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TODAY news for Thursday, March 31, 2008

Loma Linda University Medical Center news

Giving Baby Jason a new lease on life with minimally invasive surgery

Baby Jason, also known as Jason Daniel Alvarado, takes a break from his nap before dozing off again.
Baby Jason, also known as Jason Daniel Alvarado, takes a break from his nap before dozing off again. Although he was only five weeks old at the time the picture was taken, he had already earned the distinction of being the first infant to undergo minimally invasive surgery at Loma Linda University Children’s Hospital. According to his doctor, Edward Tagge, MD, the prognosis is very good for Baby Jason.
Baby Jason doesn’t look like a medical milestone. In fact, with his big, bright eyes and bountiful crop of dark hair, he looks like an ordinary 5-week-old boy. But Baby Jason is truly one-of-a-kind thanks to a revolution in surgical procedures that recently found its way to Loma Linda University Children’s Hospital, thanks to Edward Tagge, MD.

Baby Jason Daniel Alvarado was born with a congenital diaphragmatic hernia, or CDH. In lay terms, his entire abdominal contents—including stomach, intestines and spleen—had forced their way into his chest cavity and crowded the space his left lung should have occupied. Not only was the left lung substantially underdeveloped, but his aggressive intestines were also crowding into the right side of his chest and preventing that lung from properly developing as well.

Needless to say, when doctors informed Bill and Shelly Alvarado that approximately 50 percent of infants born with CDH do not survive, they became very concerned about their son. “They didn’t tell us that he was going to have the surgery until almost a week after we found out about the disease,” Shelly recalls.  

When Bill and Shelly learned that a pioneering microsurgical procedure, which had never before been performed at Loma Linda University Children’s Hospital, was available for Baby Jason, they were hopeful, yet skeptical.

But as Edward Tagge, MD, pediatric surgeon at Children’s Hospital and professor of surgery and pediatrics in the LLU School of Medicine, explained the advantages of minimally invasive surgery (MIS) over conventional operations, the couple warmed to the idea. “We felt really good once we found out the surgery was available,” Bill shares.

The new procedure—thoracoscopic repair of CDH—uses a series of diminutive tools and drastically reduces the size of the cuts made to the infant’s body. MIS also reduces the post-surgical trauma the patient must end
Edward Tagge, MD, holds minimally invasive surgery (MIS) instruments in the palm of his hand. Using the diminutive instruments, Dr. Tagge performed a thoracic repair of a congenital diaphragmatic hernia on Baby Jason Alvarado.
Edward Tagge, MD, holds minimally invasive surgery (MIS) instruments in the palm of his hand. Using the diminutive instruments, Dr. Tagge performed a thoracic repair of a congenital diaphragmatic hernia on Baby Jason Alvarado. The operation was the first MIS procedure to be performed at Loma Linda University Children’s Hospital.
ure during the healing and recovery period, and decreases the likelihood of skeletal disorders developing later in life.

Dr. Tagge explains the operation in these terms. “Basically,” he says, “we pushed his intestines and spleen out of his chest, down through the hole in his diaphragm, and back into his abdominal cavity where they belong.  We then closed the diaphragmatic hole to seal his chest from recurrent encroachment by his intestines. Then we sewed him up with miniature needles and sutures.”

The diaphragmatic hole he mentions is the hernia itself. It’s the same opening between the abdominal region and chest cavity through which the intestines migrated during fetal development. But thanks to the successful surgery, Dr. Tagge is confident that Jason’s underdeveloped lung “will slowly enlarge over a period of months and years.” 

If Edward Tagge’s name isn’t exactly a household name in this part of the world, that might be because he’s only been at Loma Linda since September of last year. Prior to that time, he was actively honing his command of MIS procedures at Medical University of South Carolina, in Charleston, where he served as professor of surgery and pediatrics for the last 17 years.

That doesn’t mean he’s a newcomer to Southern California, however. As one of eight children in his family of origin, Dr. Tagge felt it was important for his kids to deepen their relationships with his siblings and their children who live in the area; hence, the decision to accept the offer at LLUCH. His passion for innovative medicine is likewise a family matter. His father was Garth F. Tagge, MD, a prominent internist and cardiologist in Orange County for nearly 50 years, who served as chief of medical staff at both St. Jude Medical Center in Fullerton and Anaheim Memorial Hospital, as well as serving as a clinical professor at the University of California at Irvine.

Even though Dr. Edw
Bill and Shelly Alvarado are pictured above with their son, Baby Jason. The infant was the first infant recipient of minimally invasive surgery at Loma Linda University Children�s Hospital.
Bill and Shelly Alvarado are pictured above with their son, Baby Jason. The infant was the first infant recipient of minimally invasive surgery at Loma Linda University Children’s Hospital. Edward Tagge, MD, the pediatric surgeon who operated on Baby Jason, moved the boy’s intestines out of his chest cavity utilizing very small surgical instruments.
ard Tagge has only been in town for five months, he is recognized as something of a heavy hitter in the national medical community. He has been repeatedly included in both the Woodward/White, Inc. list of “The Best Doctors in America” and the Consumer Research Council of America’s “Guide to America’s Top Surgeons.” But he’s too excited about evangelizing his colleagues at Children’s Hospital on the advantages of MIS to let the accolades go to his head.

“Looking at the big picture,” he says, “MIS was pioneered in adults and then tried in adolescents. We are starting to take those techniques and apply them for diseases in newborn babies, as a large percentage of operations can now be performed on a very small scale.” He goes on to report that newborn MIS procedures are currently offered at a variety of select, high-level children’s hospitals around the country, which now includes Loma Linda.

A look inside his instrument case confirms the assertion about the scale of the equipment Dr. Tagge uses. Compared with standard-sized scalpels and surgical tools, these instruments are precise, yet elfin-scaled miniatures.

“An important tool is the TROCAR,” he explains, holding up a small black tube less than half the width of his pinky finger. Once the initial cut has been made, the TROCAR is partially placed into the appropriate body cavity. It allows very small surgical tools to enter the patient’s body through the interior of the TROCAR tube. Like the interchangeable drill bits of a carpenter’s bag, a large variety of miniaturized surgical instruments can be sent through the tube to perform a variety of specialized tasks—including dissecting, cutting, cauterizing, grasping, and sewing—inside the tiny patient.

The TROCAR also performs another crucial role in the surgical process: It introduces gas into the body cavity. “This allows the surgeon—who is performing the surgery by viewing the procedure on a video screen—to see what he’s doing,” Dr. Tagge explains. The harmless gas fills the spaces inside the body and allows the surgeon to maneuver the sharp surgical tools with a high degree of precision.

Ironically, Dr. Tagge reports that in the beginning, MIS caught on slowly with many of the established senior practitioners of the surgical community, while their younger counterparts embraced the new technology at a much faster pace. Interestingly, the reason for this generational disparity centers around the toys each group enjoyed as children.

“A lot of senior surgeons who did not grow up playing with Nintendo or PlayStation, had difficulty turning the two-dimensional TV screen into a three-dimensional model of what’s going on inside the patient,” Dr. Tagge explains. “The idea of watching a procedure performed onscreen, instead of in situ, required significant retraining for some senior surgical staff members.”

Nevertheless, Dr. Tagge is confident that minimally invasive surgery for newborns will find a welcome at Children’s Hospital once word gets out about the two significant advantages it offers over conventional methods: First, MIS leaves a very small footprint on the patient’s body. In Baby Jason’s case, he will grow up with three tiny cut marks instead of a large, unsightly abdominal scar.

“Cosmetically, there is no question that MIS is better for the patient,” Dr. Tagge asserts. The second advantage is equally compelling. “A certain percentage of children who have traditional open surgery develop problems related to their large incisions,” Dr. Tagge observes. “For instance, it is well-known that large chest incisions in infants can cause skeletal disorders, such as scoliosis, later on. But with MIS, this morbidity disappears.”

Overall, Dr. Tagge is very pleased at the way Baby Jason’s operation turned out. “I saw this first neonatal procedure at Loma Linda as a way to get the conversation on MIS going,” he says. Dr. Tagge is convinced MIS will soon become standard operating procedure (pun intended) at LLUCH for a large variety of newborn surgical conditions. An important contributing factor to his optimism is that LLUCH already has the requisite team of highly trained staff necessary to the success of MIS procedures.

“In addition to the highly specialized surgical instruments, high-tech cameras and imaging systems, neonatal MIS cannot be successfully performed without concomitant expert anesthesia, neonatology, and operating room professionals,” he notes. “Fortunately, all those individuals are readily available at Children’s Hospital.”

For his part, Baby Jason didn’t have much to say about the high-tech operation that corrected his medical condition and prolonged his life. He did manage to open one eye just long enough for the photographer to snap his picture, but half a moment later he was back to the serious business of grabbing some Zs.

He can always thank Dr. Tagge when he’s old enough to know what happened.

By James Ponder

TODAY news for Thursday, March 31, 2008