Winter 2011

healthpoints is published by the Columbia UniversityDepartment of Surgery as a service to our patients.You may contact the Office of External Affairsfor additional information and to request additional copies.Please call 201.346.7001.

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Department of SurgeryIn affiliation withNewYork-Presbyterian Hospital

A L L T H E PO S S I B I L I T I E S O F M O D E R N M E D I C I N E

IN THIS I SSUE

1 Pancreatic Cancer Using imaging and genetic testing to detect and prevent pancreatic cancer

2 Complex HerniasRepairing hernias once considered inoperable

3 Sleeve Gastrectomy for GastroparesisNovel use of weight loss surgery to curedebilitating effect of diabetes

4 Events

Understanding how cancers grow has made it possible to preventmany 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 moredangerous forms of breast, colon, and prostate cancer every year.

In the same way that colon cancer progressesthrough various stages of polyp formation, pancre-atic cancer also includes stages of premalignantgrowth. If physicians can detect precancerouslesions and remove them, pancreatic cancer cansometimes be averted.

Yet unlike the breast, colon, or prostate, thepancreas is much more difficult to access, makingtesting more invasive and expensive. For thatreason, screening for pancreatic cancer has neverbecome routine. Instead, the disease has tradition-ally been detected only in its latest stages, when itis almost uniformly fatal.

But advances in understanding cell biology andgenetics have led to the development of alternativemethods of screening at The Muzzi Mirza PancreaticCancer Prevention & Genetics Program, a specialized centerdedicated entirely to detecting and preventing pancreatic cancer.As described in a study of the center's results to date, screeningwith genetics and imaging can be highly effective in finding andcuring premalignant and malignant pancreatic lesions.

According to Harold Frucht, MD, Program Director, “Research inthe last few years has allowed us to better understand the progres-sion of pancreatic cancer, so we better know who is at risk and whatto look for. This allows us to carefully choose who to screen so thatwe don't do unnecessary testing or surgery.”

In particular, recent research has shed light on multi-organ cancersyndromes that increase the risk of developing pancreatic cancer.These syndromes include:

• FAMMM, or Familial Atypical Multiple Mole Melanoma, which canbe marked by the presence of moles on the body;

• Peutz-Jeghers syndrome, which is associated with gastrointestinaltumors;

PurpleStrideManhattan is a 1-, 2-, or 3-milewalk at RiversidePark to createawareness, raisefunds and meetothers who sharethe same goal: tofind a cure forpancreatic cancer!The November2009 walkincluded over2000 participantsand raised over$300,000 forpancreatic cancerresearch.

Pancreatic Cancer: Prevention and Genetics Muzzi Mirza Pancreatic Program uses imagingand genetic testing to prevent pancreatic cancer.

continued on page 4

Complex HerniasSpecialists in hernia repair can now correct many hernias that until recently were considered inoperable.In October 2009, Father Robert Warren underwent

surgery at NewYork-Presbyterian Hospital to remove abenign mass in his colon. In February 2006 he had under-gone a similar operation (at his community hospital), whichwas later complicated by the formation of a hernia in hisabdominal incision. The hernia was repaired at the commu-nity hospital by two surgeons who used prosthetic mesh toreinforce the hernia repair. Following his 2009 colon surgeryat NewYork-Presbyterian, a small area of the wound near hisbelly button failed to heal. But the 71-year-old Franciscanpriest focused instead on his work running a HIV/AIDSprogram and raising funds for the friars' many ministries inupstate New York. Eventually, he returned to his doctor andlearned that the mesh, which had been implanted in 2006,was now infected. His colorectal surgeon referred him toPeter L. Geller, MD, Director, NewYork-Presbyterian/Columbia University Department of Surgery Hernia Center.

Infected incisional hernias usually require two surgeries:one to remove the infected mesh and a second to repair thehernia after the infection clears. In this case, Dr. Geller wasable to perform a single procedure in which he removed theinfected mesh, mobilized the overlapping muscular layers ofthe abdominal wall, and sutured the abdominal wall backtogether without mesh. Relieved that he was able to avoidanother surgery, Father Warren has recovered very well.

Like Father Warren, many people develop complexhernias after surgery. Complex abdominal hernias mayinclude recurrent hernias following mesh placement, infectedmesh grafts, hernias characterized by loss of abdominaldomain (in which the abdominal organs protrude throughthe hernia, the abdominal cavity shrinks, and it becomes diffi-cult to replace the abdominal organs), and others.

Complex hernias present unique challenges and requirespecialized treatment. According to Dr. Geller, until recently

many patients with complex hernias were discouraged fromhaving surgery, and instead wore external support devices orunderwent unsuccessful procedures that resulted in furtherserious complications.

In the last five to ten years, the advent of new prostheticmaterials and the development of new surgical techniqueshave led to a revolution in hernia repair. As a result, thepractice of hernia repair has become a specialty rather thanone of many areas within mainstream general surgery. “Wehave become more adept at repairing hernias that wereformerly considered unfixable,” says Dr. Geller. Theseinclude extremely large hernias, hernias that have recurredmany times with increasing loss of abdominal integrity, aswell as patients with complex wounds including hernias withintestinal fistulas. “These hernias are no longer inoperable,but are often successfully repaired using new techniques andmaterials.” Moreover, the repetitive practice that comes withspecialization has enabled surgeons such as Dr. Geller toperform simple hernia repairs with less post-operative painand fewer recurrences.

In Father Warren's case, Dr. Geller used a technique calledlaparoscopic component separation. Using laparoscopicinstruments, he freed the muscle layers of the abdominal wallafter removing the infected mesh and successfully closed thewound without implanting a new mesh graft. According toDr. Geller, “This technique is very useful in difficult situations,especially in patients with wounds or infections where wecannot use mesh.”

The NYP/Columbia Hernia Center treats approximately600 patients each year at three locations. The Center plansto conduct studies to track recurrence rates, pain, andpatient satisfaction after hernia operations. n

For more information, visit: www.columbiaherniacenter.org or call 212.326.5547.

Father Robert Warrenunderwent surgery atthe NYP/ColumbiaHernia Center, wherehe says, “The care wassuperb, just amazing.”

What is a Hernia?A hernia is the protrusion of an organ or tissue through thewall of the cavity that normally contains it. Hernias canoccur in many parts of the body. The most common,inguinal hernias, account for 75% of abdominal hernias.Higher in the abdomen, a diaphragmatic hernia occurswhen part of the stomach or intestine protrudes through adefect in the diaphragm. Incisional hernias, which maydevelop when a surgical wound

fails to heal completely, often contain trapped intestineand can be more hazardous to treat. Causes of herniasinclude congenital weaknesses and collagenopathies,prior surgery or other trauma to the abdomen, increasedpressure in the abdomen, and weakening of the abdomi-nal wall due to age, obesity, smoking, poor nutrition, andother causes. Symptoms such as pain or a visible bulgemay or may not be present.

2 healthpoints • Winter 2011

As advanced as modern medicinehas become, in some cases, it still fallsshort. Patients who develop a conditioncalled gastroparesis are among thosewho may exhaust the limits of availabletherapies. It is for patients such as thesethat physicians at NewYork-Presbyter-ian/Columbia have once again steppedup and found new avenues of treat-ment – and hope.

Gastroparesis is a disorder in whichthe stomach cannot contract and emptyits contents into the intestines. Becausepatients with gastroparesis cannot movefood properly through their digestivesystem, they may experience symptomsincluding pain, nausea, vomiting,abdominal bloating, malnutrition, andmore. Although a number of conditionsmay cause gastroparesis, by far themost common is diabetes, in whichcontinued high blood sugar levelsdamage the vagus nerve, whichcontrols the movement of food throughthe digestive tract. Gastroparesis candevelop as a consequence of eithertype 1 or type 2 diabetes that is poorlycontrolled.

Conventional treatments may includemedical therapies, dietary changes,and implantation of a gastric electricalstimulator, or 'gastric pacemaker,' animplanted device that helps to controlnausea and vomiting. If all of these failto help, however, patients may have no choice but to receive nutrientsthrough feeding tubes – not an attrac-tive op tion for anyone, but especiallyyounger patients. According to MelissaBagloo, MD, Assistant Professor ofClinical Surgery, Division of MinimalAccess/Bariatric Surgery, “There aremany patients who do not improve with current treatments and whosequality of life continues to deteriorate.This is a debilitating condition that canbe very frustrating for both patientsand physicians.”

At the Center for Metabolic andWeight Loss Surgery, NewYork-Presby-terian Hospital/Columbia UniversityMedical Center, Dr. Bagloo andcolleagues are now testing a procedurethat has shown excellent initial resultsin this difficult-to-treat population.Based on their long-term experience,Marc Bessler, MD, Director, Center forMetabolic and Weight Loss Surgery, andcolleagues believed that a laparoscopicprocedure called sleeve gastrectomy justmight help patients with severe gastro-paresis. When four patients withgastroparesis were unable to receivegastric pacemakers early this year, thesurgeons performed sleeve gastrectomy,normally used to help patients loseweight, to see if it might help.

According to Dr. Bagloo, “We hadpreviously observed that after sleevegastrectomy, patients who had diffi-culty emptying their stomachs showedsignificant improvement in theirdigestion. We do not know preciselywhy this is: Sleeve gastrectomy mayhave the effect of 'resetting' thenatural gastric pacemaker, or it maybe that the smaller size of the stomachincreases intragastric pressure so thatit helps facilitate gastric emptying.There could also be other reasons whythe surgery helps.”

The four patients who underwentsleeve gastrectomy at the center in2010 were all diabetics with severegastroparesis. For various reasons, theywere not eligible to receive a gastricpacemaker. After surgery, two of thepatients did very well right away, andthe other two needed nutritionalsupport for several months. “At sixmonths after surgery, all four wereeating, drinking, and were no longerexperiencing nausea or vomiting. Forpatients who faced the prospect of life-long feeding tubes, the benefits ofsuch a successful outcome cannot beoverstated,” says Dr. Bagloo.

The risks associated with laparoscopicsleeve gastrectomy are minimal, andinclude leakage in the staple line (2-3%),wound infection, and post-operativepain. Unlike implantation of a gastricpacemaker, sleeve gastrectomy leavesno foreign object, which can erode, getinfected, or require subsequent proce-dures to replace batteries, in the body.Although other surgeries have beenattempted in patients with gastroparesis,they are larger operations with signifi-cant risks, says Dr. Bagloo. “We believethat laparoscopic sleeve gastrectomymay be a less invasive option that allowspatients to eat normally and regain theirquality of life.”

No other group has reported usingsleeve gastrectomy to treat gastropare-sis. Based on the success in the initialfour patients, NYP/Columbia isconducting further study. The Centerfor Metabolic and Weight Loss Surgeryis concurrently developing a programthat will offer all treatments, includinggastric pacemakers and sleeve gastrec-tomy, for patients with gastroparesis. n

For more information, please call 212.305.4000 or visit www.ObesityMD.org

3 healthpoints • Winter 2011

Sleeve Gastrectomy for GastroparesisNovel use of weight loss surgery may help patients debilitated by gastroparesis.

Sleeve gastrectomy, also called verticalsleeve gastrectomy or gastric sleeve, hasbeen long used as the first stage of weightloss surgery in patients with very high bodymass index (BMI). In this laparoscopicprocedure, the size of the stomach isreduced to about 15% of its size. Overmany years, physicians observed thatpatients lost weight very effectively aftersleeve gastrectomy without undergoingbiliopancreatic diversion, the second andmore invasive stage. As a result, bariatricsurgeons frequently perform sleeve gastrec-tomy as a standalone procedure today.

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

• HNPCC, or hereditary nonpolyposis colorectal cancer (alsocalled Lynch syndrome), which is associated with colorectal,endometrial, biliary, brain, and pancreatic cancers;

• Breast and ovarian cancer in association with the BRCA 1 orBRCA 2 genes; and

• Hereditary pancreatitis.

Even if a patient does not fit into one of the syndromesabove, he or she may still have a family history of cancer thatsuggests higher risk for pancreatic cancer. Important signs ofincreased risk include early onset of cancers and multiplecancers (of any type) in the family. Ideally, people should seekscreening at least ten years prior to the age at which theiryoungest relative with cancer was diagnosed.

How the Muzzi Mirza Pancreatic Cancer Prevention &Genetics Program WorksAnyone may request an appointment at the Muzzi Mirza

center, including relatives of patients who have beendiagnosed with pancreatic or other cancers. At the firstappointment, the center takes a detailed family history andperforms a physical exam. The family history is used to deter-mine whether the patient's risk of developing pancreaticcancer is average, moderate, or high.

Blood tests may be administered to check for tumormarkers, glucose levels (because many people predisposedto pancreatic cancer develop diabetes), and to assess liverfunction, pancreatic function, and other measures of health.

Some patients will undergo imaging tests such as CT scan,MRI, and endoscopic ultrasound of the pancreas. “Some

patients have just blood work, others may have blood workand endoscopic ultrasound, others may have blood workand MRI, and still others may have all three,” says JoannaMartinez-Gomez, Program Coordinator. “The higher the risk,the closer the look we need to take at the pancreas and thepancreatic ducts.”

Genetic testing may also be recommended. “We arelooking for any patterns of cancer, including breast, ovarian,colon, or others,” says Dr. Frucht. “Certain syndromes predis-pose people to certain kinds of cancers. If we suspect that asyndrome may be present, we recommend genetic testing.”

Depending on the results of these tests, the patient's risklevel may be reclassified. The team then determines howoften to monitor the patient. If an abnormality is found onimaging, the team decides whether to continue to monitor orto surgically remove it. Patients at high risk may return to thecenter at six or twelve month intervals for ongoing evaluation.

“For anyone with a family history of cancer, early screeningis very important,” says Kristin Engelstad, Genetics Counsel-ing Intern in the Muzzi Mirza Program. “If there is cancer inyour family – not just pancreatic, but any type of cancer – youcan now be proactive rather than simply wait around to getcancer. If you wait until symptoms appear, often that is toolate.” She particularly encourages younger adults, who mayresist the idea, to seek screening earlier rather than later. “Notonly can it help in treating yourself, but if you have children,knowledge about a genetic mutation or syndrome can poten-tially help your children.” n

For information or to inquire about screening, visit www.pancreasmd.org or call 212.305.9337.

Pancreatic Cancer: Prevention and Genetics ~ continued from page 1

InnovATIons In Complex

vAsCUlAr & endovAsCUlAr

InTervenTIons Special Sessions:

Management of Non-healing Wounds Vascular Lab Evaluation

A course for: vascular surgeons, general surgeons, cardiothoracicsurgeons, interventional cardiologists, vascular interventional

radiologists, podiatrists, wound care specialists, physical therapists,nurses, physician assistants, fellows-in-training

and vascular laboratory technicians

May 12 & May 13, 2011Marriott Marquis, NYC

For more information call: 201.346.7007 or visit our website at:www.ColumbiaSurgery.org/vascular

CATCH-Up 2011Heart Failure, Devices,

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A course for cardiologists, interventional cardiologists, cardiothoracic surgeons, physician assistants, physical therapists,and other medical professionals involved in the evaluation, diagnosis and/or management of patients with heart failure

Thursday, May 5, 2011NewYork-Presbyterian Hospital/

Columbia University Medical CenterVivian and Seymour Milstein Family Heart Center, NYC

.For information call: 201.346.7003 or visit our website at:

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