and students, as well as secure research funding. That all translates to better care, better health and better outcomes for patients.

For more information, visit Forwardtogether.UFHealth.org.

S E C T I O N 2 : N E W S U R G E R Y P R A C T I C E A N D U F H E A LT H | 3 1

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Science with Impact

“The future is that ultimately we’re going to recognize that

every patient is a little bit different and that personalization is going to be the key to getting better treatment responses.”

Jose Trevino, MD

— Jose Trevino, MD

P R O F I L E : J O S E T R E V I N O, M D

science for survival UF researcher hopes studies will help improve pancreatic cancer’s low survival rate.

Personalizing pancreatic cancer treatment for his patients is the main goal for Jose Trevino, MD, an assistant professor of surgery in the division of general surgery and a surgical oncologist. It may sound like a tall order for such a deadly disease, but Trevino is determined.

“One of the limitations that we’ve had since we first started treating patients with pancreatic cancer is that we really don’t fully understand the disease process,” Trevino says.

Since joining the division of general surgery’s pancreaticobiliary service in August 2011, the triplethreat researcher, surgeon and oncologist has focused his research on how tumors removed from a human patient grow in an animal model and how different combinations of chemotherapy impact a tumor’s progression. The end goal of his research is to identify the specific chemotherapy cocktail that will work best for each individual patient.

“What I explain to (my patients) is that if we get a better understanding of the microenvironment in the mouse — which is in my opinion a more representative

form of pancreatic cancer to date — we’ll be able to get a better understanding of the cancer itself, with development of better treatments in the future,” Trevino says.

Currently, the overall survival rate of those diagnosed with pancreatic cancer is about 5 percent, and Trevino is not satisfied. He says one reason the survival rate is so low is because science has not yet discovered the “whole picture” of how cancer develops. Past studies have focused on pancreatic tumor cells grown in the static medium of a petri dish, but investigating how cancer cells behave in the dynamic environment of a living organism provides more in-depth understanding of tumor growth.

“The future is that ultimately we’re going to recognize that every patient is a little bit different and that personalization is going to be the key to getting better treatment responses,” Trevino says. “Getting there will be very time-consuming, very in-the-future, but definitely a possibility. And then things get better for our patients and we have a better survival rate.”

— REBECC A

BURTON

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uf health granted $11 million to establish comprehensive sepsis research center

UF Health was awarded an $11 million, five-year grant from the National Institutes of Health to create a one-of-a-kind center to help generate treatments and prevention strategies for one of the most devastating issues critically ill patients face.

Lyle Moldawer, PhD

Frederick A. Moore, MD

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The Sepsis and Critical Illness Research Center, the first of its kind in the nation, will study longterm outcomes in patients treated for sepsis in the surgical and trauma intensive care units at UF Health Shands Hospital, with the goal of developing clinical solutions for sepsis as well as illnesses that stem from it and their enduring, dismal effects.

Sepsis is a severe, systemic combination of infection and inflammation that can shut down organs, depress or overactivate the immune system and cause death. Death from sepsis was once common, but improved treatments help many people survive to leave the hospital after battling it. Severe sepsis leaves lasting effects, however, that scientists are only beginning to understand.

In 2012, UF researchers identified a condition they call persistent inflammation, immunosuppression and catabolism syndrome, after decades of research involving critically ill patients. They say the syndrome, also known as PICS, afflicts thousands of people each year, mostly elderly people who are successfully treated for sepsis. It prevents them from recovering fully and returning to a normal lifestyle. PICS will be a major focus of the UF Sepsis and Critical Illness Research Center.

“They get sent to long-term acute care facilities and many of them never really rehabilitate,” says Frederick A. Moore, MD, head of the new center and chief of acute care surgery at UF Health. “This is increasingly being recognized, and we think we at least have a partial understanding of how this happens. It’s really just a chronic inflammatory disease and people lose a lot of lean body mass.

After they lose all their lean body mass, they really can’t get rehabilitated.”

UF Health's work on sepsis got another boost with the publication of a July 2014 New England Journal of Medicine article describing similarities between the body’s response to cancer and inflammatory diseases. Lyle Moldawer, PhD, a professor and vice chair of research in UF’s Department of Surgery, and Richard Hotchkiss, MD, a professor of anesthesiology, medicine and surgery at Washington University in St. Louis,

wrote the article promoting the testing of drugs meant to combat one of these disease categories for potential use against the other.

“If these drugs are effective in one of these diseases, they may well be effective in many others. The article is a plea to investigators not to work in silos,” Moldawer says. “Oncologists work alone; infectious disease people work alone; drug companies are broken up into sections.

Each is developing drugs in their own silo. The host response (to these diseases) is common and drugs going through development in cancer should be considered more rapidly for these other chronic inflammatory diseases, such as PICS.” With significant increases in the nation’s elderly population expected over the next several decades, sepsis and PICS are poised to demand even more health care resources.

The number of people in the U.S. age 65 and older is expected to reach 92 million by 2060, according to data from the U.S. Census Bureau.

That’s more than double the 43.1 million in that age group in 2012.

“This NIH-funded center on sepsis and critical illness addresses the increasingly significant problems of long-term mortality and functional recovery in patients with sepsis,” says David S. Guzick, MD, PhD, UF senior vice president for health affairs and UF Health president. “Doctors Moore and Moldawer have brought together a multidisciplinary team to tackle different aspects of the problem from a fresh scientific perspective, with the goal of improving the survival and quality of life of patients with sepsis and critical illness.”

Moore will lead one of four main projects to be initiated in the center’s first five years of operation. The project will study the course and outcomes of chronic, critical illness that follows sepsis in patients who have been in surgical and trauma ICUs. In collaboration with the UF Institute on Aging, the researchers will look at long-term cognitive and physical effects in patients.

This and other center projects will draw on a central database that stores de-identified information on markers of PICS in patients’ blood,

Science with Impact

tissue and urine samples, as well as data on patients’ cognitive and physical function.

Mark Segal, MD, PhD, an associate professor and chief of the UF Department of Medicine’s division of nephrology, hypertension and renal transplantation, and Azra Bihorac, MD, an assistant professor of anesthesiology, medicine and surgery in the UF College of Medicine, will lead another project to study how sepsis affects the kidneys and how these organs in turn may contribute to PICS and other forms of chronic illness.

Moldawer, Philip Efron, MD, an assistant professor of surgery and anesthesiology in UF’s Department of Surgery, and Christiaan Leeuwenburgh, PhD, a professor and chief of the division of biology of aging in UF’s Department of Aging and Geriatric Research, will explore the possible role of immature immune system cells called myeloid-derived suppressor cells in the onset of PICS. The fourth project will focus on one of the most debilitating effects of sepsis and PICS: muscle wasting. A. Daniel Martin, PhD, PT, a professor in the UF College of Public Health and Health Professions’ Department of Physical Therapy, will lead the project, which will involve Leeuwenburgh and several other researchers.

“Dr. Martin and I will determine whether clinically practical rehabilitation techniques — administered at the ICU patient’s bedside — can improve diaphragm and lower-limb muscle strength,” says Leeuwenburgh, “and examine whether strength training can interfere with the vicious cycle of inactivity, inflammation and protein catabolism in these patients.”

Weakness in the diaphragm and legs prevents patients from breathing and walking independently and is thought to create a slew of other problems.

In addition to the departments already named, the UF College of Medicine’s Department of Molecular Genetics and Microbiology and the College of Public Health and Health Professions’ Department of Biostatistics also will be involved in the center.

 The UF Sepsis and Critical Illness

Research Center is the first of its kind in the nation.

 Sepsis can shut down organs, depress or overactivate the immune system and cause death.

 PICS occurs when the immune system “panics” in response to multiple health threats and releases large numbers of immature immune cells.

 With significant increases in the

nation’s elderly population expected over the next several decades, sepsis and PICS will demand even more health care resources.

SECTION 2: UF SEPSIS RESEARCH CENTER | 35

,

Jae-Sung Kim, PhD, and Christiaan Leeuwenburgh, PhD, in the laboratory.

liver disease and recovery research at uf garners $1.3 million nih grant

In 2012, UF researchers received nearly $1.3 million from the National Institute of Diabetes and Digestive and Kidney Diseases to uncover ways to lessen liver damage by studying the body’s natural process for breaking down and removing injured cells.

The grant money provides five years of funding for the research.

During surgery or transplantation, surgeons stop blood flow to the liver, temporarily cutting off oxygen and nutrients. When blood rushes back to the organ afterward, it often causes serious damage called ischemia/reperfusion injury.

Finding a way to boost cells’ natural cleanup process — and with it, older livers’ ability to recover from such stress-related injury — would help patients recover after liver surgery. It could also increase the number of livers available for people on the transplant waiting list by reducing damage to the organs of potential donors, and may lead to therapies for other diseases, such as cancer and neurological disorders.

“All diseases, including liver disorders, are the consequence of multiple, complicated changes in the body,” says principal investigator Jae-Sung Kim, PhD, an associate professor in UF’s Department of Surgery. “I think the way to cure diseases is to fully understand complicated mechanisms. We can take advantage of our natural defense mechanism that was evolutionally developed to fight against many

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causes of illness.”

Nearly 16,000 people in the United States await liver transplants, according to the U.S. Department of Health and Human Services’ Organ Procurement and Transplantation Network. Only 7 percent of all liver donations from 1988 to 2012 came from people older than 65, despite the fact that they die at higher rates than people in other age groups.

The multidisciplinary UF research team that received the grant also includes principal investigator Christiaan Leeuwenburgh, PhD, chief of the biology of aging division in UF's Department of Aging and Geriatric Research. Kim, Leeuwenburgh and their team seek to confirm earlier findings that liver recovery from ischemia/ reperfusion injury is linked to cells’ ability to remove structures called mitochondria when they are damaged. Mitochondria provide the cell with energy.

They also found that older livers respond more slowly than young ones to stress-related damage, partly because of lower levels of a protein that directs the cell cleanup process. Injured cells resumed normal activity when inundated with the protein, called Atg4B.

Science with Impact

Older livers respond more slowly than young ones to stress-related damage, partly because of lower levels of a protein that directs the cell cleanup process.

Liver recovery from ischemia/reperfusion injury is linked to cells’ ability to remove mitochondria when they are damaged.

“Growing evidence indicates that

dysfunctional or impaired autophagy, cells’ natural cleanup process, is Dysfunction of mitochondria contributes to impaired autophagy.

directly associated with various

diseases, including autoimmune diseases, cancer, neurological disorders and diabetes.”

The researchers will study older mice to examine age-related changes in the cell cleanup process. They also will explore ways to boost that process and examine the resulting effect on damaged livers.

“There are many studies that have investigated liver injury in younger animals and mechanisms there, but these studies are unique because they’re studying older animals,” says Leeuwenburgh. “Most liver injuries occur and liver resection interventions are done in older individuals.”

Knowing more about how the cell cleanup process works could pave the way for new therapies, not just for liver disease, but also for a variety of other illnesses.

“Growing evidence indicates that dysfunctional or impaired autophagy, cells’ natural cleanup process, is directly associated with various diseases, including autoimmune diseases, cancer, neurological disorders and diabetes,” Kim says.

“Through this study, we would like to better understand basic molecular mechanisms of autophagy.”

Since receiving the initial grant money in 2012,

— Jae-Sung Kim, PhD

Kim has continued his research on ischemia/ reperfusion injury in liver cells. He says his research team has learned that dysfunction of mitochondria, the cell’s energy centers, contributes to impaired autophagy.

In addition, he and other Department of Surgery researchers, including Kevin Behrns, MD, the Edward R. Woodward professor and chair of the department, and Ivan Zendejas, MD, an assistant professor in the division of transplantation surgery, co-authored an article describing their study of the anticonvulsant drug Carbamazepine. Their results showed that the drug does promote proper autophagy in liver cells despite ischemia/reperfusion injury.

Related topics Kim and Leeuwenburgh continue to research include liver transplant and ischemia/reperfusion injury, as well as liver cirrhosis and fibrosis.

Kim and Leeuwenburgh received a competitive renewal of their funding in September 2014 and are examining a new molecular target and therapeutic strategies to help them better understand autophagy.

S E C T I O N 2 : C E L L D E AT H A N D S I G N A L I N G | 3 7

Science with Impact

math and medicine

For Scott Berceli, MD, PhD, medicine and math are a match made in heaven. “I’m a clinician, a vascular surgeon,” says Berceli, a professor of surgery in the Department of Surgery’s division of vascular surgery and endovascular therapy. “But, I have a PhD in engineering and my research interests have always been in trying to marry engineering and mathematics with clinical medicine.”

Scott Berceli, MD, PhD

Funded by a five-year, $2.5 million grant from the National Institutes of Health, Berceli is using computers to try to identify a specific gene combination that holds the key to scarring in patients who undergo vein bypass graft surgery.

The procedure routes blood flow around a problem spot in a major blood vessel, such as a blockage or severe narrowing. To do so, the surgeon attaches a graft made from synthetic tubing or the patient’s own healthy vein to the outside of the vessel. Cutting openings in the wall of the diseased blood vessel at the points where the bypass graft attaches allows blood to flow through the graft and back into the original vessel, restoring blood flow in the area.

But scarring inside the veins often creates problems after surgery, again limiting blood flow through the area. Vascular surgeons monitor their patients after vein bypass graft surgery for scarring that would block blood flow through the graft. Sometimes, a second operation is required to prevent total obstruction.

Other times, scars form rapidly before monitoring starts or between checkups. In those cases, surgeons must either find another healthy piece of vein from the patient and perform emergency bypass surgery, or amputate the limb that has the blocked vein.

For years, researchers have believed genes were responsible for scarring after vein bypass graft surgery, but time-consuming experiments that used a medication to block one gene at a time failed to detect the culprit. Berceli says he and his research team now believe they need to find a combination of genes.

“The concept we came across, and what we’re working on in this grant, is the idea that you can’t just manipulate a single gene to prevent scarring,” he explains. “The problem is, if you’re just in a lab, you’re just shooting in the dark trying to develop different combinations. Each set of experiments is going to take a very long time.”

The solution may be a method called multiscale modeling, which uses computer models to investigate scientific problems. As part of a government-affiliated group centered around multi-scale modeling, Berceli and his team have spent years developing computer models to first predict how cells behave in response to specific genes and then predict how these cells organize to form tissues.

The models mimic the cell and tissue behavior that causes scarring after vein bypass graft surgery. That means “switching off” combinations of genes in the computer models also should

Systems Biology – Network-Based Analysis of Vascular Remodeling Structural Integration Axis

TISSUE

Regional Morphology Lumen Geometry Shear Stress

Inward/Outward Remodeling

Cell Proliferation and Apoptosis

CELL

Gene Network MOLECULE

Extracellular Matrix Deposition

Time Scale Axis SECONDS

3 8 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

HOURS

DAYS

WEEKS

Science with Impact

“The advantage of doing this kind of multi-scale modeling is that it allows

you to begin to look at the whole system, and how all these pieces interact.”

mirror what would happen in real life if the same sets of genes were inactive.

“We look at how genes interact, really on a second-by-second basis. We then jump up to understand how these genes control cell behavior, and then jump up again to describe how cells combine to form tissues,” Berceli says.

“The advantage of doing this kind of multiscale modeling is that it allows you to begin to look at the whole system, and how all these pieces interact.”

With their computer models now built and their funding renewed in 2013, Berceli’s team has turned their attention to using the models to find the combination of genes that may hold the key to scarring in vein bypass graft patients.

Business + academic research = forward progress Berceli’s other major ongoing project involves creating a center that brings business and academic research together to develop computer-based innovations.

“This center will focus on the application of computational techniques to improve the

delivery of surgical care,” he says.

Berceli and Marc Garbey, PhD, a professor in the Department of Computer Science at the University of Houston, have worked together to found the center, called an industry/university cooperative research center, through a National Science Foundation program. The center, called Cyber-Physical Systems for the Operating Room, has two sites: one at UF and the other at Houston Methodist Hospital. The NSF has given Berceli two back-to-back grants to get the center up and running at UF. The latest, awarded in 2013, is worth $1 million and has a five-year term. With this money, the companies and researchers Berceli and Garbey have recruited will continue their partnerships, pursuing seven research projects in line with the center’s mission.

Four projects are based at Houston Methodist Hospital. UF faculty members lead the remaining three, including one directed by the Department of Surgery’s own Adam Katz, MD, an associate professor in the division of plastic and reconstructive surgery.

Katz’s project aims to invent “operating-room-

— Scott Berceli, MD, PhD

based technologies for stem cell isolation,” Berceli says.

At the end of 2013, six companies had paid the $50,000 membership fee to join the UF/Houston Methodist Hospital center. The money supports research projects voted on by representatives from the businesses.

“We have, twice a year, a meeting where people from the two institutions who have projects can come and present them to the industry partners,” Berceli says. “The industry partners give them feedback and say ‘This is something we’d be interested in funding, but I think the project should be more like this, or like this.’”

About 60 centers similar in structure to the UF/Houston Methodist Hospital exist. They span a wide variety of scientific disciplines.

Berceli says the idea behind these industry/ university cooperative research centers is “to take very basic science concepts and take companies who might be interested in them, and put them into one place so they can begin to interact and communicate and advance university technologies forward.”

S E C T I O N 2 : VA S C U L A R B I O LO G Y | 3 9

skin regeneration research grant to benefit injured troops

The U.S. Department of Defense awarded $1.2 million to the UF College of Medicine’s Department of Surgery for skin regeneration research that may benefit injured troops and also help civilians.

Adam Katz, MD, a UF Health plastic surgeon and an associate professor in the Department of Surgery’s division of plastic and reconstructive surgery, has worked as a researcher for the Armed Forces Institute of Regenerative Medicine, or AFIRM, since 2008. A member of the institute’s skin regeneration research group, he investigates possible techniques to help wounds heal more effectively and to improve the appearance of existing scars by using patients’ own excess fat tissue and the stem cells it holds.

The new round of funding for the institute, which began in September 2013 and will last for five years, marked the start of AFIRM II. The Institute for Regenerative Medicine at Wake Forest University School of Medicine leads AFIRM II, which brings together 32 separate institutions to work with the U.S. Army Institute of Surgical Research and Walter Reed National Military Medical Center. AFIRM's goal is “to develop advanced treatment options for our severely wounded servicemen and women,” according to its website.

For one project, Katz and his team are working in the laboratory to explore whether they can prompt the body to heal wounds faster and with less scarring. Their starting point is the patient’s own fat. The researchers extract “a particular cell fraction from a patient’s fat and then combine it with other biological components to create a novel wound healing therapy that essentially ‘recycles’ a patient’s own excess fat tissue into a sophisticated but personalized bioactive adhesive bandage,” Katz says.

The so-called adhesive bandage actually would be a paste applied to the scar or wound to improve healing and prevent excessive contraction. Contraction, the pulling inward of wound edges, is a normal aspect of wound healing. But too much contraction can cause problems, such as skin that’s overly tight, which can restrict movement. These scar contractures can be painful and disfiguring, and may result in loss of function.

This approach is meant to enhance the healing of chronic wounds — such as those caused by diabetes — and to improve

the healing of wounds that result from trauma or cancer resection.

“In the case of wounded warriors, we’re usually talking about otherwise young, healthy patients who are in good shape,” Katz says. “They may have a big wound on their face. We’re trying to prevent or treat excessive contraction, because if the wound heals by too much contraction, then it will distort other parts of their face as it does so.”

Katz’s other project, aimed at making existing scars look and “feel” better, involves removing fat tissue from one part of a patient’s body using liposuction techniques, and injecting it under a scar at another site. Katz and his team are currently testing this potential procedure, called fat grafting, through a clinical trial funded by the U.S. Department of Defense under the first phase of the AFIRM program. The trial has sites at UF Health and at Brooke Army Medical Center in Fort Sam Houston in San Antonio, Texas.

In essence, Katz and his team harvest fat from a patient through several small incisions in the skin. They then wash the fat tissue and prepare it for immediate reinjection under an existing scar or skin graft at a different location, but on the same patient.

“The goal is to determine if this fat transplantation procedure can improve the appearance and/or quality of existing scar tissue,” he says.

If successful, this therapy would help people with traumatic wounds, such as those suffered in combat or a car accident, for example. Such traumatic wounds are prone to excessive contraction, and this method would be used to help ease contraction that already has occurred.

Both strategies Katz is exploring fall into a focus area that AFIRM describes as “skin regeneration.” UF Health is currently enrolling patients into the fat grafting clinical trial, while the cell-based therapy for wound healing is currently in the laboratory development stage.

Animal wound healing after two weeks of therapy This image shows fluorescent staining of an animal wound after two weeks of treatment with Katz's therapeutic paste that includes extracted fat cells. The white arrows point to new capillary-like structures forming in the wound, a part of the healing process.

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Areas with of Surgery Science Impact

"We’re trying to prevent or treat excessive contraction, because if the wound heals by too much contraction, then it will distort other parts of their face as it does so.”

— Adam Katz, MD

S E C T I O N 2 : S K I N R E G E N E R AT I O N | 4 1

“Dr. Cuenca is one of those rare individuals who has

the inclination, intelligence and enthusiasm to succeed as a surgeon-scientist at the highest levels."

Alex Cuenca, MD, PhD, is equally intrigued by research and patient care. His research efforts first earned national recognition when he worked as a biological scientist before starting medical school.

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— Lyle Moldawer, PhD

Training our next Generation

Alex Cuenca, MD, PhD

P R O F I L E : A L E X C U E N C A , M D, P H D

uf surgical resident excels as surgeon-scientist Alex Cuenca started his general surgery residency at UF in 2006, planning to become a surgical oncologist.

The first week of his rotation in pediatric surgery changed his mind.

“I helped take care of a child during that first week who was diagnosed with neuroblastoma, one of the more common types of solid malignancies in children,” Cuenca says. “It was tough. But, I knew after interacting with her and her parents and seeing the kind of effect that we could have on them that this was pretty much what I wanted to do.”

He has pursued a career as a pediatric surgeon ever since.

That isn’t his only dream. Inspired by his physician father and people who mentored him during his time working as a biological scientist and during residency, Cuenca also wants to be a basic science researcher. During his residency, he has earned a PhD through the College of Medicine’s Interdisciplinary Program in the Biomedical Sciences.

Cuenca’s first national research award came while he worked at the Moffitt Cancer Center before starting medical school at UF; in 1999, he earned a supplemental award from the National Institute on Aging. The UF Medical Guild gave him a Research Incentive Award in 2009 for a project studying sepsis in newborns. The following year, the National Institutes of Health awarded him a highly prized $52,000 postdoctoral fellowship grant to fund his research on proteins called toll-like receptors, which help to recognize infection. In subsequent years, his presentations of research that compared burns in humans with those in mouse models earned regional and national awards from the American College of Surgeons.

Cuenca continues his research on toll-like receptors, examining whether a compound produced by GlaxoSmithKline can stimulate a specific receptor called TLR-4 to cause a safe and effective immune response to infections in newborns.

Because of their immature immune systems, some newborns’ reactions to infection are insufficient and the children

do not survive.

Cuenca also investigates necrotizing enterocolitis — a condition in which large portions of a newborn’s intestinal tissue become diseased and die — in the laboratory of Shawn Larson, MB, ChB, an assistant professor of pediatric surgery at UF Health.

Cuenca sees the work he’s done and knowledge he’s gained so far as a solid foundation for a career that includes basic science research. He will complete his general surgery residency in June 2015 and plans to do a two-year pediatric surgery fellowship. He credits UF Health’s pediatric surgeons for showing him how appealing their field could be.

“All of the pediatric surgeons at UF have been fantastic role models in terms of clinical acumen and surgical skill,” he says. “I really see that it’s one of the last true general surgery specialties where you end up operating in nearly every part of the body.

You can definitely see how much influence they can have on somebody who’s interested in pediatric surgery, and their enthusiasm for the field is infectious.”

Cuenca says he also has learned much from his research mentor, Lyle Moldawer, PhD, the Department of Surgery’s vice chair of research and a professor in the department. Specifically, he mentioned Moldawer’s ability to translate clinical problems into a series of basic science questions to be investigated.

Moldawer says Cuenca’s talents and focus will take him far.

“Dr. Cuenca is one of those rare individuals who has the inclination, intelligence and enthusiasm to succeed as a surgeon-scientist at the highest levels,” he says. “He will be a true triple threat: surgically adept, with a critical scientific mind and unique communicative skills. It would be safe to say that he is on a trajectory that will take him to future leadership roles in academic surgery.”

SECTION 2: RESIDENT PROFILE | 43

B E T T E R P R E PA R E D

uf surgical residents now must complete two years of research during training

Not every UF surgical resident will choose to become a surgeon-scientist like Alex Cuenca, MD, PhD, has, but starting with the class of 2018 (those who began their residency in 2011), they’ll all be prepared to take that path.

Residents Bradley M. Schmit, MD, and Pu Yang, MD, study in the vascular research lab.

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Beginning with this class, every resident is required to dedicate two years to research, extending the length of the residency program from five years to seven. After two years of clinical training, each resident will work with an established researcher from the department faculty to select a topic to study. That topic will be his or her investigative focus for the next two years, under the supervision of the faculty mentor.

In rare cases, exceptions may be made for trainees in extraordinary circumstances, such as those in the country on a travel visa or committed to military service. The vast majority of residents, however, will get the extra research experience.

The requirement benefits trainees in several ways, said George Sarosi, MD, director of the department’s residency training program and an associate professor in the division of general surgery.

A primary benefit is sharpening trainees’ critical thinking skills in the areas of clinical and basic-science research, as well as evidence-based care, he says. The designated research period is especially pertinent for today’s residents, who must learn more forms of surgery than their predecessors did, and in less time.

“Time has progressed and residents face dutyhour restrictions,” Sarosi explains. “They spend less time training in surgery. At the same time, there are many more surgical skill sets that have come out. People who finished their training 15 and 20 years ago really just needed to learn how to do open surgical procedures. In 2014, there

are at least three major skill sets — probably four — that residents need to acquire. They need to become skilled at open surgery; they need to become skilled at laparoscopic surgery; potentially, they need to become masters of flexible endoscopy; and then, if they have an interest in vascular surgery, they also need to learn endovascular skill sets.”

With these demands, residents may find it challenging to develop expertise in one area during general surgery training. That’s where the program’s research requirement can help.

“If you’re a researcher and you’re the one who did the experiments, you actually know more about your research project than anyone else in the world,” Sarosi says. “It teaches them that becoming an expert is really a process, not just an issue of having 25 years of experience.”

The department’s two-year research requirement also will make UF residents more competitive as they seek clinical fellowships at premier institutions. In addition, it will elevate UF’s general surgery residency program. Sarosi notes that surgical training programs traditionally regarded as the best in the nation have a similar requirement or option.

The 2013-2014 academic year was the first in which all residents admitted under the twoyear research requirement were engaged in their investigations. Residents are examining a variety of fascinating topics, such as cancer stem cells and colon cancer, and the roles of specific biochemicals in the development of pancreatic cancer and aortic aneurysms, to name a few.

Training our next Generation

Kenneth DeSart, MD, is a research resident in UF's Department of Surgery.

“It teaches them that becoming an

expert is really a process, not just an

issue of having 25 years of experience.”

— George Sarosi, MD

SECTION 2: NEW RESIDENCY REQUIREMENT | 45

"I went to undergrad here and I wished I had somebody like me that

would say, ‘Yes, come see what medicine is like. Come see what surgery is like. Come to clinic. Come see if this is what you really want to do.' "

— Kfir Ben-David, MD

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Training our next Generation

from surgery to shadowing

In 2011, Chris Guido was preparing for his junior year of college at UF and a new season as the starting long snapper for the Gators football team when an unexpected medical problem sidelined him. “I was having some really bad groin and stomach pain,” he recalls.

UF athletic trainers told him they suspected he had a hernia and referred him to Kfir Ben-David, MD, an associate professor in UF’s Department of Surgery and an expert in operating on sports hernias.

After examining Guido, Ben-David told him he had one hernia and possibly more. An MRI revealed three. The hernias and the operation to repair them came at an inopportune time.

“That season, I did lose my starting job because my surgery was pretty much during preseason camp,” Guido says.

But Guido found something else to focus on. Ben-David, who regularly repairs sports hernias in athletes from UF and other schools, encouraged him to consider life after college and beyond football.

“I reminded him that football is just a sport,” Ben-David says, “that anybody could take that away from him and that his education is much more important.”

Guido was studying in the health science program in UF’s College of Public Health and Health Professions and told Ben-David he might want to become a doctor. That’s when BenDavid extended an offer any aspiring young physician would be thrilled to have: the chance to shadow Ben-David in his work with patients, both in the clinic and the operating room.

Ten undergraduate students have shadowed Ben-David since he joined the department faculty in 2007. Some are paired up with him through a UF College of Medicine class called Physician Shadowing, while others approach him on their own.

“I went to undergrad here,” Ben-David explains, “and I wished I had somebody like me that would say, ‘Yes, come see what medicine is like. Come see what surgery is like. Come to clinic.

Come see if this is what you really want to do.’ ” Guido took Ben-David up on the offer and first shadowed him in the clinic, where patient consultations and follow-ups take place. There, he met the medical students, residents and interns working on Ben-David’s team. The surgeon says contact with these people is a key benefit for students who shadow him.

“They have access to a medical student who recently went through the admission process,” he says . “I have them exposed to the residents and the residents talk to them about what a life of a trainee is like.”

Over the next two years, Guido watched Ben-David perform several surgeries, including at least one sports hernia repair and several esophagectomies, in which the surgeon removes a diseased part of the esophagus.

“It was just a really, really interesting procedure,” Guido says of one particular esophagectomy case. “The patient had cancer of the esophagus and it was a really intricate procedure. It took about four hours. I could just tell Dr. Ben-David had to be really creative in the operating room and really commanding.”

He also appreciated watching the surgeon-patient interaction in the clinic and the opportunity to process data for an educational research project Ben-David led. Guido is listed as a co-author on the article the research team published in the Journal of Laparoendoscopic Society. He is interested in pursuing research as part of his medical career.

Guido also has shadowed several other physicians at UF Health, including James Clugston, MD, an assistant professor in the Department of Family Health and Community Medicine and a team physician for UF athletes; Michael Moser, MD, an associate professor in the Department of Orthopaedics and Rehabilitation and the head team physician for UF athletes; and Seth Smith, MD, an assistant professor in the Department of Orthopaedics and Rehabilitation.

Guido began medical school at UF in 2014, and says he doesn’t know what type of medicine he will practice one day.

Surgery remains an option. Whatever practice area Guido decides to pursue, he says his shadowing experiences will help make him a better physician.

“I think I’ll have an appreciation for the whole staff and health care team.”

Ten undergraduate students have shadowed Ben-David since 2007, including Fred Bien-Aime, featured in this 2010 photo.

SEC TION 2: PHYSICIAN MENTORING | 4 7

plastic surgery residency offers a quicker path through training

The department of surgery’s training program in plastic and reconstructive surgery is making its way toward a major change.

The residency’s current format, called the independent format, provides three years of plastic and reconstructive surgery training to surgeons who have completed an initial residency in general surgery or another area of surgical training. One resident begins the program each year.

The independent residency will be completely phased out in 2015 in favor of the integrated format, which takes in new medical school graduates for a six-year program.

“Medical students electing to train in plastic and reconstructive surgery can do so directly out of medical school by matching into an integrated program, like this one,” explains Michele Silver, MEd, assistant director of education and coordinator of UF’s general surgery residency program. “Students going into an integrated program will only have to be concerned with one program and one interview and match cycle.

Integrated training shortens the training period for students who are prepared to commit early to specialty training and attracts some of the most competitive students, because it is an accelerated program.”

The division of plastic and reconstructive surgery’s first resident in the integrated program began training in July 2013. As with the independent format, one new resident will join

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the program each year.

Unlike the independent format, all residents in the new integrated program will undergo training in various surgical rotations for their first three years, including trauma, critical care, general surgery, burn surgery, orthopaedics, emergency medicine and anesthesiology. Each of those three years also will include a rotation in plastic and reconstructive surgery. The following three years will consist solely of intensive plastic and reconstructive surgical training.

“They’ll spend a lot of time in general surgery training and becoming skilled in the care of surgical patients,” Silver says. “Then they’ll become purely a trainee in the plastic surgery area. It’s integrated in that both programs, general surgery and plastic surgery, are working together to produce plastic surgeons.”

Residents in the integrated program will study all aspects of plastic and reconstructive surgery, just as those in the independent format now do, including congenital anomalies, head and neck cancer, craniofacial trauma, reconstructive and cosmetic breast surgery, abdominal and lower extremity reconstruction, microsurgery, hand and peripheral nerve surgery, burns, cosmetic surgery and laser surgery. They also will train in nonsurgical aesthetics, dermatology and oral surgery.

In addition to clinical duties, residents in the integrated program will benefit from a rigorous didactic education program and are expected to complete at least one scholarly project.

One notable difference between the two types of residency programs is that doctors who complete only the integrated residency in plastic surgery will be eligible for board certification in plastic surgery but not in general surgery. Those who complete a general surgery residency and an independent format residency in plastic surgery would be eligible for board certification in both disciplines. However, the integrated format allows participants to complete general and specialized residency training in just six years, instead of eight or more.

Training our next Generation

“I am really excited to be a part of such a great new residency here at

the University of Florida. I feel honored to start my surgery experience with such a solid foundation in general surgery, and I am looking

forward to continuing through plastic surgery over the next few years.”

— Noah Prince, MD, the department's first resident in UF's integrated plastic surgery program

SECTION 2: PLASTIC SURGERY RESIDENCY CHANGES | 49

Ashley Lentz, MD

volunteering abroad to help underserved children

UF Health pediatric plastic surgeon Ashley Lentz, MD, is actively involved with overseas travel for cleft lip and palate missions. Currently, she travels with and teaches residents from the University of Florida and Cleveland Clinic in Honduras each year with Interplast South Inc., based in Gainesville, Florida. She also is actively involved with the Global Smile Foundation, a not-for-profit corporation that focuses on alleviating the suffering of underserved patients born with facial congenital deformities. The foundation has a special focus on children with cleft lips and palates.

"One of my favorite ways to travel is with a group of highly motivated, like-minded people," says Lentz. "The volunteers for medical mission work tend to be selfsufficient, resourceful, highly adaptable and just plain fun.

By the end of the trip, you feel as though you know these team members as well as you know your own family."

Lentz also explains that medical mission patients and local health care staff are always incredibly welcoming.

"Yes, we provide a great service for the local people, but their hospitality is incredible. They make us feel valued and appreciated. It’s a wonderful relationship that continues to grow stronger with every mission," she says.

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Honduras

Photos of this UF Health patient before and after treatment show the kind of improvement cleft lip and palate repair can make for some children. This child was treated in the United States.

Reaching Out

Robert Feezor, MD

Germany

volunteering abroad to help military veterans Robert Feezor, MD, an assistant professor of surgery in UF’s division of vascular surgery and endovascular therapy, returned in February 2013 from a two-week rotation at Landstuhl Regional Medical Center in Germany. While there, he helped care for U.S. military members who needed urgent care after being critically injured in Afghanistan.

“This was my first experience volunteering at LRMC,” says Feezor. “I have no military background, but I was drawn to this opportunity by the desire to say thank you in some way to the women and men who give me the right to exercise all the liberties I have at home.”

Feezor explains that the LRMC is a stopping point where soldiers can be stabilized before returning to military hospitals in the United States. It is the largest American hospital outside the United States and an American College of Surgeons Level 1 Trauma Center. Since 2001, the medical staff at LRMC has treated more than 64,000 patients from Iraqi Freedom and Operation Enduring Freedom.

“Surgeons at LRMC were more than capable of handling everything surgical, so I mostly provided moral support and back up for them," Feezor says. "I was honored to be there and was amazed at the respect I was given which, in my opinion, should have been reversed. Those men and women — the patients, the doctors and all the staff at LRMC — were spectacular. I will definitely volunteer again in the future, and would urge all surgeons to do the same.”

SECTION 2: OUTREACH IN GERMANY AND HONDURAS | 51

working together to improve vascular surgery outcomes

The Florida-Georgia Vascular Study Group began in 2011 under the leadership of Adam Beck, MD, an assistant professor of surgery in UF's division of vascular surgery and endovascular therapy. Beck started the group, originally called the Florida Vascular Study Group, as a way to bring together vascular surgeons from medical centers across the state to compare notes, evaluate outcomes for patients and work toward quality improvement.

“Patients with vascular disease tend to have some of the most complicated and challenging medical problems that any physician must deal with,” Beck said in 2011. “The procedures performed and the conduct of the patients’ care can vary widely between surgeons, hospitals and regions, making identification of best practice difficult.”

Georgia centers started joining in 2012, and the group changed its name accordingly.

The group is a regional one under the auspices of the national quality effort established by the Society for Vascular Surgery, known as the SVS Vascular Quality Initiative. The national group fosters regional collaboration among physicians and hospitals to collect and analyze clinical data from patients undergoing vascular procedures.

With oversight by the society’s quality initiative and its associated Patient Safety Organization, regional groups collect procedural data and information about preoperative and postoperative care. This allows benchmarking of outcome variables so physicians can identify best practices and areas for quality improvement.

The national organization’s web-based dataentry system allows real-time benchmarking of outcomes after vascular procedures on a per-surgeon or per-center basis, which can inform quality improvement discussions.

More than 100 surgeons from 19 medical centers across Florida and Georgia are members

5 2 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

of the group. Together, they have collected quality improvement data for nearly 5,000 procedures. These data can be compared with data housed in the national database from more than 100,000 procedures, providing a tremendous resource for developing quality improvement initiatives and benchmarking outcomes.

Currently, one of the Florida-Georgia group’s key initiatives is using their recently developed smoking cessation protocol to help patients stop smoking. Smoking has major implications for the success of vascular procedures, and the patients’ long-term cardiovascular health, and quitting smoking has been shown to reverse some of the effects of tobacco. Beck and Yuming Lim, MSM, the Florida-Georgia study group coordinator and database manager, are leading these efforts.

The Florida-Georgia Vascular Study Group’s fall 2013 meeting took place at Florida Hospital in Orlando, and attendees discussed the group’s data, benchmarked against national data.

They also discussed ongoing regional and national quality improvement efforts, as well as new efforts that are in development in the region. These include efforts to reduce venous blood clots after major surgery, and efforts to increase the retrieval of vena cava filters placed prophylactically to prevent pulmonary embolism after trauma or recent surgery.

Reaching Out

The national group fosters regional collaboration among physicians and hospitals to collect and analyze clinical data from patients undergoing vascular procedures.

Adam Beck, MD

S E C T I O N 2 : S E C T I O N 2 : O U T R E A C H T O I M P R O V E PAT I E N T C A R E   |   5 3

cancer follow-up begins couple’s decades-long relationship with department of surgery Two of the department’s most faithful givers over the years have been John and Betty Payne, retirees from Detroit who moved to Florida in 1980 to enjoy the state’s sunshine and warmth.

John relied on Edward R. Woodward, MD, the first chair of the department, for follow-up care to check for a return of his colon cancer. He originally received treatment for the disease in Michigan. His cancer never recurred.

The couple made their first gift in 1990 after reading about research and patient care efforts in a UF Health Science Center newsletter. John later told a writer for the center’s Saturday Evening Post magazine that his own health problems and hospital stays motivated the couple to donate to a healthrelated cause. After the initial donation, the couple made 17 more, including designating a gift for the department in their estate planning. Altogether, the

gifts amount to a little more than $500,000.

In addition to giving, the couple also maintained a relationship with the department, attending various hospital tours and special events. Betty recalls watching UF football games from a special area of the Swamp, enjoying the food provided for them and the company of George Cawthon, a development officer with the University of Florida Foundation.

John died in December 2013 and Betty, now 92, still lives at their home in Stone Mountain, Georgia, near her nieces. The couple had no children.

Betty still receives invitations to department events, though these days she finds it more difficult to attend. But she looks back fondly on the relationship she and John developed with the university and the Department of Surgery.

“Everybody has been very good to us,” she says.

we sincerely thank our top donors for their gracious support.* Dr. and Mrs. Kevin E. Behrns

Dr. and Mrs. N. Joseph Espat

Dr. William C. Lineaweaver

Mr. and Mrs. Jon D. Caminez

Dr. Timothy Flynn and Dr. Marian Limacher

and Ms. Jane Y. Wood

CHERUBS

Dr. and Mrs. Leonard T. Furlow Jr.

Mrs. Joel W. Mattison (Jean)

Dr. and Mrs. Edward M. Copeland III

Dr. and Mrs. Braun Graham

Dr. and Mrs. Anthony M. McDonald

Mr. and Mrs. Franklin W. Costner

Mr. and Mrs. Mark L. Horwitz

Medtronic Inc.

Cracchiolo Foundation Inc.

Dr. and Mrs. David W. Kays

Dr. Wyndell H. Merritt

Mr. and Mrs. William R. Curry

Dr. and Mrs. Mark C. Kelley

Dr. and Mrs. Kevin T. Nini

Dr. and Mrs. Jose Erbella

Lifecell Corporation

Dr. and Mrs. C. Keith Ozaki

5 4 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

Giving

Betty Payne sits with her niece and an honorary plaque given to her by the department.

Dr. John Rectenwald and Dr. Rebecca Minter Mr. and Mrs. Paul A. Robell Dr. and Mrs. M. Brent Seagle Senator and Mrs. Jeff B. Sessions St. Jude Medical Inc. Terumo Cardiovascular Systems Corporation We would also like to thank our many donors who wish to remain anonymous. * Names reflect those who gave between July 1, 2012 and June 30, 2014.

S E C T I O N 2 : J O H N A N D B E T T Y PAY N E   |   5 5

Fiscal Year 2012 Grant Funding by Service Line

Fiscal Year 2013 Grant Funding by Service Line

Burn Surgery

Burn Surgery

8000= 2000= $46,663

Total: $57,894

$11,231

$155,068 $75,983

$696,081 $173,873

Total: $231,051 NIH total: $231,051

7400= 2600= $64,538

Total: $869,954 NIH total: $9,721

$74,313

NIH total: $178,189

Total: $92,891

$977,163

$3,384,761 $805,080

Total: $3,974,783 NIH total: $3,077,475

$3,497,777

$1,578,5007

FY2012 active grants and clinical trials – 82 (50 were clinical trials)

5 6 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

$768,178 $223,174

Total: $991,351 NIH Total: $175,071

8000= 2000= $953,329 $218,122

Total: $1,171,452 NIH total: $9,721

7100= 2900= $333,427

Total: $469,297 NIH total: $409,945

7500= 2500= $3,500,930 $1,163,620

Total: $4,926,289 NIH total: $4,138,881

Vascular Surgery

Total: $4,189,841 NIH total: $3,089,632

Research

6900= 3100=

NIH Total: $15,892

General Surgery

Vascular Surgery

8000= 2000=

8000= 2000=

$135,870

General Surgery $2,997,620

$32,793

Total: $157,447

Trauma Surgery

$18,578

7500= 2500=

$124,654

Thoracic and Cardiovascular Surgery Total: $257,303

Transplant Surgery

8000= 2000=

8000= 2000=

Plastic and Reconstructive Surgery

Trauma Surgery $192,765

Total: $101,531

Pediatric Surgery

Thoracic and Cardiovascular Surgery

8000= 2000=

$81,813 $19,718

Plastic and Reconstructive Surgery

6700= 3300=

8000= 2000=

8000= 2000= $4,036,161 $890,128

Total: $4,926,290 NIH total: $3,748,911

Research

Total: $5,076,277 NIH total: $5,016,386

7000= 3000= $3,017,190 $1,264,709

FY2013 active grants and clinical trials – 107 (57 were clinical trials)

Total: $4,281,899 NIH total: $4,281,899

Research Milestones

Fiscal Year 2014 Grant Funding by Service Line Burn Surgery

8000= 2000= $96,486

Total: $120,239

$23,753

= Direct Funds = Indirect Funds

Pediatric Surgery

8700= 1300= $35,499

Total: $40,644

$5,145

Plastic and Reconstructive Surgery

8000= 2000=

Total: $1,178,521 $893,795 $284,726

NIH Total: $175,071

Thoracic and Cardiovascular Surgery

8000= 2000= $829,928 $211,991

Total: $1,041,919 NIH Total: $9,721

Trauma Surgery

7100= 2900= $539,677 $238,555

Total: $778,232 NIH total: $601,338

General Surgery

7500= 2500= $2,193,614 $763,463

Total: $2,957,077 NIH total: $2,536,074

Vascular Surgery

8000= 2000= $4,163,500 $948,075

Total: $5,111,575 NIH total: $4,120,499

Research

7100= 2900= $3,558,442

Total: $4,969,506

NIH total: $4,969,506 $1,411,064

FY2014 active grants – 96 (51 were clinical trials)

SEC TION 2: RESEARCH MILESTONES | 5 7

Fiscal Year 2012-2014 Physician Visits Burn Surgery

209= 256= 174= 509 556 474

General Surgery

5251525 + 1= 5352535 + 2= 5259525 + 9= 10,502 10,704 10,518

Pediatric Surgery

3013301 + 3= 3038303 + 8= 3143314 + 3= 3,013 3,038 3,143

Plastic and Reconstructive Surgery

7918= 8532= 9134= 7,918 8,532 9,134

Thoracic and Cardiovascular Surgery

1761176 + 1= 1543154 + 3= 2171217 + 1= 1,761 1,543 2,171

Vascular Surgery

6358= 6452= 6861= 5,358 5,452 5,861

Transplantation Surgery

1257125 + 7= 1552155 + =2 2171217 + 1= 1,257 1,552 1,905

Trauma Surgery

1539153 + 9= 1192119 + =2 1620162 + 0= 1,539 1,192 1,620

FY2012 Resident Graduates

FY2013 Resident Graduates

General Surgery Matthew Delano, MD, PhD Matthew Hughes, MD Tad Kim, MD Bo Neichoy, MD Elizabeth Warner, MD

General Surgery Josef Braun, MD Robert E. Lee Browning IV, MD Claire Griffin, MD Luke Gutwein, MD Constance Lee, MD

Minimally Invasive Surgery Georgios Rossidis, MD

Minimally Invasive Surgery Husain Abbas, MBBCh Pediatric Surgery Anne Kim, MD

Pediatric Surgery Ami Shah, MD Plastic and Reconstructive Surgery Puya Davoodi, MD Thoracic and Cardiovascular Surgery Fawad Khawaja, MD (Superfellow, Thoracic Transplantation and Mechanical Circulatory Support) Paul Tessman, MD Vascular Surgery Alexis Jacob, MD Arne Olsen, MD Surgical Critical Care Alejandro Garcia, MD Arthur Jason Vaught, MD

5 8 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

Plastic and Reconstructive Surgery Melinda Keener, MD Thoracic and Cardiovascular Surgery Junewai Reoma, MD Vascular Surgery Alyson Waterman, MD, MPH Surgical Critical Care Vanessa Cranford, MD Dawood Dalaly, DO

2012 Total:

31,857 2013 Total:

32,569 2014 Total:

34,826

Educational & Clinical Milestones

Fiscal Year 2012-2014 OR Cases Burn Surgery

Thoracic and Cardiovascular Surgery

187= 85= 117=

180= 177= 193=

678

960

585

957

617

973

General Surgery

2142= 2410= 2707=

Vascular Surgery

Pediatric Surgery

Transplantation Surgery

1586= 1618= 1831=

2,143

1,586

2,410

1,618

2,707

1,831

2018= 1749= 1685= 2,018

361

1,749

444

1,685

447

Plastic and Reconstructive Surgery

61= 44= 47=

Trauma Surgery

124= 138= 172=

1195= 1221= 1410=

895

1,195 1,221

949

1,410

1,088

2012 Total:

9,836 2013 Total:

9,933 2014 Total:

10,758

FY2014 Resident Graduates General Surgery William Campbell, MD Trajan Cueller, MBBCh Lindsey Goldstein, MD Michael Hong, MD Makesha Miggins, MD

Surgical Critical Care Brandy Cross, MD Martin Rosenthal, MD Transplantation Surgery Rupak Kulkarni, MBBS, MS

Minimally Invasive Surgery Isaac Motamarry, MD Pediatric Surgery Ana Ruzic, MD Plastic and Reconstructive Surgery Carlos Rivera-Serrano, MD Mark Leyngold, MD (Superfellow, Aesthetic Surgery) Thoracic and Cardiovascular Surgery Thomas Caranasos, MD Ryan Mellor, MD Vascular Surgery Michael McNally, MD Gabriela Velazquez -Ramirez, MD

S E C T I O N 2 : E D U C AT I O N A L & C L I N I C A L M I L E S T O N E S   |   5 9

what's next

We strive to continually advance our department. Over the next year, we will focus on the following goals to improve our clinical, research and education missions: • Continue to improve access to our unique surgical specialty care through novel approaches using telemedicine and partner-like relationships with referring physicians in our network • Collaborate with other UF Health entities to develop a campuswide institute that advances the surgical care of all patients in the state of Florida • Adopt an educational program that challenges our trainees to think critically about each patient or research decision We look forward to continuing to grow our relationships with our colleagues at UF Health, with physicians in Florida and nationwide and with our research and educational partners to ultimately improve what’s most important to us all: quality patient care.

6 0 U F H E A LT H | U F D E PA R T M E N T O F S U R G E R Y

University of Florida Department of Surgery P.O. Box 100286, Gainesville, FL 32610 352.265.0646 / surgery.ufl.edu