{InsIde thIs Issue}
Genetics Research in Inflammatory Bowel Disease p. 6
Rectal Cancer Update: Multidisciplinary Care and IORT p. 17
Cleveland Clinic Plans Centralized “Organ Repair Center” p. 17
Digestive Disease institute | winter | 2013
Digestthis
New Section of Surgical Oncology Dedicated to Complex Malignancies p. 3
Piecing together the
Puzzle for a Premier
Center of Care p. 12
Gut rehabilitationanD transplantation
DIgeSTIve DISeaSe INSTITUTe CHaIR John Fung, MD, PhD
MaNagINg eDITOR ann Bakuniene-Milanowski
aRT DIReCTOR Michael viars
MaRkeTINg MaNageRS Priya Barra Matthew Chaney
CONTRIBUTINg PHOTOgRaPHeRS Russell Lee Cleveland Clinic Center for Medical art & Photography
CONTRIBUTINg WRITeRS glenn Campbell, Tara Stultz, Wayne kuznar
dear Colleagues,Being able to offer a patient a breakthrough surgical procedure or medical treatment is
a factor that motivates us — pushes us harder to find solutions where none were once
available. as we begin the New Year, I’m excited to share with you updates on two ar-
eas in my department that are undergoing tremendous growth and continually finding
innovative solutions to improve care for patients: transplantation and surgical oncology.
Our cover story this issue (p. 12) highlights recent advances in intestinal trans-
plantation and introduces you to kareem abu-elmagd, MD, PhD, who joined us
last summer as Surgical Director of our Center for gut Rehabilitation and Trans-
plantation (CgRT), formerly known as the Intestinal Rehabilitation and Transplant
Program (IRTP). Dr. abu-elmagd, who is widely recognized for helping develop
and standardize intestinal transplant surgical techniques and post-transplant man-
agement approaches in the 1990s, has been involved in more than 20 percent of
the procedures done worldwide. We are excited to have Dr. abu-elmagd as part of
our team and hope you enjoy reading about the plans he and CgRT Medical Direc-
tor Donald kirby, MD, have to continue improving outcomes for intestinal rehab
and transplant patients.
also new on the transplant front, we feature a collaboration (p. 17) by Bijan
eghtesad, MD; Cristiano Quintini, MD; and John Fung, MD, PhD, to establish a
centralized “Organ Repair Center” to help us study the best ways to preserve and
potentially recondition the liver and possibly other digestive organs. Dr. Quintini and
colleagues also share with us a case study (p. 8) that demonstrates how living donor
liver transplants are offering new hope to patients with end-stage liver disease.
On p. 3, we showcase a new section in our general Surgery Department, the Section
of Surgical Oncology, headed by Stephen R. grobmyer, MD, FaCS, who recently joined
our staff to lead our experts who specialize in treating advanced and recurrent tumors.
Throughout our entire Digestive Disease Institute, we remain committed to innova-
tive approaches and research, and inside this issue we also highlight three such
efforts: minimizing variations in rectal cancer care and our use of intraoperative
radiation therapy to treat these patients (p. 10), new combined adult/pediatric
clinics for inflammatory bowel disease and pouchitis patients (p. 6), and inflam-
matory bowel disease genetics research by Jean-Paul achkar, MD, the kenneth
Rainin endowed Chair in IBD Research, and Claudio Fiocchi, MD (p. 6).
I hope you enjoy this issue of Digest This, and we look forward to collaborating with
you to provide the best possible care for your patients.
Respectfully,
R. Matthew Walsh, Md Chairman, Department of general Surgery, Cleveland Clinic Digestive
Disease Institute, [email protected]
Cleveland Clinic #2 in the U.S. – Gastroenterology
clevelandclinic.org/digestive 855.ReFeR.123 {3}
Digestive Disease institute
ddI spotlight: surgical OncologyNew Section Dedicated to Complex Malignancies
Cleveland Clinic’s Department of general surgery has created a new section of surgical
Oncology, headed by stephen r. grobmyer, MD, FaCs, to formally house its experts who
specialize in treating advanced and recurrent tumors and to further its ongoing efforts to
deliver innovative care and improve outcomes.
stephen R. Grobmyer, Md, FACs
“Working in collaboration with colleagues from Taussig
Cancer Institute and across Cleveland Clinic, we
offer the ability to treat some of the more advanced
malignancies, such as retroperitoneal sarcomas and
advanced-stage melanomas,” explains Dr. grobmyer,
who joined Cleveland Clinic in September 2012 as
Director, Section of Surgical Oncology, Department
of general Surgery.
a major focus is on multidisciplinary care of the
cancer patient — collaborating with colleagues from
medical oncology,
radiation oncology
and radiology. “The
best treatment is
evolving,” he says.
“Cancer treatment
often involves sur-
gery, radiation and
medical therapy.
We are working
together to deter-
mine what the optimal combinations of treatments
and their timing will be for each patient.”
examples of innovative treatments already being
offered include:
• Minimally invasive and robotic surgery options
for gastrointestinal malignancies
• Treating advanced malignancies with regional
chemotherapy
• Using the Nanoknife® IRe system as an alternative
treatment for pancreatic cancers
• Utilizing hyperthermic intraperitoneal chemotherapy
(HIPeC) for tumors of the appendix, colon, stomach
and ovary, as well as peritoneal mesothelioma
• New catheter-based techniques for administering
radiation therapy to patients with retroperitoneal
sarcomas
• Single-dose intraoperative radiation therapy for
breast cancer
• Nipple-sparing mastectomy for breast cancer
Other areas of
emphasis will
include enrolling
patients in clinical
trials, expand-
ing the role of
genetics in how
treatments are
selected, and con-
tinuing to improve
the experience of
the cancer patient — from early diagnosis through
treatment and recovery.
“This new section will enrich our ability to further
provide the highest quality of care for patients with
solid tumors,” he says. “It also sets the platform
for us to continue to bring innovative treatments in
areas such as pancreatic cancers and others where
much overall progress has yet to be made toward
improving outcomes.”
Dr. grobmyer can be reached at 216.636.2843
or [email protected]. ■
“Our constant push is to try to continually
lessen the burden of our treatments on
patients while improving outcomes.”
– Stephen R. Grobmyer, MD, FACS
What We Treat
• gastric cancer
• pancreatic cancer
• metastatic colorectal cancer
• intra-abdominal malignancies
• benign & cancerous liver tumors
• appendiceal cancer
• carcinoid tumors
• sarcoma
• melanoma
• breast cancer
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Cleveland Clinic
number of genes identified to date associated with
IBD. Researchers at Cleveland Clinic co-authored the
paper in which the first gene associated with
Crohn’s disease (NOD2) was identified.
OF Patients with ulCerative COlitis May neeD surgery in their liFetiMe.
to
by the
35-40%AB
Ou
t
of Crohn’s disease patients may require a
reoperation every five years because of the
disease’s recurrent and complex pathology.
s M A l l e R Is BetteRCleveland Clinic surgeons performed the world’s first series of
laparoscopic J-pouches in 1991 and performed the world’s first
single-incision colectomy in 2008 and proctocolectomy in 2009,
using an incision the size of a silver dollar (2-3 cm). Prior to these
major innovations, treatment with conventional colon resections
required a footlong or larger incision. even today, many surgeons
continue to perform these operations through larger incisions
than the ones routinely created by our surgeons. Smaller incisions
equal quicker recovery, less scarring and better outcomes.
Cleveland Clinic has an international reputation for excellence in treating inflammatory bowel disease (IBD). here we take a look at why IBd expertise is critical to patients and at our volumes and outcomes.
P e O P L e I N U . S . a F F e C T e D B Y C R O H N ’ S a N D U L C e R aT I v e C O L I T I S1 in 200
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Digestive Disease institute
• Most operations for Crohn’s disease, especially
bowel-conserving strictureplasty
• highest volume of J-pouch surgeries
• Cleveland Clinic’s Pouchitis Clinic is the
world’s first and largest for treating pouchitis
and other pouch-associated disorders.
Cleveland Clinic doctors have developed a bat-
tery of novel endoscopic procedures to treat IBD
and colorectal surgery-associated complications,
such as needle knife therapy for refractory bowel
stricture and needle knife sinusotomy.
leading the world in volumes
together Cleveland
Clinic and Cleveland
Clinic Florida train
more colorectal
residents than does
any other program in
north America.
60%Cleveland Clinic’s Pouchitis Clinic is home to about 60 percent of the pouchitis research and other pouch-associated research conducted in the United States.
V O l u M e h I G h l I G h t s
Crohn’s disease surgical cases 2011 228
Ulcerative colitis surgical cases 2011 285
Number of IPaa surgeries 2011 48
Total visits for CD and UC at Cleveland Clinic Florida 2011 385
Operative success rate 95 percent for ulcerative colitis (UC) for initial pouches. Overall, our reoperative success rate is 85 percent for redo pouches or pouch revision surgery.
ReCent BReAkthROuGhRecent publications from Cleveland Clinic researchers encompass a variety of topics, such as:
• Risk factors for kidney stones in patients with ileal pouches • Osteoporosis screening in IBD patients • The effect of liver transplantation in IBD patients with primary sclerosing cholangitis • Cancer risk in patients with IBD and primary sclerosing cholangitis • Optimal dosing of infliximab for IBD patients • The effect of nutritional supplementation in Crohn’s disease patients • Therapeutic implications of the molecular pathways underlying IBD-associated cancers • Fecal lactoferrin for the diagnosis of pouchitis
an ever-increasing percentage of IBD surgeries are performed using minimally invasive and robotic techniques at both Cleveland Clinic main campus and Cleveland Clinic Florida.
{using supercharcoal helps treat pouchitis by absorbing bacterial toxins rather than destroying the bacteria.}
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Cleveland Clinic
Genetics Research in Inflammatory Bowel DiseaseAdvances in the Study of Gene Interactions, Pathways and Networks
Genetics-based research into inflammatory bowel disease (IBD) is moving toward a
systems-based approach that attempts to define how genes interact with each other in
an effort to understand how these diseases develop and to predict aggressive disease
or poor prognoses in patients with IBD.
a collaborative group of researchers in Cleveland Clin-
ic’s Digestive Disease Institute and Lerner Research
Institute (LRI) is involved in several studies looking at
the functional effects of IBD-associated genes in the
context of pathways to better understand how genetic
variations contribute to IBD development and its pro-
gression, says Jean-Paul achkar, MD, kenneth Rainin
endowed Chair in IBD Research in the Department of
gastroenterology and Hepatology.
Thus far, 163 genes associated with IBD have been
discovered. Of these, most are common to both
Crohn’s disease (CD) and ulcerative colitis (UC), but
a subset of genes is unique to each. The large num-
ber of genes involved in IBD makes it impractical at
this point to genetically determine an individual’s
susceptibility to IBD, especially given that most of
the genes identified have a weak effect. It also
affirms the complexity of the genetics of IBD.
STUDYINg SIgNIFICaNCe OF geNe INTeRaCTIONS
With most of the common variations that account for
IBD already discovered, the future of genetics studies
in IBD is to examine groups of genes with related
functions, says Dr. achkar, who also has an appoint-
ment at LRI. “It’s unlikely that studying one gene by
itself will give us significant answers as to the cause
of Crohn’s disease and ulcerative colitis,” he says.
“While the current focus has been on studying one or
two genes at a time, we’re moving toward systems-
based approaches.”
at present, Cleveland Clinic researchers are examin-
ing the functional interplay between series of IBD-risk
genes to identify common pathways altered by spe-
cific gene variants.
How microbes predispose to the inflammation in
CD is one area being explored by Christine McDon-
ald, PhD, in LRI’s Pathology Department. She has
been studying autophagy, which is a mechanism by
which intracellular microbes are sequestered in an
autophagosome and then eliminated from the cell
through a lysosome. Defects in autophagy have been
implicated in the pathogenesis of CD.
Dr. McDonald has found evidence of functional interac-
tion between two genes associated with CD, NOD2 and
aTg16L1. This interaction contributes to an autophagy-
dependent antibacterial pathway that is altered by
CD-associated variants in a cell-type-specific manner.
“Our findings highlight the importance of host response
to bacteria in the pathogenesis of IBD,” she says.
Interestingly, a study of gene combinations in
patients with ileal pouch anal anastomosis (IPaa)
by Dr. achkar’s group revealed that a variant of the
aTg16L1 gene also predicted a higher likelihood
of development of CD involving the IPaa, which is
associated with risk of pouch loss.
eXPLORINg geNe PaTHWaYS
The pathways-based approach for analysis of genes
involved in IBD is being undertaken by Dr. achkar in
Jean-Paul Achkar, Md
“While the current focus has been on studying one or two genes
at a time, we’re moving toward systems-based approaches.”
– Jean-Paul Achkar, MD
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Digestive Disease institute
collaboration with researchers at Case Western Reserve University.
Pathways-based approaches jointly consider multiple genes thought
to contribute to the same pathway of disease, with the potential to
identify missing pathway interactions. “This approach has a chance
to highlight genes that we may not have focused on so far,” he says.
“Perhaps a gene that we overlooked previously becomes more impor-
tant than we believed, once we start to look at it in the context of a
pathway. Once identified, we may be able to go back into the labora-
tory and study how these genes interact.”
SYSTeMS BIOLOgY IS NeXT STeP
The next phase of genetics-based IBD research is an approach
called “systems biology” in which computational modeling, based
on biological information, is used to predict how networks interact
and how these interactions affect an outcome, says Claudio Fiocchi,
MD, head of LRI’s IBD group.
Because genetics cannot fully explain IBD risk, other factors that
contribute to its susceptibility and severity must be considered, he
explains. These include the environment, the gut microbiota and
the immune system, and their interactions with each other and
with the genome. Immune system response to the gut microbiome,
in particular, is inappropriate in IBD patients. “The gut microbiota
is even more complex than the genes,” he says. “The human gut
microbiota as a whole has 100 times more genes than the human
host harboring the gut microbiota, which means the gut microbes
have much greater control over health than an individual does.”
gene interaction with environmental factors and the gut microbi-
ome also may determine susceptibility to IBD and how IBD mani-
fests, but studying the interaction between genes and the environ-
ment is difficult because of the environment’s enormity. Because
each person’s gut microbiome is unique, this uniqueness must be
taken into account along with the distinctiveness of the genetic
composition when studying IBD.
The only hope to gain sufficient knowledge about the interactions
between all components that contribute to IBD is to apply the
systems biology approach, Dr. Fiocchi says. “Because genomics is
more advanced in IBD than in other diseases, and because the gut
microbiome is so intimately associated with the disease, we are at
the forefront of applying the right tools,” he says.
Dr. achkar can be reached at 216.444.6513 or [email protected].
Dr. McDonald is available at 216.445.7058 or [email protected]
and Dr. Fiocchi at 216.445.0895 or [email protected]. ■
Coming Soon to Cleveland Clinic Digestive Disease InstituteCombined Pediatric and Adult Clinics for IBd, Pouchitis
Starting in early 2013, gastroenterologists and colorectal
surgeons from Cleveland Clinic Digestive Disease Institute
will combine forces with pediatric gastroenterologists and
surgeons from Cleveland Clinic Children’s Hospital in monthly
clinics for patients of all ages with inflammatory bowel
disease (IBD) and pouchitis.
These newly established clinics formalize a long-standing
collaboration between our adult and pediatric specialists to
provide the highly specialized, multidisciplinary care needed
to improve quality of life for these patients.
“each of us brings something to the table, so we feel that
combining our expertise will be worthwhile and offer value to
our patients,” says Feza Remzi, MD, Chairman of Colorectal
Surgery and an expert in both clinical areas.
IBD and pouchitis were chosen for these all-age clinics
because their complexity has led to large gray zones in disease
management. “There is no clear ownership of these patients’
problems. We can all contribute, and it will benefit all of us to
hear how our colleagues manage issues associated with these
diseases,” says Dr. Remzi, also the ed and Joey Story endowed
Chair Holder in Colorectal Surgery.
Pediatric gastroenterologist Lori Mahajan, MD, agrees.
“Physicians benefit greatly by sharing clinical experience
and medical knowledge, as well as research outcomes,
with colleagues. It translates directly into better and more
comprehensive patient care.”
In addition, exposing pediatric patients to adult-care physicians
facilitates future care transition, as has been our experience in our
collaborative efforts to date, such as in caring for patients with
familial adenomatous polyposis (FaP). “Our patients become fa-
miliar with our adult counterparts and feel more comfortable with
them when the time to transition fully arrives,” she says.
Combining pediatric and adult care in a single disease-specific
clinic is a unique approach to care made possible by Cleveland
Clinic’s group-practice model.
“Sometimes, patients get stuck in silos between groups, but our
institutional structure overcomes this barrier. With the IBD and
Pouchitis Clinics, we are breaking the silos. It’s the right thing
to do for our patients,” says Dr. Remzi.
To refer a patient to our clinics, call 855.ReFeR.123.
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Cleveland Clinic
Case stuDyliving Donor liver transplantOffering hope to end-stage liver disease patients
INTRODUCTION
The discrepancy between organ supply and demand
has reached an all-time high in the United States,
resulting in increased wait times for transplant and
a higher number of deaths on the transplant wait list.
Living donor liver transplantation (LDLT) is playing
a significant role in addressing the shortage of grafts
for patients awaiting liver transplantation.
While LDLT offers remarkable benefit to the recipient,
it also introduces some risk to a healthy donor. There-
fore, modifications to surgical technique that reduce
this risk are of great value. In the attempt to decrease
donor complications, Cleveland Clinic’s Transplant
Center has adopted the use of 3-D imaging and an
innovative 3-D navigation system. Here, we present
a case of LDLT performed using this technology.
CaSe PReSeNTaTION
In March 2011, a 59-year-old man was referred to our
Transplant Center for a liver transplant evaluation due
to end-stage liver disease secondary to nonalcoholic
steatohepatitis. His liver disease was complicated by
portal hypertension with intractable ascites, esophageal
varices and splenomegaly (Figure 1). Because of severe
portal hypertension, a transjugular intrahepatic porto-
systemic shunt (TIPS) was placed to alleviate his clini-
cal symptoms. although he continued to deteriorate
clinically, he could not receive a liver transplant from a
deceased donor because his Model for end-Stage Liver
Disease (MeLD) score (13-17) was not high enough to
give him priority on the waiting list.
The living liver donor was a 42-year-old man who
volunteered to donate to his older brother. He was
evaluated by the multidisciplinary living donor team
and was deemed an appropriate candidate for liver
donation by the Donor advocacy Team and the
Patient Selection Committee.
During the donor evaluation, a preoperative 3-D
reconstruction of the donor liver was conducted
(Figure 2), from which a detailed volumetric study
was obtained. Table 1 represents the volumetric
analysis for this donor.
The patient underwent an LDLT in July 2012 using
a right lobe graft from his brother. Surgery using
the navigation system (donor only), along with in-
traoperative ultrasound to identify the hepatic vein,
was uneventful.
The measured graft weight was 1,038 grams, resulting
in a graft-to-recipient body weight ratio (gRWR) of 1.0.
POSTOPeRaTIve COURSe
Both the living liver donor and the recipient had an
uncomplicated postoperative course. The donor was
discharged on postoperative day 5, and the recipient
was discharged on postoperative day 11. at one month
after surgery, both donor and recipient liver enzymes
normalized. Currently, the patients are followed by our
liver transplant clinic with stable liver graft function.
DISCUSSION
With the ever-growing donor shortage, LDLT has
emerged as an alternative to deceased donor liver trans-
plantation for patients with end-stage liver disease.
Figure 1
Cristiano Quintini, Md
koji hashimoto, Md, Phd
Charles Miller, Md
clevelandclinic.org/digestive 855.ReFeR.123 {9}
Digestive Disease institute
Medical urgency for liver transplant is determined
by MeLD score, which is calculated based on three
blood parameters: total bilirubin, INR and creatinine.
However, patients’ clinical symptoms and quality of
life aren’t taken into account in calculating MeLD
scores. This means that there are many critically ill
patients with low MeLD scores that underestimate
the severity of their disease. LDLT is expected to be
life-saving for these patients who don’t have priority
on the transplant waiting list but who face the risk
of death and poor quality of life.
The number of LDLTs in the United States has recently
declined, however, due to the concern for donor safety.
Only 247 LDLTs were performed in 2011, which
accounted for just 3.9 percent of all liver transplants
nationally according to UNOS data.
Many transplant centers are reluctant to perform LDLTs
because they are ethically challenging and technically
demanding – and the entire process from initial evalu-
ation to post-transplant follow-up is labor-intensive.
However, LDLT can be performed safely and success-
fully. Computer-assisted navigation has the potential to
minimize risk to the donor, and experienced surgeons
can operate with increased confidence with the use of
3-D imaging, intraoperative ultrasound and real-time
tracking of surgical instruments.
Cleveland Clinic has a dedicated multidisciplinary
team that is performing an increasing number of
LDLTs with survival rates meeting the highest stan-
dards as shown by the data extrapolated from the
Scientific Registry of Transplant Recipients.
Ms. Daneri can be reached at 216.445.8473
or [email protected]. Dr. Quintini is available at
216.445.3388 or [email protected], Dr. Hashimoto
is at 216.445.0753 or [email protected] and Dr.
Miller is at 216.445.2381 or [email protected].■
table 1: Cut 1, Right Lobe graft Without MHv (volumes)
territory Volume Relative (%)
Cutting Plane 22 ml 1.1
graft 1,028 ml 55.2
Remnant 811 ml 43.5
total 1,861 ml 100.0
Figure 2
247Only 247 LDLTs were
performed nationally
in 2011. Cleveland
Clinic is performing an
increasing number of
these technically chal-
lenging procedures with
survival rates that meet
highest standards.
Case Study by
Cristiano Quintini, Md
koji hashimoto, Md, Phd
Charles Miller, Md
Amy daneri, Rn, Bsn
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Cleveland Clinic
rectal Cancer update: Standardizing Treatment, Boosting Efficiency of IORT Delivery
Cleveland Clinic Digestive Disease institute is helping to advance the treatment of patients
with rectal cancer across north america through a commitment to core principles of
multidisciplinary care. institute members have helped establish the Consortium for Optimizing
the Surgical Treatment of Rectal Cancer (OSTRiCh), an amalgam of 16 U.S. institutions
and one Canadian center focused on a multidisciplinary team (MDT) approach to eliminate
variations in care. as part of its comprehensive intraoperative program, the Digestive Disease
institute offers coordinated multidisciplinary treatment of rectal cancer that includes mobile
intraoperative radiation therapy. this article provides updates from both of these dynamic
fronts in rectal cancer care.
PROMOTINg aCCeSS TO MDT ReCTaL CaNCeR CaRe
Feza Remzi, MD, Chair of Colorectal Surgery at
Cleveland Clinic’s main campus and the ed and Joey
Story endowed Chair Holder in Colorectal Surgery,
and Steven Wexner, MD, Chair of Colorectal Surgery
at Cleveland Clinic Florida, organized the inaugural
OSTRiCh event in 2011. It gathered institutions with
expertise in the care of patients with rectal cancer, with
the purpose of addressing disparities in treatment and
variability in outcomes achieved in U.S. hospitals.
The consortium’s model was an MDT approach
devised in the United kingdom and adopted
successfully in several european centers of excel-
lence that contributed to a significant improvement
in rectal cancer oncologic outcomes. The main
principles include an MDT approach for individual-
ized patient treatment, surgical quality assessment
through pathology reporting, and pretreatment
MRI measurement of the radial margin.
In a presentation at the 2012 american College of
Surgeons meeting, David Dietz, MD, vice Chair of
the Department of Colorectal Surgery at Cleveland
Clinic, reported on the practice patterns of OSTRiCh
consortium members as determined from a survey
of the 16 U.S. institutions. all 16 had an identifi-
able MDT in place for the treatment of rectal cancer
patients, but “adherence to the specific principles of
rectal cancer treatment was variable,” says Dr. Dietz.
among the findings from the survey, MDT conferences
were held at 94 percent of participating institutions,
but their frequency varied. Only 12 percent of centers
discussed all rectal cancer cases at an MDT confer-
ence, and 50 percent discussed less than half of cases.
although specialized pathologists were present in 87
percent of the centers, pathology markers of surgical
quality were not universally reported. Some 88 per-
cent had radiologists who specialize in rectal cancer,
but the accuracy of MRI was validated in only 38
percent, and standardized MRI reports were gener-
ated in 70 percent.
The findings should help identify areas in need of
improvement at U.S. hospitals that serve patients
with rectal cancer and help achieve the consortium’s
ultimate goal, which is to “expand access to quality,
evidence-based rectal cancer care,” says Dr. Dietz.
“The model we want to institute is about creating a
patient care process that any hospital can put into
place, as long as they are motivated to do it, can
follow the rules, track their outcomes and allow
those outcomes to be verified.”
The consortium continues to build alliances to make
MDT care a reality. It now has representation from
various surgical and pathology societies, Dr. Dietz
says, and is in the process of engaging other disci-
plines such as radiation oncology, medical oncology
and radiology.
david dietz, Md
What Is OSTRiCh?The Consortium
for Optimizing the
Surgical Treatment
of Rectal Cancer
(OSTRiCh) consists
of 16 U.S. institu-
tions and one
Canadian center
and is devoted to
minimizing varia-
tions in rectal can-
cer care. OSTRiCh
was created in
2011 to establish
process-driven,
evidence-based
standards of care
for rectal cancer.
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Digestive Disease institute
MOBILe DevICe eaSeS USe OF IORT
The MDT approach also applies to the use of intra-
operative radiation therapy (IORT) for patients with
rectal cancer, which is now delivered more efficiently
and conveniently at Cleveland Clinic through the use
of IntraOp’s latest model of its Mobetron.
High-dose intraoperative radiation therapy for pa-
tients with rectal cancer is used predominantly in the
setting of recurrent rectal cancer, although patients
with locally advanced primary rectal cancer are
candidates as well, says Dr. Dietz. Obtaining a clear
margin around the tumor has been shown to be the
most important prognostic indicator in the treatment
of rectal cancer. Intraoperative radiation is applied
directly to the tumor bed in the hopes of removing
microscopic bits of tumor that may be left behind
after surgery, while minimizing the dose to normal
tissues by moving them out of the radiation field.
“The challenge with intraoperative radiation therapy is
being able to deliver it efficiently,” he says. “The old
model required an entire room dedicated to intraop-
erative radiation. The Mobetron electron beam device
employs the most advanced technology, as its mobile
platform allows radiation to be delivered at greater
depths than with other technologies, without the
need to move the patient out of the operating room.
It’s important to have as part of the armamentarium
for treating these complicated patients.”
The decision to pursue an IORT treatment plan is de-
termined in a multidisciplinary manner with involve-
ment of colorectal surgeons in the Digestive Disease
Institute in coordination with radiation oncologists
from the Taussig Cancer Institute following discussion
of cases in a tumor board conference. The intraop-
erative procedure reflects this MDT approach with
collaboration between the colorectal surgeons and
radiation oncologists in the OR to determine optimal
cone placement and area at risk. The electron cone/
field size, electron energy, bolus use and other factors
are determined by the radiation oncologist. In addi-
tion, specialized radiation physicists are present in
the OR throughout the procedure for consultation on
radiation parameters and for radiation Qa and dose
calculations. This is a true team approach.
The Mobetron device allows a wide array of electron
beam energies to be used during surgery to control
the depth of tissue penetration, similar to a linear
accelerator. In addition, the wide range of field sizes
and cones, some of which are beveled with angles
of 15 to 30 degrees, allows better customization of
the radiation to the patient’s unique clinical situ-
ation, says May abdel-Wahab, MD, Section Head
of gastrointestinal Cancer Radiation Oncology in
the Department of Radiation Oncology at Cleveland
Clinic’s Taussig Cancer Institute.
“The choice of energy and the angles at which the
beam can be delivered offer flexibility to customize
radiation treatment to the patient’s needs,” she says.
The high dose rate of the Mobetron permits a beam
“on time” of only one to two minutes, says Dr. abdel-
Wahab, which is much faster than with other mobile
systems for intraoperative radiation.
Dr. Dietz can be reached at 216.445.6597 or
[email protected]. Dr. abdel-Wahab is available at
216.445.7930 or [email protected]. ■
100 40 80
80
88%
31% 31%69%
62%
19% 38%
75%
6%
70%
56%
12%
60
30 60
40
20 40
2010 20
0 0 0specialized
in rectal cancer
< 25% specialized in rectal cancer
MRI accuracy validated
standardized MRI reports
25-49% 50-74% 75-99% 100%Quality of mesorectum
always reported
Radial margin always
reported
> 12 lymph nodes always
harvested
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How Mobetron Helps Rectal Cancer PatientsAdvantages include:
• Potentially improved
outcomes
• High doses of radiation
delivered directly to the
tumor bed, allowing for
more complete removal
of tumor at the margins
of the resection
• Minimal exposure to nor-
mal surrounding tissue
• Superior control of
the depth of tissue
penetration
• Delivery of the energy
beam with better preci-
sion from a wider range
of angles
• Better local control of
the tumor, reducing the
risk of metastatic spread
• No need to move the
patient to deliver IORT
means a shorter surgical
procedure
{12} digest this Winter | 2013
Cleveland Clinic
Piecing Together the Puzzle for a Premier Center of Care
Gut rehabilitation anD transplantation
COver Feature
clevelandclinic.org/digestive 855.ReFeR.123 {13}
Digestive Disease institute
“Outcomes with intestinal and multivisceral transplantation have markedly
improved over the last two decades.” If there is a single message that kareem
abu-elmagd, MD, PhD, has had for the digestive disease community since
arriving at Cleveland Clinic last summer as the new Surgical Director of the
Center for gut Rehabilitation and Transplantation (CgRT), formerly known
as the Intestinal Rehabilitation and Transplant Program, that would be it.
dr. abu-elmagd has been advancing that message over the
last several years, in his previous post at University of Pitts-
burgh Medical Center (UPMC), as current president of the
Intestinal Transplant association (ITa) and as a pre-eminent innova-
tor and researcher in the field for more than two decades. In fact,
he was intimately involved in the clinical introduction and further
development of intestinal transplantation and has played a dominant
role in the development of multivisceral transplantation (see sidebar,
“Another Role for Dr. Abu-Elmagd”).
INDISPUTaBLY POSITIve vISCeRaL TRaNSPLaNT OUTCOMeS
The message itself is indisputable. While early attempts at intestinal
transplant were hampered by technical and immunologic complica-
tions that resulted in patient death and/or graft failure, continual
technical and immunologic innovations have lifted one-year patient
survival rates above 90 percent at experienced large-volume centers.
Dr. abu-elmagd embodies experience in the procedure, having
been involved in more than 20 percent of all intestinal transplants
performed worldwide, according to the most recent report from the
Intestine Transplant Registry.
as that experience has mounted, long-term outcomes have improved
and compare well with outcomes for other organ transplants. In a
landmark review of their first 500 intestinal and multivisceral trans-
plants, Dr. abu-elmagd’s team reported overall patient survival rates
of 61 percent at five years, 42 percent at 10 years and 35 percent
at 15 years.1 Notably, the best survival rates, 70 percent at five
years, were achieved more recently because surgical techniques and
immunosuppression have improved. a subsequent report among five-
year survivors found significant post-transplant improvement across
a range of quality-of-life measures.2
COMPLeTINg THe PUZZLe FOR UNPaRaLLeLeD CaRe
Dr. abu-elmagd’s arrival represents the final piece of the puzzle
to make Cleveland Clinic one of the world’s premier centers for
the management of intestinal failure, says Donald kirby, MD,
Medical Director of Cleveland Clinic’s CgRT. “We have one of the
largest and most comprehensive intestinal rehabilitation programs
in the world, and we have developed a multidisciplinary approach
to patients with intestinal failure,” he explains. “Now we have the
world’s most experienced surgeon in intestinal transplantation. He
has dealt with almost every possible complication, and he knows
how to work the immune system — that’s the hardest part of in-
testinal transplants, which pose a greater immunologic challenge
than do other transplant types.”
at Cleveland Clinic, intestinal transplant is not new territory.
Cleveland Clinic performed its first adult intestinal transplant in
2008 and received Centers for Medicare & Medicaid Services
(CMS) certification for adult intestinal/multivisceral transplanta-
tion in December 2010. It is one of the few U.S. medical centers
to perform intestinal transplants, which remain far less com-
mon than other transplant procedures. Whereas several hundred
thousand kidneys and livers have been transplanted to date, fewer
than 3,000 intestinal transplants have been performed worldwide.
Dr. kirby sees Cleveland Clinic’s intestinal transplant volumes
increasing substantially with Dr. abu-elmagd’s arrival. “Because of
his international reputation in this field, people want him as their
surgeon and are willing to come from afar,” he says. “and he is
helping to train the next generation of intestinal and multivisceral
transplant surgeons here.”
INTeSTINaL ReHaB: a LONg-TeRM ReLaTIONSHIP
Both Drs. kirby and abu-elmagd note that all the patients the
CgRT manages for intestinal failure, including those with short
bowel syndrome (SBS), motility disorders, malabsorption, gard-
ner’s syndrome with desmoid tumors, complex abdominal patholo-
gy and other rare disorders, should be thoroughly evaluated using a
multidisciplinary approach and treatment tailored according to the
primary disease and expected long-term outcome (see box, “How
Our Program Works”). Commonly utilized therapeutic modalities
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Cleveland Clinic
are diet management, augmented
medical therapy, autologous surgi-
cal reconstruction and ultimately
visceral transplantation, when
indicated.
“In our center, we aim to establish
long-term relationships to success-
fully manage intestinal failure pa-
tients with optimization of their gut
function and improvement of their
quality of life,” explains Dr. kirby,
who also is Director of the Center
for Human Nutrition in Cleveland
Clinic’s Digestive Disease Institute.
Such a task is achievable through a
comprehensive assessment of each
patient by a dedicated team that
consists of an experienced gastroen-
terologist, certified dietitian, surgeon
with vast experience in complex
abdominal surgery, psychosocial
worker, financial counselor and
other highly specialized staff. The
evaluation process addresses the
anatomical and functional capacity
of the gut and guides short- as well
as long-term management.
Medical management involves
intensive, personalized diet/nutrition
counseling with use of oral rehydration
solutions, enteral feeding and, if nec-
essary, medications or growth factors
that reduce the transit time of food to
improve absorption by the remaining
bowel. “Commonly, we have success-
ful outcomes with these methods,”
Dr. kirby observes. He also notes
that some of these patients had lost
continuity of their gut and required
reconstructive operations by Cleveland
Clinic’s surgical team.
HOMe PaReNTeRaL NUTRITION
(HPN): PROMISe aND CHaLLeNgeS
“Cleveland Clinic’s nutrition sup-
port program, part of the Center for
Human Nutrition, is caring for the
largest HPN cohort followed in one
U.S. center — and one of the largest
A Vision for the Future as the new Surgical Director of Cleveland Clinic’s
Center for gut Rehabilitation and Transplantation
(CgRT), kareem abu-elmagd, MD, PhD, has extensive
plans to continue the program’s history of innovation
and to lobby for broader indications for different types
of intestinal transplantation.
“Our intention is to lead the field in clinical outcomes
by building on and enhancing the program’s multidisci-
plinary approach of comprehensive medical and surgi-
cal therapy including autologous surgical reconstruc-
tion of the gut and visceral transplantation,” he says.
here is a closer look at what dr. Abu-elmagd
hopes to accomplish:
Research and innovation
• Introduce novel immunosuppressive protocols that minimize the need for long-term
immunosuppression and promote possible achievement of clinical tolerance
• Improve outcomes with all types of visceral transplantation
• Continue to improve quality of life in these unique patients, as recently demonstrated
in a landmark publication2
• Further the research in gut immunity, enterocyte trophic factors, gut homeostasis, intestinal
ischemia, preservation injuries, alloimmunity and the value of healthcare
Medical advances
• Select the appropriate candidates for the new gLP-2 analog teduglutide (gattex®), which
received orphan drug designation for SBS treatment and was unanimously recommended for
approval by an FDa advisory committee in October. according to CgRT Medical Director Donald
kirby, MD, an investigator in the pivotal phase 3 drug trials, teduglutide is a “potentially very
useful drug” that may reduce the need for HPN in those with SBS due to trauma, vascular
thrombosis and other benign conditions.
surgical initiatives
• Restore gut function without transplantation using a reconstructive surgical approach, including a
lengthening procedure. These novel techniques will help achieve full nutritional autonomy, normal
glucose homeostasis and excellent quality of life.
• Identify a biomarker for intestinal allograft rejection to enable early diagnosis and promp treatment
of rejection. “The intestine is an unforgiving organ,” Dr. abu-elmagd notes. “If you wait until you
identify rejection via scoping or pathology, you are a bit too late.”
• Further improve long-term transplant outcomes with new anti-rejection medications, especially
for the liver-free allografts in recipients who are presensitized with antibodies
Advocacy for patients
• Use his platform as ITa president to lobby CMS to loosen the tight control on the current indications for
intestinal transplant. “If we wait too long, then patients may succumb — even after transplantation —
to the complications they developed from HPN before being transplanted,” he says.
clevelandclinic.org/digestive 855.ReFeR.123 {15}
Digestive Disease institute
in the world,” says Mandy Corrigan, a dietitian with the program,
which has been recognized as a program of excellence by the ameri-
can Society for Parenteral and enteral Nutrition. The program team’s
expertise is reflected in an invitation to write an HPN tutorial for
the November 2012 issue of the Journal of Parenteral and Enteral
Nutrition.3
Long-term HPN is not easy for many patients to endure because
most patients need to infuse HPN daily. “If they do it at night to free
up their day, then they need to go back and forth to the bathroom
at night, which doesn’t allow for a good night’s rest,” says Dr. kirby.
“It’s more burdensome than dialysis.” That’s why one of the CgRT’s
major goals is to continue working with patients to enhance their
bowel adaptation with the aim of reducing or potentially eliminating
the need for HPN. “It behooves patients who need nutrition support
to be seen at an HPN center of excellence so they can improve their
quality of life through the type of intensive education we offer here,”
he says. “We look at the endgame and how well we can make a
patient’s present physiology work, with transplantation used as a
rescue therapy for those who fail comprehensive medical therapy
and no longer can be maintained on HPN.”
SURgICaL ReSTORaTION aND TRaNSPLaNT
Before recommending intestinal transplant, the CgRT can offer
surgical treatments, short of transplant, to enhance the absorptive
function of the residual native intestine in selected patients. These
include lengthening procedures such as serial transverse enteroplasty.
“Only a couple of other U.S. centers are offering the lengthening pro-
cedures that we are now doing here,” says Dr. abu-elmagd.
He also performs reconstructive operations in many patients with
very complex abdominal pathology or “hostile abdomen” that few
other surgeons nationally are willing to take on, for conditions such
as abdominal cocoon syndrome, extensive abdominal adhesions,
multiple enteric fistulae and extensive thrombosis of the portal
venous system of the gI tract. “For the patients who cannot undergo
reconstructive surgery because of the nature of the underlying dis-
ease, transplantation may be the only solution,” he explains.
“One of the things that distinguish our center now is that Dr. abu-
elmagd doesn’t think simply in terms of ‘transplant’ vs. ‘no trans-
plant,’” observes Dr. kirby. “He is highly creative in looking at a
patient’s problem and arriving at a surgical solution that might not
be a transplant and might not be easy but is the best option for the
given patient. That type of comfort and versatility is enormously
valuable in a surgeon, and our next generation of surgeons is being
trained in it.”
aN INTeRDISCIPLINaRY eTHIC
That clinical creativity is drawn upon in the center’s weekly interdis-
ciplinary conferences, which discuss potential transplant candidates
and ways to possibly stave off the need for transplant in difficult
cases. The conferences bring together a team of transplant surgeons,
How Our Center WorksOver the last year, 401 patients were
under the continuous care of our team
for management of intestinal failure,
HPN therapy and transplantation. These
complex patients were followed by
their primary care physician, returning
to Cleveland Clinic annually and when
clinically indicated. The transplant
recipients are closely monitored with
special attention to allograft function and
immunosuppression level. We believe
our patient population is the largest to
be followed by a single multidisciplinary
team. equally important is the recent
center expansion with active medical
care of pediatric patients who suffer from
SBS due to congenital disorders and
other acquired diseases.
Dr. Abu-Elmagd (left) and Dr. Kirby (right) say the CGRT uniquely offers creative surgical solutions that may not be a transplant and may not be easy but may be the best option for the patient.
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Cleveland Clinic
ReFeReNCeS
1. abu-elmagd kM, Costa g, Bond gJ, et al. Five hundred intesti-nal and multivisceral transplantations at a single center. Ann Surg. 2009;250(4):567-581.
2. abu-elmagd kM, kosmach-Park B, Costa g, et al. Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg. 2012;256(3):494-508.
3. kirby DF, Corrigan ML, Speerhas Ra, emery DM. Home parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr. 2012;36(6):632-644.
gastroenterologists with vast experience in nutrition, dietitians,
social workers, transplant immunologists, nurses and physi-
cians who are highly specialized in transplant psychology and
behavioral science.
With the gCRT being part of the Digestive Disease Institute,
patients are managed by physicians and surgeons who are
highly specialized in a wide spectrum of gastrointestinal
disorders. These disorders include inflammatory bowel
disease (IBD), gardner’s syndrome, gut dysmotility and other
gI disorders. “Because of Cleveland Clinic’s international
reputation in treating IBD, severe IBD is one of the leading
causes of short bowel syndrome in the patients we manage
in the program,” says Dr. kirby.
For Dr. abu-elmagd, postoperative care is where Cleveland
Clinic’s collaborative ethic shines brightest. “You can oper-
ate on any high-risk patient, but postoperative care can be
the most important factor in saving the patient’s life,” he
says. “I am very confident that my colleagues at Cleveland
Clinic are providing my patients with the best care they
could have anywhere.”
Dr. abu-elmagd sees Cleveland Clinic’s current group practice
model as a wonderful and impressive outgrowth of its past,
further demonstrating the value of healthcare and academic
medicine. “The multidisciplinary team approach for patient
care and the vision of the physician-based administrative lead-
ership that I’m seeing at Cleveland Clinic should be a model for
most of the healthcare providers across the country,” he says.
Prospective patients and referring physicians can reach a
CgRT member at any time via the program’s 24-hour referral
line, 216.445.1748. The program also offers online medical
second opinions through Cleveland Clinic’s MyConsult service
(clevelandclinic.org/myconsult or 800.223.2273, ext. 43273).
Dr. abu-elmagd can be reached at 216.445.8876 or
[email protected]. Dr. kirby can be reached at 216.445.6609
or [email protected]. ■
Another Role for dr. Abu-elmagd: Transplant Center DirectorIn addition to his role as Surgical Director of the CgRT, Dr. abu-
elmagd is the new Director of Cleveland Clinic’s Transplant Center, a
position turned over to him by John Fung, MD, PhD, who remains
Chairman of Cleveland Clinic’s Digestive Disease Institute. The two
men are longtime friends and colleagues who trained together under
transplant pioneer Thomas Starzl, MD.
“Dr. abu-elmagd is singularly qualified to lead both the Transplant
Center and the CgRT,” says Dr. Fung. “He has earned an interna-
tional reputation for significant clinical and technical contributions
to the fields of intestinal, liver and multivisceral transplantation as
well as immunosuppression and transplant immunology.”
here are a few highlights from dr. Abu-elmagd’s diverse achieve-
ments to date:
• Played a pivotal role in the clinical introduction of the immunosup-
pressive agent Fk506 (tacrolimus)
• Convinced CMS in 1999 to provide reimbursement for intestinal and
multivisceral transplantation as the standard of care for patients with
irreversible intestinal failure
• Introduced innovative gastroenterological autologous reconstruc-
tive procedures for patients with complex abdominal pathology and
intestinal failure
• Introduced a novel tolerogenic immunosuppressive protocol in
humans, achieving unprecedented outcomes, including complete
discontinuation of immunosuppression in a few privileged visceral
recipients
• Demonstrated, for the first time in humans, the immunoprotective
effect of the engrafted liver on other simultaneously transplanted
visceral organs
• established UPMC’s Intestinal Rehabilitation and Transplantation
Center in 1999
One of his early priorities is to establish a transplant research center
at Cleveland Clinic. “Our aim is to gather all our transplant physi-
cians, surgeons and scientific researchers to collaborate in advanc-
ing the field of transplantation technically and immunologically, with
the ultimate goal of minimizing immunosuppression and maximizing
allograft tolerance across all organs,” he explains. The center, which
is now in the planning stage, will support more collaborative transla-
tional/basic research and foster more efficient use of resources.
another of Dr. abu-elmagd’s priorities is to launch a formal pediatric
transplant program, starting with intestinal and composite visceral
transplants including the liver.
clevelandclinic.org/digestive 855.ReFeR.123 {17}
Digestive Disease institute
the Future of transplantationCleveland Clinic Plans Centralized ‘Organ Repair Center’ to Focus on Ex Vivo Perfusion of Multiple Organs
“We will have approximately eight stations with
the capacity to pump various organs,” says Bijan
eghtesad, MD, liver transplantation surgeon in the
Department of general Surgery in the Digestive Dis-
ease Institute. “We are remodeling our g3 operating
room to provide a sterile area that is able to accom-
modate a variety of pumps for different organs.”
Digestive Disease Institute clinicians are focused on
studying the best ways to preserve and potentially re-
condition the liver and possibly other digestive organs,
including the pancreas and intestines. Specifically,
the liver research, which is currently being conducted
in large animal (pig) models, centers on evaluating
normothermic oxygenated perfusion vs. cold storage
of organs. Researchers hope to start testing the pro-
cess on human livers within six to 12 months, with a
goal of a controlled clinical transplantation trial.
“The heart and lung team has been very active in this
field, including international trials,” says Cristiano
Quintini, MD, surgeon in the Department of general
Surgery and Cleveland Clinic’s Liver and Intestinal
Transplant program. “We are now expanding into the
abdominal component, starting with the liver,” says
Dr. Quintini, one of the primary researchers at Cleve-
land Clinic studying ex vivo liver perfusion, which is
currently done by no more than a handful of medical
institutions worldwide.
ORgaN aSSeSSMeNT aND ReCONDITIONINg
Cold storage, which has been used for more than
40 years, does reduce metabolic demand, but the
method also has limitations. Normothermic oxygen-
ated perfusion is based on the rationale that both
metabolic injury and cold injury from damage to cell
membrane permeability can be prevented ex vivo by
providing oxygen at physiologic temperatures.
“We will be able to assess, recondition and possibly
repair organs,” says John Fung, MD, PhD, Chairman
of the Digestive Disease Institute, whose clinical spe-
cialty areas include liver transplantation. “We will be
able to get organs that otherwise wouldn’t be utilized
to function better.”
a multidisciplinary team of transplant surgeons and organ preservation specialists from Cleveland Clinic’s
Transplant Center are working together with a goal of creating a centralized “Organ Repair Center” — which
may be one of the nation’s first multi-organ ex vivo perfusion centers.
Bijan eghtesad, Md
Cristiano Quintini, Md
John Fung, Md, Phd
-1
0
1,000
2,000
3,000
4,000
5,000
6,000Preservation Phase (A)
hours
Transplant Phase (B)
2 4 8 10 0 1 4 8 12 16 24
live
r en
zym
es
Blood
Control
Perfusion X
Perfusion Y
Figure 1. these graphs demonstrate the Ast and Alt levels during both the preservation phase and the transplant phase using whole blood, a control and two other types of perfusion solutions (Perfusion X and Perfusion Y).
{18} digest this Winter | 2013
Cleveland Clinic
Dr. Fung says that normothermic oxygenated
perfusion may have advantages in vivo, in addition
to ex vivo. “Reparative pathways are turned on,”
he explains. “Organs may continue to repair even
after transplant.”
Organs typically remain on perfusion machines for
12 to 24 hours. “It depends on how they are revived
and how they respond. It also is based on the organ
function and how quickly it gets back to normal,” Dr.
eghtesad says. “Within three to six hours, you normally
know if you can use the organ.” With the liver, for ex-
ample, a hallmark of a usable organ is bile production.
MakINg MaRgINaL ORgaNS vIaBLe
The normothermic oxygenated perfusion approach
could prove to be especially beneficial for donation
after cardiac death (DCD), older donors, and/or
organs that have structural or other issues such as
fatty liver disease that typically would make them
unusable, Dr. Fung says.
approximately 20 to 30 percent of liver donations
currently fit the criteria as coming from “marginal”
donors. While liver transplantation of healthy organs
should be done right away, perfusion is ideal for mar-
ginal or previously unusable organs.
“There is a potential to increase organ use by 15 to 20
percent,” Dr. Quintini says. “The assessment process
during normothermic perfusion also can help us avoid
a transfer that could result in patient mortality.”
While the liver perfusion device currently being used
at Cleveland Clinic is experimental, eventually a
refined, more commercial version will be developed.
“The pumps, tubing — everything is an evolution,”
Dr. eghtesad says, adding that adjustments will be
made based on what investigators observe during
their ongoing research.
although ex vivo liver perfusion eventually may
become more routine, it is currently a process that
requires the resources available at a leading clinical
center of excellence such as Cleveland Clinic. “It
is very labor-intensive — you have to have a huge
team to work on it,” Dr. eghtesad says. “a handful of
programs may update the system until it is perfected
— just like kidney transplants, where every center
can now pump.”
The goal of Cleveland Clinic’s ongoing research —
and ultimately, the centralized, multispecialty Organ
Repair Center — is to increase the number of organs
available and the quality of those organs, Dr. Fung
says. This is a critical priority given that up to 20
percent of patients on transplant lists never receive an
organ because of a lack of availability and viability.
Dr. Quintini says: “Our hope is to potentially decrease
that number — ideally to a rate of zero.”
For more information, please contact Dr. Fung at
216.444.3776 or [email protected]. Dr. eghtesad can
be reached at 216.444.9898 or [email protected]; and
Dr. Quintini is at 216.445.3387 or [email protected]. ■
Figure 2. Pig liver biopsy after 36 hours of ex vivo perfusion using a perfusion solution and packed red blood cells.
20%Up to 20 percent of patients
on transplant lists never
receive an organ due to lack
of availability and viability.
Our hope is to potentially
decrease that number,
ideally to a rate of zero.
Cleveland Clinic Florida launches transplant Program under dr. Andreas tzakis
Cleveland Clinic
Florida recently
received approval
of its applications
for heart, liver and
kidney transplant
services, from
Florida’s agency
for Health Care
administration.
Internationally rec-
ognized transplant
surgeon andreas
Tzakis, MD, PhD, has joined Cleveland Clinic
Florida to direct the new program there in col-
laboration with leaders from Cleveland Clinic
Heart & vascular Institute. He previously di-
rected the University of Miami Miller School of
Medicine’s abdominal transplantation program.
Cleveland Clinic Florida created the programs
in response to the needs of a growing number
of patients in South Florida who previously
had to seek transplant services outside the
region. With more than 215 physicians in 35
medical specialties, Cleveland Clinic Florida
has the best clinical expertise to support a
comprehensive transplant program, including
top-level pre- and post-transplant care.
“I am delighted to welcome Dr. Tzakis to Cleve-
land Clinic to expand our transplant services
to an additional region of the nation,” says
Dr. kareem abu-elmagd, Director of Cleveland
Clinic’s Transplant Center. “He is an eminently
accomplished transplant surgeon and has
been a colleague of mine since 1990, when
we worked together under the leadership of Dr.
Thomas Starzl.”
Dr. Tzakis’ expertise includes intestinal and
multivisceral transplantation, and Dr. abu-
elmagd hopes that these services will be
brought to Cleveland Clinic Florida in the very
near future. “For now, Dr. Tzakis is joining us
one week a month in our Cleveland location
on the main campus,” he says.
CMe CalendarMedical professionals are invited to attend the following continuing education programs:
digestive disease Institute’s International Interdisciplinary education Week
24th Annual Jagelman International
Colorectal disease symposium and
34th Annual turnbull symposium
Feb. 12-17, 2013
Fort Lauderdale, Fla.
2nd Annual Gastroenterology
and hepatology symposium
Feb. 14-16, 2013
Fort Lauderdale, Fla.
12th Annual surgery
of the Foregut symposium
Feb. 17-20, 2013
(with live surgery Feb. 20)
Coral gables, Fla.
Visit ClevelandClinicFloridaCMe.org for more
information about the above events and more
CMe offerings from Cleveland Clinic Florida.
Be the First to know! get breaking news from Cleveland Clinic’s Digestive Disease Institute delivered straight to your email inbox.
Our quarterly edigest – a supplement to our Digest This newsletter, features:
• Surgical and medical innovations• Pioneering research• CMe opportunities
• and much more
simply log on to clevelandclinic.org/enewsletters to sign up for edigest under the “For health Professionals” section.
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• To arrange for a critical care transfer, call 216.448.7000 or 866.547.1467 (see clevelandclinic.org/criticalcaretransport).
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about Cleveland ClinicCleveland Clinic is an integrated healthcare delivery system with local, national and international reach. at Cleveland Clinic, nearly 3,000 physicians represent 120 medical specialties and subspecialties. We are a main campus, 18 family health centers, eight community hospitals, Cleveland Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las vegas, Cleveland Clinic Canada, Sheikh khalifa Medical City and Cleveland Clinic abu Dhabi.
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