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Posted by Stony Brook Surgery on December 17, 2014

Acid Reflux Disease Is a Serious Health Condition That Doesn't Just Cause Heartburn

Suffering Laryngopharyngeal Reflux

President Barack Obama made an unscheduled trip to Walter Reed National Military Medical Center earlier this month because of a sore throat he had for a couple of weeks. The president's physician, Ronny L. Jackson, MD, recommended that he go there for diagnostic tests, in particular computed tomographic (CT) imaging, as well as an evaluation by an otolaryngoloist.

The CT scan was normal. "The president's symptoms are consistent with soft tissue inflammation related to acid reflux and will be treated accordingly," Dr. Jackson says in a written statement released by the White House.

Acid reflux, or gastroesophageal reflux disease (GERD), is a digestive disease that affects an estimated 25% to 35% of the U.S. population. Its common symptom is heartburn. This burning sensation in the chest is caused by stomach acid that flows back into the esophagus, the tube connecting the throat to the stomach.

President Obama's sore throat is a dramatic reminder that stomach acid can also be refluxed into the throat, a condition called laryngopharyngeal reflux (LPR).

LPR can occur without heartburn, making it difficult to diagnose. This is why it is sometimes called "silent reflux."

If LPR is left untreated, it can cause serious damage to the tissues of the throat, upper airway, and the lungs. LPR can also lead to serious problems including vocal cord nodules, subglottic stenosis (airway narrowing), granulomas, and even cancer. In addition, LPR can worsen the conditions of asthma and sinusitis. Common symptoms of LPR include:

  • Hoarseness, especially in the morning
  • Chronic throat clearing or persistent cough
  • Chronic sore throat
  • A feeling of something caught in the throat
  • Excessive mucous/post-nasal drip
  • Difficulty swallowing
  • Restless sleep
  • Prolonged vocal warm-up (for singers)

President Obama's sore throat offers the opportunity to alert Americans that reflux disease
doesn't just cause heartburn — it's a serious health condition, not to be ignored.

Elliot Regenbogen, MD | Stony Brook ENT & Laryngology Specialist
Dr. Elliot Regenbogen

Melissa M. Mortensen, MD | Stony Brook ENT & Laryngology Specialist
Dr. Melissa Mortensen

Commenting on the news about the president's sore throat, Elliot Regenbogen, MD, one of our otolaryngologists with special laryngology expertise, says:

"Initial diagnosis of a sore throat lasting more than five to seven days may consist of a visit to a primary care doctor for simple examination of the mouth and throat culture.

"For persistent symptoms beyond three weeks, a more detailed evaluation by an otolaryngologist is recommended.

"In the president's case, this evaluation included direct visualization of his throat and voice box with a fiberoptic nasopharyngoscope, a tool used in office by otolaryngologists to quickly provide a more detailed understanding of the source of the discomfort.

"If findings are consistent with LPR, 24-hour at-home pH monitoring will frequently be considered prior to treating with medication, dietary modification, or consideration of further workup.

"We offer the Restech pH (acidity) testing for laryngopharyngeal reflux as part of our laryngology program here at Stony Brook. It is a very useful diagnostic tool, and it enables us to provide the most proper treatment to patients.

"Placement of the Restech probe takes only a few minutes, and it is extremely well tolerated."

Melissa M. Mortensen, MD, our other otolaryngologist with special laryngology expertise, also treats LPR using the latest technology. Drs. Mortensen and Regenbogen both focus their clinical practices on advanced diagnosis and treatment of voice and swallowing disorders, as well as on general otolaryngology-head and neck surgery.

Reflux disease doesn't just cause heartburn. It can also cause a type of esophageal cancer, of which sore throat is a possible symptom. Because there generally are no early signs or symptoms of esophageal cancer, most patients are diagnosed at late stages, when treatment is rarely successful. Fewer than one in five patients (20%) survive more than five years. As a common digestive disease that affects an estimated 25% to 35% of the U.S. population, GERD attacks flare during the holiday season as a result of the consumption of an overabundance of festive foods. It's that time of the year to be especially aware of reflux!

For consultations/appointments with our laryngology specialists, please call 631-444-4121. Watch this ABC news clip (2:13 min) about Restech pH testing and hear what two patients have to say about it:

Posted by Stony Brook Surgery on December 10, 2014

Magnets Are Associated with an Alarming Increase in Pediatric Ingestion Injuries in Recent Years

Chest X-Ray of Little Boy Showing Toy Part Lodged in His Esophagus
X-ray of 4-year-old boy showing toy part
(arrow) lodged in his esophagus.

Children's toys are potentially dangerous, and it's that time of the year to be especially mindful of this fact. Foreign body ingestion by children represents a major challenge to the treating physicians and to the parents/guardians. Diagnosis can often be challenging because not all ingested objects can be seen by routine x-ray exams.

Only metallic objects can be seen by x-ray. Objects made out of plastic and glass can be easily missed. Diagnosis, therefore, is often made by direct observation with a history of choking, or new onset of certain symptoms.

Of the many ingestion injuries treated by our pediatric surgery service, one involved a little boy who had sudden chest pain and was brought to our ER: he had swallowed a toy part that lodged in his esophagus (see x-ray at right).

Treatment of a swallowed or inhaled foreign body is dependent on the location and the type of the foreign body. In the digestive tract, if the object is stuck in the esophagus and fails to pass into the stomach, it must be removed using endoscopic techniques.

A foreign body that passes into the stomach can be observed without intervention, because it will usually pass through the intestine and exit with stool. Even sharp objects such as pins can pass without perforating the intestine. The passage into stool can take up to one to two weeks.

Certain types of ingested objects represent a major concern: button batteries and supermagnets (neodymium magnets; typically 10 to 20 times stronger than traditional magnets) are two of the most common types.

Button batteries can be easily swallowed, and these batteries release corrosive chemicals that can erode through the esophagus and intestine if they fail to move. Therefore, our pediatric surgeons try to remove all of such batteries when seen in the esophagus. Once a battery passes into the intestine, it can only be watched, with the hope it will pass out with the stool without damaging result.

Magnets are another type of object that has been identified as especially dangerous. In recent years, many reports of ingested small magnets eroding through the bowel by magnetic force have appeared in the medical literature.

A study titled "Pediatric Magnet Ingestions: The Dark Side of the Force," published this year in the American Journal of Surgery, found that injuries caused by children ingesting magnets are increasing (see study abstract). The authors conclude that "magnet safety standards are needed to decrease risk to children."

Another recent study, titled "Supermagnet Ingestion — an Emerging Paediatric Threat," which was presented last year at the American Academy of Pediatrics National Conference, found that magnets have caused an alarming increase in pediatric ingestion-related injuries over the past five years, with the age of patients ranging from 17 months to 13 years (see study abstract).

Stony Brook Children's is the only hospital in Suffolk County with board-certified pediatric surgeons who treat children with toys ingested into the airway and digestive tract.

Magnets that are swallowed can clump together on opposite sides of the intestinal wall, and their pinching action can be so tight that holes are made in the intestine, thus creating a dangerous problem, according to Thomas K. Lee, MD, chief of pediatric surgery.

The current standard of care for children who have more than one magnet is to consider performing emergency abdominal surgery.

A foreign body inhaled into the airway by children is a surgical emergency. Many objects have been identified as high risk for inhalation by young children. These include popcorn seeds, peanuts, and latex balloons. Unusual inhaled objects that I have seen include a broken Monopoly piece and a screw.

Observing choking with an object in the mouth may be the only history. Sometimes, it is a child with new onset wheezing. Chest x-ray may not necessarily make the diagnosis. Rigid bronchoscopy is the utilized for both diagnosis and treatment.

Children's Toys May Be Hazardous to Their Health; Prevent Ingestion Injuries During the holiday season, children's gifts need to be age appropriate for many reasons. Prevention of foreign body aerodigestive ingestion is one of them. However, this is a problem seen throughout the entire year at Stony Brook Children's Hospital.

Stony Brook Children's is the only hospital in Suffolk County with board-certified pediatric surgeons who treat children with toys ingested into the airway and digestive tract. We also have specialists from our pediatric emergency department who can make diagnosis to the surgeons and a pediatric otolarygologist, who can perform all of the above procedures and operations in children.

Foreign body ingestion injuries related to toys often happen when parents overestimate their child’s level of development and make the mistake of buying a toy beyond the suggested age range: toys designed for older children may contain parts that are choking hazards.

A recent compelling study of foreign body ingestion injuries in children ("Toys in the Upper Aerodigestive Tract") found that despite the adoption of preventive strategies, including product modification by manufacturers, which have decreased the mortality rate due to choking, preventive strategies imposing regulations on industrial production, even if fundamental, are not sufficient.

In addition to these strategies, it was concluded that what's needed is other preventive intervention aimed at improving parents' awareness of foreign body ingestion injuries and at increasing their watchfulness of their children.

Harmful If Swallowed

Here's a very partial list of toy types/parts that young children have swallowed and that have sent them to the emergency room:

  • Ball bearings
  • Board game pieces
  • Button batteries
  • Doll shoes
  • Lego-type toys (interlocking bricks)
  • Round small toys
  • Toy insects
  • Toy soldiers
  • Toy train signs
  • Wheels of toy cars & other vehicles

ALERT: Children under the age of 3 should not play with toys that could fit inside a toilet paper roll. Read magnet safety alert of U.S. Consumer Product Safety Commission. Check www.cpsc.gov to make sure your children's toys are not recalled products.

Watch this CBSNewYork News video (2:07 min) about a Long Island boy who swallowed magnets and luckily was saved at Stony Brook Children's with help from our pediatric surgery service:

Posted by Stony Brook Surgery on December 3, 2014

By Brian J. O'Hea, MD, Chief of Breast Surgery, and Director, Carol M. Baldwin Breast Care Center

Dr. Brian O'Hea at Podium
Dr. Brian J. O'Hea

Lumpectomy, also known as breast-conserving surgery, is the most common form of breast cancer surgery today.

Lumpectomy may be used as a part of a treatment plan for breast cancer in cases of small, localized tumors. During lumpectomy, the cancerous lump and a portion of the breast tissue around the cancerous lump are removed.

With lumpectomy, the breast itself remains intact, and this treatment option appeals to many women. Studies have shown that women who undergo lumpectomy followed by radiation have similar overall survival rates as those who undergo mastectomy.

A new study, titled "Repeat Surgery after Breast Conservation for the Treatment of Stage 0 to II Breast Carcinoma," was just published in JAMA Surgery.

This study analyzed records from over 300,000 breast cancer patients who had lumpectomy as their initial surgical procedure: 76% had successful lumpectomy, whereas 24% of patients required additional surgery because of close or positive microscopic margins (inadequate lumpectomy).

The ideal lumpectomy removes all breast cancer cells with a small healthy rim of tissue around it. That’s called a clear margin. However, cancer cells are not readily visible at the time of surgery, and even the most sophisticated preoperative imaging techniques can only estimate the size and extent of cancer in the breast.

So, the lumpectomy is performed to hopefully get clear microscopic margins, using the best available preoperative information, while trying to save as much breast tissue as possible.

The safety of breast conservation treatment has withstood the test of time. If re-excision rates
alone are used as quality indicators, the message will be inaccurate and misleading.

Mohs surgery for skin cancer utilizes real-time margin analysis, permitting the surgeon to afford negative margin surgery during the first operation. Unfortunately, because of the fatty nature of breast tissue, the "frozen" technique is not possible, so that Moh’s surgery cannot be applied to breast lumpectomy surgery.

There are many factors that can affect the rates of additional surgery (re-excision rates).

First of all, the definition of a clear margin varies. A surgeon who requires a 3-mm microscopic margin will have a higher re-excision rate than one who accepts a 1-mm margin.

Also, a surgeon who performs a larger lumpectomy initially has a better chance of clear margins, but what if it turns out that a big lumpectomy wasn’t really needed?

Finally, a surgeon who takes on challenging lumpectomy cases will have a higher re-excision rate than one who is quick to recommend mastectomy for difficult cases.

A recent panel of experts, convened at a consensus conference concerning lumpectomy margins, concluded that even a very narrow microscopic margin is acceptable, as long as cancer cells are not touching the inked margin, assuming that post-lumpectomy radiation is utilized:

"The use of no ink on tumor as the standard for an adequate margin in invasive cancer in the era of multidisciplinary therapy is associated with low rates of IBTR [ipsilateral breast tumor recurrence] and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease healthcare costs" [read more]. The authors of the JAMA Surgery study promote these guidelines.

Women with breast cancer interested in breast-conserving lumpectomy as an alternative to
mastectomy should seek out an experienced, knowledgeable, skillful breast surgeon.

In 1990, the National Institutes of Health Consensus Development Conference on Treatment of Early-Stage Breast Cancer concluded:

"Breast conservation treatment [BCT] is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable because it provides survival rates equivalent to total mastectomy while preserving the breast" [read more].

In the 25 years since, nothing about that statement has changed. The safety of BCT has certainly withstood the test of time.

If re-excision rates alone are used as quality indicators, the message will be inaccurate and misleading.

Women who are interested in BCT as an alternative to mastectomy should seek out an experienced, knowledgeable, skillful breast surgeon, who will work hard to save the breast, with the best cosmetic result possible, even if it requires more than one operation.

Whether to have a mastectomy or a lumpectomy? First, talk to your surgeon to see whether both are options for you. If they are, you must weigh the risks and benefits of each surgery, and choose the one that's right for you. For helpful information concerning this matter, visit Susan G. Komen.

Read the abstract of "Repeat Surgery after Breast Conservation for the Treatment of Stage 0 to II Breast Carcinoma." Call 631-638-1000 for consultations/appointments with our breast surgeons.

Posted by Stony Brook Surgery on November 26, 2014

How to Avoid a Gallbladder Attack from All the Delicious Thanksgiving Food

Dr. Mark A. Talamini
Dr. Mark A. Talamini

Most surgeons on-call during the Thanksgiving holiday and the subsequent holiday season are not surprised when a patient visits the ER complaining of upper right side, abdominal pain and tenderness radiating through to the back.

There are also no surprises when an ultrasound shows a dilated gallbladder, possibly with a thickened wall, and gallstones ranging from the size of a pebble to the size of a marble or even an egg. At this point, surgery is the next logical step — a cholecystectomy, or gallbladder removal, which is one of the most common surgical procedures in the United States.

In 2013, over the Thanksgiving holiday weekend, surgeons at Stony Brook University Hospital performed 16 cholecystectomies. This number reflects the common spike associated with the holiday.

Here, Mark A. Talamini, MD, professor and chairman of surgery, who is a renowned gastrointestinal surgeon, shares a few practical tips on how to prevent a visit to the ER, and keep you at home with your family during the Thanksgiving holiday:

  • Eat smaller portions of high-fat, high-sugar foods: Thanksgiving celebrations are traditionally filled with buttery mashed potatoes, festively fatty appetizers, gooey desserts, and cheerfully spirited cocktails. Take it easy at the Thanksgiving dinner; not only will it spare you a possible trip to the hospital, but you will avoid packing on those extra end-of-the-year pounds. Researchers say many gallbladder symptoms stem from our Western diet, full of refined carbohydrates and saturated fats. "If you're having symptoms from gallstones, it's because as your gallbladder tries to squeeze, some of the gallstones are blocking the outflow of bile that is stored in your gallbladder," Dr. Talamini says. "You're basically squeezing against a closed door, and that's where the pain comes from. When you eat fatty foods that makes the gallbladder squeeze more."
  • Stay hydrated: During the cold months, our indoor environment is often warm and dry, making us sweat more fluid than we might expect, therefore causing dehydration. Overdoing it on holiday cocktails can accentuate dehydration. Staying hydrated also keeps the blood flowing to all organs, including the gallbladder.
  • Eat more fruits and vegetables: Eating fruits and vegetables increases the ratio of fiber to nutrients, which improves overall digestion and decreases the proportion of fat. Fat will stimulate the gallbladder.
  • Get some exercise: Exercise increases overall blood flow and motility, the ability to move food through the gut. After your Thanksgiving meal, get out with the family for a walk!
  • Understand your gallbladder: Watch this video (1:48 min).

In case of an emergency. The ER at the Stony Brook Trauma Center is here to help around the clock. With the establishment of the Department of Surgery's new exigent general surgery service, there is a special protocol in place for patients with acute cholecystitis, or gallbladder attack.

Patients with acute cholecystitis are streamlined from initial presentation in the ER, to exigent general surgery service evaluation, to a dedicated exigent general surgery service operating room during daytime hours, then to the post-anesthesia care unit and discharge home within 24 hours.

For more complicated patients, the exigent general surgery service is able to direct preoperative optimization so that the time-interval to surgery may be decreased. Our goal is to overall decrease patient duration until surgery, length of stay, and hospital costs, while providing the best care for the patient.

Click here for more about gallstones and how to prevent a gallbladder attack. And don't let heartburn be a GI holiday spoiler, either: see our tips blog from last year about GERD Awareness Week, which is Thanksgiving week.

Posted by Stony Brook Surgery on November 19, 2014

Excellence and Innovation Are Focus of Stony Brook University Heart Institute

Dr. James R. Taylor Jr.
Dr. James R. Taylor Jr.

James R. Taylor Jr., MD, joined our faculty in 2012 as professor of surgery and chief of the Cardiothoracic Surgery Division. He serves as co-director of Stony Brook University Heart Institute. He and co-director Harold A. Fernandez, MD, came to us together with the goal of transforming our robust cardiothoracic surgical program into a regional center of excellence, incorporating the most advanced cardiac surgical techniques.

Since his arrival at Stony Brook, Dr. Taylor has made heart surgery more available here for people who need it. Among his accomplishments, he led the creation of our new cardiothoracic intensive care unit (CTICU) for the care of patients immediately after cardiac surgery.

Dr. Taylor received his medical degree from the Medical University of South Carolina, followed by residencies in general and cardiothoracic surgery at New York Hospital-Cornell Medical Center. He completed a cardiothoracic surgery fellowship at the same institution. He joined St. Francis Hospital in Roslyn, NY, in 1991, and built a reputation during 21 years there as one of the most prolific and top-quality heart surgeons in New York State.

Here, Dr. Taylor answers questions about himself as well as about his vision of the future of heart surgery, including the upcoming use of innovative techniques to advance the care provided patients at Stony Brook.

Q: Why did you select your field?

A: I began my career as a pharmacist and after serving the needs of many patients with heart problems and getting to know them — their concerns, their fears, their hopes — I realized that I wanted to do more than just manage their drug therapy. The challenge of diagnosing and treating cardiac patients appealed to me, and I was interested in cardiovascular physiology. I knew then that cardiovascular surgery was the right choice.

Q: Why choose to work at Stony Brook? What is the opportunity here?

A: At Stony Brook, I saw tremendous potential and an opportunity to grow. Stony Brook is the only true university healthcare system on Long Island, and we offer a full range of advanced treatments: extracorporeal membrane oxygenation (ECMO), left ventricular assist devices (LVADs), complex aortic aneurysm surgery, valve surgery, robotic surgery, coronary bypass surgery, and transcatheter aortic valve replacement (TAVR).

I also was pleased to be able to bring my co-director at the Heart Institute, Dr. Fernandez, with me after 10 years of working together at Saint Francis Hospital. I am not sure I would have come if I had not been able to encourage him to join me.

"I'd like to advance the use of robotic cardiac surgery … We're honing our techniques for
robotic mitral valve repair, and will be using this innovative technique regularly."

Q: What is the most rewarding aspect of your job?

A: There are two. As a cardiac surgeon, I am with patients and families during pivotal moments in their lives. I learn from them every day about the strength of the human spirit and how much families really rely on each other when faced with these sort of life-altering challenges. I've been doing this for over two decades, and it's always rewarding to hear from patients about how they are enjoying life again.

It's also rewarding to be educating the next generation of surgeons who are so hungry to learn and experience, and have the same drive and passion that I have for our profession.

Q: What breakthrough would you most like to make?

A: I'd like to advance the use of robotic cardiac surgery. Its advantages for patients are that you don't have to open the sternum so there is much less discomfort in the early postoperative period. And the visualization offered by robotic surgery is exceptional. For example, with robotic mitral valve surgery, we can look at the mitral valve without having to distort or retract it as we would if going in through the sternum. Seeing it in situ helps us evaluate the valve better. We're honing our techniques for robotic mitral valve repair, and will be using this innovative technique regularly within a few months.

Q: What might your field look like in the year 2020?

A: If you look at what's been happening in the last five years, it's clear more people will be able to benefit from cardiac interventions done percutaneously, that is, through tiny punctures in the skin. We will be able to do the majority of procedures through small ports, either through the apex of the heart or through the aorta or its branches, using high-tech operating rooms combined with radiology suites. We'll be looking at the heart, great vessels, and valves in real time with both x-ray and echocardiography, while accessing the arteries and veins using guide wires and other techniques to deliver a valve or implant a stent. We're doing these things now, but in a small subset of the population. By 2020, it is expected that this will be the norm.

Q: If you could send one message to the community about your field, what would it be?

A: I'd like people to know that cardiac surgery is well tolerated, life changing, beneficial, and should not be feared. Even though it's serious surgery, it's very low risk for most people, and the outcomes are excellent. I'd also like people to know that postoperative pain is not the issue it used to be. The techniques we are using now make recovery much easier and faster.

Our Cardiothoracic Surgeons
Dr. Taylor leads our Cardiothoracic Surgery Division and its faculty, all board-certified surgeons, each of whom contributes to the excellence and innovation of the Heart Institute: (left to right) Drs. Sandeep Gupta, Frank S. Seifert, James R. Taylor Jr., Harold A. Fernandez, Thomas V. Bilfinger, and Allison J. McLarty.

Together, they perform over 600 adult cardiac procedures and 200 adult thoracic procedures annually.

For consultations/appointments with our cardiothoracic surgeons (links to profiles), please call 631-444-1820. Learn more about the Stony Brook University Heart Institute.

Posted by Stony Brook Surgery on November 12, 2014

Measuring Up to the Professional Standards of the American College of Surgeons

Three members of our faculty — plastic surgeon Tara L. Huston, MD, vascular surgeon Shang A. Loh, MD, and general surgeon Dana A. Telem, MD, all assistant professors of surgery — were inducted into the fellowship of the American College of Surgeons at the annual ACS congress held last month in San Francisco. Now, the credentials of Drs. Huston, Loh, and Telem include FACS, and this says a lot about them as surgeons. It means they measure up to the high standards of excellence maintained by the ACS.

Tara L. Huston MD | Stony Brook Plastic Surgeon
Tara L. Huston, MD, FACS
Plastic Surgeon
       
Shang A. Loh, MD | Stony Brook Vascular Surgeon
Shang A. Loh, MD, FACS
Vascular Surgeon
       
Dr. Dana A. Telem | Stony Brook General Surgeon
Dana A. Telem, MD, FACS
General Surgeon

FACS means a surgeon's education and training, professional qualifications, surgical competence,
and ethical conduct measure up to the high standards of the American College of Surgeons.

The ACS is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.

Members of the ACS are referred to as fellows. The letters FACS (Fellow, American College of Surgeons) after a surgeon's name mean that the surgeon's education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the college.

The ACS currently has about 79,000 fellows, including more than 4,000 fellows in other countries, making it the largest organization of surgeons in the world.

Click here to learn more about what FACS means and the qualifications required to achieve it. Watch this ACS video (4:21 min) celebrating the college's centennial last year and its commitment to quality:

Posted by Stony Brook Surgery on November 5, 2014

Dr. Purvi Y. Parikh | Stony Brook Hepatobiliary Surgeon
Dr. Purvi Y. Parikh

We are very pleased to introduce Purvi Y. Parikh, MD, who has joined our General Surgery Division as assistant professor of surgery.

Dr. Parikh comes to Stony Brook from the Albany Medical Center, where since 2010 she was an attending surgeon and full-time member of the surgical faculty of SUNY's University at Albany.

Board certified in surgery, Dr. Parikh specializes in hepatobiliary and complex foregut general surgery. She performs a wide range of procedures. She has advanced training in hepatobiliary surgery, having completed a two-year fellowship at Indiana University.

Dr. Parikh's clinical interests include pancreatic cancer, liver cancer, and other complex biliary procedures with a specific interest in necrotizing pancreatitis and other benign pancreatic conditions. Additionally, she has an interest in complex gastrointestinal cancers.

Given the range of her surgical expertise, Dr. Parikh will contribute to our general surgery service, as well as to our upper gastrointestinal and general oncologic surgery service.

In addition, Dr. Parikh will contribute to our new exigent general surgery service that streamlines the care of patients presenting in the ER with acute abdominal conditions. Providing minimally invasive treatment in most cases, this new service decreases both the time to surgery and the length of stay in the hospital.

Dr. Parikh's research interests include clinical research that focuses on pancreatic disorders, as well as other gastrointestinal and hepatobiliary diseases. By concentrating on clinical treatment regimens and outcomes research, her research examines quality, delivery, and financing of care in order to have an immediate impact on patient care and systems improvements.

Dr. Parikh received her MD from Drexel University in 2001. She completed her residency training in general surgery at the University of Nebraska Omaha, followed by her fellowship in hepatobiliary surgery at Indiana University.

"I pursued surgery and hepato-pancreato-biliary surgery because of the intellectual stimulation that comes from treating complex diseases and the ability to combine advanced technical skills, pioneering research, and innovative treatment modalities," says Dr. Parikh. "I find it very rewarding to work with patients."

See Dr. Parikh's profile page for more information. For consultations/appointments with her, please call 631-444-4545 for general surgery and 631-638-1000 for cancer care.

Posted by Stony Brook Surgery on October 29, 2014

Study Finds Increase in Patients, Once Deemed High Risk, Who May Be Eligible for Immediate Reconstruction

By Tara L. Huston, MD, of the Stony Brook Plastic and Reconstructive Surgery Division

Dr. Tara L. Huston | Stony Brook Plastic Surgeon
Dr. Tara L. Huston

Breast reconstruction can be performed at many different time points following care for breast cancer. Immediate breast reconstruction means surgery is done at the same time, while delayed reconstruction is carried out months or years later, once all oncologic care is complete. National rates of breast reconstruction following mastectomy have risen over the past decade.

Here at Stony Brook Medicine, we reconstruct approximately 90% of our patients who have mastectomy. However, surprisingly, this rate is still below 40% across the country.

Both methods of breast reconstruction — implant-based and autologous (using a patient's own tissues) — have seen a significant increase.

This observed increase is due to many factors, including the passage of the Women's Health and Cancer Rights Act; more prophylactic mastectomies; a greater acceptance of breast implants following the FDA's lifting of the silicone implant ban; and state laws that mandate that breast surgeons inform their patients about reconstructive options.

An important study, titled "Diminishing Relative Contraindications for Immediate Breast Reconstruction," was published this month in the Journal of the American College of Surgeons by the team at Memorial Sloan Kettering Cancer Center. It is an exciting multi-center study that supports and underscores what we do here in Stony Brook's state-of-the-art breast reconstruction program.

This well-executed retrospective study, encompassing data from 1,040,088 patients over a 14-year period, verified that more women are having reconstruction surgery at the time of surgical treatment for their breast cancer. Even more remarkably, there is a rise in patients who were once considered too high risk for the reconstruction.

Patients, their breast surgeons, and their plastic surgeons are, as a team,
more willing to push the envelope in order to improve care.

Features considered high risk are: age over 60; stage III or IV breast cancer; and history of, or present need for, radiation therapy to the chest wall.

As little as ten years ago, the need for postoperative radiation was considered by many to be an absolute contraindication to immediate reconstruction. Fortunately, this is no longer the case.

The authors of the study concluded that a leading force behind the change is plastic surgeons' willingness to perform reconstruction in these high-risk patients. The authors believe that increased experience with high-risk patients has given plastic surgeons the knowledge to push the boundaries of what can be achieved.

This forward thinking is important because nearly half of all newly diagnosed patients fall into one of the high-risk categories. The good news is that the overall reconstructive success rate in this population was found to be greater than 88%. Adverse events the authors discussed were tissue expander loss, permanent implant removal, and complications with the autologous flaps.

Not only do the study authors believe that the increased rate is due to plastic surgeons who are willing to attempt breast reconstruction following mastectomy, but even more importantly, they believe that there is an increased acceptance on the part of patients. The risks of failure of immediate reconstruction are often outweighed by the tremendous benefits including an improved body image and higher quality of life.

There are data demonstrating a greater satisfaction with quality of life in the first two years following mastectomy if reconstruction was performed.

What does all this mean for our patients at Stony Brook Medicine? It means progress. Rates of breast reconstruction have gone up in high-risk patients. Reasons that patients should not have immediate reconstruction are shrinking. This is because of patients, their breast surgeons, and their plastic surgeons, who, as a team, are willing to push the envelope in order to improve care.

At Stony Brook Medicine, we strongly believe that all women have the right to learn about and potentially proceed with reconstruction which may improve self-image, self-esteem, and quality of life.

October is National Breast Cancer Awareness Month and a special time for us to promote breast cancer awareness and provide information on the disease. Established in 1985, this awareness month, now an international health observance, has from the start aimed to promote mammography as the most effective weapon in the fight against breast cancer. Since then, breast cancer research has also become an important weapon in this fight. Early diagnosis is the best chance for a cure. Learn more about our team and our services at the Carol M. Baldwin Breast Care Center.

Read the abstract of the MSKCC study provided by the National Library of Medicine. Please call 631-444-4666 for an appointment to discuss reconstruction options with Dr. Huston and our other breast reconstruction specialists.

Posted by Stony Brook Surgery on October 22, 2014

Odds Were against Officer Surviving Traumatic Head Injury from Hit-Run Driver

Dr. James Vosswinkel shakes hands with Officer Nicholas Guerrero
Dr. James Vosswinkel shakes hands with Officer Nicholas Guerrero as he enters ambulance taking him to a local rehabilitation facility.
______________________________________

The Suffolk police officer who was critically injured by a hit-run driver in Huntington on September 22nd was discharged last Friday, three and a half weeks later, from Stony Brook University Hospital.

Officer Nicholas Guerrero, 36, was escorted out of the hospital front lobby with applause from more than 100 fellow officers along with physicians, nurses, and other medical staff as he made his way into an ambulance that would transport him to a local rehabilitation facility.

"Statistically, he had only a one-in-three chance of surviving," said James A. Vosswinkel, MD, chief of our Trauma, Emergency Surgery, and Surgical Critical Care Division and medical director of the Stony Brook Trauma Center.

"We are all ecstatic today at his great recovery. However, throughout this process, if it were not for Nick's character, his strength, and his will, as well as the overwhelming support of his immediate family and his extended family of the police department, I truly don't believe any of this could have happened."

Police line up to applaud and cheer Officer Guerrero as he leaves University Hospital
Fellow police officers line up to applaud and cheer Officer
Guerrero as he leaves University Hospital.

Officer Guerrero, a four-year veteran of the Suffolk County Police, spent weeks in a medically-induced coma after suffering a serious head injury.

"One of our Heroes, Police Officer Nick Guerrero, who suffered life-threatening injuries from attempting to stop some of the bad guys out there doing harm in our community, will leave Stony Brook University Hospital today on the road to recovery," said Suffolk County Executive Steve Bellone.

"Officer Guerrero's injuries could have been much worse and fatal if it was not for the swift, immediate action from his colleagues, first responders, and the outstanding medical team here at Stony Brook University Hospital."

Stony Brook University Hospital is the only Regional (Level I) Trauma Center for Suffolk County.

Our trauma specialists coordinate the initial evaluation and treatment of all injured patients transported by ambulance or helicopter to the ER. Stony Brook Medicine's trauma program has been recognized as being in the top 4% nationally, and is the top-ranked center in the care of pedestrian trauma.

Officer Guerrero is expected to make a full recovery, and there is even hope that he will return to the police force.

Stony Brook University Hospital is Suffolk County's only designated Regional (Level I) Trauma Center — the highest designation possible — which means it has the capabilities to care for the most complex illness and injuries, and takes referrals from the surrounding community hospitals. Stony Brook's Trauma Center is among four of 40 trauma centers in New York State whose survival rates for patients with severe traumatic injury were significantly above the statewide average — and is one of only two centers recognized twice consecutively for this achievement. Learn more about our Trauma Center.

Watch this video clip (0:17 min) of Officer Guerrero leaving University Hospital in the ambulance that would transport him to a local rehabilitation facility:

Posted by Stony Brook Surgery on October 15, 2014

New Study Finds Daytime Better for Minimally Invasive Surgery for Acute Cholecystitis

By Purvi Y. Parikh, MD, of the Stony Brook General Surgery Division


Dr. Purvi Y. Parikh

Laparoscopic gallbladder removal — cholecystectomy — was introduced in the late 1980s, and has largely replaced the open procedure for the majority of the 770,000 cholecystectomies performed annually in the United States. Indeed, laparoscopic cholecystectomy is currently the most commonly performed major abdominal procedure in Western countries.

This procedure generally decreases post-op pain, decreases the need for post-op pain medication, and speeds recovery and the patient's return to full activity, compared with open cholecystectomy. It also provides less scarring, and it is associated with improved patient satisfaction as compared with the open procedure.

However, certain circumstances in the operating room may necessitate converting to an open procedure, thus depriving patients of the benefits of the laparoscopic technique. Last month, the American Journal of Surgery published a news-making study based on a large retrospective analysis comparing daytime versus nighttime laparoscopic cholecystectomy for acute cholecystitis.

Here, Purvi Y. Parikh, MD, assistant professor of surgery, who is a leader on our exigent general surgery service, provides commentary on this study, and explains how the study findings relate to the newly established special protocol and resources for optimum treatment of acute cholecystitis at Stony Brook Medicine.

~~~~~~~~~~

With the current emphasis on outcomes-based surgery, the cholecystectomy study just published in the American Journal of Surgery is important to help establish guidelines for optimal timing for surgery, as the optimal timing of surgery for acute cholecystitis remains controversial.

One area of uncertainty remains whether patients should undergo early (same hospitalization) versus delayed (six or more weeks after discharge) cholecystectomy. Studies have found that delayed cholecystectomy was associated with higher rates of conversion to open surgery and longer hospital stay.

In a systematic review of randomized controlled trials, 18% of patients randomized to delayed cholecystectomy experienced recurrent symptoms necessitating emergent cholecystectomy, and that subset of patients experienced a 45% conversion rate to open surgery.

A large review of laparoscopic cholecystectomy for acute cholecystitis found incrementally worse outcomes for each day surgery is delayed during the hospitalization. Patients that undergo cholecystectomy within 48-72 hours of admission for acute cholecystitis were associated with reduced conversion rate, operative time, length of stay, and hospital costs.

The so-called Tokyo guidelines, a consensus statement developed by hepato-biliary-pancreatic specialists, recommend early cholecystectomy for acute cholecystitis, and only delayed cholecystectomy in select high-risk patients. Considering these findings, some institutions perform cholecystectomy at night to avoid an excessive delay in time to operation.

At Stony Brook we believe the best treatment for acute cholecystitis is early
laparoscopic cholecystectomy performed in the daytime by a dedicated surgical team.

In this present study, nighttime (7 pm to 7 am) cholecystectomy was associated with an increased conversion rate to open surgery but had a similar length of stay and complication rate as daytime (7 am to 7 pm) cholecystectomy.

The observed increase in conversion rate during nighttime cholecystectomy was not associated with worse severity of disease or patient condition.

The study presumed that the increased conversion rate was attributable to system-based factors, such as limited operating room availability during daytime hours, limited nighttime resources and personnel, and anticipation of trauma cases at trauma centers that may influence provider decision-making at night that would increase conversion rate to open surgery.

The authors of the study concluded that because of the elevated conversion rate, laparoscopic cholecystectomy for acute cholecystitis should be delayed until regular daytime hours.

We believe that early cholecystectomy for acute cholecystitis is the best treatment for the patient.

With the establishment of the Department of Surgery's new exigent general surgery service, we have developed a protocol for patients with acute cholecystitis.

Patients with acute cholecystitis are streamlined from initial presentation in the emergency room, to exigent general surgery service evaluation, to a dedicated exigent general surgery service operating room during daytime hours, then to the post-anesthesia care unit and discharge home within 24 hours.

For more complicated patients, the exigent general surgery service is able to direct preoperative optimization so that the time-interval to surgery may be decreased. Our goal is to overall decrease patient duration until surgery, length of stay, and hospital costs, while providing the best care for the patient.

Signs and symptoms of cholecystitis may include: intense and sudden pain in the upper right part of the abdomen; recurrent painful attacks for several hours after meals, particularly a large or fatty meal; pain that radiates from to the right shoulder or back, often worse with deep breaths; tenderness over the abdomen when it's touched; nausea; vomiting; fever; chills; and abdominal bloating.

Seek medical attention when worrisome signs and symptoms occur. For intense abdominal pain so severe it isn't possible to sit or get comfortable, be driven to the emergency room.

See abstract of the article, "Can It Wait until Morning? A Comparison of Nighttime versus Daytime Cholecystectomy." For consultations/appointments with Dr. Parikh concerning general surgery, please call 631-444-4545.

Posted by Stony Brook Surgery on October 8, 2014

Dr. Brian J. O'Hea Reading a Mammogram
Dr. Brian J. O'Hea reading a mammogram.

October is National Breast Cancer Awareness Month and a special time for us to promote breast cancer awareness and provide information on the disease.

Established in 1985, this awareness month, now an international health observance, has from the start aimed to promote mammography as the most effective weapon in the fight against breast cancer. Since then, breast cancer research has also become an important weapon in this fight.

At Stony Brook Medicine, breast cancer is the focus of a comprehensive, academic program — the only one of its kind on Long Island. At its core is our multidisciplinary breast cancer team.

Here, Brian J. O'Hea, MD, chief of breast surgery and director of Stony Brook's Carol M. Baldwin Breast Care Center, answers some of the frequently asked questions women raise after they have been diagnosed with breast cancer. The bottom line is that every woman's situation is different, and treatment needs to be tailored to the type of cancer, personal and family history, tolerance levels for treatment, and personal preferences.

Dr. O'Hea's perspective, as one of the area's premier breast cancer surgeons, gives women information to serve as discussion points with their doctors.

Breast cancer is the most common cancer among American women, other than skin cancer.

Q: What is a lumpectomy and is it safe?

A: A lumpectomy is the removal of a tumor from the breast along with some of the surrounding normal tissue.

When a lumpectomy is recommended, many women consider whether a mastectomy might be a safer choice in terms of recurrence and survival. Long-term studies have demonstrated that a lumpectomy provides survival rates equivalent to a mastectomy while preserving the breast.

A lumpectomy is often recommended to treat a single tumor that is small to medium in size. Patients with a large tumor or multiple tumors are often treated with a mastectomy. Also, the location, type of tumor, and other factors all must be considered with your doctor when making this important treatment decision.

Q: Why do lumpectomies require follow-up radiation?

A: Even when lumpectomies show totally “clean" (cancer-free) margins after surgery, radiation is required because of the natural distribution pattern that breast cancer takes. Not all the cancer stays together.

Some tiny, isolated cells may migrate to other parts of the breast beyond the scope of the surgery. This has nothing to do with the skill of your surgeon, but everything to do with the nature of breast cancer and how it manifests.

Q: If lymph nodes are “clean" (cancer-free) following surgery, why is chemotherapy needed?

A: Think of chemotherapy as an insurance policy against future cancer. This form of treatment circulates a powerful drug or a combination of drugs through all parts of the body to kill any cells that may have floated away from the cancer site and lodged in other areas.

Whether this actually happens depends on the characteristics of the tumor; some tumors can put women at a higher risk for scattered cells. This is why chemotherapy is the recommended precautionary measure.

Are you worried about the cost of mammography? CDC offers free or low-cost mammograms.

Q: If a doctor recommends a mastectomy on just one breast, wouldn't it be safer to have a bilateral mastectomy (removal of both breasts)?

A: Long-term studies show that there is a 15% risk of a woman developing cancer in the opposite breast. However, women at higher risk may need to consider the bilateral mastectomy because their odds of developing cancer in the healthy breast are much higher.

These risk factors include a strong family history of breast cancer and the presence of the BRCA gene, which indicates a genetic disposition to breast cancer.

Q: Are there any new options when it comes to reconstruction?

A: Fortunately, because of dramatic improvements in imaging and screening technology, we are more able to find cancer in its earliest stages, which offers some women an opportunity for breast conservation instead of mastectomy.

At Stony Brook, 65% of the women treated for breast cancer have breast preservation surgery. Our surgeons work closely with plastic and reconstructive surgeons to maximize cosmetic outcomes.

Techniques include inserting AlloDerm®, a type of collagen, along with the tissue expander to give a more natural shape to the breast; smaller and more limited incisions that preserve as much of the natural breast skin as possible to facilitate a more natural reconstruction; and a new total skin- and nipple-sparing technique that leaves all of the breast skin in place, which also helps achieve the most natural result available.

However, the nipple-sparing technique is possible in only a small group of highly selected patients requiring a mastectomy [see our FAQs about nipple-sparing mastectomy].

As an academic medical center and accredited breast care center, Stony Brook works to continually refine techniques to make them more widely available for more patients.

Four important things every woman can do about breast cancer:

1. Be scrupulous about scheduling annual screening mammograms and clinical exams after the age of 40.
2. Perform monthly breast self-examinations.
3. If you have a strong family history of breast or ovarian cancer, seek BRCA genetic testing. Once you know your risk, you can take preventive measures and risk-reduction steps that may prevent cancer from occurring.
4. If you are scheduled to have a surgical biopsy, inquire about having a needle biopsy instead. Core needle biopsy is the preferred initial breast biopsy method.

Community Update: "Latest Treatment Options for Patients with Breast Cancer"

Hear Stony Brook physicians discuss the latest advances in breast cancer treatment. Hosted by Dr. Brian J. O'Hea, director of the Carol M. Baldwin Breast Care Center. A question-and-answer session will follow the presentation. Participants can view educational exhibits that promote breast health awareness. Community members, patients, family members, caregivers, and healthcare professionals are welcome. Enjoy a buffet supper before the presentation. Tuesday, Oct. 28, 6 to 9 pm, at the Charles B. Wang Center Lobby, Stony Brook University, 100 Nicolls Road, Stony Brook. Free. RSVP to 631-444-4000.

Special events for Breast Cancer Awareness Month: Stony Brook University Cancer Center and the Town of Brookhaven are partnering to "Turn the Town Pink." CDC fact sheet, "Breast Cancer: What You Need to Know."

Posted by Stony Brook Surgery on October 1, 2014

Providing Special Guidance and Support to Female Medical Students


Our 2014-15 matched mentors (left to right): Drs. Paula Denoya, Angela Kokkosis, Melissa Mortensen, Aurora Pryor, and Laurie Shroyer.

The Stony Brook Medicine Student Branch of the American Medical Women's Association (AMWA) sponsors a mentoring program for medical students to provide them with special guidance and support. Faculty in the Department of Surgery are active in the program, and of the 28 school-wide faculty matched this year to provide mentor oversight, five (18%) are from our department.

At the start of each academic year, the AMWA mentoring program pairs female faculty members with female students in Stony Brook's School of Medicine, providing them with opportunities to gain insight into their fields of interest from the perspectives of professional women who have gone through the process.

A common focus is placed on work/life balance, as well as long-term professional career development, scholarly endeavors, and life-long learning skills.

AMWA focuses on effective mentor-mentee interactions balancing three key elements:
support, challenge, and a vision of the mentee's future career.

The Department of Surgery's faculty that matched as mentors this year are: Paula I. Denoya, MD, assistant professor of surgery; Angela A. Kokkosis, MD, assistant professor of surgery; Melissa M. Mortensen, MD, assistant professor of surgery; Aurora D. Pryor, MD, professor of surgery and chief of general surgery; and A. Laurie W. Shroyer, PhD, MSHA, professor of surgery and vice chair for research.

Dr. Shroyer says, "I strongly support this program, and I am very excited to see the very high participation rate of our Department of Surgery's female faculty members."

Eight students have been assigned to these mentors for the current academic year. Four are first-year students — Chelsea Dahl, Danielle Fassler, Malack Hamade, and Kelli Summers — and the others are second-year students — Sydney Beck, Nicole Golbari, Jessica Johl, and Lydia Liu.

Ms. Brianne Sullivan | Stony Brook Medical Student
Brianne Sullivan

One of Dr. Shroyer's several long-time mentees is Brianne Sullivan, a fourth-year student, who is applying to surgical residency programs this year. She is a former co-president of Stony Brook's AMWA Student Branch.

About her experience in the mentoring program, Ms. Sullivan says: "This program is wonderful, and I think it is very important for those seeking guidance and mentorship, especially when relating to some of the unique challenges faced by females in medicine. The program gave me a glimpse at my potential future, and made me realize that to a degree I needed to be considering future goals and plans. It gave me a rough idea of what to expect in the years to come.

"We have a potluck dinner where the faculty mentors come to meet the students, and they discuss a little bit about their personal and professional life and how they got to where they are today.

Mentees are encouraged to look for opportunities to expand their network of colleagues
and to acquire a multitude of individuals they admire and respect.

"I think this exposure is invaluable. I could look at successful women who at one point were in my shoes, wondering where medicine was going to take them, and hear about their journey. Their stories gave me confidence that I would make it to, and made me excited for the ride.

"Dr. Shroyer lent unconditional support and advice throughout my four years of medical school. Having a person like that to reach out to is very reassuring, and I am very grateful to have been involved in this program and to have met her.

"For me, surgery more fell into place once I did my third-year rotation and realized that I had the same passion for the OR and surgeries as the vascular surgeon I spoke to at the potluck dinner."

Commenting on the importance of the department's contribution to the AMWA mentoring program, Mark A. Talamini, MD, professor and chairman of surgery, says: "The specialty of surgery, unfortunately, is late in its appropriate incorporation of women at all levels into the field. There are reasons for this which are inherent in the specialty itself.

"We have made it difficult for women to both have a successful career in surgery and be effective in their family roles. This has been a deficit and a loss both for our patients and for our profession. We are in the process of correcting this, and the mentorship by our spectacular women surgeons and scientists will go a long way, person to person, to address the profession's shortfall."

About AMWA and Its Presence at Stony Brook

AMWA is a professional organization that functions at the local, national, and international level to advance women in medicine and improve women's health. It fulfills its mission by providing and developing leadership, advocacy, education, expertise, strategic alliances, and mentoring.

Founded in 1915, AMWA began when women physicians were an under-represented minority. As women in medicine increase in numbers, new issues arise that were not anticipated. AMWA has been addressing these issues for nearly a century. Its membership comprises women physicians, medical students, and others dedicated to the advancement of women in medicine.

AMWA's Student Branches provide support and resources for their members, plus valuable leadership and mentoring opportunities. Branches organize local events and facilitate interactions and connection with national AMWA initiatives and leadership. Branch leaders also act as the face of AMWA on their medical school campuses.

At Stony Brook, women physicians on the faculty established AMWA's presence here soon after the School of Medicine was established. Last year, the Student Branch renewed its official affiliation with the national organization. It is run by medical students themselves, with a faculty advisor.

"We will continue to seek venues and ways to attract women to our field, and to our department
here at Stony Brook," says Dr. Mark Talamini, professor and chairman of surgery.

The mentoring program sponsored by our Student Branch was started in the 1990s.

Jadry Gruen, one of the branch's current co-presidents, says, "In addition to matching interested students with female physicians at Stony Brook through our mentoring program, we also host events like an annual student-faculty potluck, lectures on women in medicine/the workforce, preview documentaries, and host panel discussions and any number of events that promote insightful conversation about the role of women in leadership and in medicine."

"Several of our members are helping to organize an upcoming regional AMWA event held in New York," adds Ms. Gruen. "AMWA members from Stony Brook have participated in this regional conference in the past, and we have even hosted the event at the SBU campus."

Most of the current female faculty in the Department of Surgery have participated in the Stony Brook AMWA mentoring program. Some not matched in the current academic year continue to mentor students from previous years. New faculty intend to join.

All told, the department is doing its part to provide special guidance and support to female medical students here through AMWA, and to encourage them to pursue careers in surgery.

While the gender gap remained particularly large among surgeons throughout the 20th century, the new century has seen the number of women attending US medical schools reach that of men, and the gap is apparently closing among graduates entering general surgery training programs, according to a recent study published in the Journal of the American College of Surgeons.

"We will continue to seek venues and ways to attract women to our field, and to our department here at Stony Brook," says Dr. Talamini. "Fortunately, we have a nucleus of absolutely outstanding women surgeons and scientists on our faculty who are naturally attractive as role models to our learners here at Stony Brook."

"The idea of winning a doctor's degree gradually assumed the aspect of a great moral struggle, and the moral fight possessed immense attraction for me."

"A blank wall of social and professional antagonism faces the woman physician that forms a situation of singular and painful loneliness, leaving her without support, respect, or professional counsel."

"It is not easy to be a pioneer — but oh, it is fascinating! I would not trade one moment, even the worst moment, for all the riches in the world."

— Elizabeth Blackwell, MD, the first woman to receive a medical degree in the United States (1849)

Visit the American Medical Women's Association to learn more about its mission, history, and resources. Download the student membership brochure.

Posted by Stony Brook Surgery on September 24, 2014

Angela A. Kokkosis, MD | Stony Brook Vascular Surgeon
Dr. Angela A. Kokkosis

Varicose veins affect approximately 40% of the adult population. They are superficial vessels that are abnormally lengthened, twisted, or dilated, and are seen most often on the legs and thighs.

Varicose veins bulge and rise above the skin's surface. They may be uncomfortable and result in swelling of the legs. If left untreated, varicose veins may lead to more serious medical problems, such as phlebitis (swelling and inflammation of a vein) or leg ulcers.

Here, Angela A Kokkosis, MD, assistant professor of surgery (Vascular Surgery Division) who practices at the Stony Brook Vein Center, answers questions about endovenous laser treatment for varicose veins. Dr. Kokkosis and her vascular colleagues also offer free screenings at the Vein Center to discuss these and other related questions; see contact info below.

Q: What is endovenous ablation?

A: Endovenous ablation is a treatment for closing the saphenous vein in the leg, which is typically the main superficial vein associated with varicose veins. This treatment can be performed with either laser or radiofrequency (RF) technology.

Q: How does endovenous ablation work? What does it do to a varicose vein?

A: A thin catheter (flexible tube) is inserted into the vein through a tiny skin puncture, and the entire length of the vein is treated with laser or radiofrequency through the catheter, thus "injuring" the vein's wall.

This causes the veins to close and eventually turn into scar tissue.

By treating the saphenous vein, it also helps the visible varicose veins regress. For the varicosities that do not completely regress, adjunctive procedures of sclerotherapy injections and/or microphlebectomies are recommended.

At the Stony Brook Vein Center, we use the latest technology to treat varicose veins with
endovenous ablation, and we also are leaders in using minimally invasive treatments.

Sclerotherapy involves the injection of a specially-developed solution (Sotradecol) into the varicose vein. The solution then hardens, causing the vein to close up or collapse.

Microphlebectomies involve the removal of the vein by tiny punctures or incisions along the path of the enlarged vein. Through these tiny holes, we use a surgical hook to remove the varicose vein, which results in minimal scarring.

Q: Does loss of a laser-treated vein create a health problem in any way?

A: The leg has two systems of veins, the deep and the superficial. Between these two systems there are many collateral pathways to enable normal venous blood flow. When the diseased superficial system is treated, the blood gets redirected into the deep system without affecting blood flow in the leg.

Q: What is the recovery time after endovenous laser treatment?

A: Patients are encouraged to start walking immediately after the procedure, but they should avoid any strenuous exercises involving the legs (such as weight training) for two to three weeks, to enable adequate time for healing and for the treated veins to remain closed. There is bruising and mild discomfort in the treated leg for two to four weeks.

Q: How much time does it take to see the results after the laser procedure?

Varicose veins before (left) and after treatment at the Stony Brook Vein Center.
Varicose veins before (left) and after ablation
treatment at the Stony Brook Vein Center.

A: Within one week patients may start to notice a difference in the prominence of their varicose veins, but complete results may take weeks to months. Additionally, some patients may require adjunctive procedures depending on the severity of their varicose veins, as mentioned above.

Q: What is the risk of recurrence of varicose veins after endovenous ablation treatment?

A: Varicose veins are the result of a progressive disease, and while we can treat the problematic veins now, it is up to the individual patient, their genetics, and their lifestyle which dictate whether other varicosities will develop over time.

Q: What are the risks and potential complications of the laser/RF procedure?

A: The goal of the endovenous procedure is to thrombose, or clot, the saphenous vein (a superficial vein). Rarely, there are situations where the clot can extend into the deep vein system and cause a DVT (deep venous thrombosis).

Should this happen, a short course of blood thinners is warranted to treat and prevent further clot extension. Other infrequent complications are skin infection (which is prevented by performing the procedure under sterile conditions) and bleeding.

Q: How does laser/RF treatment compare with other treatment options, including surgery?

A: Previous generations performed the tradition “vein stripping" in which the entire saphenous vein would be removed through large skin incisions, with less than cosmetic results. With the current endovenous ablation, there is no need for skin incisions to obtain excellent results of varicose vein resolution.

Q: Will insurance cover the laser procedure?

A: Many insurance companies cover the endovenous ablation procedure with or without the adjunctive sclerotherapy or microphlebectomy procedures based on various criteria. In our practice at Stony Brook, an individualized discussion takes place with the patient regarding this process.

Q: Why is the Stony Brook Vein Center the place to go for endovenous ablation treatment? What makes it special there?

A: Our staff and vascular surgeons manage a large population of patients with venous disease, and we manage a variety of both common and complex cases. The unique needs of patients with varicose veins are recognized by everyone at our practice, and we strive for exceeding the expectations of our patients.

We use the latest technology to treat varicose veins with endovenous ablation, and we also are leaders in using minimally invasive treatments, such as the new drug therapy called Varithena, which we are the first on Long Island to offer.

Click here for more information about varicose veins and their treatment. For consultations/appointments with Dr. Kokkosis and our other vein specialists, please call 631-444-VEIN (8346).

Posted by Stony Brook Surgery on September 17, 2014

Boxer Travels from Greece to Be Treated by Our Doctors to Get Back in the Ring

Boxer Nikoleta Pita with her parents post-op
Nikoleta Pita (center) with her parents, post-op.
(Click on photo to enlarge.)

For the past five years, 17-year-old Nikoleta Pita of Piraeus, Greece, has dreamed of making her country's Olympic boxing team. As a two-year national team member with a strong won-lost record, her dream was getting close to becoming a reality.

But almost a year ago, after a period of intense weight training, her right arm and shoulder suddenly swelled up and became very painful. And she developed numbness in her fingers.

Doctors in Greece told her she had clotted her right subclavian and axillary veins, the main veins draining the arm, and to stop everything — making her dream to become an Olympian come to a sudden halt.

Ms. Pita was diagnosed with thoracic outlet syndrome (TOS), a disorder that occurs when the blood vessels or nerves of the arm become compressed in the space between the collarbone and the first rib (thoracic outlet).

She was offered only conservative treatment with blood thinners by her doctors in Greece, who strongly suggested that she should completely abandon boxing or any other sport that involves intense weight training of the arms.

The boxer in Ms. Pita was hit hard by all this, but she wasn't going to give up.

With the support of her family she found out that a surgical treatment could help her keep her boxing career alive, but she would have to travel abroad to get the treatment she needed.

Through a family friend who had visited Stony Brook Medicine as an observing physician, Ms. Pita and her parents — Archilleas and Agapi Pita — learned of a doctor that could take care of her problem in the United States.

Apostolos K. Tassiopoulos, MD, professor of surgery and chief of vascular and endovascular surgery, who was in Athens for a scientific meeting, met with Ms. Pita and her family, and he discussed the surgical treatment that could get their daughter back in the ring.

Drs. Thomas Bilfinger (left) and Apostolos Tassiopoulos
Drs. Thomas Bilfinger (left) and Apostolos
Tassiopoulos, who operated on Ms. Pita.

Ms. Pita arrived in New York on August 31. The next day, Dr. Tassiopoulos and his colleague Thomas V. Bilfinger, MD, ScD, professor of surgery and director of thoracic surgery, performed the surgery together to remove the first rib and free the attached muscles in order to free the compressed vein.

The surgeons made an incision in the armpit, and then removed the rib and the muscle attached to it, which allowed for more space around the vein. Patients usually need physical therapy after surgery to get their strength back.

One day after surgery, Ms. Pita felt great and ready to get back to her dream. "I'm feeling really strong, physically and mentally," she said. "This has definitely changed my life — Stony Brook saved my career, saved my dream."

Just after one week in the United States, Ms. Pita and her parents flew back to Greece.

About Thoracic Outlet Syndrome

Common causes of TOS can include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (such as having an extra rib), and pregnancy. However, often doctors cannot determine the exact cause of this syndrome.

TOS symptoms can vary, depending on which structures are compressed.

When nerves are compressed, signs and symptoms of TOS include wasting in the fleshy base of the thumb (Gilliatt-Sumner hand); numbness or tingling in the arm or fingers; pain or aches in the neck, shoulder, or hand; and weakening grip.

The hallmark of venous compression is painful swelling of the forearm and back of the hand particularly, often accompanied by a bluish discoloration of the skin. Symptoms may include numbness, tingling, aching, swelling of the extremity and fingers, and weakness of the neck or arm.

The purpose of thoracic outlet surgery is to release or remove
the structures causing compression of the nerve or blood vessels.

When arteries are compressed, the most prominent features are change in color and cold sensitivity in the hands and fingers, swelling, heaviness, paresthesias (tingling, tickling, or burning sensation of the skin), and poor blood circulation in the arms, hands, and fingers.

TOS is more common in women. The onset of symptoms usually occurs between the ages of 20 and 50. Doctors usually recommend nerve conduction studies, electromyography, or imaging studies to confirm or rule out a diagnosis of TOS.

Common treatment for TOS usually involves physical therapy and pain relief measures. Often, when only nerves are compressed but blood vessels are intact, patients will improve with these approaches.

However, when clots develop in the blood vessels or when pain from nerve compression is not improved with conservative measures, doctors usually recommend surgery.

The purpose of thoracic outlet surgery is to release or remove the structures causing compression of the nerve or blood vessels. TOS is known to affect athletes, particularly overhead athletes such as swimmers and baseball players. With appropriate care, these athletes can return to full activity within three to four months from surgery.

Click here for more information about thoracic outlet syndrome. For consultations/appointments with our surgical specialists, please call 631-444-4545.

Posted by Stony Brook Surgery on September 15, 2014

Our Chairman Talks about the Power of Innovation and Excellence at Stony Brook

Dr. Mark A. Talamini
Dr. Mark A. Talamini

Mark A. Talamini, MD, professor and chairman of surgery, just appeared as the featured guest on BlogTalkRadio's "Strategies of Success." Host Brian A. Cohen interviews him, focusing on how Dr. Talamini identified his career goals, and how he has pursued them to the max.

Dr. Talamini explains that Stony Brook Medicine and Stony Brook University attracted him as an opportunity to further his career goals by joining a dynamic multidisciplinary team committed to advancing healthcare through technological innovation.

Dr. Talamini also discusses his role in the advances in surgical care that have been made through the development of minimally invasive endoscopic surgery, as well as advances in treating inflammatory bowel disease, specifically, Crohn's and colitis, where he is a specialist.

Mr. Cohen's program, "Strategies of Success," explores actionable ideas leading to success. His guests come from different places, he says, but they all share the goal of developing the right strategies of success for them.

BlogTalkRadio produces audio podcasts as a social radio network with independent experts hosting shows on every kind of topic — from politics and current affairs, entertainment and sports to health and finance.

Click here to listen to the entire interview (31:04 min).

Posted by Stony Brook Surgery on September 10, 2014

What Can Actress Farrah Fawcett Teach Us about Anal Cancer?

Paula I. Denoya, MD, a Stony Brook colorectal surgeon
Dr. Paula I. Denoya

One of the cancers that receives less attention than others but is just as important to be aware of is anal cancer, which occurs in 1 in 600 adults nationwide.

According to the American Society of Colon and Rectal Surgeons, the number of patients that develop anal cancer each year is slowly increasing, especially in some higher risk groups.

Survival rates are greatly affected by how early this cancer is detected. Awareness is thus important.

Here, Paula I. Denoya, MD, assistant professor of surgery and a member of our Colon and Rectal Surgery Division, answers a few of the frequently asked questions about anal cancer and what people can do about it.

Q: What are the signs and symptoms of anal cancer?

A: The symptoms of the most common type of anal cancer, squamous cell carcinoma, tend to be similar to those of hemorrhoids. Because of this — and its relative low rate of occurrence in relation to other cancers — it tends to be misdiagnosed or overlooked. See your doctor if you experience any of the following:

  • Anal bleeding
  • A lump or mass at the anal opening
  • Persistent itching and pain
  • Drainage or discharge
  • Swollen lymph glands in the groin area
  • Changes in bowel habits

Q: People may feel uncomfortable talking about these symptoms: what do you suggest as the best approach?

A: I urge people not to be embarrassed to go to the doctor. We are talking about a body part like any other. Your doctor will be very matter-of-fact with you; remember, he or she has seen it all before. Their major concern will about your health and how to best help you — and to do so in a way that makes you feel comfortable.

Try to be as open as possible and to share all of your concerns because the earlier anal cancer is detected, the better the survival rates. For example, when detected in stage 1, the five-year survival rate is 70%. However, at stage 4, it drops to 20%.

Q: Who is at risk for anal cancer?

A: Anal cancer occurs in both men and women, although is slightly more prevalent in women. Risk factors include:

  • Age — the risk grows as you age
  • Presence of the human papilloma virus (HPV) infection
  • HIV infection
  • Immunosuppressant therapy (for example, in transplant patients)
  • Chronic inflammation of the anus
  • Open wounds
  • Radiation to pelvis
  • Anal sex (men and women)
  • Smoking

Q: Are there any prevention measures I can take?

A: It is important to have regular checkups that include a digital rectal exam. Check your stool for the presence of blood, and see your doctor if you detect any. You can also protect yourself by not smoking, having safe sex and getting the HPV vaccine. People who are at high risk, such as the HIV positive population, can now get anal pap smears to screen for the precancerous cells that can develop before anal cancer.

Q: How is anal cancer diagnosed?

A: If your personal physician suspects a problem, you should get referred to a colorectal surgeon who can run a number of tests. This includes a physical exam, a digital exam, a palpable groin exam, an anoscopy and a full colonoscopy. If we uncover any lesions, we can biopsy them. At Stony Brook University Cancer Center, we also use CT and PET scanning for testing, as well as to evaluate if the cancer has metastasized or invaded any other structures around the anus.

Q: What treatment options are available?

A: Approximately 80% of patients respond to chemotherapy and/or radiation therapy. At Stony Brook, we take a multidisciplinary team approach to cancer treatment. We have a highly specialized team that focuses exclusively on cancers of the colon, rectal, and anus, which includes:

  • Colorectal surgeons
  • Gastroenterologists
  • Oncologists
  • Radiation oncologists
  • Anesthesiologists
  • Pathologists
  • Nurses
  • Enterostomal therapists

Team members have the experience, knowledge, and compassion to deliver expert and highly personalized care coordinated across the full spectrum, from diagnosis through discharge and beyond. Upon completion of the course of treatment, we follow the patient at regular intervals — checking though ultrasound and anoscopy for the presence of additional cancer cells. If cancer remains or recurs, we can perform what is called an abdominal perineal resection (APR) to remove the anus and surrounding tissue.

At Stony Brook, we believe that we can offer patients what they most need: high-level cancer care close to home. Not only do we offer the type of specialized care typically only found in urban areas, but it also is comfortable and convenient for patients. Nearly all services — diagnostics, chemotherapy, radiation therapy, surgery, follow-up appointments, and support groups — are located in the Cancer Center or Stony Brook University Hospital.

For consultations/appointments with our colorectal specialists, please call 631-638-1000. Watch this preview video (1:36 min) of "Farrah's Story" about actress Farrah Fawcett (1947-2009) and her battle with anal cancer:

Posted by Stony Brook Surgery on August 27, 2014

Learn about Our Surgical Advances & Why Patients Come to Us from around the Nation

POST-OP 31 | Spring-Summer 2014 POST-OP, the Department's semi-annual newsletter, offers a range of information about our programs in patient care, education, research, and community service, plus health information of interest to our community and beyond. The new issue features:
  • Performing Robotic Colorectal Surgery to Achieve Superior Results
  • Weight Loss Center Earns Top-Level Accreditation for Bariatric Surgery
  • Introducing New Faculty: General/Bariatric Surgeon + Laryngologist/ENT Surgeon + Vascular Surgeon
  • Open Heart Surgery Saves Pregnant Mother and Her Baby
  • Woman Travels across Country for Leading-Edge Salivary Gland Surgery
  • First Non-Surgical Procedure to Treat Leg Varicose Veins
  • Our Residents Win New York State Surgical Jeopardy Championship
  • Research Day Success, Moving the Science of Surgery Forward
  • Introducing Our New Department Administrator & Business Manager
  • Division Briefs … Residency Update & Alumni News … CME Opportunities … Plus More!
Read POST-OP online now. To receive a complimentary free subscription to POST-OP (printed), please send request with your complete postal mailing address.

Posted by Stony Brook Surgery on August 20, 2014

Daughter to Run 26.2-Mile Marathon to Benefit Haitian Hospital Serving the Underserved


Dr. David J. Kreis Jr. (middle) on rounds with
our residents. (Click on photo to enlarge.)

The founding chief of our trauma service, David J. Kreis Jr., MD, died young (age 38) from cancer a quarter century ago. He was a founding father of our Department of Surgery — and of the life-saving Stony Brook Trauma Center, the only designated Level 1 regional trauma center in Suffolk County.

Dr. Kreis was also the father of two girls, who were little girls when he passed away. Now grown up, one of them, Sandra (Sandy) Kreis, 32, has taken upon herself the challenge of running the Maine Marathon in Portland, ME, this coming October in memory of him.

More than a challenging race, Sandy will run this major marathon to raise funds to benefit a Haitian hospital where her father once volunteered.

Sandy explains it this way: "On October 5, 2014, I will run the Maine Marathon — a distance of 26.2 miles — in memory of my dad.

"Why Maine? Because he liked to camp there. Why that weekend? Because it marks the 25th year of his passing. Why run? Because he was a runner, and one of my only memories of him is of playing with his yellow walkman earbuds. Why a marathon? Because I have found that it forces me to exert myself to my individual limit, both physically and mentally.

Please help me raise $6,000 to build a well that will serve 500 people
with fresh and safe drinking water year-round.

"In the late 1970s, my dad provided volunteer medical services at Hôpital Albert Schweitzer (HAS), the only full-service hospital within a 610-square-mile area in Haiti's Artibonite Valley. Haiti has the highest rates of infant mortality and maternal mortality in the entire Western Hemisphere. It is the poorest country in the Americas, and half the population lives without access to clean water.

"Every dollar I raise in memory of my dad will go to HAS to build a well that will serve 500 people with fresh and safe drinking water year-round."

Dr. Kreis with His Daughter Sandy
Dr. Kreis with his daughter Sandy in late 1980s,
and Sandy now. (Click on photo to enlarge.)

Jane E. McCormack, RN, our trauma nurse manager, worked closely with Dr. Kreis, and she remembers him with great affection and admiration. In her tribute to him at the presentation of our first annual David J. Kreis Jr. Award for Excellence in Trauma Surgery, in 2000, she described him as follows:

"David Kreis was the first chief in the Division of Trauma. He came to Stony Brook in 1986 with a simple mission — to build a world-class trauma center. He was well on his way to that end when his life was cut short by cancer and he passed away in 1989, at age 38.

"Dr. Kreis left behind the foundation upon which the Trauma Center at Stony Brook rests today.

"He was the force behind the Medevac helicopter in the county. He created the trauma research laboratory. He brought the ATLS [Advanced Trauma Life Support] course to the region. He had a hand in many other programs too numerous to mention.

"Even with these many accomplishments, Dave Kreis remained down to earth — a regular guy.

"Dave Kreis was the ultimate team player. He knew each and every member of the trauma team, from the sub-specialty attendings to the housekeepers. He made sure we all did our best. He held us to high standards, provided instruction if we needed it, and set us straight if we needed to be set straight. He led by example and never asked of us what he himself was not willing to do.

"He was an unparalleled leader, and an important figure in trauma surgery both nationally and locally."

Through stories about him over the years since his passing, Sandy's father came to represent for her a "keen sense of right and wrong, of moral rectitude." That, she adds, "is within my fibers."

Summing up the reasons for her marathon run and fundraiser to benefit the Schweitzer Hospital, she says, "I run not just for my dad, but for what he practiced."

Sandy, who grew up in the local Three Village community, graduated from Georgetown University and subsequently from the Fletcher School of Law and Diplomacy. She currently works under Governor Deval Patrick of Massachusetts as the international business advisor with a focus on clean energy and water innovation.

Our annual Kreis Award for residents was established in 2000. This award recognizes the unique characteristics that make a trauma surgeon — the characteristics Dr. Kreis personified: integrity, educational acumen, leadership, and excellence both in clinical practice and medical research. All together, the certain "something" that makes a trauma surgeon.

The first award was given to James A. Vosswinkel, MD, when a resident here. Now, Dr. Vosswinkel, who after his training at Stony Brook went to Yale for his fellowship in trauma and surgical critical care, is a member of our faculty. He is chief of our Division of Trauma, Emergency Surgery, and Surgical Critical Care and a leader of the Stony Brook Trauma Center.

Visit Sandy's website to learn more about her father and benefit, plus how to donate. Learn about HAS in video (4+ min) and about the importance of water to it.

Posted by Stony Brook Surgery on August 13, 2014

New Study Expands Role of Patient-Centered Treatment Option for Women with Breast Cancer

By Tara L. Huston, MD, of the Stony Brook Plastic and Reconstructive Surgery Division

Dr. Tara L. Huston | Stony Brook Plastic Surgeon
Dr. Tara L. Huston

The surgical treatment of breast disease is rapidly evolving. The desire to develop treatments that are less invasive and afford a higher level of cosmesis for patients is strong.

One of our faculty, Dr. Tara L. Huston, assistant professor of surgery and a member of our plastic and reconstructive surgery team, just published a scientific paper detailing her study of patients who had undergone prior breast surgery to see if it was safe and feasible to perform nipple-sparing mastectomy in this group.

The peer-reviewed article appears online in Annals of Plastic Surgery, the only independent journal devoted to general plastic and reconstructive surgery. This journal serves as a forum for current scientific and clinical advances in plastic surgery.

Dr. Huston's work shows that patients who have scarring from prior breast surgery can successfully undergo nipple-sparing mastectomy with immediate reconstruction. Here, she explains how her findings may benefit patients who come to our Carol M. Baldwin Breast Care Center.

~~~~~~~~~~

On Long Island, one in nine women will be faced with the diagnosis of breast cancer in her lifetime. The number of women undergoing mastectomy is increasing. Fortunately, the field of plastic and reconstructive surgery has evolved dramatically over the past thirty years to keep up.

The trend for immediate breast reconstruction after mastectomy has grown from 10% in the 1980s to about 90% today here at Stony Brook. Most recently, our breast surgeons have adopted the technique of nipple-sparing mastectomy, preserving the nipple-areola complex as well as all of the breast skin.

This is a method that we employ when both the oncologic and reconstructive surgeon believe it is safe and feasible.

As we have begun performing more and more nipple-sparing mastectomies with immediate reconstruction, our empowered patients here at Stony Brook continue to encourage us to expand the indications for this surgery.

At this time, the ideal patients for this procedure from an oncologic perspective are those undergoing risk-reducing mastectomies or those with small, well-differentiated tumors located far from the nipple.

Patients with scarring from prior lumpectomy do not have a higher rate of compromised blood flow
in the nipple-areolar complex, and may be considered for nipple-sparing mastectomy.

From a reconstructive standpoint, we find that smaller cup sizes, with minimal ptosis (drooping) and breasts which have not yet undergone radiation or surgery are the best candidates. However, with each passing year, we expand the scope of the nipple-sparing mastectomy procedure, and are able to offer this procedure to more and more women.

For many years, we have known that nipple-sparing mastectomy can provide superior cosmesis with a high level of patient satisfaction. Because of concerns for nipple-areolar complex survival using this technique, selection criteria can be limited.

In my study reported in Annals of Plastic Surgery, we evaluated the impact of scarring from prior lumpectomy on nipple-areolar complex viability.

A total of 318 nipple-sparing mastectomies were performed over a six-year period. We compared 122 breasts with prior lumpectomy incisions/scars to 196 breasts without prior surgery. All nipple-sparing mastectomies in this study were followed by implant-based reconstruction.

Factors analyzed included reasons for surgery, technical details of the operation, co-existing medical conditions, and whether or not additional radiation or chemotherapy was needed.

In this study, approximately 20% of the nipples studied had some degree of compromised blood flow. However, there was no statistically significant difference in the rates between the two groups.

Of all of these patients in the study, only two actually required return to the operating room for debridement; that is, removal of damaged tissue to improve the healing potential of the remaining healthy tissue. The great majority healed with conservative management consisting of dressing changes.

At an average follow-up of one and a half years, patient satisfaction was very high. The take-home message is that patients with scarring from prior lumpectomy do not have a higher rate of nipple-areolar complex ischemia, and may be considered for this procedure.

"In carefully selected patients, [nipple-sparing mastectomy] may significantly improve the cosmetic result by allowing the breast to maintain its virtual appearance," says Dr. Huston. "Preservation of the nipple-areolar complex has important implications for the well-being of our female patients." ¶ Research has demonstrated improved psychosocial well-being, sexual function, and overall satisfaction with aesthetic outcome. — "Nipple-Sparing Mastectomy Is Improving the Care of Patients with Breast Cancer"

Read the abstract of Dr. Huston's study of nipple-sparing mastectomy in patients with scarring from prior lumpectomy. For consultations/appointments with her, please call 631-444-4666.

Posted by Stony Brook Surgery on August 6, 2014

FREE Vascular Screening on Saturday, September 27, 2014, at Stony Brook Heart Institute

Drs. Shang Loh and Apostolos Tassiopoulos
Dr. Shang Loh and Dr. Apostolos Tassiopoulos

Aortic disease is serious and potentially life-threatening, often occurring "silently" without any symptoms.

For this reason early detection and treatment are crucial. It's important for people to understand that when affected by disease, the blood vessel (artery) called the aorta can split (dissection) or bulge (aneurysm) and, in either case, the rupture may have fatal results.

Here, Apostolos K. Tassiopulos, MD, professor of surgery, chief of our Vascular Surgery Division and co-director of the Stony Brook Aortic Center, and Shang A. Loh, MD, assistant professor of surgery and also a leader of the Aortic Center, answer questions about aortic disease and about the care we provide for it.

Q: What should I know about the aorta and aortic problems?

A: The aorta is the main vessel carrying oxygenated blood from the left ventricle of the heart to other parts of the body. The aorta ascends from the top of the heart, arches up and over it, descends through the chest behind the lungs and in front of the spine to the abdomen, and then branches off at the pelvis.

Aortic diseases can occur for many reasons and often develop in tandem with coronary artery disease. The biggest risk factors for aortic diseases are being male, over age 55, a smoker and having high blood pressure or heart disease — but anyone can develop an aortic condition at any age.

When your doctor suspects an aortic problem, rest assured: your destination
for top-level diagnosis and treatment is as close as Stony Brook Medicine.

Q: What conditions do you treat?

A: We treat patients with the full spectrum of aortic problems, including those with co-existing conditions and other high-risk factors.

The most common aortic problem is an aneurysm, which is a blood-filled bulge in a blood vessel resulting from a weakening in the vessel wall. Small aortic aneurysms often can be managed medically and monitored for change; larger aortic aneurysms usually require treatment either with surgery or by using a stent graft to bridge the damaged area.

We repair aneurysms located anywhere on the aorta, with the most common being abdominal aortic aneurysms, also known as AAAs. We also treat all other clinical problems related to the aorta or to the arteries that branch from it to the gastrointestinal tract, the kidneys, and the extremities.

Q: Is it true that many advanced procedures are minimally invasive?

A: Yes. At Stony Brook, we can offer lifesaving options to otherwise inoperable patients and treat a wider spectrum of patients with shorter hospital stays and fewer postoperative complications.

In fact, the vast majority of the AAAs done at Stony Brook are minimally invasive and we now provide incisionless repair of AAAs for patients meeting the criteria.

A regional referral center serving Long Island and beyond, the Stony Brook
Aortic Center offers comprehensive, coordinated care by renowned specialists.

Q: What procedures put you at the forefront of care?

A: Customized AAA stent grafts. We are the only providers in Suffolk County offering custom-built endovascular stent grafts for patients who cannot be treated with a standard stent graft, either because of a complex anatomy or the location of the aneurysm.

This unique capability requires highly sophisticated imaging technology and the collaboration of surgeons and radiologists. Together, they develop a complex 3D model of the area of the patient's aorta requiring repair, and a stent graft is then custom built to match it.

Incisionless repair of abdominal and thoracic aneurysms. We can now repair abdominal and thoracic aortic aneurysms without a surgical incision. Both procedures — percutaneous EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aneurysm repair) — result in less discomfort for the patient and less potential for wound infection.

Endovascular and hybrid thoracic aortic aneurysm repairs. We repair aneurysms of the thoracic aorta with endovascular techniques using stent grafts similar to the AAA procedure, or in more complex cases, we offer a hybrid open endovascular procedure that helps reduce the magnitude of surgery and the patient's recovery time.

Minimally invasive treatment of acute aortic dissections. Aortic dissection repairs also may be treated with stent grafts — a significant advance over what once was a dangerous open surgery.

An aortic dissection occurs when the thinly layered walls of the aorta tear or separate, causing blood to travel between the layers. Acute dissections may require emergency surgery to avoid rupture and restore blood flow to the organs and legs.

Our group of specialists collaborates to treat all of these conditions in the most safe and effective way.

Free Vascular Screening. Saturday, September 27, 2014, from 8 am to 4 pm. At the Stony Brook University Heart Institute. Three simple, non-invasive, painless tests. For people 60 or older, with at two of the following risk factors: current or past smoker; diabetes; high blood pressure; high cholesterol; heart disease; family history of aortic aneurysm. Call for a brief qualifying interview: 631-638-2100.

Learn more about the Stony Brook Aortic Center and the leading-edge services provided by its physicians. Need vein care? Get additional information about our vascular screenings.

Posted by Stony Brook Surgery on July 30, 2014

Using the Latest Advance in Minimally Invasive Surgery to Meet a Therapeutic Challenge

Drs. Mark F. Marzouk and Ghassan J. Samara
Dr. Mark Marzouk and Dr. Ghassan Samara

Sialolithiasis, or salivary duct stones, is the most common cause of swelling of the salivary glands. Symptoms of stones include pain (often worse at the mere thought of food), intermittent swelling of the gland, and possibly severe infection.

The current standard in most institutions for treating salivary duct stones has been surgical removal of the gland, which entails an incision in the neck and an overnight stay in the hospital.

The conventional "open" operation carries with it the potential complications of scarring, wound infection, and facial nerve injury resulting in facial paralysis.

Salivary endoscopy is a relatively new minimally invasive gland-preserving procedure — available on Long Island only at Stony Brook Medicine — that allows for salivary surgery in a safe and effective way, and is done on an outpatient basis.

However, this procedure is limited to stones smaller than roughly a quarter inch. Stones as big as two inches long have been reported, though such "megaliths" are rare. The majority of stones are less than half an inch in size.

Robot-assisted stone removal with sialendoscopy is a minimally invasive,
gland-preserving, same-day surgery, with high patient satisfaction.

The success rate of salivary endoscopy in treating sialolithiasis is over 90%, as reported in the current literature, with less than 5% recurrence. Recovery time is much faster than with an open technique, and patients may return to a normal diet the same day.

Large salivary gland stones (bigger than a quarter inch) have always been a therapeutic challenge. Several factors can make removal of large stones technically challenging, including a small mouth opening, large teeth, and obesity, which limit access and exposure.

Limited exposure also greatly complicates the identification and preservation of the lingual nerve — the nerve that provides sensation to the tongue — as well as the placement of sutures to repair the salivary duct if necessary.

The development of robotic surgical technology has led to the latest advance in the minimally invasive removal of salivary stones.

Stony Brook Medicine acquired the da Vinci robot — the only available robotic surgical system worldwide — seven years ago. In fact, our medical center was the first on Long Island to acquire the most technically advanced model of this robot. We now have two of them.

The da Vinci robot provides magnified 3D high-definition vision, which greatly helps to meet the challenge of removing large stones. In view of the level of expertise required to perform robotic salivary gland stone removal, few medical centers nationwide provide it.

Robot-assisted stone removal with sialendoscopy represents
a tremendous advance over the traditional gland-removing surgery.

In fact, Stony Brook Medicine is one of only two centers nationwide now providing salivary stone removal with robotics. The other center is located in Louisiana.

Our salivary endoscopy program is led by head and neck surgeon Mark F. Marzouk, MD, who joined our faculty in 2010. He performed the first salivary endoscopy ever done on Long Island.

Dr. Marzouk and his colleague, Ghassan J. Samara, MD, have been successfully using the da Vinci robot to remove large salivary gland stones.

Their recent study conducted here, titled "Robot-Assisted Sialolithotomy with Sialoendoscopy: A Novel Approach to Management of Large Submandibular Gland Stones," documents the largest patient series to be described so far.

They presented the study last month at the Department's of Surgery's annual Research Day, and this fall they will present it at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery, to be held in Orlando, FL.

Commenting on our use of salivary stone removal with robotics, Dr. Marzouk says: "The robot-assisted sialolithotomy [stone removal] procedure involves utilizing the latest robotic technology available, namely, the da Vinci robot.

"This technology ensures superb visualization of the important structures — in particular, the lingual nerve — and more precise surgical access to a difficult area to reach deep inside the mouth.

"The robot provides a safe, minimally invasive access to large stones. The robotic procedure is an excellent alternative to the traditional approach of removing the gland, which carries the risk of injuring the facial nerve, resulting in significant morbidity [facial paralysis].

"Most of the patients we have treated for stones have had a functioning salivary gland. They got to keep it with a very low risk of recurrence of stones. Our recent study found patient satisfaction to be more than 98%."

"Preliminary data in the management of large SMG [submandibular gland] stones with RASS [robot-assisted sialolithotomy with sialoendoscopy] show improved procedural success in comparison to CTSA [combined transoral and sialoendoscopic approach]. Furthermore, the morbidity of lingual nerve damage seen in CTSA has yet to be encountered with RASS, likely due to improved visualization."

— Razavi C, Pascheles C, Samara G, Marzouk M. Robot-assisted sialolithotomy with sialoendoscopy: a novel approach to management of large submandibular gland stones. Department of Surgery Research Day. Stony Brook, NY, June 2014.

Click here for more information about our otolaryngology-head and neck surgery services. For consultations with our head and neck surgery specialists who have robotic expertise, please call 631-444-4121.

Posted by Stony Brook Surgery on July 23, 2014

Answering Questions about the Final Moments of Doomed Passengers on Malaysia Flight 17


Dr. James A. Vosswinkel

The downing of Malaysia Airlines Flight 17 last week left the world in a state of shock and disbelief. Why was it shot down? Who did it? Why did 298 innocent people — men, women, and children — have to lose their lives?

These questions following the event have been swirling around the globe like desperate wraiths.

Other questions concern the experience of the plane's passengers after it was hit by the lethal missile: Did they die right away, or endure the horror of the plane's crash? Were they conscious as they fell through the sky until they hit the ground?

Not morbid curiosity but a compassion for suffering souls can motivate such haunting questions about the final moments of the passengers of Flight 17. To know the end came swiftly, to know the horror was momentary — this would give a measure of comfort to the world.

For answers, Bloomberg News turned to Stony Brook Medicine and our trauma specialist, James A. Vosswinkel, MD, chief of our Trauma, Emergency Surgery, and Surgical Critical Care Division and medical director of the Stony Brook Trauma Center.

"No one was conscious or experienced that fall."

Bloomberg News disseminated a wire story featuring its interview with Dr. Vosswinkel, and news media around the world picked it up, publishing it both in print and online. The story opens this way:

"The blast force from the missile that slammed into a Malaysian plane over Ukraine, combined with the plane's dramatic deceleration, probably instantly rendered everyone on board unconscious or dead.

"That's the best guess of James Vosswinkel, a trauma surgeon who led a definitive study of TWA Flight 800 that exploded and crashed off New York's Long Island in 1996, killing all 230 on the flight."

Dr. Vosswinkel's study mentioned by Bloomberg was conducted with members of our trauma team, and published in 1999 in the Journal of Trauma. He was a resident at the time in our general surgery training program. (He was the first recipient, in 2000, of our annual David J. Kreis Jr. Award for Excellence in Trauma Surgery.)

The Bloomberg story, titled "Instant Death or Blackout: Likely Fate of Passengers on Jet Shot Out of Sky," continues:

"Vosswinkel's research found that trauma in a mid-air explosion occurs from three sources, the force of the blast, the massive deceleration when a plane going 500 miles an hour stops in mid-air, and the impact of the fall. Additionally, the loss of cabin pressure can cause hypoxia [oxygen deprivation] within seconds at 33,000 feet, leading to loss of consciousness.

"You have such horrific forces that it's essentially unsurvivable … No one was conscious or experienced that fall."

Tragedies like Flight 17 require factual information, together with different ways and stages of grieving, to process them both intellectually and emotionally. At best, we learn to live with the fact they occur in our world.

Dr. Vosswinkel joined our faculty in 2002, following his fellowship training in trauma and surgical critical care at Yale University. He was appointed chief of the newly formed Trauma, Emergency Surgery, and Surgical Critical Care Division in May 2013.

To conduct his study of the TWA Flight 800 explosion that occurred in July 1996 just off the south shore of eastern Long Island, Dr. Vosswinkel reviewed the Suffolk County Medical Examiner's autopsy reports of the victims. The study concludes:

"Passengers of Flight 800 sustained instantaneous fatal blunt force injury. Analysis of the data revealed no global correlation between seat position and pattern of injury. In contrast to injuries incurred during crashes at takeoff and landing, these midflight injuries were too extreme to warrant a reappraisal of current passenger protective safety measures or standards."

Vosswinkel JA, McCormack JE, Brathwaite CE, Geller ER. "Critical Analysis of Injuries Sustained in the TWA Flight 800 Midair Disaster." Journal of Trauma (1999).

Read "final moments" Flight 17 story on Bloomberg News website, which includes additional information about the passengers' fate and also about Dr. Vosswinkel's research. Learn about Stony Brook Medicine's Trauma Center and its services.

Posted by Stony Brook Surgery on July 11, 2014

Ours Is the Only Accredited Vein Center on Long Island and a National Leader in Vein Care

The Stony Brook Vein Center team
Vein Center team: (l to r) Aldona Wojdat; Krystal Sposito; Kristy Stanfield,
PA; Antonios Gasparis, MD; Doreen Elitharp, NP; and Tina O'Connell.

We are very pleased to announce that the Stony Brook Vein Center has just been granted full accreditation by the Intersocietal Accreditation Commission (IAC).

IAC accreditation is a trusted "seal of approval" in healthcare today, and demonstrates our commitment to providing quality vein care to our patients.

"Our Vein Center is among only 12 in the United States and the two in New York State to obtain IAC accreditation," says Antonios P. Gasparis, MD, professor of surgery and director of the Vein Center.

Dr. Gasparis adds that at present the IAC has received more than 70 applications for vein center accreditation.

Our Vein Center specializes in providing the most sophisticated diagnosis and treatment — both surgical and non-surgical — for superficial venous disorders, including varicose and spider veins of the leg, among other vein-related conditions.

The purpose of IAC accreditation is to ensure high-quality patient care and to promote healthcare by providing a mechanism to encourage and recognize the provision of quality imaging diagnostic evaluations by the accreditation process.

Through the accreditation process, facilities assess every aspect of daily operation and its impact on the quality of healthcare provided to patients. While completing the accreditation application, facilities often identify and correct potential problems, revise protocols, and validate quality improvement programs.

Because accreditation is renewed every three years, a long-term commitment to quality and self-assessment is developed and maintained. Facilities may use IAC accreditation as the foundation to create and achieve realistic quality care goals.

The IAC provides accreditation programs for vascular testing, echocardiography, nuclear/PET, magnetic resonance imaging (MRI), diagnostic computed tomography (CT), dental CT, carotid stenting, and vein treatment and management.

The IAC incorporated all of its divisions into one IAC organization in 2008, but its history began more than 20 years ago with the inception of the first of the IAC accreditation divisions, IAC Vascular Testing (formerly, the Intersocietal Commission for the Accreditation of Vascular Laboratories).

Modeled after the success of IAC Vascular Testing, IAC Vein Center was created last year to accredit vein centers, becoming the seventh member division of the IAC.

Our Vein Center currently has four offices in Suffolk County, the main office in East Setauket and branch offices in Smithtown, Sayville, and Huntington.

Are you suffering from painful swollen, ropey veins on your legs? Our free-of-charge varicose vein screenings provide an examination of the lower legs for venous insufficiency.

IAC information about vein center accreditation aimed at informing patients about vein care and the importance of accredited facilities. For consultations/appointments with our vein specialists, please call 631-444-VEIN (8346).

Posted by Stony Brook Surgery on June 18, 2014

Using the Latest Technology to Provide More Effective Surgery & Lead the Way in Patient Care

Dr. Roberto Bergamaschi with Our Da Vinci Robot in the OR
Dr. Roberto Bergamaschi with our da Vinci robot
in the OR, positioning its arms.

Despite the demonstrated advantages of laparoscopic surgery for treating colorectal conditions, some limitations continue to exist and call for improvement.

Robot-assisted colorectal surgery is addressing most of the shortcomings of the standard laparoscopic approach, and the robotic technique has proved its safety profile in both colon and rectal surgery.

Indeed, robotic technology has during the past decade revolutionized minimally invasive surgery in several surgical specialties, including cardiothoracic surgery, otolaryngology-head and neck surgery, and general (gastrointestinal) surgery, among others, and it is also advancing minimally invasive surgery in the colorectal field.

Our Colon and Rectal Surgery Division has been providing robotic colorectal surgery with great success, and is a leader in the use of robotic technology.

Roberto Bergamaschi, MD, PhD, professor of surgery and chief of colon and rectal surgery, who is an internationally renowned specialist in laparoscopic surgery, is leading our colorectal robotic surgery program. He has been specially trained and certified to operate with the robot.

The surgeon — not the "robot" — performs the surgery, and
is in full control of the robotic system and the procedure.

The surgeon is in full control of the robotic system, which translates his or her hand movements into smaller, more precise movements of tiny instruments inside the patient's body.

The development of robotic surgical technology took off in the mid-1980s with remote surgery (also known as telesurgery) being the major driving force. Since that time, several robotic devices have been developed. The da Vinci system — the first system approved by the Food and Drug Administration in 2000 — is now the only available robotic surgical system worldwide.

Stony Brook Medicine acquired the da Vinci system seven years ago. In fact, our medical center was the first on Long Island to acquire the most technically advanced model of the robot.

The first report about robotic colorectal surgery was published in the medical literature in 2002. Since then, more and more surgeons have become interested in robotic surgery, and the number of articles about robotic colorectal surgery has been markedly increasing.

The study of robotic colorectal resection as an alternative treatment option for colorectal cancer is of particular interest.

We provide robotic colorectal surgery for colon cancer,
rectal cancer, diverticulitis, and inflammatory bowel disease.

The da Vinci robot is
six feet tall and has
four spider-like arms.

Instead of a large abdominal incision used in open surgery, surgeons using the robotic system make a few small incisions, similar to what's done in traditional laparoscopy. The robotic system features a magnified 3D high-definition vision system and special wristed instruments that bend and rotate far greater than the human wrist.

As a result, the robotic system enables the colorectal surgeon to operate with enhanced vision, precision, dexterity, and control.

Operative experience with the robot is important for the successful performance of robotic colorectal surgery.

Another member of our Colon and Rectal Surgery Division who is skilled at robotic colorectal surgery is Paula I. Denoya, MD, assistant professor of surgery.

We provide robotic colorectal surgery for colon cancer, rectal cancer, diverticulitis, and inflammatory bowel disease (ulcerative colitis and Crohn's disease).

Robotic surgery for rectal cancer provides better margins
than laparoscopic or traditional surgery can achieve.

Commenting on the use of robotic colorectal surgery at Stony Brook, Dr. Bergamaschi says: "The robot represents a major advance in colon and rectal surgery that offers patients more benefits of the minimally invasive approach.

"We are the first to have published evidence that robotic surgery for rectal cancer provides a radial resection margin larger than the margin laparoscopic or traditional surgery can offer. This is very important because radial resection margin is the metric that predicts survival."

Colon Cancer Surgery

Robotic colectomy (removal of all or part of the colon) offers the following potential benefits:

  • Precise removal of cancerous tissue
  • Low blood loss
  • Quick return of bowel function
  • Quick return to a normal diet
  • Low rate of complications
  • Low conversion rate to open surgery
  • Short hospital stay
  • Better cosmetic result compared to open surgery
Rectal Cancer Surgery

Robotic low anterior resection (rectal cancer surgery) offers precise removal of cancerous tissue as well as the following potential benefits when compared to conventional open surgery:

  • Less blood loss
  • Less pain
  • Shorter hospital stay
  • Quicker return of bowel function
  • Quicker return to a normal diet
  • Faster recovery
  • Better cosmetic result

When compared to traditional laparoscopy, robotic low anterior resection offers the following potential benefits:

  • Lower conversion rate to open surgery
  • Fewer major complications
  • Shorter hospital stay
  • Quicker return to a normal diet
  • Quicker return of urinary function
  • Quicker return of sexual function

Laparoscopic surgery is now considered by many experts as the approach of choice for the surgical treatment of both benign and malignant colorectal diseases.

Advancing the laparoscopic approach, the robot is gaining acceptance supported by clinical studies, and its use is providing patients more benefits of minimally invasive surgery.

"There are concerns about the impact of robotic proctectomy with total mesorectal excision (TME) compared with laparoscopic proctectomy on the depth of the circumferential resection margin (CRM). The aim of this study was to compare the first 20 consecutive robotic proctectomies performed in our unit with matched series of open and laparoscopic proctocolectomy by the same surgeon [Dr. Roberto Bergamaschi].… The study reports no statistically significant difference from open or laparoscopic techniques in the quality of TME during the learning curve of robotic proctectomy for rectal cancer and demonstrates an improved CRM."

— Barnajian M, Pettet D III, Kazi E, Foppa C, Bergamaschi R. "Quality of Total Mesorectal Excision and Depth of Circumferential Resection Margin in Rectal Cancer." Colorectal Disease (2014).

For consultations/appointments with our colorectal robotic specialists, please call 631-444-4545 (Surgical Care Center) or 631-638-1000 (Cancer Center).

Posted by Stony Brook Surgery on June 11, 2014

Our Residency Programs Train Physician-Scientists to Both Practice and Advance Surgery


Poster competition judges reviewing poster.

The Department of Surgery's Fifth Annual Research Day took place on June 5 at the Charles B. Wang Center on west campus of Stony Brook University. This year's program was another success, as the event continues to grow, with more presentations.

The morning forum showcased ongoing and completed research projects by way of oral platform presentations, as well as a poster competition by our residents, medical students, and faculty.

"Stony Brook Medicine is geared for making research happen," said Mark A. Talamini, MD, professor and chairman of surgery, in his opening remarks at the program. "Our Research Day celebrates our discoveries. Not only that, it demonstrates a truly impressive breadth of interests and research capabilities for our department."

The program included nearly 50 posters presenting study abstracts, plus five oral presentations moderated by faculty discussants, and it attracted more than a hundred attendees from Stony Brook Medicine and the University community.

The keynote speaker was F. Charles Brunicardi, MD, vice chair of the Department of Surgery at the University of California, Los Angeles. His talk, "Patient-Based Leadership Training and Personalized Surgery," addressed the need for leadership training for surgical residents, and why surgeons who must function as leaders will benefit.

Discussing his own research, Dr. Brunicardi talked about personalized genomic medicine and surgery, which represents a new approach to healthcare that customizes patients' medical treatment according to their own genetic information.

A. Laurie W. Shroyer, PhD, MSHA, professor of surgery and vice chair for research, who oversees Research Day, said that "it takes a village — an entire department — to foster research, and Research Day shows our commitment to advancing scientific knowledge in order to improve patient care and population health."

All categorical residents in our general surgery residency program are now required to conduct at least one research project each year, and to present their studies at the Research Day program. All of our residency programs are committed to training physician-scientists who can both practice and advance surgery in their careers after they graduate from Stony Brook.

Established in 2010, Research Day is an opportunity for our residents as well as our faculty and medical students to present their surgical research. The focus of the program, which takes place from 8:00 am to noon, is moving the science of surgery forward. The program offers continuing medical education (CME) credit; this activity is designated for a maximum of 3.5 AMA PRA Category 1 Credits™.

2014 Research Day Posters

Here are the titles and authors of the posters exhibited at this year's Research Day program, which demonstrate the range of research activity within the Department, and the remarkable productivity of our residents:

  • Amyand’s hernia after nonoperative treatment of perforated appendicitis | Kim P, Adamo A, DeMuro J.
  • Assessment of voice quality and extra-esophageal reflux pre- & post-bariatric surgery | O'Brien S, Telem DA, Pryor AD, Altieri MS, Regenbogen E.
  • Bilateral juvenile gigantomastia in a 13-year-old girl: a brief report | Peredo AL, Virvilis D, Lee TK, Khan SU.
  • Can intraoperative indocyanine green angiography predict fat necrosis in free flap breast reconstruction? | Levites H, Trasolini NA, Fourman MS, Gersch RP, Phillips BT, Khan SU, Gelfand MA, DT Bui. Winner of poster competition.
  • Characterization of acute venous congestion in a rat model using ICG angiography | Nasser AE, Fourman MS, Gersch RP, Hsi H, Phillips BT, Dagum AB, Khan SU, Gelfand MA, Bui DT.
  • Chondrosarcoma of the chest wall | Chiu J, DeMuro J.
  • Coil embolization of an aortic pseudo-aneurysm post open repair of type A aortic dissection | Jain V, Gruberg L, Bilfinger TV, Tassiopoulos AK, Loh SA.
  • Creation of gastric conduit free-graft with intraoperative perfusion imaging during pancreaticoduodenectomy in a patient post esophagectomy | Virvilis D, Pagkratis S, Phillips BT, Bao PQ, Khan SU, Ganz JC, Watkins KT.
  • CT scan is helpful for internal hernia detection following weight loss surgery | Altieri MS, Telem DA, Hall K, Zawin M, Dubrovski G, Brathwaite CE, Pryor AD.
  • Dearterialization vs hemorrhoidectomy: a 3-year follow-up of a randomized controlled trial | Tam J, Denoya PI, Bergamaschi R.
  • Early unplanned hospital readmission following acute traumatic injury | Copertino LM, Jawa RS, McCormack JE, Rutigliano D, Huang EC, Shapiro MJ, Vosswinkel JA.
  • Effect of aprepitant (Emend) in postoperative nausea and vomiting in morbidly obese patients undergoing laparoscopic sleeve gastrectomy: cost and effectiveness | Rubano JA, Orioles C, Gohil KN, Gracia GJ, Telem DA, Pryor AD.
  • Emerging technologies and procedures: results of an online survey and real time poll | Verma R, Eid G, Ali M, Saber A, Pryor AD.
  • Examining coronary artery bypass grafting outcomes of multi-institutional cardiac surgeons: should the regionalization of CABG services be revisited? | Bilfinger TV, Shroyer AL, Taylor JR Jr, Gioia W, Bishawi M.
  • First in man experience with the ReVive PV peripheral thrombectomy device for the revascularization of below-the-knee embolic occlusions | Margolis J, Landau DS, Moomey C, Fiorella D.
  • Frequency and time of reintervention following Heller myotomy | Chantachote C, Telem DA.
  • Impact of rectal mobilization, fixation to sacrum and access on recurrence rates following rectopexy for full-thickness rectal prolapse: a pooled analysis of 532 patients | Bishawi M, Foppa C, Bergamaschi R, for the Rectal Prolapse Recurrence Study Group.
  • Institutional experience with the ReVive PV peripheral thrombectomy device for the revascularization of below-the knee embolic occlusions | Monastiriotis S, Loh SA, Tassiopoulos AK.
  • Intravascular leiomyomatosis: a systematic review of the literature | Terrana LM, Labropoulos N, Gasparis AP, Tassiopoulos AK, Loh SA.
  • Long-term mortality rates normalize to the general population following bariatric surgery in New York State | Altieri MS, Pryor AD, Yang J, Zhang Q, Shroyer AL, Telem DA.
  • Management of intraluminal thrombus in the non-diseased aorta | Jain V, Koullias G, Tassiopoulos AK, Zawin M.
  • Omega-3 fatty acid supplementation as an adjunct to bariatric surgery in the obese patient | Lacayo-Baez MJ, Altieri MS, Gohil KN, Telem DA, Pryor AD.
  • Optimal pain control after open pancreaticoduodenectomy | Pagkratis S, Moller D, Watkins KT, Mazirka P, Bao PQ.
  • Pancreatic duct-to-β-cell transdifferentiation represents the most likely source of new beta cells during post-natal growth and regeneration | El-Gohary Y, Tulachan S, Guo P, Xiao X, Wiersch J, Gaffar I, Prasadan K, Shiota C, Gittes G.
  • Pathologic predictors of complete response after neoadjuvant chemotherapy for breast cancer | Ahn S, Piotrowski J, O'Hea BJ.
  • Perioperative VTE rates in normal weight versus morbidly obese surgical patients | Wang L, Pryor AD, Romeiser JL, Altieri MS, Talamini MA, Telem DA. Semi-finalist in poster competition.
  • Postoperative infections in tissue expander based breast reconstruction | Klein G, Nasser AE, Landford W, Bui DT, Dagum AB, Ganz JC, Gelfand MA, Huston TL, Khan SU.
  • Quantitative analysis of nipple areola complex tattoo fade patterns: a prospective study | Levites HA, Lyubchik A, Trasolini NA, Fromm IM, Fourman MS, Phillips BT, Khan SU, Dagum AB, Bui DT.
  • Repair, replacement or Ross procedure: developing and algorithm for valve selection for adults with aortic stenosis and/or regurgitation | Koudoumas D, Iliopoulos D, Yacoub M, Khalpey Z.
  • Review of tertiary center outcome: laparoscopic vs open pancreatectomy | Em M, Bao PQ.
  • Robot-assisted sialolithotomy with sialoendoscopy: a novel approach to management of large submandibular gland stones | Razavi C, Pascheles C, Samara GJ, Marzouk MF. Semi-finalist in poster competition.
  • Role of ALT flaps in foot reconstruction | Gulamhusein T, Gelfand MA, Bui DT.
  • Roux-en-Y gastric bypass (RYGB) in a severely type 2 diabetic rodent model | Lau R, Brathwaite CE, Rideout D, Hall K, Radin M, Ragolia L.
  • Secondary appendicitis in the setting of colonic inflammation | Hartendorp P, DeMuro J.
  • Single shot thoracic epidural: an aid to earlier discharge for pediatric laparoscopic cholecystectomy | Hsieh L, Tan JM, Gruffi C, Grewal S, Scriven RJ, Seidman PA, Lee TK.
  • siRNA delivery by mesenchymal stem cells as a therapy for colorectal cancer | Gersch RP, Gordon C, You K, Want HZ, Brink P, Bergamaschi R.
  • Sizes of abdominal aortic aneurysms being repaired: a review of the surgical literature | Kelly B, Svestka M, Labropoulos N, Tassiopoulos AK.
  • Sternal wound reconstruction with pectoral, omental, and falciform flaps for poststernotomy mediastinitis: a case report | Kaymakcalan O, Levites H, Phillips BT, Dagum AB.
  • The effect of sleeve gastrectomy on extraesophageal reflux disease | Frenkel C, Telem DA, Pryor AD, Talamini MA, Altieri MS, Shroyer KR, Korman M, Regenbogen E.
  • The extent of extracapsular extension may influence the need for axillary lymph node dissection in patients with T1-T2 breast cancer | Gooch J, King TA, Eaton A, Dengel L, Stempel M, Corben AD, Morrow M.
  • The role of duplex ultrasound in the pelvic congestion syndrome workup | Spentzouris G, Malgor RD, Adrahtas D, Gasparis AP, Tassiopoulos AK, Labropoulos N. Semi-finalist in poster competition.
  • The use of CT scan in diagnosing appendicitis in the pediatric population | El-Gohary Y, Shapiro MJ.
  • Total situs inversus with hepatocellular carcinoma (HCC): a case report and review of literature | Zhao K.
  • Viral preconditioning of rat ischemic skin flaps is similar to physiologic delay | Gersch RP, Fourman MS, Phillips BT, Nasser AE, Kaminsky SM, Crystal RG, McClaine SA, Khan SU, Dagum AB, Bui DT.
  • What makes bariatric surgery a success? The use of fMRI to determine the role of reward pathways in post-bariatric surgery patients | Sullivan B, Telem DA, Pryor AD.

Next year's Research Day will take place on Thursday, June 4, from 8:00 am to noon, at the Wang Center. For more information, please call 631-444-7875.

Posted by Stony Brook Surgery on June 3, 2014

All through an Extraordinary Act of Giving by Stony Brook Medicine and Its Doctors

Saline Atieno post-op with Dr. Leon S. Klempner (left)
and Dr. Alexander B. Dagum.

After one year in the United States and ten reconstructive surgeries at Stony Brook Children's Hospital, Saline Atieno, a 12-year-old Kenyan girl, will soon be going home with a transformed face, a new ability to smile, and a future with promise.

At age 3, Saline was diagnosed with noma, a devastating bacterial necrosis that develops in the mouth and ravages the faces of victims. According to the World Health Organization, some 140,000 new cases of noma are diagnosed annually in developing countries.

Noma affects primarily young children. The disease is called the "face of poverty" because it results from poor water sources, hygiene, and/or malnutrition. Ninety percent of the children who contract noma die from it. Somehow Saline managed to survive but was left with a severely deformed face. So disfigured, Saline found eating food became more difficult, and the ability to smile impossible.

Alexander B. Dagum, MD, professor of surgery and chief of our Plastic and Reconstructive Surgery Division, led the team in the ten surgeries at Stony Brook Children's. The series of surgeries involved major reconstructions of Saline's lips, mouth and nose. A hole in her face was sealed, and Dr. Dagum created a palate that separated her oral and nasal cavities so Saline could eat and speak normally again. With grafts from Saline's ribs, Dr. Dagum recreated her missing nose. He used tissue from her lower lip to help create a new upper lip.

It was not possible to successfully treat Saline in Kenya, and thankfully
she was able to come to the United States and to Stony Brook.

"All severe facial deformities are difficult to treat and are devastating to the children affected and their families," says Dr. Dagum, who has traveled worldwide on many medical missions to treat children affected by noma and other facial deformities. "It was not possible to successfully treat Saline in Kenya, and thankfully she was able to come to the United States and to Stony Brook. Here we saw her transform not only physically, but emotionally and socially, from a shy girl who'd cover her face to a girl who plays and enjoys life."

In June 2013, Leon S. Klempner, DDS, assistant clinical professor of dentistry, who assisted Dr. Dagum during all of the surgeries, led the process to bringing Saline to Stony Brook.

When Dr. Klempner visited Nairobi, Kenya, in 2010, it became a tipping point in his efforts to help children with cleft palates and other dental deformities. Upon learning about a young girl named Saline who suffered from the effects of noma, he decided to start his own non-profit organization to help kids like her. The following year, the Smile Rescue Fund for Kids became a reality. The fund enabled Saline to come to the U.S and Stony Brook.

On his fateful 2010 trip to Kenya, Dr. Klempner was accompanied by his wife, Laurie Klempner, RN, who works in the antepartum unit at Stony Brook University Hospital, and Dr. Dagum. Now Dr. Dagum serves on the board of directors of the Smile Rescue Fund for Kids.

According to Dr. Klempner, in Saline's case, the progression of the bacteria was "somehow self-limiting" but the bacteria left scar tissue. Kenyan surgeons performed a microvascular free-flap reconstruction, but it failed. Her condition was too severe to be assisted by any of the world's known charities, including the Smile Train organization, which referred her to Dr. Klempner. So he decided to start his own non-profit organization with the mission to "help one kid at a time."

Here we saw her transform not only physically, but emotionally and socially,
from a shy girl who'd cover her face to a girl who plays and enjoys life.

From June 2013 to June 2014, Saline's life would dramatically change. Under the direction of Dr. Dagum, the Departments of Surgery, Anesthesia and Pediatrics performed the work free of charge as a designated School of Medicine teaching case. Three local families stepped forward to house Saline, including of Douglas Muller, PA, of Dr. Dagum's division. Saline's mother remained in Kenya with her older sister; two other siblings and her father are deceased.

The complicated procedures, and time needed for healing in between each reconstructive surgery, extended the need for Saline to remain in the United States. What was projected to take several or perhaps six months took one year.

Saline had no problem with being on Long Island for one year, as she looked beyond the toil of enduring all those procedures and embraced her host families. Not knowing a word of English when she came, Saline now understands English quite a bit and speaks some too. While living the past few months with Jennifer Crean's family in Hauppauge, NY, she went skiing, ice skating, and fishing. Just before leaving for Kenya, Saline went on a roller coaster for the first time.

Ms. Crean said Saline is like any pre-teen who loves to do things, has a lot of energy, and plays video games too. Proud of her face, Saline is now enjoying smiling and looking forward to a new adventure in Kenya — attending a boarding school arranged by donors and volunteers via the Smile Rescue Fund for Kids.

Noma (from Greek nomē meaning to eat up) is a disease of extreme poverty and malnourishment, reported throughout history in Asia, Europe, South America, and Africa. It was found in German and Japanese concentration camps during World War II.

Infection occurs mostly in children, though it has been described in neonates, adults, and the chronically ill. The true prevalence and incidence of noma aren't fully known, as it is believed only 15% of patients with acute cases of it get medical care.

Noma is a disease of shame, and the condition often results in forced isolation from the community and family; many children are sent to live in isolation rather than being taken to medical care. (See African patients with nomawarning: graphic images.)

Untreated, acute noma in children is usually lethal. Antibiotic treatment and nutritional support decreases mortality to less than 10%. Nevertheless, plastic orofacial reconstruction is often necessary for both functionality and cosmesis.

Watch this news clip (1:00 min) about the story from FiOS1 Long Island News:

Posted by Stony Brook Surgery on May 30, 2014

Earning Yearlong Bragging Rights for Best Surgical Residency Program in State

Our winners of 2014 NY State Surgical Jeopardy Championship
Our winners of the 2014 NY State Surgical
Jeopardy Championship, Dr. William
Gioia (left) and Dr. Brett Phillips.

We are very pleased to announce that our resident Jeopardy team — William Gioia, DO (PGY-2), and Brett Phillips, MD (PGY-5) — won first place in the Second Annual Resident Jeopardy Competition sponsored by the New York Chapter of the American College of Surgeons.

This is the first year we entered the statewide competition. Harlem Hospital's team were the reigning champs, and we beat them in the first round. We played Lenox Hill in the final round and won on the final jeopardy question.

The final question was: What is the anatomical landmark for an unsuccessful complete vagotomy? And the winning response: What is the "criminal nerve" of Grassi?

The competition took place on May 18 at Albany Medical Center in Albany, NY. Each Jeopardy team consisted of two residents; one PGY-1 or -2 and one PGY-3, -4, or -5. First-place winners won $1000 to split, and second-place won $500 to split.

Surgical Jeopardy is modeled in format after the popular TV show and in content by a game created by the American College of Surgeons to test and increase surgeons' knowledge.

As of 2014, the college has held Surgical Jeopardy at its Annual Clinical Congress for over a decade. The game tests general and specialty surgery knowledge of residents around the country, and has been a great success.

Our residents and faculty faced off in our first annual Jeopardy game here at Stony Brook in 2008, with questions on "All the World's a Stage" (tumor staging), "Tons of Fun" (bariatric surgery), and "Odds and Ends" (colorectal surgery), among other categories.

"The quiz type and competitive gaming sessions can be used as a primary instructional technique leading to significant improvements in delayed posttests of medical knowledge and high resident satisfaction of educational value. Knowledge gains seem to be sustained based on the intervals between the interventions and recorded gains."

— "Gaming Used as an Informal Instructional Technique," Journal of Surgical Education (2012).

Established in 1975, a total of 214 physicians to date have completed their residency training in general surgery at Stony Brook. Click here for information about our residency program.

Posted by Stony Brook Surgery on May 14, 2014

Full Approval as a Comprehensive Bariatric Facility Granted to Stony Brook Medicine

Stony Brook Medicine has just been granted full accreditation as a comprehensive bariatric facility by the new Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) of the American College of Surgeons and American Society of Metabolic and Bariatric Surgery.

MBSAQIP accreditation demonstrates our Bariatric and Metabolic Weight Loss Center's commitment to delivering the highest-quality care for bariatric surgery patients.

To earn MBSAQIP accreditation, Stony Brook University Hospital met the essential criteria that ensure its ability to support a bariatric surgical care program and measure up to the institutional performance requirements outlined by the MBSAQIP accreditation standards.

MBSAQIP accreditation is an important way to verify that a hospital has
everything needed for optimal care of bariatric surgery patients.

Accredited bariatric surgery centers provide both the hospital resources necessary for optimal care of morbidly obese patients and the support and resources necessary to address the entire spectrum of care and needs of bariatric patients, both pre- and post-operatively.

"We are very pleased to receive accreditation from the American College of Surgeons," says Aurora D. Pryor, MD, professor of surgery, and director of the Stony Brook Bariatric and Metabolic Weight Loss Center. "They were very impressed with our entire staff and the Stony Brook facilities. Our group should be commended for their team effort and attention to detail as acknowledged by the surveyor."

Team Members of the Stony Brook Bariatric and Metabolic Weight Loss Center
Team members of the Stony Brook Bariatric and Metabolic Weight Loss Center.

Dr. Pryor emphasizes, "Accreditation is an important way for patients to verify that a practice has access to all the key resources necessary for optimal care, and we are proud to be acknowledged here for our excellence at Stony Brook Medicine."

MBSAQIP is administered by the American College of Surgeons. In 2012, the college and the American Society of Metabolic and Bariatric Surgery announced plans to combine their respective national bariatric surgery accreditation programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers. This joint effort resulted in MBSAQIP, which is designed to achieve a single national accreditation standard for all bariatric surgery programs.

MBSAQIP accreditation is awarded in categories, each with its own criteria that must be met. Facilities undergo a site visit by an experienced bariatric surgeon, who reviews the facilities' structure, process, and data quality. Because optimal surgical care requires documentation using reliable outcomes measures, accredited bariatric surgery centers are required to report their outcomes data to the MBSAQIP Data Registry Platform.

Stony Brook Medicine received the highest level of accreditation possible
and is authorized to treat the most complex bariatric patients here.

In the United States, more than 15 million people suffer from severe obesity, and the numbers continue to increase. Obesity increases the risks of morbidity and mortality because of the diseases and conditions that are commonly associated with it, such as type 2 diabetes, hypertension, and cardiovascular disease, among other health risks. At present, weight loss surgery provides the only effective, lasting relief from severe obesity.

Therefore, the American College of Surgeons believes it is of utmost importance to extend its quality initiatives to accrediting bariatric surgery centers so that it can assist the public in identifying those facilities that provide optimal surgical care for patients who undergo this surgical procedure.

The American College of Surgeons is a scientific and educational association of surgeons that was founded in 1913 to raise the standards of surgical education and practice, and to improve the quality of care for the surgical patient. Its achievements have placed it at the forefront of American surgery, and have made the college an important advocate for all surgical patients. With more than 79,000 members, the college is the largest organization of surgeons in the world.

The American Society of Metabolic and Bariatric Surgery is the largest organization for metabolic and bariatric surgeons in the world. It is a not-for-profit organization that works to advance the art and science of metabolic and bariatric surgery, and is committed to educating medical professionals and the lay public about metabolic and bariatric surgery as an option for the treatment of morbid obesity, as well as the associated risks and benefits.

The society encourages its members to investigate and discover new advances in metabolic and bariatric surgery while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for morbidly obese patients. It should be noted that Dr. Pryor is a leader in the society, and will serve as program chair of its 2015 national meeting.

Our bariatric team in photo: Seated from left, Catherine Tuppo, PT, bariatric coordinator; Aurora Pryor, MD, director, bariatric surgery; and Dana Telem, MD, associate director, bariatric surgery. Standing from left, Kaitlyn Roggemann, database manager; Christine Erickson, bariatric administrator; Kartik Gohil, MBBS, bariatric fellow; Kathryn Cottell, RD, dietitian; Darragh Herlihy, NP, bariatric nurse practitioner; Maria Altieri, MD, research fellow; Genna Hymowitz, PhD, psychologist; Renee Browning Goss, pre-certification specialist; Jennifer Rosenstein, RN, clinical nurse specialist; and Donna Hoffman, RN, nurse manager.

For more information about the Stony Brook Bariatric and Metabolic Weight Loss Center, please call Christine Erickson, bariatric administrator, at 631-444-BARI (2274).

Posted by Stony Brook Surgery on May 7, 2014

Antonios P. Gasparis, MD
Dr. Antonios P. Gasparis

Varicose veins affect millions in the United States — over 20% of the adult population. They are superficial vessels that are abnormally lengthened, twisted, or dilated, and are seen most often on the legs and thighs. Women are twice as likely as men to develop varicosities.

Varicose veins bulge and rise above the skin’s surface. They may often be uncomfortable and result in swelling of the legs. If left untreated, varicose veins may lead to more serious medical problems, such as phlebitis, inflammation, or leg ulcers.

Now, our vascular specialists are providing a non-surgical treatment that involves the injection of a foam drug; specifically, polidocanol endovenous microfoam (PEM; Varithena).

PEM injection requires no anesthesia or sedation, and is the most minimally invasive treatment option for varicose veins. The treatment only requires an ultrasound machine and standard medical supplies, in addition to the foam solution.

This advance in the treatment of varicose veins is the result of a successful research effort that involved multicenter clinical trials in which the principal investigator at Stony Brook Medicine was Antonios P. Gasparis, MD, professor of surgery (Vascular Surgery Division) and director of the Stony Brook Vein Center.

Varicose leg veins can be more than just a cosmetic problem, and when symptoms are present,
they're deemed a medical condition for which treatment is covered by most insurance.

Results of the U.S. phase 3 trial of PEM in 2012 showed a high degree of statistical significance.

PEM is the first and only foam drug approved by the Food and Drug Administration (FDA) for the treatment of incompetent veins and visible varicosities of the great saphenous vein (GSV) system.

"Varithena sets a new standard for the treatment of both the symptoms and the appearance of varicose veins," says Dr. Gasparis. "It provides comprehensive therapy for the widest range of varicose veins — incompetent GSV, accessory saphenous veins, and visible varicosities of the GSV system both above and below the knee."

"Patients undergoing treatment with Varithena can return to normal activities and work following administration of the drug."

Patients are encouraged to walk/mobilize the same day with minimal restrictions. The only restrictions post-treatment are to wear compression stockings for two weeks and to avoid heavy exercise for one week and extended periods of inactivity for one month.

PEM is a sclerosant, that is, a chemical (drug) that causes veins to close. This sclerosant has been made into foam of very small bubbles to create microfoam.

Patients with varicose leg veins treated with PEM (Varithena) in the doctor's office can return
to normal activities and work immediately following administration of the foam.

Leg of patient in the Varithena trial at the Stony Brook Vein Center, before (left) and after treatment.
Leg of patient in the Varithena trial
at the Stony Brook Vein Center,
before (left) and after treatment.
(Click on image to enlarge.)

PEM is intended to act as follows: (1) the foam displaces blood from the vein to be treated and (2) the polidocanol then scleroses the endothelium (inner lining of vein).

Varicose veins often require treatment for symptoms including leg pain, aching, heaviness, restless legs, cramps, throbbing, fatigue, itchiness, tingling, and edema.

These symptoms are frequently the cause of absenteeism from work, disability, and decreased quality of life.

Varicose veins are a clinical presentation of superficial venous insufficiency — a condition in which veins are inefficient in returning blood to the heart because of venous hypertension. One-way valves that normally direct blood towards the heart are damaged or missing, and instead, some blood refluxes (moves in the opposite direction) and often pools in the vein.

Current treatments for varicose veins include thermal ablation and surgery, both of which are excellent options with proven long-term results.

PEM provides an effective alternative that should appeal to patients who are candidates. It was approved by the FDA in November 2013.

"Polidocanol endovenous microfoam [PEM] provided clinically meaningful benefit in treating symptoms and appearance in patients with varicose veins. Polidocanol endovenous microfoam was an effective and comprehensive minimally invasive treatment for patients with a broad spectrum of vein disease (clinical, etiology, anatomy, pathophysiology clinical class C2 to C6) and great saphenous vein diameters ranging from 3.1 to 19.4 mm. Treatment with polidocanol endovenous microfoam was associated with mild or moderate manageable side effects."

— "The VANISH-2 Study: A Randomized, Blinded, Multicenter Study to Evaluate the Efficacy and Safety of Polidocanol Endovenous Microfoam 0.5% and 1.0% Compared with Placebo for the Treatment of Saphenofemoral Junction Incompetence." Phlebology (2014).

For an appointment with one of our vascular specialists to learn more about PEM (Varithena) and/or for a free varicose vein screening, please call 631-444-VEIN (8346).