JOHNS HOPKINS WINTER 2017

NEWS FROM THE JOHNS HOPKINS SurgeryDEPARTMENT OF SURGERY

Johns Suburban Hopkins Surgical Hospital Howard County Bayview General Medical Oncology Hospital Center

Sibley Expands in Memorial Hospital Baltimore National Capital Columbia Region

Washington, D.C.

hen Johns Hopkins acquired Baltimore City Hospitals in 1984, later renaming it Johns Hopkins WBayview Medical Center in 1994, it offered a novel opportunity: Physicians could provide patients the innovative style of medicine and services SURGICAL ONCOLOGISTS ARE NOW PRACTICING AT EACH OF THESE that were previously only available at The Johns LOCATIONS, SERVING PATIENTS FARTHER SOUTH IN MARYLAND, WASHINGTON, Hopkins Hospital. In turn, more patients could access the institution’s unique protocols in a location D.C., AND NORTHERN VIRGINIA, AND OFFERING MORE CONVENIENT that was convenient for them. LOCATIONS FOR OUT-OF-STATE PATIENTS. Years later, Johns Hopkins has forged similar relationships with other local community hospitals, including Howard County General Hospital General, Suburban and Sibley, all with specialized preoperative and postoperative care, chemotherapy, in Columbia, Maryland; Suburban Hospital in surgeons. Surgeons with expertise in lung cancer radiation and other cancer-related services at Johns Bethesda, Maryland; and Sibley Memorial Hospital are now practicing at The Johns Hopkins Hospital, Hopkins member hospitals closer to their homes. in Washington, D.C. Johns Hopkins Bayview and Sibley. In fact, Sibley “Cancer care in the D.C. area is often fragmented. This enormous expansion, explains colorectal now hosts a branch of the Johns Hopkins Kimmel Patients might have their surgeon at one hospital, surgeon Jonathan Efron, presents an opportunity Cancer Center, with surgeons who treat breast, their medical oncologist at another and their for Johns Hopkins to offer regional centers for hepatobiliary, endocrine, neurological, head and radiation oncologist at a third location,” he says. specific diseases, including cancer. Surgical neck, and thoracic conditions. Plans are in the works “We can offer comprehensive, multidisciplinary care oncologists are now practicing at each of these to expand these offerings over the next several years. under one roof.” n locations, serving patients farther south in According to thoracic surgeon Stephen Maryland, Washington, D.C., and northern Broderick, one of the newest To refer a patient: 443-997-1508 Virginia, and offering more convenient locations for members of the team at out-of-state patients. Sibley, these centers are “By expanding the regionalization of cancer care, able to provide most of we’re trying to make treatment more convenient for the standard surgical “WE CAN OFFER COMPREHENSIVE, both patients and referring doctors away from The procedures available MULTIDISCIPLINARY CARE UNDER Johns Hopkins Hospital,” Efron says. “The goal is at The Johns Hopkins to have the correct patient cared for in the correct Hospital. Even though ONE ROOF.” setting.” the most complex For example, Efron explains, there are now breast operations will still —STEPHEN BRODERICK cancer centers of excellence at The Johns Hopkins take place at the main Hospital, Johns Hopkins Bayview, Howard County campus, patients can access PANCREAS SURGERY

In FY2016, Johns Hopkins surgeons performed Fighting 500+ Pancreatic pancreas operations. Cancer As a Team

hristopher Wolfgang, who directs Johns Hopkins’ Hepato-Pancreato-Biliary Program, says that to win the war against “OUR GOAL FOR ALL PATIENTS WHO WALK Cpancreatic cancer in a patient, two battles INTO THIS CLINIC IS A CURE.” must be fought. The first battle, he says, is a local one that involves removing primary tumors via com- —CHRISTOPHER WOLFGANG plex procedures, such as the Whipple, the modified Appleby, the distal pancreatectomy and others. The second battle is a broader, systemic effort to catch the micrometastases that can spread to distant sites, in- cluding the liver, lungs, bone, brain and other organs. Other medical oncologists on the team include Dan having our team provide every cutting-edge and “No one specialty can fight both these battles on Laheru, Lei Zheng, Dung Le, Ana DeJesus personalized treatment for every case will give them its own,” Wolfgang says, “and it’s nearly impossible and Nilo Asad. Each works to incorporate the best chance.” n to win the war unless specialties are functioning as immune treatments with traditional and innovative a team.” chemotherapies to systemically contend with That’s why Johns Hopkins started the Pancreatic metastatic disease. Watch a webinar on surgical advances in pancreatic cancer at Cancer Multidisciplinary Clinic in 2007. At the In addition, radiation oncologists led by bit.ly/PancreasWebinar. time, says Wolfgang, it was the first clinic of Amol Narang, pain medicine led by Michael its type nationally, integrating specialists from Erdek, pathology led by Ralph Hruban, surgery, medical oncology and radiation oncology, and diagnostic imaging led by Elliot Fishman Karen Horton and incorporating the latest research from Johns and ESEARCH Hopkins and elsewhere to fight pancreatic cancers. round out the team. Each of these R Nearly a decade later, the program is the most individuals is recognized as a experienced and busiest in the country—factors leader in his or her field. shown time and again to improve patient outcomes. Members from all specialties O For example, Johns Hopkins pancreatic surgeons work in concert, discussing AL NCO IC L performed 349 Whipple operations and over 500 each patient to decide on ED O pancreas operations in fiscal year 2016. The group the best course of care. Their M G IS performs many of the operations using a minimal experiences in the clinic inform T access approach, such as laparoscopic and robotic, as their lab work, Wolfgang says, S well as the traditional open method. with new innovations stemming Besides Wolfgang, surgeons on the team from patients at Johns Hopkins include John Cameron, one of the fathers of and elsewhere. Physician-scientists, pancreatic surgery, who has spent nearly five decades including Wolfgang, are currently The Pancreatic performing it. When he began his career at Johns working to better understand Cancer Multidiscplinary Hopkins in the 1970s, the mortality rate for the pancreatic cancer GEON Clinic integrates specialists UR S and incorporates the Whipple procedure was nearly 30 percent. His genetics to develop S latest research to fight efforts brought that rate down to less than 2 percent personalized pancreatic cancers. at Johns Hopkins, and he instructed countless other approaches to surgeons in the process to spread his lifesaving treatment and technique throughout the world. early detection. Other surgeons on the team include Marty They’re also studying Makary, Matt Weiss and Jin He, who together circulating metastatic comprise a premier pancreatic surgery program cells to develop directed that includes minimally invasive techniques, an therapies and to use the irreversible electroporation program, innovative cells as a window into the clinical trials and cutting-edge translational research. primary tumor. R S The medical oncology program is led by “Our goal for all patients A T Elizabeth Jaffee D IS , who developed a powerful who walk into this clinic is a IA G T O therapeutic vaccine to mobilize patients’ immune cure,” Wolfgang says. “Sometimes IO OL systems to combat pancreatic cancer recurrence. the odds can be stacked against them, but N ONC

2 • JOHNS HOPKINS SURGERY • WINTER 2017 ONCOLOGY After removing all disease in the abdomen, surgeons close the cavity and insert two catheters, including one More Effective to deliver chemotherapy to the patient. The chemotherapy exits Treatment of through the second catheter, recirculates through a machine and Peritoneal Tumors returns to the patient.

ancers that originate in the abdomen and spread throughout the peritoneal cavity used to be universally fatal, says surgeon Fabian Johnston, who joined the Johns Hopkins faculty in May 2016. Surgically removing the many metastatic sites seemed Clike an impossible task, and systemically delivered chemotherapy doesn’t penetrate deep enough into the peritoneal lining to catch budding, as-yet-invisible tumors. However, he explains, a technique that’s been selected chemotherapeutic drug to enter cells more slowly gathering steam over the past few decades easily, increasing its killing power. But since its “OUR ENTIRE TEAM WORKS could offer patients a chance at extended survival or activity is confined to the abdomen, patients avoid TOGETHER TO GIVE PATIENTS THE even a cure. Known as hyperthermic intraperitoneal some side effects common with systemically delivered chemotherapy, or HIPEC, it involves flooding the chemotherapies. BEST RECOVERY AND OUTCOME.” cavity with a warm chemotherapy solution, catching Performing HIPEC successfully isn’t possible —FABIAN JOHNSTON errant malignant cells and small, imperceptible without a multidisciplinary team with expertise on tumors before they develop a foothold in the this technique, Johnston says, which isn’t available abdomen or metastasize elsewhere in the body. at many institutions. For example, he says, due to The treatment can be an option for patients with the nature of these cancers, many patients aren’t appendiceal, colon, ovarian, gastric or primary optimally nourished before surgery. Working peritoneal cancers, Johnston says, because these with nutritionists gets patients on track before cancers tend to spread locally at first, colonizing HIPEC, which helps ease the postoperative period. the peritoneal cavity. To perform HIPEC, he and Anesthesiologists familiar with HIPEC also use the surgical team must first perform a complete protocols that fast-track recovery, including epidurals cytoreduction of all visible disease throughout the instead of narcotics and minimal use of fluid, which entire abdomen, checking for evidence of lesions on allow patients’ bowels to recover faster and let the diaphragm, liver, bladder, bowel and paracolic patients receive oral nutrition earlier. gutters—anywhere cancerous cells might have “I always tell patients that this procedure is a traveled throughout the cavity. This initial part of marathon,” Johnston says. “HIPEC is like nothing Candidates for HIPEC the procedure might take two hours or up to 12 they’ve ever been through before. Our entire team Patients with certain peritoneal depending on the extent of cancer spread. works together to give patients the best recovery and surface malignancy cancers, such as: “It’s a very exhaustive surgery to get patients down outcome.” to an extremely low level of disease,” Johnston says. Besides achieving excellent clinical outcomes, • Selected late-stage colon cancer Once cytoreduction is complete, the next step is Johnston notes that it’s important for him and other to fill the peritoneal cavity with a chemotherapeutic surgical team members to make sure that patients • Appendiceal cancers solution heated to 42 degrees Celsius, about the and their families are cared for like family. • Pseudomyxoma peritonei temperature of a warm bath, and allow it to circulate “We hold the entire team,” he says, “to the same up to 90 minutes. Heating the solution allows the standard of care we’d want for our own families.” n • Select gastric and ovarian cancers

Watch Fabian Johnston discuss hyperthermic intraperitoneal chemotherapy at bit.ly/JohnstonHIPEC.

JOHNS HOPKINS SURGERY • WINTER 2017 • 3 ICD-10 Is Here New Surgeons at Johns Hopkins Medicine Explore Our New When referring patients to Johns Hopkins Shane Ottmann is the director of the Living Donor Medicine, please be sure to include ICD-10 codes. Online Resource for Kidney Transplant Program within the Comprehensive Transplant Center. His areas of clinical expertise For more information, visit Physicians: Clinical include abdominal surgery, dialysis access, liver www.cms.gov/Medicare/ transplant, kidney transplant, pancreas transplant, Coding/ICD10/. Connection live donor transplant, hepatobiliary surgery and laparoscopic nephrectomy. His research interests Johns Hopkins Surgery Connect with include organ preservation, hepatocellular carcinoma Referral Line Johns Hopkins health care and the expansion of living donor transplant. Before joining Johns Hopkins, professionals about the latest he served as chief of the Army-Navy Transplant Service at Walter Reed Call 443-997-1508 to refer a patient. clinical innovations and advances National Military Medical Center and transplant consultant to the Army Get easy access and quick appointments for your in patient care. Access videos, surgeon general. patients at multiple locations. articles, news, clinical trials and Jacqueline Garonzik Wang is a surgeon in the much more. Comprehensive Transplant Center. Her areas of clinical Our schedulers are available to assist you Monday through Friday, 8 a.m. to 5 p.m. Visit www.hopkinsmedicine. expertise include hepatobiliary surgery; liver, pancreas For after-hours or emergency transfers, org/clinicalconnection. and kidney transplantation; and living kidney donation. please use the Hopkins Access Line at Her research interests include exploring and developing 410-955-9444. methods to increase living donation, utilizing large health care data sets to improve access to transplantation and post-transplant outcomes, and increasing deceased donor transplant rates by safely expanding organ acceptance criteria.

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For referrals or appointments to the Department of Surgery, call 443-997-1508. SurgeryJOHNS HOPKINS WINTER 201 7

NEWS FROM THE JOHNS HOPKINS DEPARTMENT OF SURGERY 1 2 3

Inside Surgical Fighting More Effective Oncology Pancreatic Treatment Expands in Cancer As a of Peritoneal National Team Tumors Capital Region