N E W Y O R K – P R E S B Y T E R I A N DIGESTIVE DISEASES DIGESTIVE DISEASES

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Spring 2007 ACS Recognizes New Technology for Pancreatic Advances in Cancer Shines in Early Trials

Obesity Therapy . D M

ith few signs in its earliest stages , s n he American College of Surgeons and later symptoms that mimic e v e t S

(ACS) recently accredited the those of many other illnesses, . D

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NewYork-Presbyterian Hospital pancreatic cancer is notoriously difficult to r e t T e P

Center for Obesity as a Center pinpoint. However, a new fiber-optic device f o

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of Excellence, inducting the program being tested at NewYork-Presbyterian s e t r

into its Center Hospital/Columbia University Medical Center u o c

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Network. may ultimately enable physicians to diagnose o h

In recognition of the Center’s high the disease with visually directed biopsy. P level of care and superior facilities, the The new instrument, a choledochoscope A SpyGlass endoscopic image of the pancreatic ACS designated it a top-rated 1A facili- known as the SpyGlass System, will soon be duct shows neoplastic mucosa appearing like a ty, the first such honor given in New launched by Boston Scientific Corporation. A crescent moon (lower left) in a patient with intraductal papillary mucinous neoplasms. York State. The accreditation applies to choledochoscope is an extremely small scope the programs at both Centers of designed to examine the interior of the common and is used in concert with NewYork-Presbyterian: the Weill endoscopic retrograde cholangiopancreatography (ERCP). Endoscopists at NewYork- Cornell Weight Loss Surgery Center and Presbyterian/Columbia perform nearly 1,000 ERCP procedures per year. the Columbia Center for Weight Loss “It’s a tool to visualize in real color and real time what’s going on in the [gastroin- Surgery. As leaders in their field, the testinal] tract,” said Peter D. Stevens, MD. “It builds on technologic advances in bariatric surgeons of NewYork- fiberoptics, which have gotten much easier to make and less expensive.” Presbyterian are also called on to help The system consists of a 6,000-pixel choledochoscope that can be reused approxi- the ACS evaluate other institutions. mately 20 times, a disposable delivery catheter that enables the delicate fiber to travel “There has been a huge growth in the further into the body, accessories for taking tissue samples or removing stones, and number of places doing bariatric surgery capital equipment such as a monitor, cart, and light source. over the past 5 years, but not all are SpyGlass offers several advantages over previous choledochoscopes, which first achieving a high level of excellence,” see SpyGlass, page 8 said Marc Bessler, MD. “Patients can greatly benefit from this surgery, but Case Study: Crohn’s Disease Pediatric Capsule Archived Web Cast elective operations that are high-risk The application of new options should be done in centers such as ours 2 available for the treatment of IBD. Advances in Colorectal Cancer Therapies that have been recognized for their Web Cast Jill Roberts IBD Center June 20, 2007 expertise.” New center fosters collaboration, “Pure” laparoscopic versus “hand-assisted” laparoscopic The prestige of the accreditation E innovation in the treatment of IBD. surgery; new approaches to minimally invasive surgery. D 4 holds another important benefit for I Update in Gastroenterology 2007 CME S patients: better insurance coverage. Crohn’s Disease June 22-23, 2007 N “There’s a direct relationship between I Fabrizio Michelassi, MD, pioneered a Simultaneous broadcasts in New York and Moscow. accreditation as a Center of Excellence 5 surgical technique more than a decade ago; today, it continues to improve News flash: Columbia doctors perform revolutionary and [reimbursement] by the Centers for patient outcomes. procedure to remove a patient’s gall bladder. Medicare & Medicaid Services (CMS). For more information, please visit ES www.nypdigestive.org AT see Obesity, page 6 PD U N E W Y O R K – P R E S B Y T E R I A N The case was discussed with Peter D. Green, MD, and an overlap with celiac DIGESTIVE DISEASES disease was excluded by serologic evalua- tion including antigliadin, antiendomysial, and antireticulin antibodies. A small Case Study: Considering New bowel series was performed at the Jill Roberts Center to further rule out celiac Options in the Treatment of IBD disease and to define the extent of ileal Crohn’s disease. The X-ray images showed The Case possible abscess in the right lower quad- 3 strictures in the distal 2 feet of the A 20-year-old woman diagnosed with rant. She was treated aggressively with ileum, with what appeared to be some Crohn’s ileocolitis presented to the Jill I.V. antibiotics. A second CT scan showed obstructive component with mild dilation Roberts Center for Inflammatory Bowel a resolution of the abscess, but no of the loops proximal to the strictures. Diseases (IBD) at NewYork-Presbyterian improvement in the other findings. There was a long segment of relative nar- Hospital/Weill Cornell Medical Center for indicted an ulcerated ter- rowing 9 to 10 cm in the distal ileum and a second opinion regarding her severe minal ileum and a segmental colitis 10 cm from the ileocecal valve. There was weight loss and loss of response to inflix- involving the cecum, the right and trans- no evidence of fistula or abscess.

imab therapy. verse colons, and the rectosigmoid. The . D

The woman’s medical history had been was relatively spared, with only M

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one of progressive decline. She had been in patchy hyperemia and no fistula noted. e h c S

perfect health until summer 2005, when The patient was started on infliximab . J

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she suddenly developed new-onset diar- 5 mg/kg, with a 3-dose induction, at zero, e l l E

rhea, which failed to subside. She subse- 2, 6, followed by every 8 weeks. Her aza- f o

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quently detected traces of blood in her thioprine dose was increased to 100 mg. s e t r

stool. Presenting to an outlying hospital She remained on prednisone 50 to 60 mg. u o c

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emergency room, she was found to have a By summer, she had 7 infusions of inflix- t o h

hemoglobin level of 5 g/dL. imab and was able to come off the P Upon admission, the woman under- steroids. Initially, she regained much of went a computed tomography (CT) scan, the lost weight. which showed extensive segmental colitis. In December 2006, she presented to She was started on intravenous (I.V.) the Jill Roberts Center with a 40-lb Small bowel series showing 3 strictures in the antibiotics, ciprofloxacin and metronida- weight loss and more than 10 watery, distal 2 feet of the ileum with mild dilation. zole, and I.V. steroids. semiformed bowel movements per day.

.

After 2 weeks, she was discharged She was no longer responding to inflix- D M

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home on oral antibiotics, prednisone, and imab and was considered refractory to l r e h mesalamine (Pentasa). Within 1 week, she mesalamine, azathioprine, and steroids. c S

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developed new-onset tachycardia, and in a The clinical question became: What was n e l second hospitalization was diagnosed to causing her attenuated response to inflix- l E

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have Wolff-Parkinson-White syndrome. imab? What are her surgical options? y s e After undergoing ablation, she developed t r u o c

a thrombosis secondary to ablation that Discussion o t o

required anticoagulation therapy. Because According to Ellen J. Scherl, MD, the h she was still on steroids, she was started patient’s failure to respond is typical of P on low-dose azathioprine. many cases seen at the Jill Roberts Center. Over the next 4 months, the patient’s One explanation in this case, Dr. Scherl Crohn’s symptoms gradually improved said, was that the patient had become Severe left-sided colitis with deep ulcerations. with steroids and low-dose azathioprine, resistant to infliximab. Other possibilities but she never went into remission. She were that she needed a higher dose or had A colonoscopy indicated severe left- was having 3 to 4 semiformed bowel developed strictures that were not improv- sided inflammation from the anal verge movements per day, and her weight was ing on the medication. An option was to to the splenic flexure with narrowing at down from 138 to 115 lb. In January shorten the interval between infliximab 5 to 10 cm and then 20 to 30 cm. Above 2006, she began to have 10 to 15 bowel infusions and increase the dose while eval- the splenic flexure the colon appeared movements per day, and by February she uating whether the patient had developed normal, and there was a narrowing of the weighed 85 lb. antibodies to infliximab or was a true terminal ileum. Biopsies showed focally During a subsequent hospitalization, a nonresponder (with therapeutic levels of active colitis. No granulomas were seen CT scan showed extensive thickening of infliximab in her blood but no antibodies and upper endoscopy showed no gastro- the entire colon and distal ileum, and a to infliximab). duodenal Crohn’s disease.

2 www.nypdigestive.org “We could increase the patient’s med- NewYork-Presbyterian Digestive Diseases ication or discuss a clinical trial,” Dr. is a publication of the Digestive Diseases Centers of NewYork-Presbyterian Hospital. The Digestive Diseases Centers are Scherl said, “but we need to consider at the forefront of research and practice in the areas of gastroenterology; GI surgery; and , bile duct, and pancreat- surgery for her obstructive symptoms. ic disorders. NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-Presbyterian She’s losing weight because she is not Hospital/Weill Cornell Medical Center are respectively affiliated with Columbia University College of Physicians and eating, due to pain from these partial Surgeons and Weill Cornell Medical College. obstructing lesions in the small bowel. Is she going to get away with ileal sur- NewYork-Presbyterian gery alone? No, because she has had sig- Digestive Diseases Editorial Board nificant colonic disease,” said Dr. Scherl. “However, her weight loss is related to partial obstruction,” she added. John Chabot, MD Mark Pochapin, MD Chief, Division of GI and Endocrine Surgery Director, The Jay Monahan Center for Gastrointestinal Health The physicians at the Jill Roberts NewYork-Presbyterian/Columbia Chief, Gastrointestinal Endoscopy Center elected to shorten the interval of Associate Professor of Clinical Surgery Division of Gastroenterology and Hepatology infliximab infusion to every 6 weeks and Columbia University College of NewYork-Presbyterian/Weill Cornell Physicians and Surgeons Associate Professor of Clinical Medicine increase the dose to 10 mg/kg while the [email protected] Weill Cornell Medical College surgical team follows the patient closely. [email protected] More novel anti-tumor necrosis factor Kenneth Forde, MD Ellen J. Scherl, MD therapies such as adalimumab (HUMI- José M. Ferrer Professor Emeritus of Clinical Surgery Columbia University College of Director, Jill Roberts Center for Inflammatory Bowel Disease RA)—which has recently been FDA Physicians and Surgeons NewYork-Presbyterian/Weill Cornell approved for the treatment of Crohn’s [email protected] Associate Professor of Medicine disease, with an induction dose of 160 Division of Gastroenterology and Hepatology Dennis Fowler, MD mg subcutaneous followed by 80 mg in Weill Cornell Medical College Vice President and Medical Director, Perioperative Services [email protected] 2 weeks and then 40 mg every other NewYork-Presbyterian/Columbia week—are now available for select U.S. Surgical Professor of Clinical Surgery Lewis Schneider, MD patients with moderate to severe Crohn’s Columbia University College of Physicians and Surgeons Assistant Attending Physician NewYork-Presbyterian/Columbia [email protected] disease. Assistant Professor of Clinical Medicine “We have a very good working rela- Michel Gagner, MD Columbia University College of tionship with surgeons here,” said Brian Physicians and Surgeons Chief, Section of Laparoscopic and Bariatric Surgery (212) 326-8426 Bosworth, MD, “and although medical Director, Minimal Access Surgery breakthroughs are revolutionizing IBD NewYork-Presbyterian/Weill Cornell Peter D. Stevens, MD therapy, surgical breakthroughs such as Professor of Surgery Director, Gastrointestinal Endoscopy Department Weill Cornell Medical College Clinical Director, Division of Digestive and Liver Diseases bowel sparing sricturoplasties also have [email protected] NewYork-Presbyterian/Columbia a significant impact on the lives of our Assistant Professor of Clinical Medicine IBD patients.” Ira Jacobson, MD Columbia University College of Chief, Division of Gastroenterology and Hepatology Physicians and Surgeons NewYork-Presbyterian/Weill Cornell [email protected] Vincent Astor Professor of Clinical Medicine Brian Bosworth, MD, is Assistant Attending Weill Cornell Medical College Timothy C. Wang, MD Physician at NewYork-Presbyterian [email protected] Chief, Division of Digestive and Liver Diseases Hospital/Weill Cornell Medical Center, and is NewYork-Presbyterian/Columbia Assistant Professor of Medicine at Weill Fabrizio Michelassi, MD Dorothy L. and Daniel H. Silberberg Professor of Medicine Cornell Medical College. Surgeon-in-Chief Columbia University College of Physicians and Surgeons E-mail: [email protected]. NewYork-Presbyterian/Weill Cornell Lewis Atterbury Stimson Professor and Chairman [email protected] Department of Surgery Richard L. Whelan, MD Peter D. Green, MD, is Director, Celiac Weill Cornell Medical College [email protected] Chief, Section of Colon and Rectal Surgery, Herbert Irving Disease Center and Director, GI Endoscopy Comprehensive Cancer Center Unit at NewYork-Presbyterian Jeffrey Milsom, MD NewYork-Presbyterian/Columbia Associate Professor of Surgery Hospital/Columbia University Medical Center, Chief, Section of Columbia University College of and is Professor of Clinical Medicine at NewYork-Presbyterian/Weill Cornell Physicians and Surgeons Columbia University College of Physicians and Professor of Surgery, Colon and Rectal Surgery Section [email protected] Surgeons. E-mail: [email protected]. Weill Cornell Medical College [email protected]

Ellen J. Scherl, MD, is Director, Jill Roberts Paul Miskovitz, MD Center for Inflammatory Bowel Disease at Attending Physician NewYork-Presbyterian Hospital/Weill Cornell NewYork-Presbyterian/Weill Cornell Medical Center, and is Associate Professor of Clinical Professor of Medicine, Division of Gastroenterology and Hepatology Medicine, Division of Gastroenterology and Weill Cornell Medical College Hepatology at Weill Cornell Medical College. [email protected] E-mail: [email protected].

3 DNIEGWEYSO TR KIV–EP RDE ISSB YETAESR IEASN clinical research. Jill Roberts Center Fosters “The addition of the Jill Roberts Center has allowed Dr. Scherl to bring together a group of experts in management of IBD Collaboration in Treatment of IBD patients,” said Peter Green, MD. “Their team approach will provide the best care Open for less than a year, the Jill getting married and having children,” Dr. available. This, together with their studies Roberts Center for Inflammatory Bowel Scherl said. of new-generation biological therapies, is a Disease (IBD) at NewYork-Presbyterian “Crohn’s disease and ulcerative colitis wonderful asset in the management of Hospital/Weill Cornell Medical Center are lifelong illnesses. We are committed to these complicated patients.” has already become a major referral center getting patients well and keeping them “This is a wonderful environment to for complicated cases of Crohn’s disease well,” added Dr. Scherl. work in,” noted Brian Bosworth, MD, and ulcerative colitis. Funded by a $4 million gift from who joined the Center last July. “It’s a “We see 15 to 20 cases a day, including NewYork-Presbyterian Hospital benefac- place where patients come to receive cases from the tristate area and beyond,” tor Jill Roberts, the Center was launched seamless care for inflammatory bowel dis- said Ellen J. Scherl, MD. “Many are in September 2006 as the third of 3 ease. Many of them are really quite sick. referred because medical or surgical thera- world-class gastrointestinal (GI) treatment We want to be able to look out for all of py has failed,” she added. and research centers located in the Stich their interests—their medical, physical, emotional, and family needs.” In addition to offering the most advanced medical and surgical treatment options, the Jill Roberts Center provides early-detection screening for long-term complications of IBD, including colo- rectal cancer and osteoporosis. Patients have access to a full range of treatment approaches, including nutritional coun- seling and other support services key to maintaining GI health. On the research front, the Jill Roberts Center is engaged in a broad, collaborative effort to advance understanding of the genetic and molecular pathways involved in bowel inflammation and translate that knowledge into new therapies. According to Dr. Scherl, more than 15 clinical and investigator-initiated studies are in progress. They include trials to evaluate novel biologic agents that target tumor necrosis factor, such as adalimumab, cer- tolizumab pegol, and golimumab. “We’re also looking at other biologics Left to right: Herbert Pardes, MD, Brian Bosworth, MD, Jill Roberts, Ira M. Jacobson, MD, Ellen in clinical trials, such as anti-IL [inter- J. Scherl, MD, and Antonio M. Gotto, Jr., MD, marked the opening of the Jill Roberts Center for leukin] 12 agents, basilixumab and Inflammatory Bowel Disease in a ribbon-cutting ceremony on September 12, 2006. visilizumab, as well as at novel mesalamine therapies,” said Dr. Scherl. More than 1 million Americans suffer Building at NewYork-Presbyterian/Weill Other studies are following additional from IBD. The largest concentration is Cornell. The others are the Jay Monahan promising leads, such as the correlation found among individuals 15 to 30 years of Center for Gastrointestinal Health and the between hemangiogenesis and IBD and age. “The medical tragedy is that it affects Center for Colon and Rectal Surgery. The the role of mucosal bacteria in bowel young people in their prime—when they 3 centers not only share facilities, but also inflammation. begin dating, when they’re going to col- collaborate in educational outreach, The Center’s partnership with colorectal lege, when they’re looking for jobs and patient care, and basic scientific and see Jill Roberts, page 7

4 www.nypdigestive.org Surgeon Pioneers Strictureplasty for Crohn’s Disease

ore than a decade ago, . D M

Fabrizio Michelassi, MD, pio- , i s s

neered a surgical technique for a l e

M h c

patients with extensive Crohn’s disease i M

that alleviates symptoms and offers a o i z i bowel-saving alternative to resection in r b a the treatment of strictures. Today, the F

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Michelassi strictureplasty has been y s e t r

adopted by surgeons throughout the u o c

world and has been reproduced with o t o h

similar results. P An international, multicenter study recently published in Diseases of the Colon & Rectum examined 184 patients with Crohn’s disease who had undergone the procedure, also known as side-to-side isoperistaltic strictureplasty. The researchers concluded that the procedure carries a very low mortality and morbid- ity rate, with an acceptable recurrence rate (Dis Colon Rectum 2007;50:277- 284). The study found that 41 of the patients required surgery for recurrent Strictureplasty success: A study published in 2000 found that the procedure preserved an average of 17% of disease, but only 14 patients experienced small-bowel length in 21 patients (Ann Surg 2000;232:401-408). recurrence of disease at the site of the strictureplasty. Although the risk for cramps, abdominal distension, bloating malnutrition, and it should not be per- recurrence at the strictureplasty site was and vomiting—commonly experienced formed on segments with acute inflam- not entirely eliminated, the observed by patients with many strictures. Like mation and phlegmon. Also, long, high- risk was less than the expected risk. any strictureplasty, the Michelassi pro- grade strictures are often not adaptable “We all know that Crohn’s disease is a cedure is contraindicated in patients to strictureplasty. recurring disease,” said Dr. Michelassi. with generalized peritonitis or profound The technique was initially proposed “What the study points to is the fact for the surgical treatment of extensive that the disease recurs less frequently jejunoileitis with multiple fibrotic stric- than expected at the side-to-side stric- tures. It has since been modified to treat tureplasty site, suggesting that the stric- recurrent neoterminal ileal disease. “It tureplasty has a protective effect against “We all know has been modified to face different tech- Crohn’s disease recurrence.” Crohn’s disease is a nical challenges within the same patient The technique is performed by divid- population,” said Dr. Michelassi. ing the diseased loop of small bowel at recurring disease. [With An added advantage of the procedure its midpoint. The proximal portion of strictureplasty], the is that it is designed to avoid sacrificing diseased intestine is then moved over extensive amounts of intestine. the distal portion of diseased intestine disease recurs less “Extensive intestinal resections or repeat- in a side-to-side manner. Using sutures, frequently than expected, ed resections may precipitate short-gut the surgeon approximates the 2 loops. syndrome, a situation where the patient Two parallel longitudinal openings are suggesting that [the does not have enough intestine to absorb then created, 1 in each loop. The 2 procedure] has a adequate amounts of nutrients, vitamins openings are then sutured together, and minerals,” noted Dr. Michelassi. widening the intestinal lumen. The protective effect.” With the Michelassi strictureplasty, the result of the procedure is a larger intes- —Fabrizio Michelassi, MD bowel is not resected. tinal lumen through which food can In a study published in 2000, the pro- transit unimpeded and nutrients can be cedure preserved an average of 17% of absorbed. The larger intestinal passage- small-bowel length in 21 patients who way alleviates the symptoms—such as see Strictureplasty, page 7

5 DNIEGWEYSO TR KIV–EP RDE ISSB YETAESR IEASN

Obesity Michel Gagner, MD. In sleeve gastrec- is able to offer 5 laparoscopic bariatric continued from page 1 tomy, the left side of the is sur- procedures: gastric bypass, duodenal gically removed to create a new stomach switch, , sleeve Over time, with CMS approval, insur- with roughly the size and shape of a , and revisional ,” ance companies come along, too,” banana, whereas in , a said Dr. Gagner. “Most programs do explained Alfons Pomp, MD. partial gastrectomy is created and the only one type. That’s a detriment to the Both NewYork-Presbyterian sites, intestinal flow is rerouted while the patients. They want a surgeon who can which also have received a 5-star pyloric valve is kept intact. An impor- determine exactly which surgery is best HealthGrades rating, are known for tant aspect of the duodenal switch pro- for them.” their extensive medical resources, such cedure is that it reduces the absorption NewYork-Presbyterian is also as round-the-clock coverage by bariatric of dietary fat by approximately 70%, a engaged in a wide spectrum of research surgeons and a multidisciplinary team valuable benefit for patients attempting projects investigating surgical tech- including nutritionists and psycholo- to reduce their cholesterol or triglyc- niques, how preoperative weight loss gists. The facilities provide additional eride level. The Weill Cornell group has influences surgical outcomes, the mech- amenities for bariatric patients: larger recently introduced a revision strategy anism behind the postsurgical improve- hospital beds, chairs, and toilets that that transforms gastric bypass into ment noted in the condition of patients can hold their weight. laparoscopic duodenal switch, resulting with diabetes, and other related ques- tions. The Hospital is one of only 6 clinical centers taking part in the National Institutes of Health “We’re one of the few centers in the United States who Longitudinal Assessment of Bariatric Surgery (LABS) study. Drs. Gagner and are able to offer 5 laparoscopic bariatric procedures: Bessler, who is Chairman of the gastric bypass, duodenal switch, adjustable gastric band, American Society of Bariatric Surgery Committee for Emerging Technologies, , and revisional surgeries.” are researching new technologies for the —Michel Gagner, MD treatment of obesity.

Marc Bessler, MD, is Director, Columbia Center for Weight Loss Surgery, Director, Laparoscopic Surgery at NewYork- The NewYork-Presbyterian/Columbia in the loss of nearly 80% of excess Presbyterian Hospital/Columbia University Center is best known for its revisional weight after 1 year. Medical Center, and is Assistant Professor of procedures to correct failed bariatric sur- Currently, duodenal switch accounts for Surgery at Columbia University College of gery. When weight loss is inadequate fol- approximately 5% of all bariatric surger- Physicians and Surgeons. lowing gastric bypass, surgeons can place ies, with gastric bypass making up 80% E-mail: [email protected] adjustable silicone gastric banding and gastric banding the remaining 15%. Michel Gagner, MD, is Director, Weill around the patient’s gastric pouch. When The primary reason for this imbalance, Cornell Weight Loss Surgery Program, the opening between the stomach and said Dr. Gagner, is a lack of insurance cov- Chief, Laparoscopic and Bariatric Surgery, intestines dilates over time after the initial erage for duodenal switch, although both Director, Minimal Access Surgery at surgery, a sclerosing agent can be injected Aetna and CMS recently decided to cover NewYork-Presbyterian Hospital/Weill to narrow it. Another common revision the surgery. And after an article published Cornell Medical Center, and is Professor of that surgeons at the NewYork- in October 2006 reported that weight loss Surgery at Weill Cornell Medical College. Presbyterian/Columbia Center perform is after duodenal switch is better than E-mail: [email protected] endoluminal suturing, during which sur- weight loss after gastric bypass, he noticed Alfons Pomp, MD, is Associate Attending geons enter the stomach with an endo- a surge of interest from surgeons wanting Surgeon at NewYork-Presbyterian scope and stitch the opening more tightly. to learn the procedure (Ann Surg Hospital/Weill Cornell Medical Center and The NewYork-Presbyterian/Weill 2006;244:611-619). is Associate Professor of Surgery and Frank Cornell Center specializes in laparo- Both Centers perform an unusually Glenn Faculty Scholar at Weill Cornell scopic duodenal switch and sleeve diverse array of surgeries. “We’re one of Medical College. gastrectomy, procedures pioneered by the few centers in the United States that E-mail: [email protected]

6 www.nypdigestive.org Jill Roberts “Remember that this is a disease that continued from page 4 affects young people,” said Dr. Scherl, “so “If we can make the there are many children who grow up and surgeons has been a key factor in its suc- diagnosis [of celiac come over here, and many young people cess, according to Dr. Scherl. “We could that end up seeing Dr. Sockolow. It is an not do this without the stellar surgeons disease] and withdraw interactive collaboration.” that we have,” she said, “and that begins the offending dietary with Dr. Fabrizio Michelassi [Surgeon- in-Chief at NewYork-Presbyterian/Weill substance, we can Brian Bosworth, MD, is Assistant Attending Cornell] and Dr. Jeffrey Milson [Chief, improve some of the Physician at NewYork-Presbyterian Division of Colorectal Surgery at Hospital/Weill Cornell Medical Center, and is NewYork-Presbyterian/Weill Cornell].” symptoms.” Assistant Professor of Medicine at Weill Dr. Michelassi and Dr. Milson are co- Cornell Medical College. —Ellen J. Scherl, MD authors of “Operative Strategies in E-mail: [email protected]. Inflammatory Bowel Disease,” the definitive work on IBD surgery. Peter D. Green, MD, is Director, Celiac The Jill Roberts Center has also col- Disease Center and Director, GI Endoscopy laborated with Dr. Green at NewYork- Scherl. She noted that the Jill Roberts Unit at NewYork-Presbyterian Presbyterian Hospital/Columbia Center works with expert rheumatolo- Hospital/Columbia University Medical Center, University Medical Center in exploring gists, endocrinologists, and hematologists and is Professor of Clinical Medicine at the overlap between Crohn’s disease and as well as with Sudhir Diwan, MD, at the Columbia University College of Physicians and celiac disease found in a small number Weill Cornell Pain Medicine Center. Surgeons. E-mail: [email protected]. of patients. “If we can make the diagno- The Jill Roberts Center also has sis [of celiac disease] and withdraw the access to an outstanding hepatobiliary Ellen J. Scherl, MD, is Director, Jill Roberts offending dietary substance that causes department and 2-campus liver trans- Center for Inflammatory Bowel Disease at it, namely gluten, we can improve some plant program. Furthermore, it has NewYork-Presbyterian Hospital/Weill Cornell of the symptoms,” Dr. Scherl said. begun a successful pediatric collabora- Medical Center, and is Associate Professor of Clinicians in other disciplines have also tion with Robbyn Sockolow, MD, Medicine, Division of Gastroenterology and provided support. “IBD tends to involve Section Chief in the Division of Hepatology at Weill Cornell Medical College. various parts of the bowel, but there are Pediatric Gastroenterology and Nutrition E-mail: [email protected]. extraintestinal manifestations,” said Dr. at NewYork-Presbyterian/Weill Cornell.

Strictureplasty In the future, Dr. Michelassi envisions continued from page 5 greater potential for the procedure, par- “A multidisciplinary ticularly if the technique can be modi- underwent the side-to-side strictureplasty approach and medical fied so that it can be used to manage to relieve symptomatic partial intestinal primary Crohn’s disease in the last foot obstruction due to Crohn’s disease. The treatment are very of the small bowel, which is often study found radiographic, endoscopic, important and postpone removed in surgery. and histopathologic evidence that active “I think the side-to-side strictureplasty Crohn’s disease regressed to quiescent the need for surgery in could be modified to address the disease of disease at the site of the Michelassi stric- patients with Crohn’s the terminal ileum, extending the concept tureplasty, suggesting that the stricture- of bowel-sparing surgery to the intestinal plasty technique may return the bowel to disease.” site most commonly affected by Crohn’s normal anatomy and possibly normal —Fabrizio Michelassi, MD disease,” said Dr. Michelassi. function (Ann Surg 2000;232:401-408). In addition, medicinal advances and a Fabrizio Michelassi, MD, is Surgeon-in-Chief multidisciplinary approach play signifi- at NewYork-Presbyterian Hospital/Weill cant roles in helping patients with Cornell Medical Center and is Lewis Atterbury advanced Crohn’s disease. patients with Crohn’s disease,” explained Stimson Professor of Surgery and Chairman of “A multidisciplinary approach and Dr. Michelassi, adding that appropriate the Department of Surgery at Weill Cornell medical treatment are very important medical therapy lowers the risk for recur- Medical College. and postpone the need for surgery in rences after surgery. E-mail: [email protected].

7 SpyGlass treating refractory biliary stones with elec- actually look inside the ducts and take continued from page 1 trohydraulic . With no reported specimens from each section. Dr. Stevens complications or technical failures to cited a recent case in which the entire appeared several decades ago but were deliver the fiber optics, they achieved appeared to be involved in a never widely adopted. Earlier scopes were stone clearance in 85% of cases tested. mucus-producing tumor. The patient was not only fragile but also expensive to Currently, the 5 centers are conducting reluctant to undergo an entire pancreatic repair or replace, whereas the most fragile a second research phase, the Spy 2 Clinical resection because of the high risk for com- component of SpyGlass is designed to be Registry, to gather more information plications such as glucose intolerance, disposable and thus more affordable. about how the method affects clinical pancreatic fistulas, and delayed gastric Irrigation with the new device is practice. The investigators are looking at emptying. improved, so that the extra step of insert- patients who have indications for choledo- “So we put the Spy scope up and used ing irrigating catheters next to the endo- choscopy and pancreatoscopy. Pancreatic forceps to biopsy along the length of the scope is no longer required. Prior scopes cancer will be a particular focus during pancreatic duct from the tail to the head. small enough to navigate the bile and the clinical registry because of the large We were able to demonstrate both visibly pancreatic ducts could move in only 2 volume of patients treated for this disease and by biopsy that the disease was limited directions; SpyGlass, on the other hand, at NewYork-Presbyterian/Columbia. to the head,” said Dr. Stevens. Thus, the is capable of 4-way deflection. Finally, the The SpyGlass has been found to offer new method may prove to be a pancreas- entire procedure can be carried out by a 2 major advantages over ERCP alone. preserving diagnostic evaluation, allowing single endoscopist. Because of imprecise methods of tissue the surgeon to target only areas found to Investigators at NewYork- acquisition, pancreatic cancer can be diffi- be abnormal by biopsy. Presbyterian/Columbia have been cult to diagnose with ERCP brushings Although researchers are still in the researching SpyGlass since its earliest use and biopsy specimens from the pancreatic early stages of assessing the applications of in human trials in January 2005. Together or bile ducts. “When you’re just using SpyGlass in pancreatic cancer, he added, with specialists from the University of X-rays, you brush blindly,” said Dr. historical precedence suggests that such Colorado Health Sciences Center in Stevens. “What direct visualization pro- improvements in direct visualization Denver, Beth Israel Deaconess Medical vides is the ability to say, ‘Okay, in this greatly improve diagnosis and treatment. Center in Boston, Fox Chase Cancer square millimeter of tissue, there’s a break Peter D. Stevens, MD, is Director, Center in Philadelphia, and Mayo Clinic in the mucosa.’ With SpyGlass, you actu- Gastrointestinal Endoscopy Department College of Medicine in Rochester, Minn, ally look at the most abnormal tissues and and Clinical Director, Division of they have completed the first phase of take a biopsy [specimen] from that area.” Digestive and Liver Diseases at NewYork- their project. The hope is that this visualization capabil- Presbyterian Hospital/Columbia In a presentation at Digestive ity will improve accuracy in the diagnosis University Medical Center, and is Diseases Week 2007, the investigators of pancreatic tumors. Assistant Professor of Clinical Medicine at announced their findings from a 15- Furthermore, in patients with certain Columbia University College of patient study indicating that SpyGlass tumors, the only way to identify the Physicians and Surgeons. provides a safe and effective method for portion of the pancreas involved is to E-mail: [email protected].

NewYork-Presbyterian Hospital • Columbia University College of Physicians and Surgeons • Weill Cornell Medical College N S Important news from the Digestive Diseases Services Centers of NewYork-Presbyterian A E I R

S Hospital, leading the way in treatment and research in gastrointestinal, liver and bile E A T duct, pancreatic, and nutritional disorders. E Y B S S I Spring 2007 E

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