Performing the Stretta Procedure for GERD New Minimally Invasive Treatment of Gastroesophageal Reflux Disease

WINTER/ SPRING 2002 Number 14

PNews UpdateO from the STDepartment of SurgeryOp UNIVERSITY. HOSPITAL. AND. HEALTH. SCIENCES. CENTER. AT. STONY. BROOK

Performing the Stretta Procedure for GERD New Minimally Invasive Treatment Of Gastroesophageal Reflux Disease

he Center for Minimally Invasive Surgery is pleased to announce the introduction of a new minimally invasive technique for the treatment Tof gastroesophageal reflux disease (GERD). Called the Stretta procedure, this newly developed outpatient endoscopic procedure takes about one hour to perform, and provides considerable benefits to patients. Stony Brook University Hospital is the only health facility in Suffolk that offers the Stretta procedure, the use of which further demonstrates our commitment to providing truly state-of-the-art patient care. Arif Ahmad, MBBS, assistant professor of surgery and director of the Center for Minimally Invasive Surgery, and Louis T. Merriam, MD, assistant Initial experience with the Stretta professor of surgery, have acquired the training necessary to perform the procedure for the treatment of procedure. With special expertise in minimally invasive “videoscopic” gastroesophageal reflux disease surgery, they both have a long-standing interest and proficiency in the BACKGROUND: The Stretta device (Curon Medical, surgical correction of GERD. Sunnyvale, CA) is a balloon-tipped four-needle catheter that delivers radiofrequency (RF) en- Because there is no hospital stay involved with the Stretta ergy to the smooth muscle of the gastroesoph- procedure, patients undergoing the procedure are able to ageal junction. It can be used for the endoscopic treatment of gastroesophageal participate in normal activities the following day. reflux disease (GERD).

Describing the procedure’s benefits, Dr. Ahmad says: “No hospital stay PATIENTS AND METHODS: Data prospectively col- lected on the first 25 consecutive patients un- is required and typically patients may return to normal activities the dergoing the Stretta procedure at Vanderbilt following day. Moreover, most patients are able to discontinue acid-reducing University Medical Center between August GERD medications in a month.” 2000 and March 2001 are reported. Patient The procedure itself is performed with a flexible, disposable catheter evaluation included esophageal manometry, connected to a radiofrequency (RF) generator. With the patient under ambulatory 24-hour pH testing, a standard GERD-specific quality-of-life survey (QOLRAD), conscious sedation, the surgeon delivers controlled RF energy to the lower a general quality-of-life survey (SF12), and en- esophageal sphincter (LES) muscle and gastric cardia to create thermal doscopy. lesions. As the lesions heal, the barrier function of the LES is enhanced, Stretta surgery was performed following a standardized protocol. Thermocouple-con- reducing the frequency of reflux events. trolled RF energy was delivered to the lower Early clinical studies appearing in the medical literature demonstrate esophageal sphincter (LES) after endoscopic that the Stretta procedure is a promising new treatment of GERD, which location of the z-line. Patients were followed affects 1 in 14 adults in the United States today. up 3 months after endoscopic treatment. Results are presented as mean ±SEM. For consultations/appointments with Dr. Ahmad and Dr. Merriam, DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY (Continued on Page 3) — 1 — please call the Center for Minimally Invasive Surgery at (631) 444-4545. AMBULATORY SURGERY CENTER NOW OPEN AT STONY BROOK

pened in early March, the new Ambulatory Surgery Center at Stony Brook Ois located next to University Hospital. The spacious, state-of-the-art facility (32,000 square feet) is designed to create a comfortable, stress-free outpatient surgery experience for both adult and pediatric patients. The Center has six operating rooms and two minor procedure rooms— all with the latest equipment and monitors. Consistent with the latest concepts in ambulatory surgery, the recovery area is divided into two stages. The first-stage room serves as a conventional recovery area and is set up for those patients requiring more frequent observation. But many patients go directly to a second-stage room where they can be fed, en- joy their families, and relax before going home—thanks to new short-acting anes- thetics, combined with minimally invasive surgical techniques, that are allowing more and more patients safely to bypass the conventional recovery process with minimal, if any, pain or nausea. The Center’s planners paid particular attention to the needs of children and their families. There are pediatric play areas with specially designed furniture for children, as part of our effort to make their experience as pleasant as possible. Easy accessibility for both patients and surgeons is a high priority of the Center. Parking is easy, plentiful, and free of charge. The Center also houses the preoperative testing area for inpatient surgery. POST-OP is published by the This area allows patients to have their inpatient preoperative lab tests, EKGs, Department of Surgery University Hospital and chest x-rays, and history/physicals all done in one easy visit. Health Sciences Center Stony Brook University For more information, please visit the Ambulatory Surgery Center’s website at Stony Brook, New York www.uhmc.sunysb.edu/AMB Editor-in-Chief John J. Ricotta, MD The Lung Cancer Evaluation Center, established by the Cancer Institute of Long Island at Stony Brook, Writer/Editor provides comprehensive care for patients with known Jonathan Cohen, PhD or suspected lung cancer, as well as those individuals Contributing Editor at special risk of developing lung cancer. Andrew E. Toga, FACHE lung Advisory Board Patients who have x-ray abnormalities that might Collin E.M. Brathwaite, MD represent lung cancer, or patients who have a known Alexander B. Dagum, MD diagnosis of cancer, can undergo evaluation by all of Peter J. Garlick, PhD the physicians involved in the diagnosis and treatment Arnold E. Katz, MD cancer Irvin B. Krukenkamp, MD of lung cancer. Cedric J. Priebe, Jr., MD evaluationAt the conclusion of the initial visit, each patient’s case Harry S. Soroff, MD has been reviewed by the Center’s multidisciplinary All correspondence should be sent to: team of physicians, and a plan for diagnosis or Dr. Jonathan Cohen treatment is then formulated based on their combined Writer/Editor, POST-OP center Department of Surgery expert opinion. Health Sciences Center T19 Stony Brook, NY 11794-8191, USA For more information, please call the program coordinator, Eileen Vilim, RN, at (631) 444-2981.

— 2 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY Performing the Stretta PERFORMING HISTORIC Procedure for GERD (Continued from Page 1) HEART OPERATION RESULTS: Prior to treatment, patients had a Saving Patient’s Life With mean DeMeester score of 31.0 ± 11.4, Five Simultaneous Procedures an LES pressure of 24 ± 2 mm Hg, and normal esophageal peristalsis. Of the 25 Including New Technique outpatient procedures, 19 were done under conscious sedation and 6 under gen- n December, the Division of Cardiothoracic Surgery made history by eral anesthesia. There was a small performing a series of five heart procedures on a single patient during a learning curve (76 8 min for the first I ± single operation, giving the patient a new and unexpected lease on life. three procedures; 50 ± 2 min for the subsequent 22). This operation marked the first time so many cardiac procedures were successfully performed at once. The mild to moderate pain during the A novel microwave technique, moreover, was first 24 postoperative hours was controlled with over-the-counter medication. used to treat the patient’s abnormal heart rhythm. Two complications were noted: one pa- The history-making heart operation, which took tient presented with ulcerative esophagi- three and a half hours to complete, was performed by tis and gastroparesis 10 days after the Irvin B. Krukenkamp, MD, professor of surgery and Stretta treatment, and one patient devel- physiology/biophysics and chief of cardiothoracic sur- oped pancreatitis on postoperative day 27, which was probably unrelated to the gery, and Adam E. Saltman, MD, PhD, assistant pro- Stretta procedure. fessor of surgery and physiology/biophysics, along with eight other members of Stony Brook’s cardiac Eight of the thirteen patients (62%) avail- Dr. Irvin B. team. able for 3-month follow-up were off all Krukenkamp antisecretory medication. The other five The patient, a 69-year-old man from Blue Point, patients were still taking medications but NY, was released from cardiac rehabilitation in early had been able to reduce the amount con- January, after having successfully completed his for- siderably. The average daily dose of pro- mal recuperation post-surgery. Prior to the operation, ton pump inhibitors was 43.0 ± 5.0 mg/ he had a life expectancy of about six months. preoperatively and 6.4 ± 2.2 mg/3 months postoperatively (P < 0.001). Now, according to Dr. Krukenkamp, the father of Other classes of GERD treatment such as three and grandfather of four can expect to live well metoclopramide had been completely into his eighties. abandoned. The entire operation comprised a single-vessel In all patients, QOLRAD scores improved bypass procedure to relieve a blocked coronary artery; (3.5 ± 0.4 to 5.5 ± 0.5; P < 0.001) as did replacement of a damaged aortic valve; patching the SF12 physical (23.7 ± 3.0 to 31.0 ± 3.4; Dr. Adam E. hole between the heart’s upper chambers; repairing a Saltman P < 0.008) and mental (40.5 ± 2.9 to leaky tricuspid valve to restore proper blood flow in 47.7 ± 3.2, P < 0.017) scores. All pa- the right side of the heart and relieve the heart failure and potential liver tients would undergo a Stretta procedure again except one 78-year-old man with failure; and curing the abnormal heart rhythm with the new microwave progressive Alzheimer’s disease. catheter technique. CONCLUSION: The Stretta procedure is a promising new modality in the manage- SAVING A LIFE AND ment of GERD. It can be safely performed ADVANCING CARE in one short session with gastroesoph- The patient had arrived at University Hospital a week before Christ- ageal endoscopy under conscious seda- mas, suffering from atrial fibrillation, a potentially lethal cascade of abnor- tion in an outpatient setting. It improves mal heartbeats. The cardiac team was aware of his fibrillation, as well as GERD symptoms and quality-of-life his congestive heart failure. scores in patients at 3 months and elimi- nates or significantly reduces the need But the initial evaluation of the patient further revealed two more se- for antisecretory drugs. rious problems: a blocked coronary artery and a damaged aortic valve in need of replacement. •Richards WO, Scholz S, Khaitan L, Sharp KW, Holzman MD. Initial experience with Three major procedures were thus planned preoperatively. At sur- the Stretta procedure for the treatment of gastroesophageal reflux disease. Journal of gery, two additional serious problems were identified: an atrial septal de- Laparoendoscopic and Advanced Surgical fect—a hole in the patient’s heart—and a leaky tricuspid valve. Techniques. Part A. 2001 Oct;11:267-73. (Continued on Page 10)

DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY — 3 — WHAT IS MINIMALLY INVASIVE SURGERY? INTRODUCING OUR NEW Minimally invasive surgery (MIS) is also known as Pediatric Surgeon minimal access surgery or as videoscopic and endoscopic surgery. The terms, laparoscopy or homas K. Lee, MD, has joined Richard thoracoscopy, which are commonly used references to MIS, describe the specific body cavity where the T J. Scriven, MD, and Cedric J. Priebe, Jr., surgeon is working; that is, abdomen and thorax, MD, in our Division of Pediatric Surgery as respectively. assistant professor of surgery. Board certified MIS is an expanding group of different kinds of in both general surgery and pediatric surgery, operations performed with newly developed surgical Dr. Lee comes to Stony Brook from a presti- instruments and methods that minimize physical gious private pediatric surgical practice in stress to patients. It involves the use of a small telescope and thin instrument (3-12 mm; or about New Hyde Park, NY. one-sixteenth to three-quarters of an inch). Dr. Lee received his MD from the Uni- The telescope magnifies the body’s internal struc- versity of Chicago in 1988. He subsequently tures with the help of digital imaging, and projects completed his residency in general surgery at the image onto a video monitor in the operating room. the New York Hospital-Cornell University MIS requires only small incisions, a distinguishing Medical Center in 1995. During his general feature of this revolutionary approach to surgical surgery residency, he spent two years in the care. Without the trauma of the larger incision used in conventional operations, both pain and healing laboratory at the University of Pittsburgh time are greatly reduced. Dr. Thomas K. Lee Health Center, studying small bowel transplantation. With smaller incisions, smaller and more cosmetic scars are a major advantage of MIS. In 1997, he completed his residency training in pediatric surgery at Cardinal Glennon Children’s Hospital-St. Louis University. Other benefits of MIS include shorter hospital stays OR no hospital stays at all, less need for postop- Dr. Lee’s clinical practice at Stony Brook will provide comprehensive erative pain medication, and earlier returns to surgical care for children—from newborn infants to adolescents. work and normal activity/diet. Reduced hospital- The spectrum of his pediatric surgical expertise includes the manage- ization, it should be noted, means reduced costs. ment of congenital and/or acquired diseases of the neck (cystic hygroma, The total hospital cost of a laparoscopic operation is torticollis, masses) and chest (airway, chest wall deformity, mediastinal, generally less than what conventional surgery requires. For example, a cholecystectomy (gallbladder lungs, esophagus), hepatobiliary system (biliary atresia, gallbladder dis- removal) using the laparoscopic method may cost at ease, liver, spleen), alimentary tract (appendicitis, Hirschsprung’s disease, least three to four times less than the same operation anorectum abnormality), and the skin and soft tissues; repair of inguinal done with open surgery. hernia and undescended testicles; and surgical management of childhood PEDIATRIC SURGEONS PERFORMING MIS tumors, including those of the kidney and adrenal glands. Laparoscopic procedures, such as cholecystectomy and appendectomy, were being performed with regu- Stony Brook University Hospital is one of the few centers larity in adults by the beginning of the 1990s. How- ever, use of MIS in children did not gain popularity in the New York City area and on Long Island that offers until now. pediatric minimally invasive surgery. Several limitations existed for the development of MIS in children. One is the small number of patients. In addition, Dr. Lee will also be associated with the pediatric trauma For example, gallbladder disease is rare in children. program at Stony Brook. Therefore, there is less opportunity for the applica- As a member of the perinatal group at Stony Brook, Dr. Lee will be as- tion of the minimally invasive techniques. sisting our maternal-fetal medicine and neonatology physicians in the management of congenital anomalies and newborn emergencies. In most cases, pediatric MIS has Dr. Lee also has extensive experience in extracorporeal life support reduced hospitalization to either (ECMO), and plans to eventually bring that special treatment to Suffolk outpatient or short stay, with County. just one- to two-week recovery at Areas of Dr. Lee’s special clinical interest include pediatric advanced home. Some patients can return minimally invasive surgery (laparoscopy and thoracoscopy). to school in just a couple days In addition to performing laparoscopic cholecystectomy and appen- after their operation, and parents dectomy, he performs advanced minimally invasive surgery in children in- can then return to work. cluding antireflux procedures (fundoplications), splenectomy, orchiopexy for intra-abdominal testicle, and a variety of thoracic operations. (Continued on Page 11)

— 4 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY Dr. Lee is also planning to intro- duce to our area “minimal access re- INTRODUCING OUR NEW pair” of pectus excavatum, a chest Plastic and Cosmetic Surgeon wall deformity seen in children and adolescents. alvant P. Arora, MBBS, has joined Dr. Lee is a member/fellow of B Alexander B. Dagum, MD, and Steven several prestigious national and local M. Katz, MD, in our Division of Plastic and medical associations. He is a fellow of Reconstructive Surgery as assistant profes- the American College of Surgeons, sor of surgery. He comes to Stony Brook surgery specialty fellow of the Ameri- from Lenox Hill Hospital in New York, can Academy of Pediatrics, member of where he spent the previous academic year the American Pediatric Surgical Asso- as a fellow in cosmetic surgery. ciation, associate member of the Dr. Arora received his MBBS (Bach- Children’s Oncology Group, and elor of Medicine and Bachelor of Surgery) member of Suffolk County Medical in 1984 from the University of Baroda, in Society and Medical Society of the Vadodara, India. From the same institution, State of New York. he then received his MS (Master of Surgery, 1988) in general surgery and his MCh For consultations/appointments with Dr. Lee, (Magister Chirurgie, 1991) in plastic Dr. Balvant P. Arora please call (631) 444-4538. surgery. ▼ In 1992, after practicing plastic surgery in India, Dr. Arora moved to the United States. He subsequently joined MINIMALLY INVASIVE our residency program here at Stony Brook in 1995. He left in 1998 to pursue SURGERY FOR CHILDREN further training in plastic surgery at the Oregon Health Sciences University in Abdominal Portland, which he completed in 2000. • Diagnostic laparoscopy This training was followed by his fellowship in cosmetic surgery at • Appendectomy Lenox Hill Hospital. • Antireflux surgery Dr. Arora’s practice at Stony Brook includes general plastic and recon- • Splenectomy structive surgery, with an emphasis on cosmetic surgery in which he has spe- • Pyloromyotomy cial expertise. He is skilled at providing care for both adults and children. • Colectomy, pull-through procedures Among the cosmetic surgery procedures that Dr. Arora performs are • Small bowel resection face-lift, blepharoplasty (eyelid lift), liposuction, breast augmentation and re- • Meckel’s diverticulum resection duction, total body contouring, laser resurfacing, chemical peel, Botox injection, collagen injection, and hair transplantation. • Peritoneal management of VP shunt In addition, Dr. Arora also performs minimally-invasive endoscopic plas- Genitourinary tic surgery including breast augmentation and brow-lift. • Orchiopexy/exploration Hand surgery is another specialty at which Dr. Arora is skilled. His ex- for undescended testis pertise enables him to treat the most challenging and complicated hand and • Contralateral hernia exploration wrist problems as well as minor conditions and injuries. • Nephrectomy Dr. Arora’s research interests include cultured skin graft and skin substi- • Adrenalectomy tution. Hepatobiliary • Liver biopsy For consultations/appointments with Dr. Arora, please call (631) 444-4545. • Cholecystectomy • Common bile duct exploration Thoracic • Thoracoscopy with or without biopsy • Thoracoscopic decortication • Wedge resection of lung • Video-assisted anterior spinal fusion • Pectus excavatum repair

DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY — 5 — TRACHEAL STENTING FOR Some Recent Publications* Barle H, Gamrin L, Essen P, McNurlan MA, Garlick ELIEVING IRWAY PJ, Wernerman J. Growth hormone does not R A affect albumin synthesis in the critically ill. Intensive Care Med 2001;27:836-43. OBSTRUCTION Cadet P, Mantione K, Bilfinger TV, Stefano GB. Real-time RT-PCR measurement of the modulation of Mu opiate receptor expression lthough the mainstay of therapy for patients with lung cancer remains by nitric oxide in human mononuclear cells. Med Sci Monit 2001;7:1123-8. Acomplete surgical resection, not every patient is a candidate for this Chen EH, Logman ZM, Glass PS, Bilfinger TV. A type of surgery. Specifically, patients with narrowing of their airways due to case of tracheal injury after emergent endotra- tumors or other types of obstructions suffer from the complications of little or cheal intubation: a review of the literature and causalities. Anesth Analg 2001;93:1270-1, no airflow to the affected lung. Chen EH, Rosa D, El-Maghrabi MR, Maitra SR. The goal of our program in tra- Effects of sepsis on mitogen-activated protein kinase signal transduction pathways [abstract]. cheal stenting is to relieve this obstruc- Shock 2001;15:62. tion, re-establishing normal airflow. Chen EH, Rosa D, Pang E, Brathwaite CE, Maitra Over the years, several methods SR. Effects of sepsis on the expression of SAPK/ JNK signaling pathway [abstract]. FASEB J of relieving these obstructions have 2001;15:A1123. been attempted. One of the most suc- Eslami MH, Ricotta JJ. Operation for acute cessful is to first remove the obstruct- peripheral arterial occlusion: is it still the gold ing lesion, such as a tumor, and to standard? Semin Vasc Surg 2001;14:93-9. keep the opened airway patent with a Friedman S, DeMuro JP, Brebbia J, Ortega D, Barraco R, Brathwaite CE, Perez JM, Smith stent—a cage-like cylinder made of T. Pneumatosis cystoides intestinalis in a patient metal mesh. with celiac sprue. Contemp Surg 2001;57:11-3. Imoberdorf R, Bartsch P, Peheim E, Garlick PJ, Our thoracic surgeons are well McNurlan MA, Turgay M, Ballmer P. Plasma versed in these techniques to open the volume, albumin and fibrinogen synthesis during active and passive ascent to high airway and re-establish airflow to the altitude. J Appl Physiol 2001;90:528-37. lungs. Irie H, Abrahimi A, Abumrad N, Gaudette GR, The stenting procedure consists Saltman AE, Krukenkamp IB. The CD36 protein is an important modulator of ischemia/ of performing a bronchoscopy to look reperfusion injury in the murine heart. Surg in the airways under general anesthe- Forum 2001;52:72-4. sia. The obstructed area is then opened Ricotta JJ. Presidential address: Towards compe- tence in vascular care. J Vasc Surg either with a balloon or by removing 2001;34:955-61. the obstructing tissue. The length and Ricotta JJ, Bilfinger TV, Gorski Y. Carotid plus width of the area to be treated are coronary disease. In: Conwett JL, Rutherford RB, editors. Decision-making in vascular disease. measured, and the stent delivery sys- Philadelphia: Saunders, 2001: 84-7. tem is then inserted and the stent ex- Smouha EE, Chen D, Li B, Liang Z. Computer- panded. aided virtual surgery for congenital aural atresia. Am J Otol 2001;22:178-2. The management of symptom- Stefano GB, Murga J, Benson H, Zhu W, Bilfinger atic tracheobronchial complications TV, Magazine HI. Nitric oxide inhibits norepi- can be an important adjunct to the sur- nephrine-stimulated contraction of human internal thoracic artery and aorta. Pharmacol gical care of patients with unresectable Res 2001;43;199-203. benign or malignant airway obstruc- Stefano GB, Neenan K, Cadet P, Magazine H, tion. For these patients, stenting may Bilfinger TV. Ischemic preconditioning - an opiate constitutive nitric oxide molecular offer significant palliation and im- hypothesis. Med Sci Monit 2001;7:1357-75. proved quality of life. van Bemmelen PS, Gitlitz DB, Faruqi RM, Weiss- Olmanni J, Brunetti VA, Ricotta JJ. Limb salvage using high-pressure intermittent For consultations/appointments with our compression arterial assist device in cases thoracic surgeons, please call (631) 444-1820. unsuitable for surgical revascularization. Arch Surg 2001;136:1280-6. The insertion of a tracheal stent to Zhu, Bilfinger TV, Baggerman G, Goumon Y, establish normal airflow and thereby Stefano GB. Presence of endogenous relieve the symptoms of airway morphine in human heart tissue. Int J Mol Med obstruction. 2001;7:419-22.

* The names of faculty authors appear in boldface.

— 6 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY For consultations/appointments with Dr. van Bemmelen, please call (631) 444-4545. TREATING INOPERABLE Patients who already have undergone arteriography/angiography should bring the x-ray films with them at the time of their CIRCULATION DISORDERS initial consultation. Please turn to page 8 for Bio-note on Dr. van Bemmelen. n November, Paul S. van sion regimen that effectively simulates ▼ IBemmelen, MD, PhD, clinical the beneficial effects of brisk walking, Limb salvage using high-pressure assistant professor of surgery, and fel- without pain or tissue trauma. intermittent compression arterial low members of our vascular surgery First, using wrapped cuffs, the division published an article in the Ar- device compresses the foot and ankle. assist device in cases unsuitable for chives of Surgery describing the clinical A second surgical revascularization study of a nonsurgical treatment of in- later the calf Hypothesis: Intermittent compression therapy for operable circulation disorders. is com- patients with inoperable chronic critical is- This novel treatment is good pressed, and chemia with rest pain or tissue loss may have beneficial clinical and hemodynamic effects. news for patients with poor circulation the foot, Study Design: Case series of 14 consecutive is- who are not good surgical candidates. ankle, and chemic legs that underwent application of a 3- The first author of the report, Dr. calf veins month treatment protocol during a 2 1/2-year van Bemmelen is a pioneer in the use are almost study. of external intermittent compression completely Setting: Veterans Administration Hospital. Patients: Thirteen patients with 14 critically is- devices for treating circulation disor- emptied. In chemic legs (rest pain, n = 14; tissue loss, n = ders in patients for whom surgery is return, the 13) who were not candidates for surgical recon- not possible. arterial struction were treated with rapid high-pressure blood is intermittent compression. The patients had a Dr. Paul S. van Bemmelen Good news for patients with more easily mean age of 76.2 years, 8 were diabetic, and pushed down to the toes and blood- they represented 10% of referrals for chronic poor circulation who are not critical ischemia. They were not amenable to good surgical candidates deprived tissues. revascularization owing to lack of outflow arter- A second mechanism of action ies (n = 7), lack of autogenous vein (n = 5), or Dr. van Bemmelen is the inven- accounting for the large blood-flow in- poor general medical condition (n = 3). tor of the patented arterial assist de- crease involves the endothelium—cells Intervention: All patients were instructed to use the that form the lining of all blood ves- arterial assist device for 4 hours a day at home vice called ArtAssist, which is for a 3-month period. sels. The endothelial cells release im- currently used throughout the world. Main Outcome Measures: Limb salvage and cali- He has the longest clinical experience portant biochemical factors, such as brated pulse volume amplitude. with the use of this device for the nitric oxide that helps circulate the Results: After 3 months, 9 legs had a significant treatment of rest-pain, necrosis (black blood. increase in pulse-volume amplitude (P<.05). These legs were salvaged, whereas the 4 am- discoloration) of parts of the foot, and This substance is released in amounts corresponding to the rate of putated legs demonstrated no hemodynamic intermittent claudication (walking dif- improvement. We noted a direct correlation be- ficulty). blood flow moving along the cells that tween patient compliance and clinical outcome. Typical reasons to use this type line the vessels. Patients in whom limb salvage was achieved of treatment are: advanced age and Patients with poor circulation used their compression device for longer peri- poor medical condition, multiple pre- (peripheral arterial occlusive disease) ods of time (mean time, 2.38 hours a day) com- have lost pulsatile blood flow, and pared with those who underwent amputation vious bypass attempts, lack of veins (mean time, 1.14 hours a day) (P<.05). These their blood circulates in a sluggish that could be used to make a new by- mean hours of use were derived from an hour pass, and lack of distal outflow arter- manner. This inhibited movement counter built into the compression units. ies in the foot to which to connect a causes a loss of those important bio- Conclusions: Intermittent high-pressure compres- bypass. chemical factors needed to maintain sion may allow limb salvage in patients with proper circulation. limb-threatening ischemia who are not candi- When the arterial assist device is dates for revascularization. Further studies are ARTERIAL ASSIST warranted to assess intermittent compression Dr. van Bemmelen’s arterial as- used, pulsatility is returned to a limb as an alternative to amputation in an increas- sist device applies a unique form of by rapid compression. This creates ingly older patient population. pneumatic compression to the foot, high flow rates intended to stimulate release of these important biochemical •van Bemmelen PS, Gitlitz DB, Faruqi RM, Weiss- ankle, and calf to increase arterial Olmanni J, Brunetti VA, Ricotta JJ. Limb salvage blood flow to the lower limbs. factors and likely stimulates the forma- using high-pressure intermittent compression arterial assist device in cases unsuitable for surgical The device triples blood flow at tion of collateral vessels. revascularization. Archives of Surgery the tissue level. It provides a compres- 2001;136:1280-6.

DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY — 7 — For the second year in a row, the Dr. Ahmad and Dr. Louis T. Division Briefs cardiac laboratory has been recog- Merriam, assistant professor of sur- nized by the Intel Science Talent gery, have completed special training Cardiothoracic Surgery Search (STS). In January, Lukasz K. in the technique of the new Stretta procedure for the minimally-invasive Dr. Irvin B. Krukenkamp, Oleszak, a senior at Ward Melville treatment of gastroesophageal reflux professor of surgery and chief of High School in East Setauket, NY, was disease (see cover story). cardiothoracic surgery, is chair of the named a semifinalist in the 61st an- 2002 Research Classic Golf Tourna- nual competition. He had conducted ment, to take place in September. his study in the laboratory: “Using Otolaryngology-Head and Proceeds of this major fundraiser Computer-Aided Speckle Interferom- Neck Surgery will benefit cardiac research at etry to Determine Regional Deforma- Dr. Arnold E. Katz, professor of Stony Brook. tion in the Beating Rabbit Heart.” clinical surgery and chief of otolaryn- In October, Dr. Krukenkamp was Often considered the “Junior Nobel gology-head and neck surgery, has appointed director of the Heart Center Prize,” the Intel STS is America’s old- served as chair of the ad hoc commit- of University Hospital. The full devel- est and most prestigious pre-college tee of the executive board of the fac- opment of cardiac services is one of science competition. ulty senate to establish a code of ethics the hospital’s recently announced stra- for our medical school. tegic initiatives. The goals of the pro- General/Gastrointestinal Dr. Katz has also served as ad- gram are to provide excellence in Surgery viser to a group of medical students cardiac care, develop the academic Dr. Arif Ahmad, assistant pro- who are committed to creating a code programs in teaching and research, fessor of surgery and director of the of ethics for medical students. and increase the volume of patients Center for Minimally Invasive Sur- Last September, Dr. Katz and cared for at Stony Brook. gery, joined our faculty last July, and Boston-based dermatologist Dr. The hospital plans to invest over continues to build his practice: in Donald Grande presented a workshop $10 million that will help create a January he performed laparoscopic titled “Reconstruction of Large Facial state-of-the-art heart center and con- bariatric surgery to treat morbid obe- Defects after Mohs Surgery” at the an- comitantly create additional capacity. sity—the first time such surgery was nual meeting of the American Acad- ever done at University Hospital. emy of Otolaryngology-Head and Neck Surgery, held in Denver, CO. In Bio-note November, he presented a lecture Dr. Paul S. van Bemmelen, who joined the Department in 1998, is currently co-director of titled “Special Problems and Survival University Hospital’s Leg and Foot Ulcer Treatment Group, medical director of the Non-Inva- Strategies: Can the Small Division Sur- sive Vascular Laboratory, and chief of vascular surgery at the Northport Veterans Affairs vive?” at the meeting of the Society of Medical Center. University Otolaryngologists-Head and Neck Surgeons, held in Washing- Dr. van Bemmelen received his MD from the University of Leiden (Netherlands) in 1978, and ton, DC. his PhD from the University of Amsterdam in 1985, for which he developed an experimental Once again, Dr. Katz is cited as a model of venous hypertension to study damage to vein valves. “doctor of excellence” in the latest edi- After completing his general surgery residency in Rotterdam in 1988, Dr. van Bemmelen tion (2001) of the Castle Connolly went to the University of Washington in Seattle for a one-year research fellowship in vascular Guide, Top Doctors: New York Metro surgery. He then returned to the Netherlands for a two-year clinical fellowship in general vas- Area. cular surgery. Dr. Eric E. Smouha, associate professor of surgery and neurological In 1991, Dr. van Bemmelen returned to the United States, going to Southern Illinois Univer- surgery, was recently elected to the sity, where he completed his residency training in general vascular surgery. From there he Otosclerosis Study Group, a national relocated to Long Island, establishing a private practice in Port Jefferson, NY, and subse- organization. quently joining our vascular surgery team. In September, Dr. Smouha pre- Dr. van Bemmelen’s clinical practice encompasses all aspects of general vascular surgery. sented his study titled “Computer Databases in Clinical and Academic Areas of particular interest include wound care management; noninvasive vascular diagnosis Practice,” at the annual meeting of the with color-duplex in arterial and venous disease; nonsurgical treatments for vascular disor- American Academy of Otolaryngol- ders; use of laser-Doppler techniques to study changes in the circulation of the skin in patho- ogy-Head and Neck Surgery, in logical states (e.g., diabetes, arterial disease, and venous insufficiency) and their relationship Denver, CO. with ulceration of the toes, feet, ankle, and legs.

— 8 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY Supporting his research, Stony surgery and director of surgical re- Dr. Fabio Giron Retires Brook’s General Clinical Research search. A number of disease states, After 24 Years Of Center has awarded Dr. Smouha a re- such as renal failure and critical ill- Distinguished Service search grant to fund his project titled ness, are associated with acidosis (the “Matrix Metallo-Proteinases in Cho- blood becoming more acid), and pa- lesteatoma.” tients with it can often have life-threatening wasting. Plastic and Reconstructive Dr. Garlick has already shown, Surgery in a collaboration with a group in Dr. Alexander B. Dagum, associ- Switzerland, that acidosis in healthy ate professor of surgery and chief of volunteers inhibits new protein syn- plastic and reconstructive surgery, is thesis, and he now is undertaking currently working with Dr. Arnold E. projects in kidney dialysis patients and healthy volunteers to further in- Katz, professor of surgery and chief of In October—on the last day of that vestigate this problem. otolaryngology-head and neck sur- month—Fabio Giron, MD, PhD, retired from his In addition, Dr. Garlick has been gery, to establish an integrated cuta- faculty position in the Department. Dr. Giron had heavily involved with the Food and neous oncology program that will been a distinguished member of our faculty Nutrition Board of the National Acad- provide a multidisciplinary approach since 1977, when he started his position here as emy of Sciences in revising its recom- to the reconstruction of large defects professor of surgery and chief of vascular sur- mendations for the dietary intake of following the removal of advanced gery at the VA Medical Center in Northport. From protein and amino acids. skin cancer. 1978 until his retirement, he also served as chief Dr. Dagum’s current research ac- of vascular surgery at University Hospital. tivities include a collaboration with Surgical Oncology Born in Sanlucar de Barrameda, Spain, in Dr. Brian J. O’Hea, assistant pro- the School of Medicine’s orthopaedics 1931, Dr. Giron received his MD with honors fessor of surgery and medical director department and the School of (premio extraordinario) in 1954 from the Univer- of the Carol M. Baldwin Breast Care Engineering’s materials science de- sity of Valladolid. In 1960, he completed his sur- Center, has again been cited as a “doc- partment in novel research to eluci- gical training in Madrid, after which he served tor of excellence” in the latest edition date the biomechanical aspects of on the surgical faculty of the University of (2001) of the Castle Connolly Guide, wrist and mandibular fractures. Madrid for four years. Top Doctors: New York Metro Area. Last October, Dr. Dagum pre- In 1964, Dr. Giron came to the United sented a lecture titled “Current Con- States. From then until 1970, he pursued re- cepts in Replantation and Free Tissue Vascular Surgery search at Tufts-New England Medical Center Transfer” at the annual meeting of the Dr. John J. Ricotta, professor Hospital in Boston for two years, and then fur- American Association of Surgical Phy- and chairman of surgery and chief of ther clinical training in vascular surgery at Mount sician Assistants, held in New Or- vascular surgery, delivered the Presi- Sinai Hospital in New York for two years. Subse- leans. dential Address at the 30th Annual quently, he served for two years as a member of Symposium on Vascular Surgery of the surgical faculty of Tufts University, from Surgical Research the Society for Clinical Vascular Sur- which he received his PhD in 1970. The recent award of a research gery, held in mid-March in Las Vegas. That year, Dr. Giron moved to New York to grant to Dr. Margaret A. McNurlan, The audience included about 1,000 join the surgical faculty of the Mount Sinai associate professor of surgery, by the vascular surgeons from all over the School of Medicine, and to serve as chief of vas- National Institutes of Health has en- United States and Canada. He focused cular surgery at the VA Medical Center in the abled studies of the mechanisms of on issues related to endovascular Bronx. He then came to Stony Brook in 1977. muscle wasting in the elderly to com- training. Highly respected by his peers, Dr. Giron mence. This project is designed to Dr. Paul S. van Bemmelen, distinguished himself as one of the “Doctors of demonstrate whether subclinical in- assistant professor of surgery, has Excellence” featured in past editions and the lat- flammation and insulin resistance are been appointed chief of vascular sur- est edition (2001) of the Castle Connolly Guide, responsible for the failure of new pro- gery at the Northport Veterans Affairs Top Doctors: New York Metro Area. His genius, tein synthesis in muscle as aging Medical Center. See the article on page his humanity, and his humor will be missed, but progresses. 7 about his novel treatment of inoper- long remembered, by those who worked with A second project on muscle able circulation disorders, called him, as well as by those whom he taught the art ArtAssist. wasting is currently being carried out of surgery. by Dr. Peter J. Garlick, professor of

DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY — 9 — Performing Historic Alumni News Heart Operation (Continued from Page 3) Since the class of 1975 entered the profession of surgery, 149 physicians have completed their residency training in general surgery at Stony The new microwave technique Brook. The alumni of our residency program now practice surgery was presented for the first time in No- throughout the United States, as well as in numerous other countries vember, during the annual meeting of around the world. the American Heart Association. This procedure had never been Dr. Juan R. Madariaga (’79), an ment in the US Public Health Service, performed on the East Coast. Dr. expert in the surgical treatment of for which he was stationed at the Saltman, who is director of our surgi- hepatobiliary diseases and bile duct Phoenix Indian Medical Center, a 150- cal electrophysiology program, used a tumors and an active liver transplant bed tertiary care hospital in down- microwave ablation catheter to create surgeon, is no longer with the Univer- town Phoenix, where he was staff therapeutic lesions on the heart. The sity of Pittsburgh Medical Center, surgeon. He then became chief of sur- procedure, which took no more than where he had been for a decade. In gical oncology at Maricopa Medical 20 minutes, is expected to perma- January 2001, he joined the transplant Center in Phoenix, a position he held nently cure the patient’s irregular team at the University of Miami/Jack- until June 2000. heartbeats. son Memorial Medical Center. He now Dr. Elias R. Quintos (’87), a is professor of surgery in the surgery cardiothoracic surgeon with Successful use of new microwave department at the University of Miami Binghamton Cardiovascular and Tho- technology for treating atrial and a member of its Division of Liver/ racic Surgeons, PC, located in Johnson fibrillation Gastrointestinal Transplant. City, NY, writes to us: “All our sur- This division is directed by an- geons have been doing nearly all our In addition, Drs. Krukenkamp other alumnus of our residency pro- myocardial revascularizations using and Saltman performed a bypass op- gram, Dr. Andreas G. Tzakis (’83). the off-pump technique for nearly eration to overcome the clogged artery Like Dr. Madariaga, Dr. Tzakis went three years with good results. Bleed- and used a bovine heart valve to re- to the University of Miami from the ing, postoperative pulmonary compli- place the patient’s faulty aortic valve. University of Pittsburgh, where he cations, and postoperative length of The new microwave technique had started performing liver trans- stay appear to be less.” was beneficial because the conven- plants in the early 1980s and subse- Dr. Dean P. Pappas (’99), after tional operation to correct an irregular quently progressed to directing his residency at Stony Brook, com- heartbeat takes three hours to com- Pittsburgh’s pediatric and intestinal pleted fellowship training in colorectal plete. By shortening the operating transplant programs. Dr. Tzakis joined surgery in Florida. In July 2000, he en- time and also reducing blood loss, the the faculty at Miami in 1994. tered private practice in Garden City, new microwave technique was a much Dr. Tom R. Karl (’81) started a NY, working with Dr. Victor A. Gallo safer procedure for the patient. new position, in November, as profes- (’79). He recently achieved board certi- In the conventional operation, a sor of surgery and chief of pediatric fication in both general surgery and series of cuts are made on the heart to cardiac surgery at the University of colon/rectal surgery. In order to best create scar tissue. The scars block mis- California-San Francisco. care for women with pelvic floor dys- firing impulses, which then lose their Dr. Peter J. Ferrara (’87), who function, he and his partner have chaotic path across the heart. specializes in surgical oncology and teamed up with a local urologist, and With the newly FDA-approved general surgery, entered private prac- together they have created the microwave technology, Dr. Saltman tice early last year in Scottsdale, AZ. Wellness Pavilion located in Garden accomplished the same goal in a frac- His residency at Stony Brook had been City, which is a combined colorectal tion of the time. He worked with a followed by a two-year fellowship in and urology physiology lab. narrow foot-long catheter that uses surgical oncology at Ohio State Uni- microwave energy to destroy the ab- versity, and then a two-year commit- normal electrical pathway causing the To submit alumni news online AND to find current mailing patient’s arrhythmia. addresses of our alumni, please visit the Department’s Restoration of normal heart website at www.uhmc. sunysb.edu/surgery rhythm also improves the function of www. the heart and relieves the symptoms of GENERAL SURGERY ALUMNI: Please send your e-mail address—for inclusion in the Alumni Directory—to congestive heart failure. [email protected]

— 10 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY Deborah Iorio Receives Trauma Award OUR ELECTRONIC

In December, Deborah A. Iorio, RN, PHYSICIAN DIRECTORY trauma registrar of our trauma program, was chosen the 2001 New York State Trauma he Department provides a physician directory as part of its website— Registrar of Distinction by the New York Tplease visit us at the following address to find information about our indi- State Trauma Advisory Committee (STAC) vidual surgeons (see sample page below), as well as our programs in patient and the New York Division of the American care, education, research, and community service: Trauma Society—for her “commitment to and pursuit of excellence.” www.uhmc.sunysb.edu/surgery Iorio, who joined the Department’s trauma division in 1996, contributes to the MD: University of Ottawa (1987). Suffolk County Trauma Registry. She has Residency Training: Plastic Surgery, been innovative in streamlining the registry University of Toronto. requests for medical records. She trains Fellowship Training: Hand and Microsurgery, new personnel, and also assists the data- University of Toronto and SUNY-Stony Brook. base manager in report writing on a daily Certification: Plastic Surgery (Royal College of basis. Physicians and Surgeons of Canada). Iorio is also responsible for data col- Specialties: Reconstructive and aesthetic surgery; breast lection at the non-trauma medical centers in reconstruction after cancer, breast reduction, and breast Dr. Alexander B. Dagum Suffolk County. She has successfully main- augmentation; nose surgery; cleft lip and cleft palate sur- tained a good relationship with each hospital gery; treatment of facial fractures; hand surgery (microsurgical repair of bony, that ensures the data is available. soft tissue, and nerve injuries); reconstructive surgery for burn patients; facelift, Five years ago, New York’s STAC and general liposuction, and tummy-tuck surgery; evaluation and surgical manage- Trauma Society created awards of distinc- ment of chronic wounds (skin grafting and soft tissue flap coverage). tion for a nurse and physician in trauma to Additional: Chief of Plastic and Reconstructive Surgery; expertise in not only recognize excellence. In 1999, the category conventional surgical approaches, but also the latest microsurgical techniques; of registrar was added because of the Fellow, American College of Surgeons (FACS); Fellow, Royal College of Physi- unique contributions that registrars make to cians and Surgeons of Canada (FRCSC); see recent publications. a trauma program. Languages Spoken: English, Spanish, and French. This prestigious award is peer-nomi- Consultations/Appointments: 631-444-4545. nated, and selected by a committee that re- views the recommendations in a blinded manner. There are almost 50 trauma centers throughout the state, and there are at least that many registrars. The Suffolk County Trauma Registry is an information system of the most seriously injured patients and the treatment that they have received. The purpose of the registry is to evaluate the quality What Is Minimally Invasive Surgery? of trauma patient (Continued from Page 4) care and to plan Second, the increased number of MIS per- Finally, many established and fine technical sur- formed corresponds to the development of geons needed to learn a new method of opera- and evaluate in- better and smaller computer components. The tion. Thus, we needed to be trained. jury prevention development of computer components, spe- Surgery to treat a variety of pediatric abdominal programs. cifically, digital imaging, improved the pediatric surgeon’s ability to visualize the operating and thoracic problems—such as gallbladder dis- field. ease, appendicitis, disease of the spleen, undescended testicle, gastroesophageal reflux Third, our subjects are smaller, and we need disease, spontaneous pneumothorax, and even smaller instruments. We could not use adult pectus excavatum (a congenital abnormal devel- instruments for many of our patients. There- opment of the chest wall)—used to require large fore, we had to wait for the surgical instrument incisions, and about a week in the hospital, and company to manufacture those important tools. a six- to eight-week recovery time.

DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY — 11 — STONY BROOK SURGICAL ASSOCIATES, PC

BREAST CARE OTOLARYNGOLOGY- TRAUMA/SURGICAL VASCULAR SURGERY John S. Brebbia, MD HEAD AND NECK CRITICAL CARE John J. Ricotta, MD Martyn W. Burk, MD, PhD SURGERY (ENT) Robert D. Barraco, MD Paul S. van Bemmelen, MD, PhD Louis T. Merriam, MD Arnold E. Katz, MD Collin E.M. Brathwaite, MD Brian J. O’Hea, MD Denise C. Monte, MD John S. Brebbia, MD Ghassan J. Samara, MD J. Martin Perez, MD BURN CARE Maisie L. Shindo, MD Collin E.M. Brathwaite, MD Eric E. Smouha, MD John S. Brebbia, MD Please visit our website at Harry S. Soroff, MD PEDIATRIC SURGERY www.uhmc.sunysb.edu/surgery Thomas K. Lee, MD CARDIOTHORACIC Cedric J. Priebe, Jr., MD SURGERY Richard J. Scriven, MD Thomas V. Bilfinger, MD, ScD Irvin B. Krukenkamp, MD PLASTIC AND Allison J. McLarty, MD RECONSTRUCTIVE Adam E. Saltman, MD, PhD SURGERY Frank C. Seifert, MD Balvant P. Arora, MBBS For consultations/appointments with our physicians, please call Alexander B. Dagum, MD •(631) 444-4550 for our specialists in breast care GENERAL/ Steven M. Katz, MD •(631) 444-1820 for our specialists in cardiothoracic surgery GASTROINTESTINAL •(631) 444-4545 for our specialists in general/gastrointestinal surgery SURGERY SURGICAL ONCOLOGY •(631) 444-4121 for our specialists in otolaryngology-head and neck surgery (ENT) Arif Ahmad, MBBS John S. Brebbia, MD •(631) 444-4538 for our specialists in pediatric surgery Robert D. Barraco, MD Martyn W. Burk, MD, PhD •(631) 444-4545 for our specialists in plastic and reconstructive surgery Collin E.M. Brathwaite, MD Louis T. Merriam, MD •(631) 444-4545 for our specialists in surgical oncology John S. Brebbia, MD Brian J. O’Hea, MD •(631) 444-2209 for our specialists in transplantation Martyn W. Burk, MD, PhD •(631) 444-1045 for our specialists in trauma/surgical critical care Louis T. Merriam, MD TRANSPLANTATION •(631) 444-2565 for our specialists in vascular surgery J. Martin Perez, MD John J. Ricotta, MD •(631) 723-5000 for our specialists at Stony Brook Outpatient Services in Wayne C. Waltzer, MD Hampton Bays: breast care - general/gastrointestinal surgery - pediatric surgery - vascular surgery

The State University of New York at Stony Brook is an equal opportunity/ affirmative action educator and employer. This publication can be made available in an alternative format upon request.

______DEPARTMENT OF SURGERY ______UNIVERSITY HOSPITAL AND ______HEALTH SCIENCES CENTER ______STONY BROOK UNIVERSITY Stony Brook, New York 11794-8191

In this issue . . . ■ Performing Stretta for GERD ■ Ambulatory Surgery Center Opens ■ Historic Heart Operation ■ Introducing New Faculty ■ Tracheal Stenting for Airway Obstruction ■ Treating Inoperable Circulation Disorders ■ Electronic Physician Directory ■ Alumni News ■ Division Briefs—And More!

— 12 — DEPARTMENT OF SURGERY • UNIVERSITY HOSPITAL AND HEALTH SCIENCES CENTER • STONY BROOK UNIVERSITY