It may seem peculiar that removing part of the lung can improve its function, but that’s the basis of Lung Volume Reduction Surgery (LVRS). Normally, inhaled air travels through branched tubes in the lung to collections of tiny balloon-like sacs. These sacs, called alveoli, are where oxygen enters the blood and carbon dioxide is removed so it can be exhaled. In people with emphysema, a form of Chronic Obstructive Pulmonary Disease (COPD), the alveoli and supporting tissue are gradually destroyed, leaving the lungs with less surface area for gas exchange and a diminished ability to push air out.

Topography of Lungs

During LVRS, surgeons remove the most damaged tissue, up to 30% of the lung. This allows the remaining lung to work more efficiently. Air that might have previously become trapped in impaired alveoli can now be exhaled more completely, and the major muscle involved in breathing, the diaphragm, can do its job without struggling against overinflated lungs. Like cleaning out your closet so that your best clothes hang more comfortably, LVRS improves the environment for the healthiest lung tissue. The surgery is performed by a minimally invasive thoracoscopy, in which a camera and lung reduction tools are inserted through small slits between the ribs. Patients normally undergo pulmonary rehabilitation both before and after the operation.

The National Emphysema Treatment Trial (NETT), completed in 2003, showed that for the right candidates, LVRS can improve both lung function and life expectancy compared to medical treatments for people with emphysema. NewYork-Presbyterian Hospital/Columbia University Medical Center has been designated by the National Institutes of Health as a center of excellence in LVRS.

Emile Bacha, MD

Interview with Emile Bacha, MD, Chief, Division of Cardiothoracic Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center

In this interview, Dr. Bacha, Chief of the Division of Cardiothoracic Surgery at NewYork-Presbyterian/Columbia, provides a glimpse into what it is like to perform open heart surgery on children every day, and what it takes to excel in such demanding circumstances. Having previously served as the director of pediatric heart surgery programs at Children’s Hospital in Boston and the University Hospitals of Chicago, Dr. Bacha has had many years of experience in learning how to be at one’s absolute best, day in and day out, when a child’s life is on the line.

Q: You describe something you consider indispensable to being a successful surgeon: the ability to be “in the zone,” as you put it. How would you describe being “in the zone?”

Dr. Bacha: Being “in the zone” means maintaining complete focus, concentration, and equanimity so that nothing distracts you from the task at hand. And this has to be done under any circumstance. It means being able to control your emotions so you can focus exclusively on the patient’s heart surgery. It means leaving your problems, whatever they may be — spousal, financial or whatever — at the door in the OR. It means not losing composure no matter what else may be going on.

Q: Why is this important?

Dr. Bacha: Being able to be “in the zone” really differentiates a successful surgeon from one who isn’t as successful. If you have a patient dying before your eyes, a limited time to do an operation, and the clock is ticking, are you able to hold it together and do the right thing? Or do you compensate by falling apart, or yelling or lashing out at your colleagues? In the field of pediatric cardiac surgery, emotions are especially magnified because we are dealing with a child’s life. Going through years of training is not enough; I have seen doctors who have had impeccable training and who are extremely ‘book-smart’ but who break down under pressure in the operating room. If you’re not able to control your emotions, you can’t function at a high level day after day after day.

I teach my residents that the tougher and the more acute it gets in the OR, the slower you should get. Because the adrenaline is flowing, you are usually not slower, but in fact achieve a sort of middle range where you are not hasty in your decisions and actions. Remember that a surgeon has to be physically proficient as well as intellectually. That is, you can be the smartest surgeon in the world, but if that stitch is not placed perfectly, the patient will die no matter how smart you are. Another thing I teach my residents is that the best teams handle emergencies in an orderly fashion, such that if an observer was watching the team work from the outside, he wouldn’t be able to tell that an emergency was going on.

Q: Was there ever a time you could not stay in the zone?

Dr. Bacha: A few years back, my wife and children got stuck in Lebanon in a war situation. They were at my mother’s house, and bombs were falling, and I was terribly worried. That was the one time I could not uncouple myself from what was going on, and I could not go into the operating room, and therefore canceled my cases.

Q: How do you maintain your equanimity – do you have any particular practices that help you stay balanced?

Dr. Bacha: I don’t meditate or do yoga or other practices in particular, no. I do have a stable family life, and I think that’s a big part of it. I think I am lucky because I have found it not too difficult to remain balanced. Other things are harder for me, but I grew up during the Lebanese civil war, with a lot of mayhem around me, so maybe I learned to have some innate order.

Related Link:
NewYork-Presbyterian/Columbia appoints Emile Bacha, MD, Chief of Cardiothoracic Surgery

Approximately 30,000 children are born each year with congenital heart defects (about one percent of all live births) in the United States, and .2 to .3 of these children will require cardiac surgery. The Congenital Heart Center at NewYork-Presbyterian Morgan Stanley Children’s Hospital (NYP-MSCHONY) brings together an integrated team of specialists to provide seamless collaboration and a continuum of care for these young patients.

Treatment options are tailored to the diagnosis and presentation of symptoms for each patient and any other medical conditions that may need to be taken into consideration. Increasingly, many congenital heart defects can now be effectively treated with minimally invasive catheter-based interventions that reduce both risk and recovery duration. These treatments often require only a single day of hospitalization, and can eliminate the need for open-heart surgery. The Congenital Heart Center has particular expertise in pediatric interventional cardiology, a specialty that involves non-surgical treatment of congenital and acquired cardiovascular disorders.

Additionally, the Congenital Heart Center is also one of only a few in the U.S. to have a hybrid program for infants and children who do require surgery but could benefit from a minimally invasive surgical procedure in combination with catheter-based interventions. Hybrid heart surgery refers to techniques that combine conventional surgical procedures with minimally invasive, catheter-based interventions. These alternatives typically involve only a small incision through the breast bone or right chest, and advantages include less pain, elimination of the heart-lung machine (and its associated risks), a faster return to normal activities, as well as cosmetic advantages.

Congenital Heart Center

In Surgery, Less is More

According to Emile Bacha, MD, Chief of Congenital and Pediatric Cardiac Surgery, patients at the Congenital Heart Center are always evaluated for less invasive treatment options first. In some cases, a hybrid approach will allow the surgeon to treat a condition with a single operation rather than a series of surgeries, or to treat conditions that would otherwise be inoperable. Dr. Bacha explains, “As with any treatment options, hybrid techniques may not be appropriate for every child. Some babies still benefit from more traditional surgical procedures, and surgeons evaluate each patient to determine which procedure carries the best possible benefits and outcomes.”

Hybrid techniques can offer significant benefits for some patients, including infants with difficult-to-treat conditions. Surgeons at the Congenital Heart Center have been successfully using a less invasive hybrid technique for a very difficult-to-treat defect in newborns known as hypoplastic left heart syndrome (HLHS). To survive, babies born with this anomaly must undergo surgery during the first week of life, and until recently the only treatment available was the Norwood procedure, requiring three difficult standard open operations and carrying a 10-20 percent greater risk of mortality (based upon national statistics). Because infants with HLHS require treatment at a very young age, hybrid procedures can be used to provide immediate interventions and delay more invasive surgeries until infants are older and stronger.

Surgical outcomes are currently comparable between the hybrid approach and the Norwood procedure, but the hybrid approach is thought to be safer for high-risk patients such as in infants with a low birth weight or who are born prematurely, in large part by avoiding the use of a heart-lung bypass machine.

The Congenital Heart Center has been widely recognized for excellence in treating congenital cardiac conditions in infants and children. Minimally invasive and hybrid procedures are just another set of state-of-the-art techniques the Congenital Heart Center is able to employ to minimize risks and maximize positive patient outcomes. Incorporating significant experience, expertise, and tailored treatment plans, the Congenital Heart Center is able to provide exemplary treatment and care for young patients across the spectrum of congenital cardiac conditions.

For more information about pediatric heart surgery, please visit childrensnyp.org, download the NewYork-Presbyterian Congenital Heart Center brochure or call 212.305.2688.

In an unexpected twist of fate, the death of a star athlete saves the life of his former baseball coach. Read the full story of how a young man’s tragedy provided life-saving organs not only for his coach but 50 organ recipients at NewYork-Presbyterian/Columbia.

The December 2011 edition of the Manhattan Times featured two CLDT patients, Jeff Isaacs and Tony Herrera, in Celebrating the Gift of Life, One Transplant at a Time. Both had been severely ill with end-stage liver disease, but went on to receive liver transplants at NYP/Columbia: Isaacs received a deceased donor organ, and Herrera received a living donor liver from his son. Read the inspiring story of how transplantation not only treated their diseases, but completely transformed their lives.

Though she’d been into fitness for most of her life, Gina C., an administrator at a hospital, suddenly found herself putting on unhealthy amounts of weight as she approached her fiftieth birthday. After making every attempt to combat her weight gain in other ways, she finally decided that she would consult the bariatric surgeons at The Valley Hospital, certified as a center of excellence by the American Society of Metabolic and Bariatric Surgery. She arranged for laparoscopic gastric banding surgery with Beth Schrope, MD, Director of the Center for Metabolic and Weight Loss Surgery at The Valley Hospital.

Sleeve Gastrectomy

It wasn’t until her final consultation with Dr. Schrope, however, that Gina decided to ask about an alternative treatment called sleeve gastrectomy, which involves removing about three-fourths of the stomach. The name “sleeve” comes from the appearance of the stomach afterwards; instead of looking bulb-shaped, the stomach is so much smaller and slimmer that it almost looks like a continuation of the esophagus.

Gina was thrilled to hear that the minimally invasive procedure, though a slightly longer operation, seemed to be just as effective, if not more effective, than laparoscopic adjustable gastric banding — but with a much lower rate of long-term complications (due to the reoperation rate after banding). No reconnecting of the intestines would be necessary, as in a gastric bypass, nor would an artificial device need to be implanted and regularly adjusted, as required by gastric banding. Most importantly — in Gina’s eyes, at least — one of the procedure’s unique effects is to substantially reduce the body’s production of the hormone ghrelin, which is responsible for stimulating hunger. “When I heard that [the sleeve gastrectomy] removes ghrelin, I raised my hand: I’m in!” Gina said. “The removal of ghrelin really needs to be investigated by anybody with an addiction to food — it’s amazing.”

The catch about sleeve gastrectomy, though, is that it’s permanent. A gastric band can be removed, and a gastric bypass undone — but after actually removing a portion of the stomach, as in the gastrectomy, it cannot be put back. As convinced as Gina was that sleeve gastrectomy was the way to go, Dr. Schrope insisted that she take a week to think about whether she wanted to make this irreversible decision. Gina did so. At home, she went to online forums and message boards, chatted with others who had gotten the procedure, and carefully weighed all of her options. She remained convinced that sleeve gastrectomy was the best choice for her.

On October 4, 2011, Gina had her operation. It went wonderfully. Even the unexpected presence of a hiatal hernia hardly slowed Dr. Schrope, who easily repaired the hernia as she went. The whole procedure was done laparoscopically, meaning that there was not so much an incision as set of five tiny holes. Only a couple hours after the operation, Gina was walking around. Two days later, she went home.

Since the surgery, Gina, an Italian, has lost the taste for pasta, carbohydrates, and starches; the effects of the lack of ghrelin, she says, are extremely noticeable, and wonderful. More importantly, perhaps, she has been steadily losing weight. She’s already lost 50 pounds — a good 20% of her body weight — and she says that although she’s already very happy with where she is now, it’s quite possible that she’ll continue to lose weight. She’s also been able to stop taking all the medications she’d needed before her surgery (namely, those for fibromyalgia, arthritis, and high blood pressure) because her dramatic weight loss has reduced or eliminated her symptoms.

All in all, Gina is incredibly pleased with the results of her operation: “I’m over the moon about it,” she said, “I’m the cheerleader. My results are fantastic, I’m off all my prescription medications, and I couldn’t be happier.” She’s even bringing exercise back into her life again, and can’t wait to go skating and biking once the weather warms back up in the spring.

Drs. Daniel Brodie, left, and Matthew Bacchetta, right

We all know what it’s like to bump an elbow or jam a finger and watch it swell up like rising dough. This swelling, due to increased fluid in the injured tissue, is part of the body’s attempt to promote healing. However, when it occurs in the lungs, it can have dangerous consequences.

Acute respiratory distress syndrome (ARDS) occurs when the millions of tiny air sacs in the lungs, called alveoli, fill with excess fluid. This can be the result of any kind of injury to or illness in the lung. Pneumonia, trauma, sepsis, and inhalation of stomach contents or smoke can all cause the body to initiate an inflammatory response, sending excess fluid to the lungs.

In healthy lungs, the alveoli fill with inhaled air, transferring oxygen into the blood carried by small neighboring vessels. The oxygen-rich blood can then travel throughout the body to deliver its cargo to the kidneys, brain, liver, and other organs. But when fluid accumulates in the alveoli, they can no longer fill with air, and oxygen cannot pass as easily into the blood. Soon after the initial injury or illness, blood oxygen levels decline, and breathing becomes fast and difficult as the body tries to compensate. There may also be signs, such as confusion or low blood pressure, that the vital organs aren’t getting enough oxygen. In some patients, the lung may try to heal itself, creating scar tissue that decreases the lung’s elasticity and makes it still harder to breathe. The majority of patients recover, but around 40% die in the setting of ARDS, says Daniel Brodie, MD, Director of the Medical ECMO Program at NewYork-Presbyterian Hospital/Columbia University Medical Center.

Treatment for ARDS aims to restore oxygen levels. This may be done with a mechanical ventilator, or through a process called extracorporeal membrane oxygenation (ECMO), in which the blood is removed from the body and oxygenated externally before it is returned. In November 2011, NewYork-Presbyterian Hospital/Columbia University Medical Center opened the Center for Acute Respiratory Failure, which specializes in ECMO. Accompanying the Center’s launch was an article on ECMO for ARDS in adults by the Center’s co-directors, Daniel Brodie, MD, and Matthew Bacchetta, MD, published in the New England Journal of Medicine.

The ECMO program’s innovative approach has been highly successful: every adult ECMO patient has recovered and is now thriving. Click here to read their stories.

Browse the success stories in the weight loss section of the Department of Surgery’s website and you’ll notice a running trend beyond the impressive drops in weight maintained by these patients.

Lisa Pre-Op

They are all enjoying new activities, exercising, overhauling their eating habits, and one has even become a personal trainer. These new habits and lifestyles speak to comprehensive changes in their lives, made possible through the Center for Metabolic and Weight Loss Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center. For sure, bariatric surgery was one of the first and biggest steps in the transformation undergone by every one of these patients, but it wasn’t the surgeon who signed Lynda up for kickboxing classes or turned Lisa into an athlete and personal trainer.

Another trend you’ll notice is how the patients who have been successful in maintaining their new lower weights are still benefiting from the professional staff with whom they have worked since before having surgery. The center integrates a broad spectrum of medical professionals because sustainable weight loss depends on a lasting change in lifestyle. The key is the combination of the talented physicians, surgeons, nurse practitioners, registered dieticians, behavioral therapists, and a host of ancillary support professionals—all dedicated to helping each patient make a smooth transition into a new, healthier set of habits.

Lisa Post-Op

“Seventy percent of a person’s weight is genetically determined,” says Marc Bessler, MD, Surgical Director, Columbia University Center for Metabolic and Weight Loss Surgery Director of Laparoscopic Surgery, “However, obesity has been increasing in the United States at a much faster rate than genetic changes occur, which tells us that environment also plays a huge role.” The environmental causes of obesity are precisely what make a comprehensive approach to weight loss so crucial. The registered dieticians and behavioral therapists at the center are trained to help patients confront the lifestyle changes that necessarily accompany their significant weight loss.

When a patient like Irina says, “I cannot imagine having these kinds of results without the undying support and unsurpassed care I received, and continue to receive, at the Columbia University Center for Metabolic and Weight Loss Surgery,” it becomes clear that there is a lot more successful weight loss than a date with the surgeon.

Organ transplantation may be the most intense journey that a family ever experiences, complete with daunting challenges and the joys of triumph. On the Facebook site of the Center for Liver Disease and Transplantation, many organ donors and recipients have shared the stories of their struggles so that others will know what to expect and that they are not alone.

One such story is that of Kevin Martinsen, who received a living donor liver from his brother Daniel. Read how Kevin and Daniel share their moving stories in their own words.

So Many Roads, Ease My Soul: A Story of Living-Liver Transplantation

Kevin Martinsen

NewYork-Presbyterian Hospital has a distinguished track record for liver transplantation and features a team of world renowned leaders in the field. The Center for Liver Disease and Transplantation offers a seamless integration of medical, surgical, radiological, and support services — using both deceased and living donor liver tissue, and minimally invasive laparoscopic techniques whenever possible.

Founded in 1998, the Center for Liver Disease and Transplantation at NewYork-Presbyterian Hospital/Columbia University Medical Center is one of the first liver programs built from its inception as a multidisciplinary unit. As of July 2011, the Center had performed more than 1,400 liver transplants, including over 200 living donor transplants. NewYork-Presbyterian Hospital/Weill Cornell Medical Center’s strong hepatobiliary program was bolstered by the addition of adult liver transplantation to its services in 2010.

Together these programs provide compassionate, individualized care to a wide variety of patients, combining exceptional care with the most innovative approaches for expanding access to liver transplantation to reduce the mortality of patients on the waiting list.

Alyson Fox, MD, NewYork-Presbyterian/ Weill Cornell Medical Center

Alyson Fox, MD

Dr. Alyson Fox earned her BA in Public Health at the Johns Hopkins University prior to attending the Mount Sinai School of Medicine. She completed her residency in Internal Medicine at NY Presbyterian Weill Cornell Medical Center, where she served as assistant chief resident. She completed her Gastroenterology fellowship at the University of Pennsylvania. While at Penn, she completed a Masters in Clinical Epidemiology and served as chief fellow. She completed her advanced fellowship training in Advanced Transplant Hepatology at the University of California, San Francisco and was named clinical fellow of the year by the department of medicine.

Dr. Fox’s clinical practice is focused on the management of patients with a variety of liver diseases including viral hepatitis, alcoholic and non alcoholic fatty liver diseases, inherited liver diseases and liver cancers. As a transplant hepatologist, she has advanced training in the management of end stage liver disease and caring for patients both pre and post liver transplantation. Her research area is focused on issues related to organ allocation and complications of portal hypertension.

Elizabeth Verna, MD, NewYork-Presbyterian/ Columbia University Medical Center

Elizabeth Verna, MD

Dr. Elizabeth Verna, Assistant Professor of Medicine, earned her BA in Biology at the University of Virginia prior to attending the Columbia University College of Physicians and Surgeons for medical school. She completed her Internal Medicine residency at Columbia Presbyterian Hospital and then served as a Chief Resident before remaining at Columbia for Gastroenterology and Advanced/Transplant Hepatology fellowships.

While in fellowship, she also completed a Masters in Biostatistics at the Columbia University Mailman School of Public Health.

Dr. Verna’s clinical practice includes the management of patients with a variety of liver diseases with a focus on viral hepatitis and liver transplantation as well as the new emerging therapies for hepatitis C. She treats patients with liver cancer, alcoholic and non-alcoholic fatty liver disease and metabolic liver diseases and has expertise in the management of end stage liver disease. She has an active research program with grant support for the study of hepatitis C in liver transplant recipients and will be actively involved in clinical trials for the treatment of hepatitis C in both the transplant and non-transplant settings.

Julia Wattacheril, MD, NewYork-Presbyterian/ Columbia University Medical Center

Julia Wattacheril, MD

Dr. Julia Wattacheril graduated magna cum laude from Brandeis University in Waltham, Massachusetts, obtained her MD with high honors from Baylor College of Medicine, did her internal medicine training at the Baylor College of Medicine in Houston, Texas and pursued her fellowship in gastroenterology, hepatology and nutrition as well as her Masters in Public Health at Vanderbilt University School of Medicine. She joined us last year for her training in transplant hepatology while maintaining an adjunct faculty appointment at Vanderbilt.

Her clinical interests include all aspects of transplant hepatology, general hepatology and gastroenterology with emphasis on metabolic liver disease and obesity. She specializes in nonalcoholic fatty liver disease as well as all forms of hepatitis, chronic liver disease, and liver cancer in addition to liver transplantation. Her research interests focus on hepatic steatosis, insulin resistance and metabolic liver disease in adults. Her current grant concentrates on the proteins and lipids that signal the transition from steatosis to steatohepatitis.