Posted by Stony Brook Surgery on April 16, 2014
The Voice Specialists of Stony Brook Medicine Are Here to Help You Take Care of Your Voice
Every year in April, otolaryngologist–head and neck surgeons — commonly called ENT doctors — and other voice health professionals worldwide join together to recognize World Voice Day.
World Voice Day, which was established 12 years ago, encourages men and women, young and old, to assess their vocal health and take action to improve or maintain good voice habits.
The long-term consequences of poor voice care can range from strained vocal cords and chronic hoarseness to deadly head and neck cancers.
The voice specialists of our Otolaryngology–Head and Neck Surgery Division provide a range of services aimed at vocal health and wellness.
Voice problems usually are associated with hoarseness (also known as roughness), instability, or problems with voice endurance.
Hoarseness or roughness in your voice is often caused by a medical problem.
When hoarse, the voice may sound breathy, raspy, strained, or show changes in volume or pitch (depending on how high or low the voice is). Voice changes are related to disorders in the sound-producing parts (vocal folds) of the voice box (larynx).
While breathing, the vocal folds remain apart. When speaking or singing, they come together and, as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal folds hinder vibration, altering voice quality, volume, and pitch.
Voice problems arise from a variety of sources including voice overuse or misuse, cancer, infection, or injury.
When is it time to see a doctor about a voice problem?
Voice specialist Elliot Regenbogen, MD, a member of the faculty of our Otolaryngology–Head and Neck Surgery Division, says, "It is time to get evaluated by an otolaryngologist when you have or suspect a voice problem and there are any of the following conditions:
"Many people don't understand the signs and symptoms of voice disorders and often put off treatment, which can cause irreparable damage to their voice quality."
How to Prevent Voice Problems and Maintain a Healthy Voice
Drink water (stay well hydrated): Keeping your body well hydrated by drinking plenty of water each day (6-8 glasses) is essential to maintaining a healthy voice. The vocal cords vibrate extremely fast even with the most simple sound production; remaining hydrated through water consumption optimizes the throat's mucous production, aiding vocal cord lubrication. To maintain sufficient hydration avoid or moderate substances that cause dehydration. These include alcohol and caffeinated beverages (coffee, tea, soda). And always increase hydration when exercising.
Do not smoke: It is well known that smoking leads to lung or throat cancer. Primary and secondhand smoke that is breathed in passes by the vocal cords causing significant irritation and swelling of the vocal cords. This will permanently change voice quality, nature, and capabilities.
Do not abuse or misuse your voice: Your voice is not indestructible. In every day communication, be sure to avoid habitual yelling, screaming, or cheering. Try not to talk loudly in locations with significant background noise or noisy environments. Be aware of your background noise — when it becomes noisy, significant increases in voice volume occur naturally, causing harm to your voice. If you feel like your throat is dry, tired, or your voice is becoming hoarse, stop talking.
To reduce or minimize voice abuse or misuse use non-vocal or visual cues to attract attention, especially with children. Obtain a vocal amplification system if you routinely need to use a "loud" voice especially in an outdoor setting. Try not to speak in an unnatural pitch. Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords with subsequent hoarseness and a variety of problems.
Minimize throat clearing: Clearing your throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing.
The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux (GERD), laryngopharyngeal reflux disease, sinus, and/or allergic disease.
Moderate voice use when sick: Reduce your vocal demands as much as possible when your voice is hoarse due to excessive use or an upper respiratory infection (cold). Singers should exhibit extra caution if one's speaking voice is hoarse because permanent and serious injury to the vocal cords are more likely when the vocal cords are swollen or irritated. It is important to "listen to what your voice is telling you."
Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voices are invaluable for both our social interaction as well as for most people's occupation. Proper care and use of your voice will give you the best chance for having a healthy voice for your entire lifetime.
Voice health information here is provided by the American Academy of Otolaryngology–Head and Neck Surgery. For consultations/appointments with our voice specialists, please call 631-444-4121. Watch this video about the voice:
Posted by Stony Brook Surgery on April 8, 2014
New Study Casts Doubts on the Value of Mammograms to Save Lives, Stirs Controversy & Questions
Breast cancer is the most common cancer in women. It affects one in eight women in the United States. It is an extremely curable disease in most situations, and early detection is the key to that. The question always becomes when to start mammograms and how often to get them as they are lifesaving.
There have been at least six landmark clinical studies that have all demonstrated a clear survival benefit to early detection and screening with mammogram.
However, the recent publication of a news-making study has added new doubts about the value of regular mammography screening for women. This particular study has created much controversy and needs to be put in perspective. Women need to understand why mammograms are essential to maintaining their health.
In the absence of a family history of breast cancer, the American Cancer Society guidelines recommend beginning at age 40. Ideally, women should have a mammogram every year. However, if we look purely at the data for women 40 to 50, they can potentially have a mammogram every one to two years. At age 50, women should have a mammogram every year thereafter.
The news-making mammogram study is a flawed study.
The controversial Canadian study that was published in the British Medical Journal has unfortunately confused many women and sent a very dangerous message. This study found no benefit to mammograms. Because of its large size and its radical conclusions, the study attracted much media attention (for instance, New York Times article).
However, it is important to look at the study and to see that it had significant design flaws.
The first flaw to consider is that the study was initiated 25 years ago. The early data included was based on mammograms that, at that time, were extremely crude and really not much better than physical exam.
Thanks to advances in imaging technology, today’s mammograms are extremely sensitive and able to detect even very small cancers before they become a problem for women.
Second, when looking at a study we always look at randomization in which groups that are compared are randomly assigned to either mammogram or not. Unfortunately, in this study, the two groups were not random. The women who got a mammogram were more likely to have a breast complaint, that is, a lump in their breast.
This study, therefore, did not compare equal groups and is flawed. It did not compare apples to apples, so to speak.
There is no question mammograms are lifesaving.
Finally, the issue of family history needs to be considered. If a woman has a strong family history — specifically, with her mother or a sister that was diagnosed with pre-menopausal breast cancer — then screening recommendations should start ten years earlier from the age of diagnoses.
For example, women who have a mother that was diagnosed at the age of 40 should consider screening starting at the age of 30. MRIs in these women may also be of benefit and should be discussed with their healthcare providers.
Simply put, every woman needs a mammogram starting at the age of 40. If there is a family history, then consideration should be given starting ten years earlier than the age of the person affected by the disease if she were pre-menopausal.
Women need to know that there is no question mammograms are lifesaving and that breast cancer is a very curable disease when found early for most women.
Visit the American Cancer Society to find out what you can do to help detect breast cancer early, when it is likely to be most easily treated. Please call 631-638-1000 for consultations/appointments with our breast care specialists.
Posted by Stony Brook Surgery on April 1, 2014
Stony Brook Vein Center to Provide 15-Minute Non-Invasive Test and Evaluation
Are you suffering from painful swollen, ropey veins on your legs? Our FREE varicose vein screening on Saturday, April 26, from 8 am to 2 pm, will provide an examination of the lower legs for venous insufficiency, which causes varicose veins.
This brief screening involves an ultrasound test that will take about 15 minutes to complete and is offered to the public.
Who should attend: Men and women between the ages of 18 and 80 with large varicose veins that are causing leg pain and/or swelling.
Varicose veins — though generally harmless, albeit painful and unsightly — may indicate underlying vascular disease that's potentially serious and that requires treatment.
Where to go: Stony Brook Vein Center, 24 Research Way, Suite 100, East Setauket, NY 11733 (map/directions).
Varicose veins are blood vessels, usually in the legs, that become permanently dilated (widened) and twisted. They may include superficial veins, deep veins, and veins that connect superficial and deep veins.
Symptoms of varicose veins may include vague discomfort and aching in the legs, especially after standing, and fatigue.
The signs of varicose veins are enlarged, disfiguring, snakelike, bluish veins that are visible under the skin upon standing. They appear most often in the back of the calf or on the inside of the leg from ankle to groin.
To register for the screening, please call 631-444-VEIN (8346). Watch this short video, just half a minute long, to learn about what causes varicose veins:
Posted by Stony Brook Surgery on March 26, 2014
Recommendations Will Spare Many Women the Painful Arm Swelling from Lymphedema
Sentinel node biopsy (SNB) is used to determine if cancer has spread beyond the place where it started and into the nearby lymph nodes. SNB has been an important advancement in improving the quality of life of breast cancer patients.
In SNB, only a few lymph nodes are removed and examined for signs of cancer. Usually, if there is no cancer in these sentinel nodes, it means the remaining lymph nodes do not have cancer. The procedure can cause side effects, but they are much less common than with axillary lymph node dissection (ALND).
ALND involves removing most lymph nodes under the arm on the same side as the breast tumor, and examining the nodes for signs of cancer spread. The ALND procedure, which sometimes is still necessary, can cause long-term side effects including pain and numbness in the arm and lymphedema, a condition that causes swelling because of a build-up of lymph fluid.
An early proponent of SNB, Brian J. O'Hea, MD, chief of breast surgery and director of Stony Brook's Carol M. Baldwin Breast Care Center, says: "Sentinel node biopsy is now standard treatment. It has been shown to be a safe and accurate alternative to full axillary surgery in patients with breast cancer."
SNB has been used effectively at Stony Brook Medicine since the 1990s, the decade that saw the advent and validation of the procedure in the management of breast cancer.
Evidence from clinical trials now supports using sentinel node biopsy in a larger group of patients.
The American Society of Clinical Oncology (ASCO) has issued new recommendations for the use of SNB in patients with early breast cancer. The guideline, "Sentinel Lymph Node Biopsy for Patients with Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update," was just published in the Journal of Clinical Oncology.
Since the Society issued its initial guideline in 2005, evidence from clinical trials now supports using the less invasive diagnostic technique, SNB, in a larger group of patients. This updated guideline will enable more women with early-stage breast cancer to avoid the more invasive ALND, which has a greater risk of complications.
"The updated guideline incorporates new evidence from more recent studies — nine randomized controlled trials and 13 cohort studies since 2005," says Armando Giuliano, MD, co-chair of ASCO's Expert Panel that updated the guideline. "Based on these studies, we're saying more [but not all] patients can safely get sentinel node biopsy without axillary lymph node dissection. These guidelines help determine for whom sentinel node biopsy is appropriate."
Commenting on the new guideline, Dr. O'Hea explains: "Sentinel node biopsy, as an alternative to ALND, is the single greatest advance in the surgical treatment of breast cancer since lumpectomy was proposed as an alternative to mastectomy some 40 years ago. As a result, many women, even some with positive sentinel nodes, can be been spared ALND, without any survival detriment."
"Unfortunately, not all women are beneficiaries of this technology, as some women still require ALND. We can only hope that as our understanding of the biology of breast cancer matures, and our treatments continue to improve, most if not all women will be able to be treated without radical armpit surgery.
"ASCO should be commended for establishing this very important guideline. We can only hope that the new recommendations will penetrate deeply into our healthcare system, and that all breast cancer physicians embrace and implement changes that are in the best interest of patients."
Some women even with positive nodes can be treated without extensive lymph node removal (ALND).
The guideline updates three recommendations based on evidence from randomized controlled trials:
The guideline updates two groups of recommendations based on cohort studies and/or informal consensus:
The ASCO committee noted that in some cases, evidence was insufficient to update previous recommendations.
"We strongly encourage patients to talk with their surgeon and other members of their multidisciplinary team to understand their options and make sure everybody's on the same page," says Gary Lyman, MD, MPH, co-chair of the Expert Panel. "The most critical determinant of breast cancer prognosis is still the presence and extent of lymph node involvement and, therefore, the lymph nodes need to be evaluated so we can understand the extent of the disease."
To update the guideline, ASCO convened experts in medical oncology, pathology, radiation oncology, surgical oncology, guideline implementation and advocacy. The committee conducted a systematic review of the literature published from February 2004 to January 2013 in Medline and based its recommendations on review of the evidence. It also includes an appendix on pathology.
See the new practice guideline, plus patient information. Read about the sentinel node biopsy history and validation. For a consultation/appointment with one of our breast surgeons, please call 631-638-1000.
Posted by Stony Brook Surgery on March 20, 2014
Springtime Means Congestion & Related Problems for Many People; Our ENT Specialists Offer a Minimally Invasive Option That May Be the Answer for Both Adults & Children
Patients suffer from headache, facial discomfort, nasal congestion, nasal drainage, loss of the sense of smell, and malaise.
Until recently, sinusitis patients were limited to two treatment options: medical therapy such as antibiotics and topical nasal steroids or conventional sinus surgery including functional endoscopic sinus surgery (FESS).
Medical therapy can help alleviate symptoms for some patients. However, for 20-25% of sufferers, this form of treatment alone is not adequate. For these patients, sinus surgery is their next hope in finding relief.
Balloon catheter dilation of paranasal sinus ostia, or balloon sinuplasty, is an effective minimally invasive technique for treating chronic sinusitis, and a leading-edge procedure of our minimally invasive ENT program at Stony Brook.
FESS is a conventional operation that requires bone and tissue removal in order to open up blocked sinus passageways. With no desirable treatment, more than 600,000 people nationwide are left living with their sinus condition.
The current revolution in minimally invasive procedures for endoscopic sinus surgery has led to the development of the new technology called balloon sinuplasty, which provides an effective alternative to FESS.
Our ENT specialists — Mark F. Marzouk, MD; Elliot Regenbogen, MD; Ghassan J. Samara, MD; and Wasyl Szeremeta, MD — are experienced in using the sinuplasty technology to treat both adults and children with chronic sinusitis.
In 2007, we became the first in Suffolk County to offer balloon sinuplasty. In 2012, we became the first to treat children with it. We proudly continue to use leading-edge technology to lead the way in patient care.
For consultations/appointments with our ENT specialists who provide balloon sinuplasty, please call 631-444-4121.
Posted by Stony Brook Surgery on March 11, 2014
Facial rejuvenation procedures have soared and surpassed both breast and body procedures, according to the 2013 statistics of the American Society of Plastic Surgeons.
Botox® treatment of the face, for instance, was the number one minimally invasive cosmetic procedure performed last year in the United States. With over 8 million treatments performed, there were actually far more appointments booked for this non-surgical facial rejuvenation option compared to the more than 133,000 facelifts performed the same year.
Q: What is facial rejuvenation? Is it for both women and men?
A: Facial rejuvenation covers a broad group of surgical procedures and non-invasive treatments which are designed to make your facial skin and profile look younger and more refreshed. The techniques are commonly employed in both women and men of all ages. In fact, although often associated with women, increasing numbers of men are having facial rejuvenation procedures.
Q: What exactly does non-surgical mean?
A: Non-surgical procedures can be topical, such as creams and peels; injectable, such as toxins and fillers; or laser based, such as CO2 resurfacing. All of these procedures take place in the office setting without the need for an operating room or anesthesia. There are no incisions.
Self-esteem is often connected to a person's appearance and, thus, to health and
Q: How do non-surgical facial rejuvenation procedures fit in with health and wellness?
A: The goal of non-surgical rejuvenation is to improve how you look and feel about yourself. It is not meant to turn you into someone else, but to help you appear to be the best, most well-rested and refreshed version of you.
More than that, self-esteem is often connected to a person's appearance, and self-esteem contributes to mental well-being, which in turn contributes to physical health. So the benefits of facial rejuvenation go beyond cosmetic.
Q: What non-surgical options are available for facial rejuvenation?
A: The most common non-surgical procedures are: injection of botulinum toxin (Botox®, Dysport®) to relax muscles and smooth wrinkles; injection of soft-tissue fillers (Juvederm®, Restylane®, Radiesse®) to fill hollow areas and deep lines minimizing the appearance of aging; laser hair removal; chemical peels to smooth the skin; and microdermabrasion, also to rejuvenate the skin.
Q: Are some non-surgical options better than traditional cosmetic surgical procedures?
A: Non-surgical procedures are useful for slight changes, for maintenance of appearance and as adjuncts to surgical treatment. Traditional cosmetic surgery results in a greater degree of change, and is best after the minimally invasive procedures have been used. It also depends on the result a person is looking to achieve.
This is why it is important to consult with a board-certified plastic surgeon who is well trained in all aspects of both non-surgical treatments as well as traditional surgical procedures, so that you may be offered the best possible treatment to reach your goals.
Q: Can a facelift be achieved using non-surgical facial rejuvenation procedures?
A: The so-called Liquid Facelift restores volume to areas which have hollowed, and decreases the appearance of wrinkles. It is a combination of toxins to relax specific facial lines and fillers to add volume to key areas.
Q: What is the difference between toxin and facial fillers, which both are injectables?
A: Botulinum toxin (Botox®, Dysport®) is a highly purified neurotoxin that temporarily relaxes muscles. This effect causes facial lines and wrinkles to appear less prominent. It is also used to treat migraine headaches and excess sweating in the armpits and palms. The facial fillers, composed of a naturally-occurring substance in the body called hyaluronan, actually fill tissue in order to restore lost volume, augment lips, and minimize the appearance of deep wrinkles and scars.
Q: How long does it take for the results of a non-surgical rejuvenation to show?
A: Toxins take about three to four days to work. The results with filler are immediate.
Q: How soon can one return to work after a non-surgical rejuvenation procedure?
A: There is no downtime after these procedures. Many can even be done during your lunch hour.
Q: Can makeup be applied immediately after rejuvenation procedures?
A: It is best to wait until the following day in order to apply makeup so that the injection sites may heal.
Q: Do non-surgical rejuvenation procedures produce bruises or flaws on the face?
A: Bruising is a potential after-effect of any injection. It is more common in patients who take blood thinners such as aspirin or herbal remedies.
Q: How many times can non-surgical rejuvenation procedures be repeated?
A: These procedures can be repeated as often as is needed to achieve the desired results. Toxins last anywhere between four and twelve months depending on the anatomic area. Fillers often need replenishment every nine to twelve months. They break down faster in areas that have more movement, such as right around the mouth.
Q: How do the non-surgical methods compare with surgical methods in terms of results, cost, and duration?
A: Non-surgical methods tend to cost less than traditional surgery, allow for a quicker recovery, and produce a more subtle result. It is best to consult with a board-certified plastic surgeon to determine which procedures will allow you to achieve your goals. A cost difference isn’t worth very much if you are not satisfied.
A board-certified plastic surgeon is the only physician specifically trained in all aspects of both
Q: How does one maximize and preserve the results of a skin rejuvenation procedure?
A: All skin benefits from hydration, from rest, and from sun protection at all times!
Q: What is the advantage of having non-surgical rejuvenation procedures performed by a plastic surgeon, instead of a dermatologist or other kind of physician?
A: A board-certified plastic surgeon is the only physician specifically trained in all aspects of both non-surgical treatments and traditional surgical procedures for facial rejuvenation. They have the unique ability to understand and offer both sets of procedures, allowing you to benefit from exactly what you need. If a practitioner only performs injections or only performs surgery, he/she may not have the ability to offer the combination that may be best for you, in terms of your desired goals.
Q: After undergoing non-surgical facial rejuvenation, when do you recommend a patient opt for surgery (if ever)?
A: When you have optimized your improvement with injectable and other non-surgical options, but still feel you are not at your goal, it is a good time to explore surgical options.
Q: Does insurance cover any of these rejuvenation procedures?
A: No, they are considered cosmetic, and cosmetic procedures are not covered.
Q: What is the Stony Brook difference with regard to having non-surgical facial rejuvenation procedures?
A: At Stony Brook Medicine all of our plastic surgeons are board certified in plastic surgery. Our plastic surgeons are leaders in their field and avid innovators. Some of their discovery work focuses on patient safety, treatment outcomes, and cosmetic injectables. It allows them to incorporate the most novel surgical and non-surgical techniques with a safe environment in order to provide our patients with the best outcomes.
Click here for more information about the plastic surgeons and the plastic surgery services at Stony Brook Medicine. Visit the Before & After Gallery of the American Society of Plastic Surgeons to see results of toxin and fillers.
Posted by Stony Brook Surgery on February 28, 2014
Following Outpatient Salivary Endoscopy at Stony Brook, Wedding to Go as Planned — Pain-Free and Happily
Tina Truglia had experienced excruciating pain in her jaw for nearly a decade and was misdiagnosed with everything from mumps to mono.
Eager to have her upcoming wedding free of pain, Ms. Truglia flew from Flagstaff, AZ, to Long Island earlier this month, trading in a June week of bridal festivities including her bachelorette party, for an appointment with Mark F. Marzouk, MD, assistant professor of surgery and member of our Otolaryngology-Head and Neck Surgery Division.
Ms. Truglia had been told by former doctors that she needed an operation to remove her salivary gland, something this 32-year-old bride-to-be did not want to do so close to her upcoming nuptials.
The current standard in most institutions for treating salivary duct stones has been surgical removal of the gland that entails an incision in the neck and an overnight stay in the hospital.
The conventional "open" operation also carries with it the potential complications of scarring, wound infection, and facial nerve injury.
Leaving the stones untreated would have left Ms. Truglia at risk for severe and repeated infections. With her wedding just months away, she turned to the web and searched for another solution.
Salivary endoscopy allows for minimally invasive salivary gland surgery in a
What and who she found was only 15 minutes away from the home she grew up in in Farmingville, NY.
During her appointment with Dr. Marzouk last week, he correctly diagnosed Ms. Truglia with five salivary duct stones, the size of baby teeth, embedded in her gland.
Ms. Truglia had a salivary endoscopy, the new minimally invasive salivary gland procedure that can be used for both diagnosis and treatment at Stony Brook University Hospital. This procedure is performed by only a few surgeons in the United States.
The patient was in and out of surgery within 25 minutes. She had all five stones removed by Dr. Marzouk during the endoscopy procedure. And following her post-op visit two days later, she returned to Arizona.
In 2010, soon after Dr. Marzouk joined our faculty, he performed the first salivary endoscopy ever done on Long Island. This minimally invasive technique allows for the examination of the salivary ducts under endoscopic guidance. Treatments, such as stone removal, duct dilatation, and steroid injection, can be done at the same time.
Sialolithiasis, or stone(s) in the salivary duct, is the most common disease of the salivary gland for which salivary endoscopy is done. It affects approximately 12 in 1,000 adults. Symptoms include pain, intermittent swelling of the gland, and possibly severe infection.
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.
Salivary endoscopy is a minimally invasive procedure. It allows for salivary gland surgery in a safe and effective way, and is done on an outpatient basis. Originally developed in Switzerland, salivary endoscopy is truly one of the most fascinating and patient-centered innovations introduced in the recent years in the field of otolaryngology-head and neck surgery.
Since Dr. Marzouk started performing salivary endoscopy at Stony Brook, he has attracted numerous patients from around the world, who travel to be cared for by him, in order to obtain the relief they seek without having a conventional operation.
For consultations/appointments with Dr. Marzouk, please call 631-444-4121. Watch this video (1:27 min) to see him do a salivary endoscopy with stone removal:
Posted by Stony Brook Surgery on February 25, 2014
Better Survival Rate Associated with Sentinel Node Biopsy; Disease Spread Detected and Treated Sooner
The New England Journal of Medicine just published the long-term results of the Multicenter Selective Lymphadenectomy Trial (MSLT-I). The report is attracting a good deal of attention for good reason.
This large, randomized international clinical trial, which began in 1994, provides the basis for utilizing sentinel node biopsy in patients with melanoma. The initial trial results indicated that evaluating the first draining lymph nodes with sentinel lymph node biopsy is feasible and accurate.
Lymph nodes are small, pea-sized structures throughout the body that work as filters for harmful substances; they contain immune cells that can help fight infection and disease (read more).
In melanoma management, a sentinel node biopsy removes the lymph node nearest a lesion and tests it for evidence of cancer. If the sentinel node is unaffected, the cancer is highly unlikely to have spread to surrounding lymph nodes or distant sites in the body.
The new report, titled "Final Trial Report of Sentinel-Node Biopsy versus Nodal Observation in Melanoma," provides the long-term follow-up data for the original clinical trial.
The largest and most important trial of sentinel node biopsy for melanoma conducted to date
These latest findings are important for several reasons. First, they confirm that sentinel node biopsy is useful for diagnosis of metastases; that is, for determining if the cancer has spread. Second, they reaffirm that sentinel node biopsy is the most powerful prognostic indicator. With newly approved adjuvant therapy regimens available for patients, this information is extremely important.
The long-term follow-up data also confirm that sentinel node-guided management protects against melanoma nodal recurrence. While nodal metastases can be removed when they are detected as palpable masses, these recurrences can substantially compromise quality of life and significantly increase the risk of long-term morbidity.
Our melanoma program at the Stony Brook University Cancer Center offers the most up-to-date treatment options for our patients. This latest research supports our current practice of offering sentinel node biopsy for patients with melanoma deeper than 1 mm (thickness of a dime). Currently, there are minimal data to support sentinel node biopsy for thin melanomas less than 1 mm deep, although its use may be considered in certain high-risk patients.
In addition, we are currently enrolling patients at Stony Brook into the Multicenter Selective Lymphadenectomy Trial II (MSLT-II). This randomized, international clinical trial is examining survival benefits for completion node dissection (removal of all lymph nodes in area with affected sentinel node). Participation in our clinical trials is always completely voluntary, and never interferes with the normal standards for patient care.
Click here to read the abstract of the study in The New England Journal of Medicine. For consultations/appointments with the surgical specialists of the Stony Brook Melanoma Team, please call 631-444-4666.
Posted by Stony Brook Surgery on February 18, 2014
Stony Brook Medicine Is 1 of 12 Institutions Nationwide Using ProvenCare in the Management of Lung Cancer
The current enthusiasm in lung cancer is focused on screening. Recently it was reported that screening for lung cancer has cleared the initial hurdles for Medicare reimbursement, and with the endorsement of screening by leading national organizations, a seemingly endless stream of media attention has been created.
This enthusiasm is justified by the fact that the earlier lung cancer can be detected, the better the chance is of obtaining a cure.
Often overlooked in this enthusiasm is the fact that even if lung cancer is detected at its earliest stage and treated with surgery, the most aggressive form of treatment available, five-year survival is far from being 100%. The best five-year results are reported in the mid 80% for stage 1 non-small cell lung cancer.
An alternative approach to improve on the care of patients with lung cancer was started in July 2010 when under the lead of Geisinger Health System and the American College of Surgeons Commission on Cancer, six institutions got together to form a consortium which thought to improve outcome by improving the overall reliability for patients who have proven non-small cell lung cancer.
Thus, the ProvenCare Lung Cancer Collaborative came into existence. This collaborative was expanded in 2012 with Stony Brook Medicine being one of only 12 institutions nationwide invited to join (read more).
Stony Brook Medicine offers nationally recognized, high reliability, up-to-date care
The collaborative seeks to use a model from the auto industry whereby 27 process measures are used on a pass/fail basis. This means that if only 1 of 27 process measures is missed, a patient is categorized as a failure in the analysis. The measures are commonly used methods of care utilized in hospitals throughout the United States.
The collaborative started out with a 40% overall reliability rating and slowly improved with the first wave to a reliability of about 75%.
At that point, the second six institutions, among them Stony Brook, joined the collaborative and the overall reliability slowly improved further. It only passed 90% in April 2013, but has reached a consistent 100% over the past three months.
A total of 1300 patients are now being tracked. While it is too early to tell if these process improvements will lead to better five-year survival, it should be reassuring to patients treated at Stony Brook that utmost attention to the most up-to-date care processes are being adhered to on a daily basis.
For the patients trying to decide where to go for screening with low-dose CT scans, one thing to consider might be what happens with the information obtained. At Stony Brook, the most sophisticated non-invasive technologies, including navigational bronchoscopy and endobronchial ultrasound (EBUS) bronchoscopy and PET/MRI imaging, are used to establish a tissue diagnosis of suspicious nodules.
If treatment then becomes necessary, Stony Brook offers nationally recognized, high reliability, up-to-date care, specifically tailored to patients with lung cancer.
Visit the Lung Cancer Evaluation Center (LCEC) of the Stony Brook University Cancer Center to learn more about the Stony Brook difference in caring for patients with lung cancer. For our screening program, please call 631-444-2981.
Posted by Stony Brook Surgery on February 11, 2014
Using Latest Advance in Patient Care; New Percutaneous Endovascular Approach Called PEVAR
Our Vascular Surgery Division is now providing a new minimally invasive procedure for treatment of aortic aneurysms. The procedure is called percutaneous endovascular aneurysm repair (PEVAR).
The first PEVAR at Stony Brook Medicine was done in April 2013. Since then, over a dozen patients have undergone the procedure with excellent results, and more patients are asking for it.
PEVAR is the latest form of advanced minimally invasive treatment of abdominal aortic aneurysms (AAAs). It does not require a surgical incision, which makes it especially attractive to patients.
Patients who have PEVAR often experience even less pain and discomfort than with traditional endovascular aneurysm repair (EVAR), leading to even faster recovery and no need for narcotic medications.
Patients seeking treatment for abdominal aortic aneurysms may now undergo
Our vascular surgeons' use of PEVAR further distinguishes the care provided by the multidisciplinary Stony Brook Aortic Center, which is the only center of its kind in our area for patients with aortic conditions. Our aortic specialists are committed to using the latest technologies to provide the best possible treatments.
"The majority of patients with AAA are candidates for PEVAR," says Shang A. Loh, MD, assistant professor of surgery and one of the leaders of the Aortic Center.
"Eligibility for PEVAR depends greatly on the quality of the femoral arteries in the groins which are the access sites for EVAR. Factors such as calcium content and atherosclerotic disease in these vessels may preclude the ability to use the PEVAR technique."
"The PEVAR technique is especially attractive for certain patients, such as those who are obese or diabetic, because it minimizes potential wound infections."
Food and Drug Administration (FDA) approval of PEVAR was given in April 2013, based on the outcomes of the first prospective, multicenter, randomized clinical trial (the PEVAR trial); the latest report describing the trial was published in the Journal of Vascular Surgery.
AAA ("triple A") is a bulging, weakened area in the wall of the abdominal aorta — the body's largest artery — resulting in an abnormal widening or ballooning, something like a bulge on an overinflated tire.
A potentially life-threatening condition, AAA has been dubbed the "silent killer" because it seldom gives warning signs. AAA is fatal in most cases if the aneurysm ruptures before being repaired. Therefore, early detection and repair are crucial.
An estimated one million Americans live with an undiagnosed AAA — including 20,000 in Suffolk County alone. According to the Centers for Disease Control and Prevention, AAA is more common in men and in individuals aged 65 years and older, particularly those with a current or remote history of smoking and with a family history of aneurysms.
About the Procedure
To repair the AAA, the surgeon uses two small puncture sites in both groins, as there is no need for an incision. The endovascular (within the vessel) repair involves a self-expanding stent that seals off the aneurysm, maintaining blood flow without risk of rupture. The patient typically goes home the day after surgery, and has minimal, if any, discomfort.
Traditional open surgical repair of AAA involves an extensive operation involving a long abdominal incision. The approach to repair changed dramatically in the late 1990s, when the FDA approved EVAR, a minimally invasive procedure that requires relatively small incisions made in each groin to access the femoral artery.
During that same period, surgeons began to investigate performing EVAR through a small puncture site in the skin above the femoral artery in the groin, rather than through a surgical groin incision. The first published report appeared in 1999.
Patients who undergo PEVAR may find it hard to believe that their aneurysm
In PEVAR, the stent graft is inserted through the puncture site, under fluoroscopic guidance, and finally deployed in the aorta.
The hole in the artery is closed using a series of sutures placed through the skin puncture site, which itself is so small that it heals without any sutures. Once the stent is released within the aneurysm, blood flows through the new graft. The aneurysm, then, slowly shrinks and is no longer a threat to the patient.
"We have used PEVAR to treat twelve patients so far at the Stony Brook Aortic Center, and have had excellent results," says Apostolos K. Tassiopoulos, MD, professor of surgery and chief of vascular surgery, who is a co-director of the Aortic Center.
"Not everyone is a candidate for this procedure, however," Dr. Tassiopoulos adds, "because patients must have large enough femoral arteries with minimal arterial calcification, and meet other selection criteria. That said, the benefits of PEVAR will certainly appeal to AAA patients who should ask to be evaluated for it."
For consultations/appointments with our vascular surgeons, please call 631-444-2683. Click here for information about our free-of-charge AAA screening program provided by the Vascular Surgery Division.
Posted by Stony Brook Surgery on February 6, 2014
Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment for symptomatic gallstones and other gallbladder conditions.
Surgical options include the standard procedure, called laparoscopic cholecystectomy, and the older, more invasive operation, called open cholecystectomy, which requires a 5- to 7-inch incision in the abdomen.
The laparoscopic procedure is deemed minimally invasive because it requires only a few small openings. Laparoscopy also has the benefit of shorter hospital stay and fewer wound problems.
Gallstone disease is one of the most common and costly of all digestive diseases, with approximately 20 million Americans having the disorder.
Annually, gallstone disease leads to more than one million hospitalizations, 700,000 operative procedures, and a cost of $5 billion. Furthermore, the prevalence of gallstones increases with age: 15% of men and 24% of women will have gallstones by age 70.
Complications related to gallstones are more common in elderly patients, with the most common being acute cholecystitis, a sudden inflammation of the gallbladder, which can cause abdominal pain, nausea, vomiting, and fever.
Understanding the best approach to treating elderly patients with gallstone disease is, thus, very important, especially in view of the fact that the oldest old — people age 85 or older — now constitute the fastest growing segment of the U.S. population.
A study was recently published in the Journal of the American College of Surgeons (see abstract) evaluating the safety of ambulatory laparoscopic cholecystectomy in patients over 65 years of age.
Outpatient gallbladder surgery has become commonplace in surgical care, allowing patients to go home the day of surgery, rather than staying in the hospital. This is also common practice at Stony Brook Medicine, but has not been studied specifically in the elderly population.
The authors of this study used a quality and outcomes database (NSQIP) maintained by the American College of Surgeons to address this question. They were able to identify 15,248 elderly patients having laparoscopic gallbladder surgery from 2007 to 2010, approximately half of which were performed on an outpatient basis. The average age of the patients studied was in the mid-70s.
The patients were not randomized, so it is likely that sicker patients had hospital admission, which proved true across several measures. Bleeding disorder, dialysis, and heart failure were the most common predictors of admission.
Not surprisingly, the admitted patients also suffered more complications, including mortality. The authors concluded that elective laparoscopic gallbladder surgery can be safely performed in healthy elderly patients, as demonstrated by low complication rates.
This observation is similar to what we have found at Stony Brook. We at Stony Brook are taking it one step further by allowing select elderly patients needing emergency gallbladder surgery to have the laparoscopic procedure without hospital admission, as well.
For more information about gallbladder surgery at Stony Brook, please make an appointment with one of our general surgeons by calling 631-444-4545. To learn more about the laparoscopic procedure, see the SAGES page about it.
Posted by Stony Brook Surgery on January 21, 2014
New Unit Will Help Improve Patient Care & Continue to Serve as Only Designated Burn Center in Suffolk County
After more than two years of planning and over six months of renovation, Stony Brook Medicine celebrated the dedication of the newly relocated Suffolk County Volunteer Firefighters Burn Center on January 16. The Burn Center recently underwent a move from the 4th level to the 8th level of the hospital and a multi-million dollar transformation, creating an enhanced and comfortable environment for patient care and healing.
The upgraded 7,200-square-foot unit has an expanded debridement and bandaging area, larger treatment rooms, and six private patient rooms with large windows with a southerly view of Eastern Long Island. In keeping with the hospital's patient- and family-centered care philosophy, these bright and spacious patient rooms are able to accommodate overnight visitors who wish to stay with their loved ones.
The Suffolk County Volunteer Firefighters Burn Center Fund was formed in 1986, two years after the Burn Center was established by the founding chairman of surgery, Harry S. Soroff, MD, who had a special interest in burn care and who forged an alliance with the county's volunteer firefighters. The Fund's mission is to help burn victims, and the organization of firefighters behind it has been working in partnership with Stony Brook University Hospital ever since.
The organization holds fundraisers, generates private and corporate donations, provides burn garments for patients who cannot afford them, purchases important equipment, supports special clinical and research initiatives, and aids in community educational seminars. The new Burn Center was named to honor these volunteer firefighters, in recognition of and thanks for their support.
"This all-volunteer group epitomizes the true meaning of community service. Over the past 25-plus years, they have generously donated more than $1 million in support of Stony Brook's Burn Center," said Kenneth Kaushansky, MD, dean of the School of Medicine. "There simply could not be a group more befitting the honor of having this caring center named in its honor."
"The key to managing any type of burn, but particularly the more severe kind, is to get appropriate treatment as quickly as possible. That means not only going to a facility with the advanced expertise, protocols, and equipment, but also one that has these capabilities 24/7. For this reason, our Burn Center has long been the go-to facility in Suffolk County." — Dr. Steven Sandoval, medical director, Burn Center
Since 1984, Stony Brook has been the only hospital in Suffolk County certified by the American Burn Association to treat both adults and pediatric patients. It is the only designated burn care facility for the more than 1.5 million Suffolk County residents, and coordinates burn services throughout the region, and conducts training and research in burn care.
"The Suffolk County Volunteer Firefighters are not just a resource for Stony Brook's Burn Center, but for the entire county, as their reach extends far beyond the four walls of this hospital," said L. Reuven Pasternak, MD, CEO of University Hospital.
"The firefighters' Fund has supported many public education programs focused on prevention of burns and fires. They provide outreach to all hospitals in Suffolk County, working with staff to evaluate and care for burn patients who may come to their facilities. They teach the importance of transferring burn patients to a burn center, which has significantly more resources to care for those types of patients. On behalf of Stony Brook University Hospital, I want to personally thank the Suffolk County firefighters for their enduring support of our Burn Center. You have made today possible," said Dr. Pasternak.
At the Burn Center, which is a specialty center of the Department of Surgery, patients receive quality care provided by a highly specialized burn team, including surgical critical care physicians and nurses, respiratory therapists to plastic surgeons, physical therapists, and occupational therapists, using sophisticated equipment designed to ease patient's pain, fend off complications, and promote healing.
"In burn care, we have a saying: 'time is tissue.' That's because advanced burn care, provided in a timely fashion, can make a tremendous difference in the patient's outcome," said Steven Sandoval, MD, medical director of the Burn Center. "It's fair to say that the generous support of the Suffolk County Volunteer Firefighters has made a tremendous difference. A difference that is meaningful and real."
Burn Center patient, Erik Unhjem, who survived a plane crash in Shirley in August of 2012, gave special thanks to the Suffolk County Volunteer Firefighters and all of the Burn Center staff for the care he was given.
"Coming to Stony Brook gave me the opportunity at a second chance at life," said Mr. Unhjem.
"This is an exciting day for Suffolk County. Today we are opening the doors to the newly renovated, newly named, state-of-the-art burn unit," said John Lussa, president of the Suffolk County Volunteer Firefighters Burn Center Fund. "And without the 109 fire departments and the 28 ambulance companies in Suffolk County, this project would have never been accomplished," added Mr. Lussa, who went on to thank Dr. Sandoval and the entire Burn Center staff for their devotion to patient care.
Participating in the ceremony were Senator John Flanagan, Senator Kenneth P. LaValle, Assemblyman Steve Englebright, Suffolk County Executive Steve Bellone, and Suffolk County Legislator Kara Hahn.
"It took a team, a lot history, and a lot of individuals to make this all happen today," said Senator LaValle. "The people who work here are very, very special because this type of care takes a true labor of love. The road to opening this new center was not a smooth one; it started with the volunteer firefighters, and they have been on the front lines to make sure it was not taken away, and for that I thank them."
Read about our Living Skin Bank that further distinguishes the Suffolk County Volunteer Firefighters Burn Center, and demonstrates our commitment to advancing patient care through innovation.
Posted by Stony Brook Surgery on January 13, 2014
Some women continue to experience pain one year after breast cancer surgery, according to a new study published in the Journal of the American Medical Association (JAMA), titled "Pain at 12 Months after Surgery for Breast Cancer." The study, conducted in Finland, is making news and calls for commentary to put it in perspective.
The study involved 860 women younger than 75 years of age who had undergone surgery for breast cancer that had not spread to other parts of their body.
The study revealed that one year after surgery, about one-third of the women reported no pain. The investigators found, however, that nearly 50% did experience mild pain, 12% had moderate pain, and almost 3% felt severe pain.
This is an important study as it reminds physicians of all specialties to expand their focus beyond treatment successes, and to consider, as well, what happens to the patient long after treatment. Side effects and other treatment-related sequelae are important factors too — all affecting overall quality of life.
In this particular study, 15% of breast cancer patients still reported moderate or severe pain 12 months after breast cancer treatment. Factors most closely associated with this pain included complete axillary lymph node dissection (ALND), radiation therapy, and depression.
The good news here is that fully 85% of breast cancer patients in this study had
Fortunately, several recent breast cancer advances have come on the heels of well-done scientific studies confirming the safety of lesser treatments.
Sentinel node biopsy (SNB), rather than ALND, is now the standard of care for operative management of the axilla in most patients with breast cancer. The less invasive approach offered by SNB spares a large number of women the morbidity (and pain) of full ALND.
Partial breast irradiation (PBI) has emerged as an alternative to conventional whole breast radiation. This shortened 5-day course of radiation is delivered to the lumpectomy site only, as compared to conventional whole breast radiation, which is delivered to the entire breast over the course of 6-7 weeks.
Less radiation should result in less long-term pain, and the PBI approach appears to be an effective option for some carefully selected women with breast cancer.
Nowadays, personalized breast cancer treatment decisions based on genomic testing of cancer tissue (Oncotype DX) can identify patients who can be effectively treated without chemotherapy.
Finally, we now have a greater understanding and appreciation of the significant emotional and psychological trauma resulting from cancer treatments. Patients suffering from depression report more bodily pain. Routine psychological screening may permit early intervention. We have made great strides in this regard, but there is still a lot of work to be done.
The good news here is that fully 85% of breast cancer patients in this study had only mild pain or no pain at all 12 months after breast cancer treatment.
Still, the most important aspect of this study is that it reminds us all to be more mindful of treatment-related morbidities. As surgeons, we should all be concerned about long-term pain issues, and should take this into consideration when prescribing treatment plans.
Going forward, treatment-related morbidities such as chronic pain should and will take on greater importance when considering options, as a greater emphasis is being placed on not only treatment successes but resultant quality-of-life issues.
To learn more about treatment options for breast cancer, please call 631-638-1000 for a consultation/appointment with one of our breast surgeons.
Posted by Stony Brook Surgery on January 2, 2014
I am the new chairman of the Department of Surgery at Stony Brook Medicine, and I am very happy to be able to use our Surgery Blog to communicate with the public in an interactive way about health matters, in particular those related to surgery and what surgical patients need to know.
My primary goal with the "Chairman's Corner" of the blog is to provide commentary about new developments in surgery and its subspecialties, in order to help people better understand them; that is, what they mean, and how they will affect patient care.
Since it was launched two years ago, our blog has aimed to educate the public about new surgical innovations, controversies in surgical care, and issues of importance in surgical news.
It is my intention to further this educational mission, and to provide useful perspectives here on such matters to the Long Island community, as well as to interested people elsewhere.
The past year, for instance, has seen the following important developments: the first five-organ transplant (liver, pancreas, stomach, small and large intestine) in a three-year-old boy, the proven effectiveness of bariatric surgery for diabetes, and of course the implications of the Affordable Care Act — all of which the public needs to understand. I will be following them and blogging about them.
With my blogs I will provide commentary about new developments in
As for my new role at Stony Brook Medicine, let me take this opportunity to say I believe that departments of surgery have their greatest impact through innovation and excellence. The Stony Brook Department of Surgery has a long tradition of surgical excellence. This tradition provides a strong foundation on which we can further define and practice surgical excellence.
Our Department of Surgery has great potential to improve surgical care through innovation in the coming years. Why?
First, we have a spectacular faculty brimming with energy and creativity. Second, we are part of a major university with great strength in engineering and computer sciences. In particular, our bioengineering department is deeply engaged in device and procedural innovation. Third, we are located on Long Island, where the development of new ideas can be fostered.
I am tremendously excited about putting all of these pieces together and seeing great success in our efforts to advance surgery and patient care. And I am honored to have the opportunity to serve the Stony Brook Department of Surgery to fulfill the surgical aspect of the Stony Brook Medicine vision.
Please use the comments feature here to provide your responses to my blogs, and also to send me questions related to them. I will respond as quickly as I can.