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					NEWYORK–PRESBY TERIAN

Digestive Diseases
Affiliated with COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS and SURGEONS and WEILL MEDICAL COLLEGE OF CORNELL UNIVERSITY

                                                                                                                                                  Fall 2004


                                              Scoping Technologies Revolutionize
Minimizing
Trauma in                                     Diagnosis of Duct Disorders
                                                       o see more clearly into the
Esophageal
Cancer Surgery
                                              T        pancreatobiliary ducts,
                                                       Columbia and Weill
                                              Cornell physicians at NewYork-
                                              Presbyterian Hospital are
         sophageal cancer, the cancer of      taking ultrasound and endo-

E        the gastrointestinal tract that is
         currently showing the largest
increase in frequency, is presenting new
                                              scope technology where few
                                              other medical centers have
                                              gone before.
problems in the OR. “It used to be that          Older scoping technologies
we saw mostly squamous cell cancer,           have been unable to access
usually from smoking,” noted Marc             the pancreatobiliary ducts suf-
Bessler, MD. “Now that people are             ficiently to provide detailed
smoking less, we’re seeing more adeno-        images because the ducts are so
carcinoma of the distal esophagus, which      narrow. This includes endoscopic
is secondary to acid reflux.”                 retrograde cholangiopancreatography
   During the past several years, sur-        (ERCP)—in which a contrast medium
geons at NewYork-Presbyterian                 is injected into the ducts and viewed
Hospital/Columbia University Medical          with X-rays—or ultrasound, which, in                      A sample cholangioscopy. Cholangio-
                                                                                                        scopy allows for better imaging of the
Center have started expanding their           this case, is used with the endoscope
                                                                                                        pancreatobiliary ducts.
skills in laparoscopic surgery into a rel-    positioned outside the ducts.
atively new area: laparoscopic                   However, 2 technologies are being                      the pancreatic or bile ducts; the second
esophagectomy.                                evaluated that allow physicians to get                    is cholangioscopy.
   Laparoscopic esophagectomy is              closer to the ducts and better treat                         “We can actually put these probes
designed to remove a diseased lower           both malignant and non-malignant                          into spaces the scopes won’t go,” said
esophagus. After years of experience          disorders. The first is called intraductal                Peter D. Stevens, MD.
with hundreds of laparoscopic stomach         ultrasound, in which a 2.2-mm probe                          According to Dr. Stevens, the
and esophageal operations, Dennis             is used to obtain images from inside                                          see New Technologies, page 7
Fowler, MD, and Dr. Bessler both
believe the improvements offered with
minimal-access esophagectomy make it                       New Options in HCV                                 Pancreatic Cancer
vastly superior to the more traditional
                                               CONTENTS




                                                                New protocols provide promising alterna-          A new chemoradiation protocol increases
                                                           2                                                  5
                                                TABLE of




methods, especially in early-stage                              tives to current pharmacologic therapies for      the surgical success rate in locally advanced
esophageal cancers.                                        patients chronically infected with hepatitis C.   pancreatic tumors that were formerly inoperable.
   “Open esophagectomy, even under the
best of circumstances, is a somewhat dis-                  Diagnosing GI Motility CME Seminars
abling surgery,” noted Dr. Fowler.                               The new Gastrointestinal Motility Center          Information on future CME programs
   According to Dr. Bessler, the proce-                    4     will lead research efforts into these        6    available through NewYork-Presbyterian
dure involves “5 or 6 small [1/4-in] inci-                 often-confusing disorders.                         Hospital and its affiliated medical schools.
sions in the abdomen and 1 in the neck,
rather than having to open the chest and
             see Esophageal Surgery, page 7
                                                                                            Presbyterian Hospital/Weill Cornell.
    N    E W       Y    O R K        – P        R E S B Y T E R I A N
      Digestive Diseases
                                                                                               “We offer a combination of investi-
                                                                                            gator-initiated trials, built on concepts
                                                                                            developed at our site, and multicenter
                                                                                            studies ranging from exploratory Phase
                                                                                            I and II trials with novel agents to
                                                                                            Phase III and postmarketing Phase IV

    Investigating New Options in the
                                                                                            studies,” said Dr. Jacobson. “We initiate
                                                                                            innovative trials to address specific
                                                                                            issues and challenges, along with par-
    Treatment of Hepatitis C                                                                ticipating in multicenter studies spon-
                                                                                            sored by the biotech and pharmaceuti-
                                                                                            cal industries, which will lead to major
                 eill Cornell researchers at        This hypothesis is the basis for many   therapeutic advances with new agents.”

    W            NewYork-Presbyterian
                 Hospital are working on
    new protocols that may provide prom-
                                                 studies conducted at the Center for the
                                                 Study of Hepatitis C, which has one of
                                                 the nation’s most diversified clinical
                                                                                               One such study for nonresponders
                                                                                            combines consensus interferon with
                                                                                            interferon gamma. Another combines
    ising alternatives to current pharmaco-      trials programs researching new treat-     novel agents like viral enzyme
    logic therapies for patients chronically     ments for the virus, according to Ira      inhibitors with standard therapy. Dr.
    infected with hepatitis C, laying the        Jacobson, MD, Medical Director of the      Lake-Bakaar is conducting a study of
    groundwork for future therapies among        Center. The Center was established in      daily consensus interferon and ribavirin
    those who are treatment-naïve.               2000 as a cooperative endeavor of          in patients who previously failed to
       Patients who relapse after completing     Rockefeller University and NewYork-        clear the virus with pegylated
    standard treatment (interferon/                                                         interferon and ribavirin, and a large
    peginterferon and ribarvirin) for hepati-                                               trial of treatment-naïve patients will
    tis C generally have limited options.                                                   compare the 2 pegylated interferons.
    Two such patients under the care of                                                     Dr. Jacobson is initiating a study of
                                                   “Reducing the viral load
    Gerond Lake-Bakaar, MD, restarted                                                       daily consensus interferon and ribavirin
    therapy. Shortly after their viral load        to undetectable levels                   in patients who come close to clearing
    dropped to undetectable levels, however,                                                the virus with standard therapy but do
                                                   with interferon and then
    he opted to stop treatment, implement-                                                  not eliminate every last trace of it.
    ing a new technique called controlled or       allowing it to rise when                    The Center is also investigating the
    cyclical therapeutic interruption.                                                      protective role of antibodies in chronic
                                                   therapy is interrupted
       After acute hepatitis C infection,                                                   hepatitis C. The virus elicits a strong
    immune response fades and CD8 cells            simulates a secondary                    antibody response, but because most
    die, explained Dr. Lake-Bakaar. They                                                    patients develop persistent chronic
                                                   infection. When re-
    leave a small number of virus-specific                                                  infection, researchers wonder whether
    T cells, called memory cells, behind,          exposed to the virus                     antibodies leave the virus unaffected.
    which respond quickly and efficiently                                                   Treatment of cryoglobulinemia, a
                                                   during this simulated
    when the body is confronted with a                                                      condition that causes neuropathy and
    secondary reinfection.                         secondary infection,                     deposits in skin, kidneys, and nerves,
       “The theory is that during the first                                                 provides a clue.
                                                   memory cells mount a
    infection the body made memory cells                                                       Cryoglobulins result when antibodies
    against hepatitis C, but these were            rapid, powerful attack                   produced by B cells form complexes
    inadequate for providing protective                                                     with the hepatitis C antigen.
                                                   on the virus before it
    immunity,” Dr. Lake-Bakaar said.                                                        Cryoglobulinemia is often unaffected
    “Reducing the viral load to unde-              can evolve and escape                    by interferon, but the symptoms
    tectable levels with interferon and then       the immune attack.”                      respond to rituximab, a chimeric mon-
    allowing it to rise when therapy is                                                     oclonal antibody directed against the
    interrupted simulates a secondary                   — Gerond Lake-Bakaar, MD            B-cell–specific antigen CD20.
    infection. When reexposed to the virus                                                     Although rituximab causes a decline
    during this simulated secondary infec-                                                  in B cells, immunoglobulin production,
    tion, memory cells mount a rapid, pow-                                                  and anti–hepatitis C virus antibody
    erful attack on the virus before it can                                                 titers, it is associated with steep
    evolve and escape the immune attack.                                                    increases of hepatitis C virus RNA lev-
    Each cycle hones immunity further                                                       els in plasma. This reaction is not well
    until hopefully, a sustained virologic                                                  understood, but it suggests that B cells
    response is achieved.”                                                                  and the immunoglobulins or antibodies


2   Fall 2004
Future Therapies for HCV
 Genome                                 • Antisense oligo-
                                                                        NewYork-Presbyterian Digestive Diseases
 sequence–based                           nucleotides                   is a publication of the Digestive Diseases Center of NewYork-Presbyterian Hospital. The Digestive Diseases Center
                                                                        is at the forefront of research and practice in the areas of gastroenterology; GI surgery; and liver, bile duct, and
                                        • Ribozymes                     pancreatic disorders. NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-
                                        • RNA interference              Presbyterian Hospital/Weill Cornell Medical Center are respectively affiliated with Columbia University College of
                                                                        Physicians and Surgeons and the Weill Medical College of Cornell University.
 Viral enzyme                           • Protease
 inhibitors                             • Helicase                                           NewYork-Presbyterian
                                        • Polymerase                                    Digestive Diseases Editorial Board
 Other                                  • IFN: albumin
                                          Consensus interferon
                                                                        John Chabot, MD                                             Paul Miskovitz, MD
                                          Interferon gamma              Chief, Division of General Surgery,                         Attending Physician,
                                                                        Medical Director, Operating Rooms,                             NewYork-Presbyterian/Weill Cornell
                                        • RBV refinements                 NewYork-Presbyterian/Columbia                             Clinical Professor of Medicine,
                                          (viramidine)                  Associate Professor of Surgery,                             Division of Gastroenterology and Hepatology,
                                          IMPDH inhibitors                Columbia University College of                               Weill Medical College of Cornell University
                                        • Immune modulation,              Physicians and Surgeons                                      paulmiskovitz@pol.net
                                          including vaccines              jac4@columbia.edu
                                                                                                                                    Mark Pochapin, MD
                                        • Antifibrotic therapy          Kenneth Forde, MD                                           Director, Jay Monahan Center for
HCV, hepatitis C virus; IFN, interferon; IMPDH, inosine monophosphate
                                                                        Vice-Chairman for External Affairs,                         Gastrointestinal Health,
dehydrogenase; RBV, ribavirin; RNA, ribonucleic acid                    Department of Surgery,                                        NewYork-Presbyterian/Weill Cornell
                                                                          NewYork-Presbyterian/Weill Cornell                        Director, GI Endoscopy, Division of
                                                                        José M. Ferrer Professor of Clinical Surgery,               Gastroenterologyand Hepatology,
                                                                          Columbia University College of                            and Associate Professor of Clinical Medicine,
                                                                          Physicians and Surgeons                                     Weill Medical College of Cornell University
                                                                        Adjunct Professor of Clinical Surgery,                        mbpocha@mail.med.cornell.edu
they produce may play a role in clearing the                              Weill Medical College of Cornell University
                                                                          kaf2@columbia.edu                                         Lewis Schneider, MD
virus from plasma.
                                                                                                                                    Assistant Attending Physician,
   Another puzzle emerges from this reac-                               Dennis Fowler, MD                                             NewYork-Presbyterian/Columbia
tion. Patients with B-cell deficiencies have                            Director of the Minimal Access                              Assistant Professor of Clinical Medicine,
more progressive hepatitis C disease, yet                               Surgery Program,                                              Columbia University College of
based on a small number of reported cases,                                NewYork-Presbyterian/Columbia                               Physicians and Surgeons
they respond well to interferon.                                        Professor of Clinical Surgery,                                (212) 326-8426
                                                                          Columbia University College of
   “These patients may progress faster because                            Physicians and Surgeons                                   Peter D. Stevens, MD
without antibodies binding to the virus, there’s                          dl91@columbia.edu                                         Director, Gastrointestinal
more free virus available to invade new liver                                                                                       Endoscopy Department,
cells,” said Dr. Lake-Bakaar. “Yet without                              Michel Gagner, MD                                           Clinical Director, Division of Digestive
antibodies, the virus doesn’t have to change                            Chief, Bariatric Surgery Program,                           and Liver Diseases,
continually, so there are fewer variants.”                                NewYork-Presbyterian/Weill Cornell                           NewYork-Presbyterian/Columbia
                                                                        Professor of Surgery,                                       Assistant Professor, Clinical Medicine,
   Dr. Lake-Bakaar’s team will examine viral                              Weill Medical College of Cornell University                  Columbia University College of
sequences after rituximab to figure out how                               mig2016@med.cornell.edu                                      Physicians and Surgeons
viral evolution changes without immune pres-                                                                                           pds5@columbia.edu
sure. “These patients will hopefully respond                            Ira Jacobson, MD
                                                                        Chief of the Gastroenterology Service,                      Timothy C. Wang, MD
better to therapy after rituximab,” he said.
                                                                          NewYork-Presbyterian/Weill Cornell                        Chief, Division of Digestive and Liver Diseases,
                                                                        Chief, Division of Gastroenterology and Hepatology,           NewYork-Presbyterian/Columbia
Ira Jacobson, MD, is Medical Director, Center for                       and Vincent Astor Professor of Clinical Medicine,           Assistant Professor of Medicine,
the Study of Hepatitis C, and Chief,                                      Weill Medical College of Cornell University                 Columbia University College of
Gastroenterology Service at NewYork-Presbyterian                          imj2001@mail.med.cornell.edu                                Physicians and Surgeons
Hospital/Weill Cornell Medical Center, and is                                                                                         tcw21@columbia.edu
Vincent Astor Professor of Clinical Medicine, and                       Jeff Milsom, MD
Chief, Division of Gastroenterology and                                 Chief, Division of Colorectal Surgery,                      Richard L. Whelan, MD
Hepatology at Weill Medical College of Cornell                            NewYork-Presbyterian/Weill Cornell                        Site Director, Minimal Access Surgery Center,
University. E-mail is imj2001@med.cornell.edu.                          Professor of Surgery,                                       Chief, Section of Colon and Rectal Surgery,
                                                                        Colon and Rectal Surgery Section,                             NewYork-Presbyterian/Columbia
Gerond Lake-Bakaar, MD, is Assistant Attending                            Weill Medical College of Cornell University               Associate Professor of Surgery,
                                                                          jwm2001@med.cornell.edu                                     Columbia University College of
Physician at NewYork-Presbyterian Hospital/Weill
                                                                                                                                      Physicians and Surgeons
Cornell Medical Center, and is Assistant Professor                                                                                    rlw3@columbia.edu
of Medicine at Weill Medical College of Cornell
University. E-mail: gvl2002@med.cornell.edu.



                                                                                                                                                                                               3
    N     E W       Y     O R K          – P        R E S B Y T E R I A N
      Digestive Diseases
                                                                                                                                    avoiding additional patient anxiety by
                                                                                                                                    preventing the need for repeat testing.”
                                                                                                                                       GI motility is a complex process, coor-
                                                                                                                                    dinated by the enteric nervous system,
                                                                                                                                    that facilitates propulsion of foodstuffs
                                                                                                                                    through the digestive tract while maxi-
                                                                                                                                    mizing nutrient absorption. While the
    Ensuring Accuracy in the Testing of                                                                                             cause of many motility-related disorders
                                                                                                                                    remains unknown, these disorders are a
    Motility-Related Disorders                                                                                                      substantial source of morbidity leading to
                                                                                                                                    frequent absenteeism from work and uti-
                                                                                                                                    lization of healthcare resources. Whereas
                 otility-related disorders of the                                                                                   endoscopy allows physicians to view the

    M            gastrointestinal (GI) tract
                 often present problems to
    both primary care physicians and gas-
                                                        “When I see patients
                                                        who’ve been tested and
                                                                                                                                    anatomy and structure of the GI tract,
                                                                                                                                    motility studies reveal how it functions.
                                                                                                                                       “I compare it to when you go to buy
    troenterologists. Despite recent interest                                                                                       a car,” said Dr. Harris. “When you sit in
    in GI motility (also known as “function-            diagnosed elsewhere, it’s                                                   the seats and look the vehicle over in
    al”) disorders such as gastroparesis, dys-                                                                                      the showroom, that’s akin to visual
    pepsia, diarrhea, constipation, and irrita-         not uncommon that I                                                         studies like endoscopy. But when you
    ble bowel syndrome (IBS) within the                 can’t make heads or tails                                                   take it to a mechanic to check how the
    research community and pharmaceutical                                                                                           engine runs, that’s like the functional
    industry, these disorders remain poorly             of their results because                                                    motility testing I do.”
    understood and frequently misdiag-                  they were performed                                                            The Center offers the latest in testing
    nosed. Few effective treatments exist,                                                                                          and diagnostic equipment. These
    and specialists still debate the exact              incorrectly or incomplete-                                                  include esophageal manometry, which
    characteristics and symptoms of many of             ly. If a patient gets                                                       measures the strength and function of
    the disorders, which affect between 60                                                                                          the esophagus and can help diagnose
    and 70 million people in the United                 referred here, doctors can                                                  disorders such as achalasia and sclero-
    States. With diagnosis and treatment                feel more confident in the                                                  derma, or evaluate function before or
    costs expected to exceed $10 billion this                                                                                       after esophageal surgery. According to
    year alone, recent research efforts have            results, thereby avoiding                                                   Dr. Harris, 24-hour pH monitoring,
    focused primarily on new diagnostic                 additional patient anxiety                                                  which measures the degree of
    procedures and systems.                                                                                                         esophageal acid reflux, can assess if
       Physicians at the new Gastro-                    by preventing the need                                                      heartburn symptoms correlate with
    intestinal Motility Center at NewYork-              for repeat testing.”                                                        changes in pH and identify if acid reflux
    Presbyterian Hospital/Weill Cornell                                                                                             is the cause of less common complaints,
    Medical Center are at the forefront of                        — Arthur D. Harris, MD                                            such as noncardiac chest pain, chronic
    this effort. The Center, which opened in                                                                                        laryngitis, and unexplained cough. For
    May with the support of the C.V. Starr                                                                                          patients with chronic constipation or
    Foundation, operates based on a “hands-                                                                                         fecal incontinence, anorectal manometry
    on approach” to testing and treatment,                                                                                          measures the various components of the
    according to Arthur D. Harris, MD,                                                                                              anorectal sphincter complex, and whole-
    director of the facility. It was established                                                                                    gut transit time measures the time it
                                                                                                 Photo courtesy of Medtronic Inc.




    so that the Hospital could lead clinical                                                                                        takes for radiopaque markers to move
    trials of promising medications for a                                                                                           through the lower GI tract.
    variety of GI motility disorders and be                                                                                            While these tests can be relatively
    among the first to implement new diag-                                                                                          time-consuming, they are vital for the
    nostic technologies.                                                                                                            proper diagnosis of the complicated
       “It’s a quality assurance issue,” said Dr.                                                                                   symptoms that often are the hallmark of
                                                     The Motility Center at NewYork-
    Harris. “When I see patients who’ve                                                                                             GI motility disorders. The Center plans
                                                     Presbyterian Hospital/Weill Cornell
    been tested and diagnosed elsewhere, it’s                                                                                       to offer wireless pH monitoring within
                                                     Medical Center plans to offer wireless pH
    not uncommon that I can’t make heads             monitoring within the next year. In this                                       the next year. In this procedure, sensors
    or tails of their results because they were      procedure, sensors (shown above) are                                           are placed endoscopically in the GI tract
    performed incorrectly or incompletely. If        placed endoscopically in the GI tract to                                       to produce the same results as 24-hour,
    a patient gets referred here, doctors can        produce the same results as 24-hour,                                           conventional pH monitoring. “And the
    feel more confident in the results, thereby      conventional pH monitoring.                                                                            see Motility, page 6



4   Fall 2004
Improving Outcomes in Pancreatic Cancer
        he success rate in treating pan-        In a study presented at the 6th     cancer patients who underwent surgery

T       creatic cancer has always been
        abysmal. “Nothing really has
worked,” said John D. Allendorf, MD.
                                             World Congress of the International
                                             Hepato-Pancreato-Biliary Association
                                             in Washington, DC, this past June, a
                                                                                    following the chemoradiation combina-
                                                                                    tion. These were patients with locally
                                                                                    advanced disease who could not be
“We have response rates in the 10% to        group from the HICCC led by Dr.        treated with surgery before chemoradi-
15% range and maybe 20% to 25%               Allendorf reported on 16 pancreatic    ation. “The first impressive thing was
with gemcitabine,” a newer chemother-                                               that during the 5 months on the proto-
apy agent that has shown promise in                                                 col, none of the patients had disease
pancreatic cancer treatment.                                                        progression, and in many cases the
   Now, a new chemoradiation protocol                                               tumor shrank,” said Dr. Allendorf.
developed at the Herbert Irving                 “If you can take that               “The median survival for patients with
Comprehensive Cancer Center                                                         locally unresectable tumors is probably
(HICCC) has increased the surgical              30% population of                   about 8 to 10 months.”
success rate in patients with locally           patients and get tumors                According to Dr. Allendorf, they
advanced pancreatic tumors that for-                                                were able to remove the tumors in 12
merly were inoperable. The protocol,            to shrink just enough so            (75%) of the 16 patients. Two of the 4
developed by Robert L. Fine, MD, and            that you can remove the             patients who could not undergo surgery
his team, involves treatment with a                                                 had tumors that were too advanced
combination of 3 chemotherapy                   tumor, you could poten-             locally, and the other 2 had disease in
drugs—gemcitabine, docetaxel, and               tially triple your surgical         their liver that had not been picked up
capecitabine—followed by combination                                                during computed tomography.
therapy consisting of gemcitabine and           impact on the disease.”                All 12 patients whose tumors were
abdominal radiation. Six weeks after                                                resected survived the surgery, which,
completion of radiation, patients under-                 —John D. Allendorf, MD     explained Dr. Allendorf, “tends to be a
go surgery to remove their tumors.                                                                see Pancreatic Cancer, page 6




                                                                                                                                  Photo courtesy of the National Cancer Institute.




Human tumor cells from the pancreas stained with an immunocytochemical stain.



                                                                                                                                                                            5
    Motility
    continued from page 4
                                                      Continuing Medical Education Seminars
                                                      The following is a partial list of CME programs offered through NewYork-Presbyterian Hospital.
    patient doesn’t have a catheter down              To register, or for more information, please visit
    their nose for 24 hours,” Dr. Harris said.        www.columbiacme.org or www.med.cornell.edu/education/cme.
       “I often tell patients that it’s never 1
                                                      Contemporary Evaluation and Management of
    individual test that gives the answer,”
                                                      Reflux and Swallowing Disorders
    he continued. “There are many things
                                                      DATE: Saturday, November 6
    that can trigger symptoms in a given
                                                      LOCATION: NewYork-Presbyterian Hospital/Columbia University Medical Center, New York City
    individual, whether it’s a systemic
    disease, functional disorder, diet, or
    superimposed and/or coexistent psy-
                                                      Obesity: Understanding the Biological and Psychological
    chological issues. You end up using
                                                      Dimensions of the Worldwide Pandemic
    complementary tests to help make a                DATE: Friday, November 12
                                                      LOCATION: Morgan Stanley Childrens Hospital of New York-Presbyterian, 3959 Broadway, New York City
    proper diagnosis.”                                Full day, maximum of 8 category 1 credits

    Arthur D. Harris, MD, is Director of
    Gastrointestinal Motility at NewYork-             Update in Gastroenterology, Hepatology, and Nutrition
    Presbyterian Hospital/Weill Cornell Medical       DATE: Friday and Saturday, December 3 and 4
    Center, and is Assistant Clinical Professor of    LOCATION: Weill Medical College of Cornell University, Uris Auditorium, New York City
    Medicine in the Division of                       Jointly sponsored by Columbia University College of Physicians and Surgeons and Weill Medical College of Cornell University.
    Gastroenterology and Hepatology at Weill          For more information, visit www.columbiacme.org.
    Medical College of Cornell University.
    E-mail: adharris@med.cornell.edu.




                                                                                                                                            “If you can take that 30% population
    Pancreatic Cancer
    continued from page 5
                                                     Suggested Reading                                                                   of patients and get tumors to shrink
                                                                                                                                         just enough so that you can remove the
                                                        NewYork-Presbyterian/Columbia                                                    tumor, you could potentially triple your
    very challenging operation. “They’ve             physicians have led or been involved                                                surgical impact on the disease,” Dr.
    had all this radiation therapy to their          in numerous studies investigating                                                   Allendorf said. Increasing the potential
                                                     pancreatic cancer and related diseases
    abdomen, and the tumors are usually                                                                                                  for surgical success is just what the
                                                     and authored or coauthored several
    larger than ones we generally operate                                                                                                Columbia team has done.
                                                     articles on the topic. Among them:
    on.” Moreover, the portal vein had to                                                                                                   “People talk about a 20% to 30%
                                                     Stevens PD, Lightdale CJ. The role of
    be reconstructed in 4 of the patients                                                                                                resectability rate with neoadjuvant
                                                     endosonography in the diagnosis and man-
    and the mesenteric artery replaced in            agement of pancreatic cancer.                                                       chemotherapy,” said Dr. Allendorf, “but
    2 others.                                        Surg Oncol Clin N Am. 1998;7:125-133.                                               this is the first study that I’m aware of
       “What we look at is the margins of            Larghi A, Verna EC, Stavropoulos SN,                                                where we had a resectability rate of
    our specimen; is there any tumor on              Rotterdam H, Lightdale CJ, Stevens PD. EUS-                                         75%. So, yes, it’s very encouraging.”
                                                     guided trucut needle biopsies in patients with
    the margins?” he said. In 10 (83%) of            solid pancreatic masses: a prospective study.
    the 12 patients whose tumors were                Gastrointest Endosc. 2004;59:185-190.                                               John D. Allendorf, MD, is Assistant
    removed, the margins were negative, he           Nord HJ, Brady PG, Lightdale CJ, Reddy RK, Eisen                                    Attending Surgeon at NewYork-
    said, “which is pretty remarkable.”              GM, Dominitz JA, Faigel DO, Goldstein JA, Kalloo                                    Presbyterian Hospital/Columbia University
       The outlook for pancreatic cancer             AN, Petersen BT, Raddawi HM, Ryan ME, Vargo JJ                                      Medical Center, and is Assistant Professor
                                                     3rd,Young HS, Fanelli RD, Hyman NH, Wheeler-                                        of Surgery at Columbia University College
    patients is generally poor. Of those             Harbaugh J; American Society for Gastrointestinal
    who present with the disease, about                                                                                                  of Physicians and Surgeons.
                                                     Endoscopy. Diagnostic laparoscopy guidelines for
    55% have tumors that have metasta-               clinical application. Gastrointest Endosc.                                          E-mail: jda13@columbia.edu.
    sized and so are not candidates for sur-         2001;54:818-820.
    gery. Overall, 15% have tumors small             Goldstein MJ, Toman J, Chabot JA.                                                   Robert L. Fine, MD, is Director of the
                                                     Pancreaticogastrostomy: a novel application                                         Experimental Therapeutics Program,
    enough to be resected surgically. The            after central pancreatectomy.                                                       Herbert Irving Comprehensive Cancer
    target population for the chemoradia-            J Am Coll Surg.. 2004;198:871-876.                                                  Center at NewYork-Presbyterian
    tion protocol is the remaining 30% of            Sherman WH, Fine RL. Combination gem-                                               Hospital/Columbia University Medical
    patients with locally advanced tumors            citabine and docetaxel therapy in advanced                                          Center, and is Herbert Irving Associate
    that cannot be operated on without               adenocarcinoma of the pancreas.                                                     Professor of Medicine at Columbia
                                                     Oncology. 2001;60:316-321.
    neoadjuvant therapy, such as the proto-                                                                                              University College of Physicians and
    col developed by Dr. Fine.                                                                                                           Surgeons. E-mail: rlf20@columbia.edu.



6   Fall 2004
Esophageal Surgery                            before the surgery; that way, we shrink       to seek consultations whenever they are
continued from page 1                         the tumor and only treat the diseased         considering esophageal surgery. Dr.
                                              esophagus and not the stomach, as would       Fowler acknowledges that for more
abdomen.” The surgeons start in the           be the case with radiation after surgery.”    advanced cancers, the Ivor-Lewis tech-
abdomen and use a laparoscope to                                                            nique is still recommended. His concern
guide them through the chest to the                                                         is that too many surgeons may be using
proximal third of the esophagus. Then                                                       it, or the open trans-hiatal technique,
they remove the esophagus through a                                                         unnecessarily.
small neck incision and replace it with a
                                                 “Open esophagectomy,                           “The only patient for whom we proba-
tube created from a portion of the               even under the best of                     bly wouldn’t do laparoscopic esophagec-
stomach. The tube is reattached to the                                                      tomy is one with cancer that has gone
still-intact upper portion of the esopha-
                                                 circumstances, is a some-                  into the full thickness of the esophagus
gus in the neck.                                 what disabling surgery.”                   or in whom it has metastasized,” added
   Although the surgery takes a bit                                                         Dr. Bessler. “If in the former case the
longer (4 to 5 hours instead of 3 to 4),                      —Dennis Fowler, MD            tumor shrank to a manageable size after
the trauma patients experience during                                                       radiation and chemotherapy, laparoscopy
the procedure is significantly less.                                                        might still be a viable option.”
Patients generally leave the hospital in 5
days instead of 10. “We can see what             However, the researchers are still look-   Marc Bessler, MD, is Surgical Director of
we’re doing, so there’s not as much risk      ing into whether the procedure can            the Center for Obesity Surgery and Director
of injury, and there’s less bleeding than     “remove as many lymph nodes,” said Dr.        of Laparoscopic Surgery at NewYork-
with open trans-hiatal esophagectomy,”        Fowler. The Ivor-Lewis technique—             Presbyterian Hospital/Columbia University
explained Dr. Bessler. “We don’t know         which requires large incisions in both the    Medical Center, and is Assistant Professor of
for sure, but by causing less trauma to       chest and abdomen—may provide more            Surgery at Columbia University College of
the body, we may be allowing the              effective harvesting of lymph nodes in        Physicians and Surgeons. E-mail:
immune system to stay in better shape         more advanced cancers than does laparo-       mb28@columbia.edu.
to fight off any residual tumor.”             scopic esophagectomy. For larger tumors
                                                                                            Dennis Fowler, MD, is Director of the
   Neither doctor can find any negatives      or tumors of the proximal esophagus,          Minimal Access Surgery Program at
to the laparoscopic procedure in patients     thoracoscopy in combination with              NewYork-Presbyterian Hospital/Columbia
with stage I or II esophageal cancer. In      laparoscopy may be used.                      University Medical Center, and is US
the latter group, according to Dr. Bessler,      Still, both doctors believe laparoscopic   Surgical Professor of Clinical Surgery at
“we’ll have them undergo pre-op               esophagectomy is a viable alternative for     Columbia University College of Physicians
chemotherapy and radiation therapy            many patients and urge their colleagues       and Surgeons. E-mail: dlf91@columbia.edu.




                                                                                               In another paper coauthored with Dr.
New Technologies
continued from page 1
                                                                                            Stavropoulos, Dr. Stevens described new
                                                 “We’re just beginning to                   software that allows reconstruction of 3-
sharper images are especially helpful                                                       dimensional ultrasound images. In a
where there are strictures or masses of an       investigate the capacity of                study of 20 patients, he evaluated 7 bil-
indeterminate nature and when there are          the software to improve                    iary strictures, 5 dilated bile ducts, 2
malignancies. “We hope that intraductal                                                     cases of choledocholithiasis, 1 ampullary
ultrasound will help us diagnose and             our diagnosis.”                            adenoma, 1 case of idiopathic pancreati-
stage the cancers earlier and more                                                          tis, 1 resected gallbladder adenoma (for
                                                           — Peter D. Stevens, MD
effectively,” he added. “It will get a                                                      surveillance), and 3 cases of biliary colic.
patient to surgery faster or avoid                                                          In each case, the 3-dimensional software
unnecessary surgery.”                                                                       considerably increased the appreciation
   Dr. Stevens—along with Stavros                                                           of anatomic structures.
Stavropoulos, MD, and Charles                 presented a paper describing a prototype         “We’re just beginning to investigate
Lightdale, MD—has been working with           technology that features production of a      the capacity of the software to improve
Olympus, the camera manufacturer, to          360-degree image with Doppler analysis.       our diagnosis,” he said.
design smaller, nimbler probes, as well as    In a study of 26 patients, he found it           Savreet Sarkaria, MD, another co-
software to better analyze the results.       allowed for easier anatomic interpreta-       author of the second paper, now special-
Earlier this year, at the Digestive Disease   tion and excellent Doppler analysis of        izes in pancreatic and biliary disease and
Week meeting in New Orleans, he               vascular flow.                                               see New Technologies, page 8



                                                                                                                                            7
                                                           narrowings in the ducts, ERCP does not        stones without directly viewing them.”
              New Technologies                             provide information about the walls of            As useful as both cholangioscopy and
              continued from page 7                        the ducts or the surrounding anatomic         intraductal ultrasound can be, however,
                                                           structures. “Sometimes intraductal ultra-     “you don’t need them that often,” Dr.
              performs ERCP, intraductal ultrasound,       sound can help characterize the nature—       Sarkaria said. She estimated that in only
              cholangioscopy, and other procedures.        benign or malignant—and extent of the         about 5% of cases are such specialized
                 “There’s a common misperception           stricture, and even help better target        technologies necessary. “When needed,
              that intraductal ultrasound is too diffi-    intraductal biopsies,” she said.              it’s nice to have the extra dimension of
              cult, adds too much time, or requires a         Drs. Stevens and Sarkaria also per-        visualization they provide.”
              sphincterotomy,” Dr. Sarkaria said.          form cholangioscopy, a procedure that
              “None of those are true. It’s very easy to   requires 2 skilled endoscopists. A            Peter D. Stevens, MD, is Chief of
                                                                                                         Endoscopy at NewYork-Presbyterian
              implement and only adds a couple of          cholangioscope is essentially a scope
                                                                                                         Hospital/Columbia University Medical
              minutes to the procedure.”                   within a scope. The outer scope is called     Center, and is Assistant Professor of
                 Standard ERCP is usually sufficient       the “mother” scope, and the inner is          Clinical Medicine in the Division of
              to diagnose gallstones in the bile ducts,    called the “baby” scope. The technology       Digestive and Liver Diseases at Columbia
              which show up as filling defects on the      allows better imaging and, ultimately,        University College of Physicians and
              X-ray images after injection of contrast.    improved diagnostics. In some situa-          Surgeons. E-mail: pds5@columbia.edu.
              However, Dr. Sarkaria explained, “intra-     tions, Dr. Sarkaria said, this direct visu-
                                                                                                         Savreet Sarkaria, MD, is Associate
              ductal ultrasound can increase the diag-     alization can be vital, such as in electro-
                                                                                                         Attending Physician at New York-
              nostic sensitivity and specificity of        hydraulic lithotripsy, in which shock         Presbyterian Hospital/Weill Cornell
              ERCP. This can help you pick up tiny         waves are used to disintegrate large          Medical Center, and is Assistant Professor
              stones or biliary sludge. It gives you a     intraductal stones.                           of Medicine in the Division of
              very fine, detailed view of the ducts.”         “The stone is crushed under direct         Gastroenterology at Weill Medical College
                 According to Dr. Sarkaria, although       observation with the endoscope,” she          of Cornell University.
              strictures show up with ERCP as              said. “It’s not safe to try to break these    E-mail: sav2004@med.cornell.edu.




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