Health News

Team develops novel technique to assess and prevent common problem that can be serious in some patients.

Frank D'Ovidio, MD, PhD

Frank D'Ovidio, MD, PhD

The Esophageal Disorders Program at NewYork-Presbyterian/ Columbia University Medical Center has wide experience in treating adults and children with esophageal diseases. According to Frank D’Ovidio, MD, PhD, Surgical Director of the Lung Transplant Program, the esophageal team’s expertise, now world-renowned, has developed over decades of multidisciplinary collaboration.

Now, Dr. D’Ovidio is drawing on that expertise to address a significant complication associated with severe gastroesophageal reflux disorder (GERD). Approximately 20% of Americans have some degree of GERD, leading to approximately 65 million prescriptions and 4.7 million hospitalizations per year in the United States.* But despite these staggering numbers, even severe GERD can go undetected for long periods of time. Whether GERD occurs on its own or in association with other esophageal and lung conditions, it can lead patients to aspirate stomach content into their lungs.

Aspiration of stomach juices into the lungs is a particularly dangerous problem because it can damage the lining of the lungs, leading to presentations of lung disease ranging from asthma to lung fibrosis. “This problem is seldom recognized and often not appropriately treated,” says Dr. D’Ovidio. Moreover it is of great concern and a significant challenge in lung transplant patients, who are often affected by severe GERD. Aspiration can cause early lung dysfunction to newly transplanted lungs in such patients.

As a result of increased awareness of the dangers of prolonged non-classic GERD symptoms, the program is now working on an approach to help detect and prevent GERD-related aspiration so that patients can avoid developing associated lung disease. Their approach entails a new methodology to assess aspiration secondary to GERD. Specifically, Dr. D’Ovidio is developing a way to measure the presence of bile acids in the airways. Bile acids are components of the gastrointestinal juices and should not be present in the lungs. If they are found in the airway, this indicates the presence of severe GERD and recurrent aspiration.

The procedure works like this: doctors obtain fluid samples during bronchoscopy procedures (and in the future, they could potentially use sputum, expectorated secretions, or exhaled breath condensate as well). They then use the mass spectrometer to test the samples for the presence of duodenal gastric juices such as bile acids. This assessment can objectively monitor whether micro-aspiration is occurring, which would then help to guide treatment decisions. The mass spectrometry approach to test for bile acids in lung fluids has been developed and will be performed in partnership with Serge Cremers, PharmD, PhD. Director of the Biomarkers Core Laboratory of the Irving Institute for Clinical and Translational Research.

As Dr. D’Ovidio explains, “Lung transplant and other patients cannot tell when they are aspirating fluid into their lungs. They know if they are aspirating large volumes of fluid, called macro-aspiration, but they often can not tell if they are inhaling smaller quantities, called micro-aspiration. The ability to detect micro-aspiration could significantly improve the health of thousands of patients with otherwise asymptomatic GERD.” The new approach was made possible by combining the knowledge available in Dr. Cremers’ special chemistry laboratory with the esophageal team’s expertise in pathophysiology and clinical presentation of esophageal and lung disorders.

“We are initially looking to help a relatively small population affected by GERD, those who have undergone lung transplant or patients with gastroesophageal motor disorders. However, this test could potentially be used to help the broader population of people who suffer from GERD but do not have typical GERD-like symptoms (cough, asthma and others), and therefore go undiagnosed for many years. Of note, pulmonary fibrosis and COPD have been associated with GERD and possible aspiration,” says Dr. D’Ovidio. This new methodology is now being cross-tested in a multicenter study.

*http://digestive.niddk.nih.gov/statistics/statistics.aspx#specific

For information on treatment of GERD at NewYork-Presbyterian/Columbia, please visit
www.columbiasurgery.org/esophageal, or email info@columbiasurgery.org

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Innovations in GI/Endocrine Surgery

by Columbia Surgery on June 7, 2014

Surgeons expand the use of the surgical robot to benefit patients undergoing complex pancreatic and gastric operations.

Yanghee Woo, MD

Yanghee Woo, MD

Readers may have heard about surgical robots, which surgeons are using in increasing numbers across the country. At NewYork-Presbyterian/ Columbia, surgeons now use the surgical robot to perform gynecologic, urologic, colorectal, and a number of abdominal procedures. According to Yanghee Woo, MD, Assistant Professor of Clinical Surgery and Director, Global Center of Excellence in Gastric Cancer Care, it provides “phenomenal advantages” during operations to remove abdom­inal cancers, allowing surgeons to perform highly precise dissections, to retrieve lymph nodes without blood loss, and promoting faster recovery. She now performs almost all gastric (stomach) cancer operations with the surgical robot.

Based on Dr. Woo’s extensive training and clinical experience with the surgical robot, as well as careful observation of published data, the Division of Gastrointestinal (GI)/Endocrine surgery is now expanding its use of the robot to a broader range of pancreatic and abdominal operations. Together with John A. Chabot, MD, FACS, Chief, Division of GI/Endocrine Surgery and Executive Director, Pancreas Center, Dr. Woo performed the first robotic Whipple procedures at NYP/Columbia this year.

Methodical approach to adopting new technology

Dr. Chabot explains how the Division of GI/Endocrine Surgery has approached the prospect of incorporating the surgical robot into its toolbox.

“We have taken a very methodical approach in evaluating the surgical robot’s benefits in gastrointestinal and endocrine operations,” says Dr. Chabot. “Dr. Woo gained extensive experience during training with the world’s foremost experts in Korea. Following this, other surgeons in our division went through extensive, rigorous training. Once we had a well-trained team assembled, we then began choosing our cases very carefully in order to use the new technology in the safest way possible.” During this process of training and evaluation, some surgeons determined that using the robot did not offer sufficient benefits. James A. Lee, MD, Chief, Endocrine Surgery, found that it did not improve upon other methods of performing thyroid surgery. Dr. Woo found that using the robot to remove the gallbladder through a single incision was possible, but not worth the larger incision it required, especially to perform a surgery that is already so highly successful and low in risk. “There is no proven benefit in this instance, and the cost is significantly higher,” she says.

Benefits for complex abdominal surgery

However, the team has found the robot to be of great benefit for other types of procedures, including many colorectal, liver, and gastric operations. During complex operations, the robot is equipped with four arms that are inserted through small ports into the patient’s abdomen. The arm with surgical instrumentation is wristed, meaning that it can articulate in all directions. Another arm is equipped with three-dimensional, magnified camera technology that provides far better visualization than the two-dimensional visualization that is available during laparoscopic surgery. “These advances give us far more freedom of movement as well as precision” explains Dr. Chabot. Dr. Woo says that because of these capabilities, she is confident that she is able to do complex gastric operations better with the robot than without, even though studies have not yet confirmed her experience.

Initially, the GI/Endocrine division has used the surgical robot in patients with less advanced cancers or premalignant conditions. Patients could not have had any previous upper abdominal surgery, and their tumors could not be attached to major blood vessels that would require blood vessel reconstruction.

Although studies have not yet directly compared robotic and traditional abdominal operations, Dr. Chabot and Dr. Woo believe that the robot offers important advantages to patients by reducing surgical trauma overall. “We are seeing patients have shorter hospital stays and shorter recovery time overall. For patients with pancreatic cancer, one of the most important aspects is that this quicker recovery may allow them to start chemotherapy sooner than they otherwise would.”

On the horizon: improved visualization and surgical outcomes

“We have developed confidence in ourselves to do more advanced cases,” says Dr. Chabot. “Our primary goal has been to maintain safety by being prudent with this new technology.” With that foundation, the team anticipates that the surgical robot will facilitate important innovations in pancreatic surgery, particularly as it allows new forms of surgical visualization. New technologies under development include the use of various wavelengths of light and injected substances that allow surgeons to better detect the boundaries of tumors or to find disease that is not visible using natural light. These innovations may allow surgeons to perform cancer operations more effectively in the future, but they­ will require laparoscopic or robotic access. “The new tools coming down the line won’t be available through traditional incisions,” explains Dr. Chabot.

To learn more about pancreatic and GI/endocrine surgery, visit pancreasmd.org

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