Winter 2011

Department of Surgery In affiliation with NewYork-Presbyterian Hospital ALL THE POSSIBILITIES OF MODERN MEDICINE

Pancreatic Cancer: Prevention and Genetics Muzzi Mi rza Pancreatic Program uses imaging and genetic testing to prevent pancreatic cancer. Understanding how cancers grow has made it possible to prevent many types of cancer. Tests such as mammograms, colonoscopy, and PSA tests can detect precancerous cells, which can be surgi - cally removed before they progress to more harmful stages – thereby preventing thousands of people from developing more dangerous forms of breast, colon, and prostate cancer every year. In the same way that colon cancer progresses IN THIS ISSU E through various stages of polyp formation, pancre - 1 Pancreatic Cancer atic cancer also includes stages of premalignant Using imaging and genetic testing to growth. If physicians can detect precancerous detect and prevent pancreatic cancer lesions and remove them, pancreatic cancer can 2 Complex Hernias sometimes be averted. Repairing hernias once considered Yet unlike the breast, colon, or prostate, the inoperable pancreas is much more difficult to access, making 3 Sleeve Gastrectomy for testing more invasive and expensive. For that Gastroparesis reason, screening for pancreatic cancer has never Novel use of weight loss surgery to cure become routine. Instead, the disease has tradition - debilitating effect of diabetes ally been detected only in its latest stages, when it 4 Events is almost uniformly fatal. But advances in understanding cell biology and genetics have led to the development of alternative methods of screening at The Muzzi Mirza Pancreatic PurpleStride healthpoints is published by Cancer Prevention & Genetics Program , a specialized center Manhattan is a th e Columbia University 1-, 2-, or 3-mile Department of Surgery as dedicated entirely to detecting and preventing pancreatic cancer. walk at Riverside a service to our patients. As described in a study of the center's results to date, screening Park to create You may contact the with genetics and imaging can be highly effective in finding and awareness, raise Office of External Affairs curing premalignant and malignant pancreatic lesions. funds and meet for additional information According to Harold Frucht, MD , Program Director , “Research in others who share and to request additional copies. the last few years has allowed us to better understand the progres - the same goal: to Please call 201.346.7001. sion of pancreatic cancer, so we better know who is at risk and what find a cure for to look for. This allows us to carefully choose who to screen so that pancreatic cancer! For physician referrals, please call we don't do unnecessary testing or surgery.” The November 1.800.227.2762 In particular, recent research has shed light on multi-organ cancer 2009 walk syndromes that increase the risk of developing pancreatic cancer. included over Deborah Schwarz, RPA, CIBE These syndromes include: Executive Director 2000 participants Office of External Affairs • FAMMM, or Familial Atypical Multiple Mole Melanoma, which can and raised over Jada Fabrizio be marked by the presence of moles on the body; $300,000 for Graphic Design • Peutz-Jeghers syndrome, which is associated with gastrointestinal pancreatic cancer research. Sherry Knecht tumors; Managing Editor continued on page 4 Father Robert Warren underwent surgery at the NYP/Columbia Hernia Center, where he says, “The care was Complex Hernias superb, just amazing.” Specialists in hernia repair can now correct many hernias that until recently were considered inoperable. In October 2009, Father Robert Warren underwent many patients with complex hernias were discouraged from surgery at NewYork-Presbyterian Hospital to remove a having surgery, and instead wore external support devices or benign mass in his colon. In February 2006 he had under - underwent unsuccessful procedures that resulted in further gone a similar operation (at his community hospital), which serious complications. was later complicated by the formation of a hernia in his In the last five to ten years, the advent of new prosthetic abdominal incision. The hernia was repaired at the commu - materials and the development of new surgical techniques nity hospital by two surgeons who used prosthetic mesh to have led to a revolution in hernia repair. As a result, the reinforce the hernia repair. Following his 2009 colon surgery practice of hernia repair has become a specialty rather than at NewYork-Presbyterian, a small area of the wound near his one of many areas within mainstream general surgery. “We belly button failed to heal. But the 71-year-old Franciscan have become more adept at repairing hernias that were priest focused instead on his work running a HIV/AIDS formerly considered unfixable,” says Dr. Geller. These program and raising funds for the friars' many ministries in include extremely large hernias, hernias that have recurred upstate New York. Eventually, he returned to his doctor and many times with increasing loss of abdominal integrity, as learned that the mesh, which had been implanted in 2006, well as patients with complex wounds including hernias with was now infected. His colorectal surgeon referred him to intestinal fistulas . “These hernias are no longer inoperable, Peter L. Geller, MD , Director, NewYork-Presbyterian/ but are often successfully repaired using new techniques and Columbia University Department of Surgery Hernia Center . materials.” Moreover, the repetitive practice that comes with Infected incisional hernias usually require two surgeries: specialization has enabled surgeons such as Dr. Geller to one to remove the infected mesh and a second to repair the perform simple hernia repairs with less post-operative pain hernia after the infection clears. In this case, Dr. Geller was and fewer recurrences. able to perform a single procedure in which he removed the In Father Warren's case, Dr. Geller used a technique called infected mesh, mobilized the overlapping muscular layers of laparoscopic component separation . Using laparoscopic the abdominal wall, and sutured the abdominal wall back instruments, he freed the muscle layers of the abdominal wall together without mesh. Relieved that he was able to avoid after removing the infected mesh and successfully closed the another surgery, Father Warren has recovered very well. wound without implanting a new mesh graft. According to Like Father Warren, many people develop complex Dr. Geller, “This technique is very useful in difficult situations, hernias after surgery. Complex abdominal hernias may especially in patients with wounds or infections where we include recurrent hernias following mesh placement, infected cannot use mesh.” mesh grafts, hernias characterized by loss of abdominal The NYP/Columbia Hernia Center treats approximately domain (in which the abdominal organs protrude through 600 patients each year at three locations. The Center plans the hernia, the abdominal cavity shrinks, and it becomes diffi - to conduct studies to track recurrence rates, pain, and cult to replace the abdominal organs), and others. patient satisfaction after hernia operations. n Complex hernias present unique challenges and require For more information, visit: www.columbiaherniacenter.org specialized treatment. According to Dr. Geller, until recently or call 212.326.5547.

What is a Hernia? A hernia is the protrusion of an organ or tissue through the fails to heal completely, often contain trapped intestine wall of the cavity that normally contains it. Hernias can and can be more hazardous to treat. Causes of hernias occur in many parts of the body. The most common, include congenital weaknesses and collagenopathies, inguinal hernias, account for 75% of abdominal hernias. prior surgery or other trauma to the abdomen, increased Higher in the abdomen, a diaphragmatic hernia occurs pressure in the abdomen, and weakening of the abdomi - when part of the stomach or intestine protrudes through a nal wall due to age, obesity, smoking, poor nutrition, and defect in the diaphragm. Incisional hernias, which may other causes. Symptoms such as pain or a visible bulge develop when a surgical wound may or may not be present.

2 healthpoints • Winter 2011 Sleeve Gastrectomy for c n I

Gastroparesis , y r e g r u S -

Novel use of weight loss surgery may help patients o d n E

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As advanced as modern medicine At the Center for Metabolic and y s e t has become, in some cases, it still falls Weight Loss Surgery, NewYork-Presby - r u o short. Patients who develop a condition terian Hospital/Columbia University C called gastroparesis are among those Medical Center, Dr. Bagloo and Sleeve gastrectomy, also called vertical who may exhaust the limits of available colleagues are now testing a procedure sleeve gastrectomy or gastric sleeve, has therapies. It is for patients such as these that has shown excellent initial results been long used as the first stage of weight that physicians at NewYork-Presbyter - in this difficult-to-treat population. loss surgery in patients with very high body ian/Columbia have once again stepped Based on their long-term experience, mass index (BMI). In this laparoscopic up and found new avenues of treat - Marc Bessler, MD , Director, Center for procedure, the size of the stomach is ment – and hope. Metabolic and Weight Loss Surgery , and reduced to about 15% of its size. Over Gastroparesis is a disorder in which colleagues believed that a laparoscopic many years, physicians observed that the stomach cannot contract and empty procedure called sleeve gastrectomy just patients lost weight very effectively after its contents into the intestines. Because might help patients with severe gastro - sleeve gastrectomy without undergoing patients with gastroparesis cannot move paresis. When four patients with biliopancreatic diversion, the second and food properly through their digestive gastroparesis were unable to receive more invasive stage. As a result, bariatric system , they may experience symptoms gastric pacemakers early this year, the surgeons frequently perform sleeve gastrec - including pain, nausea, vomiting, surgeons performed sleeve gastrectomy, tomy as a standalone procedure today. abdominal bloating, malnutrition, and normally used to help patients lose more. Although a number of conditions weight, to see if it might help. The risks associated with laparoscopic may cause gastroparesis, by far the According to Dr. Bagloo, “We had sleeve gastrectomy are minimal, and most common is diabetes, in which previously observed that after sleeve include leakage in the staple line (2-3%), continued high blood sugar levels gastrectomy, patients who had diffi - wound infection, and post-operative damage the vagus nerve, which culty emptying their stomachs showed pain. Unlike implantation of a gastric controls the movement of food through significant improvement in their pacemaker, sleeve gastrectomy leaves the digestive tract. Gastroparesis can digestion. We do not know precisely no foreign object, which can erode, get develop as a consequence of either why this is: Sleeve gastrectomy may infected, or require subsequent proce - type 1 or type 2 diabetes that is poorly have the effect of 'resetting' the dures to replace batteries, in the body. controlled. natural gastric pacemaker, or it may Although other surgeries have been Conventional treatments may include be that the smaller size of the stomach attempted in patients with gastroparesis, medical therapies, dietary changes, increases intragastric pressure so that they are larger operations with signifi - and implantation of a gastric electrical it helps facilitate gastric emptying. cant risks, says Dr. Bagloo. “We believe stimulator, or 'gastric pacemaker,' an There could also be other reasons why that laparoscopic sleeve gastrectomy implanted device that helps to control the surgery helps.” may be a less invasive option that allows nausea and vomiting. If all of these fail The four patients who underwent patients to eat normally and regain their to help, however, patients may have sleeve gastrectomy at the center in quality of life.” no choice but to receive nutrients 2010 were all diabetics with severe No other group has reported using through feeding tubes – not an attrac - gastroparesis. For various reasons, they sleeve gastrectomy to treat gastropare - tive op tion for anyone, but especially were not eligible to receive a gastric sis. Based on the success in the initial younger patients. According to Melissa pacemaker. After surgery, two of the four patients, NYP/Columbia is Bagloo, MD , Assistant Professor of patients did very well right away, and conducting further study. The Center Clinical Surgery, Division of Minimal the other two needed nutritional for Metabolic and Weight Loss Surgery Access/Bariatric Surgery , “There are support for several months. “At six is concurrently developing a program many patients who do not improve months after surgery, all four were that will offer all treatments, including with current treatments and whose eating, drinking, and were no longer gastric pacemakers and sleeve gastrec - quality of life continues to deteriorate. experiencing nausea or vomiting. For tomy, for patients with gastroparesis. n This is a debilitating condition that can patients who faced the prospect of life- For more information, be very frustrating for both patients long feeding tubes, the benefits of please call 212.305.4000 and physicians.” such a successful outcome cannot be or visit www.ObesityMD.org overstated,” says Dr. Bagloo. 3 healthpoints • Winter 2011 • Winter 2011 Pancreatic Cancer: Prevention and Genetics ~ continued from page 1

• HNPCC, or hereditary nonpolyposis colorectal cancer (also patients have just blood work, others may have blood work called Lynch syndrome), which is associated with colorectal, and endoscopic ultrasound, others may have blood work endometrial, biliary, brain, and pancreatic cancers; and MRI, and still others may have all three,” says Joanna • Breast and ovarian cancer in association with the BRCA 1 or Martinez-Gomez, Program Coordinator. “The higher the risk, BRCA 2 genes; and the closer the look we need to take at the pancreas and the pancreatic ducts.” • Hereditary pancreatitis. Genetic testing may also be recommended. “We are Even if a patient does not fit into one of the syndromes looking for any patterns of cancer, including breast, ovarian, above, he or she may still have a family history of cancer that colon, or others,” says Dr. Frucht. “Certain syndromes predis - suggests higher risk for pancreatic cancer. Important signs of pose people to certain kinds of cancers. If we suspect that a increased risk include early onset of cancers and multiple syndrome may be present, we recommend genetic testing.” cancers (of any type) in the family. Ideally, people should seek screening at least ten years prior to the age at which their Depending on the results of these tests, the patient's risk youngest relative with cancer was diagnosed. level may be reclassified. The team then determines how often to monitor the patient. If an abnormality is found on How the Muzzi Mirza Pancreatic Cancer Prevention & imaging, the team decides whether to continue to monitor or Genetics Program Works to surgically remove it. Patients at high risk may return to the Anyone may request an appointment at the Muzzi Mirza center at six or twelve month intervals for ongoing evaluation. center, including relatives of patients who have been “For anyone with a family history of cancer, early screening diagnosed with pancreatic or other cancers. At the first is very important,” says Kristin Engelstad, Genetics Counsel - appointment, the center takes a detailed family history and ing Intern in the Muzzi Mirza Program. “If there is cancer in performs a physical exam. The family history is used to deter - your family – not just pancreatic, but any type of cancer – you mine whether the patient's risk of developing pancreatic can now be proactive rather than simply wait around to get cancer is average, moderate, or high. cancer. If you wait until symptoms appear, often that is too Blood tests may be administered to check for tumor late.” She particularly encourages younger adults, who may markers, glucose levels (because many people predisposed resist the idea, to seek screening earlier rather than later. “Not to pancreatic cancer develop diabetes), and to assess liver only can it help in treating yourself, but if you have children, function, pancreatic function, and other measures of health. knowledge about a genetic mutation or syndrome can poten - Some patients will undergo imaging tests such as CT scan, tially help your children.” n MRI, and endoscopic ultrasound of the pancreas. “Some For information or to inquire about screening, visit www.pancreasmd.org or call 212.305.9337 . SAVE THE DATES InnovATIons In Complex CATCH-Up 2011 vAsCUlAr & endovAsCUlAr Heart Failure, Devices, and Interventions InTervenTIons A course for cardiologists, interventional cardiologists, Special Sessions: cardiothoracic surgeons, physician assistants, physical therapists, Management of Non-healing Wounds and other medical professionals involved in the evaluation, Vascular Lab Evaluation diagnosis and/or management of patients with heart failure A course for: vascular surgeons, general surgeons, cardiothoracic surgeons, interventional cardiologists, vascular interventional Thursday, May 5, 2011 radiologists, podiatrists, wound care specialists, physical therapists, NewYork-Presbyterian Hospital/ nurses, physician assistants, fellows-in-training Columbia University Medical Center and vascular laboratory technicians Vivian and Seymour Milstein May 12 & May 13, 20 11 Family Heart Center, NYC Marriott Marquis, NYC . For information call: 201.346.7003 or visit our website at: For more information call: 201.346.7007 or visit our website at: www.ColumbiaSurgeryCME.org www.ColumbiaSurgery.org/vascular

4 healthpoints • Winter 2011 www.facebook.com/columbiasurgery www.twitter.com/columbiasurgery