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Stony Brook Surgery Blog

Posted by Stony Brook Surgery on August 10, 2018

Learn about This Poorly Understood Motility Condition Affecting Millions

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Click on image to download poster.

August is National Gastroparesis Awareness Month. First listed on the U.S. National Health Observances Calendar in 2016 with sponsorship by the International Foundation for Functional Gastrointestinal Disorders, this awareness initiative aims to focus attention on diagnosis, treatment, and quality of life issues associated with this poorly understood motility condition that prevents the stomach from properly emptying.

Gastroparesis, or delayed gastric emptying, is a stomach disorder in which food moves through the stomach into the intestines slower than normal. (The etymology of "gastroparesis" is: gastro- from ancient Greek γαστήρ gaster, "stomach" and πάρεσις -paresis, "partial paralysis.")

Patients often experience chronic nausea, vomiting, bloating, feeling full too soon after starting to eat, and weight loss. It is a debilitating condition, at times requiring hospitalization, and can significantly affect a person's quality of life.

Common causes include diabetes and previous surgery. Diabetes has been noted to be a cause in 30% of gastroparesis cases. However, neurological disease, collagen vascular disorders, viral infection, and drugs have all been blamed.

The Stony Brook Gastroparesis Center offers state-of-the art treatment.

Gastroparesis is believed to occur in 9.6 per 100,000 people in men and 37.8 per 100,000 people in women. A recent study has also demonstrated an increase in gastroparesis-related hospital admissions by nearly 300% over a 16-year period.

Gastroparesis may result in the following complications, which, in addition to potentially problematic symptoms, justify treatment:

  • Severe dehydration: This condition is due to chronic vomiting.
  • Malnutrition: Patients tend to have poor appetites and cannot meet their daily caloric requirements.
  • Poor glucose control: Poor control over the amount and rate of food passing from the stomach to the small bowel can cause poorly controlled blood sugar levels.
  • Poor quality of life: Symptoms can make it difficult to maintain a normal quality of life and may affect a patient's work and social life.

Gastroparesis, if not cured, requires management with a long-term care plan.

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The Stony Brook Gastroparesis Center, established earlier this year under the direction of Salvatore Docimo Jr., DO, MS, offers a multidisciplinary approach that brings together experts in the areas of surgery, gastroenterology, psychology, and nutrition.

Our center's goal is to provide patients with digestive disorders, especially gastroparesis, a wide spectrum of diagnostic and treatment options under one roof.

This past May, Dr. Docimo performed Suffolk County's first per-oral pyloromyotomy (POP) — a novel, minimally invasive procedure to treat gastroparesis.

Now at the forefront of gastroparesis treatment, the POP procedure (also known as G-POEM that stands for gastric per-oral endoscopic myotomy) is a newly developed treatment offering patients attractive benefits, compared with other surgical therapies for gastroparesis.

It was in July 2016 that U.S. Senator Tammy Baldwin (WI) introduced a statement for the record on behalf of the millions of Americans affected by gastroparesis recognizing National Gastroparesis Awareness Month.

Senator Baldwin said: "Unfortunately, gastroparesis is a poorly understood condition, and so patients often suffer from delayed diagnosis, treatment, and management of this disorder. As such, further research and education are needed to improve quality of life for this patient population."

Senator Baldwin urged her fellow colleagues to join her "in recognizing August as National Gastroparesis Awareness Month in an effort to improve our understanding and awareness of this condition, as well as support increased research for effective treatments for gastroparesis" (read her entire statement).

She succeeded in Congress, and so August now is National Gastroparesis Awareness Month, a good time to learn about this poorly understood motility condition affecting millions and apparently on the rise.

The newly established Stony Brook Gastroparesis Center, under the direction of Dr. Salvatore Docimo Jr., offers a multidisciplinary approach that brings together experts in the areas of surgery, gastroenterology, psychology, and nutrition. The center's goal is to provide patients with digestive disorders, especially gastroparesis, a wide spectrum of diagnostic and treatment options under one roof.

Learn more about gastroparesis. For consultations/appointments with the specialists of the Gastroparesis Center, please call 631-444-8330/-2274.

Posted by Stony Brook Surgery on July 27, 2018

Gastroschisis Is on the Rise in Our Region and across the Nation

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Baby Christian Rojas with his mother and father and Dr. Christopher S. Muratore (center) yesterday at Stony Brook Children's Hospital.

Christian Rojas, of Port Jefferson Station, was born at Stony Brook Children's Hospital on May 5th at 35 weeks with a life-threatening condition of the abdominal (belly) wall called gastroschisis (pronounced gas-troh-skee-sis).

Through a series of operations, Christopher S. Muratore, MD, chief of pediatric surgery, and his team at Stony Brook Children's Hospital, were able to save the baby, untwist the bowel, and rescue him in time.

Now the baby is being prepared to go home soon from the hospital.

Today, Christian's story is featured in Newsday, our regional newspaper, where the headline is "Stony Brook Helps Infant Survive Congenital Disorder" (read it; login required).

Christian weighed in at a low birth weight of 5 pounds 7 ounces but is now nearly 11 pounds and hitting some key targets. More good news!

Gastroschisis is a birth defect of the abdominal wall. The baby's intestines are found outside of its body, exiting through a hole beside the belly button. The hole can be small or large and sometimes other organs, such as the stomach and liver, can also be found outside of the baby's body.

Gastroschisis requires surgical repair soon after birth, and is associated with an increased risk for medical complications and mortality during infancy.

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Baby with gastroschisis (illustration courtesy of the Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities).

The Centers for Disease Control and Prevention (CDC) estimates that about 1,871 babies are born each year in the United States with gastroschisis, but several studies show that recently this birth defect has become more common, particularly among younger mothers.

CDC researchers recently found that over 18 years, the prevalence of gastroschisis more than doubled in the United States. More research is needed to understand what is causing the increase.

The Newsday article, written by Delthia Ricks, highlights Dr. Muratore's description of the baby's case as "extraordinarily complicated and marked by an extreme twist in the bowel, a condition called midgut volvulus; the contortion threatened the bowel's blood supply."

"Many babies with gastroschisis will suffer the consequence of intestinal failure," Dr. Muratore is quoted as saying. Soon after Christian was born, Dr. Muratore and his pediatric surgery team embarked on a series of surgeries to save the baby's life.

"When we recognized the intestine was twisted, we did what we needed to do to untwist it," he explains. He worked closely with a team of five surgeons, 10 neonatologists — newborn care specialists — and a squad of nurses. Christian has been monitored around the clock since arriving in Stony Brook Children's neonatal intensive care unit (NICU).

Dr. Muratore points out that he and his Stony Brook colleagues have seen a number of babies in our area with gastroschisis. Stony Brook Children's treats about 10 cases of it annually.

Outcomes in gastroschisis have changed dramatically in the past four decades, with the advent of improved neonatal intensive care unit, surgical, obstetric, and nutritional care. Overall, survival went from 50% to 60% in the 1960s to greater than 90% currently.… The improved survival and diminished morbidity from gastroschisis may be noted from the fact that up to 60% of children will report psychological stress at the absence of a normal umbilicus, and this may be the most prevalent long-term issue requiring reconstruction in some cases. — "Advances in Surgery for Abdominal Wall Defects," Clinics in Perinatology (2012)

Learn more about gastroschisis from the Centers for Disease Control and Prevention. Watch the News12 piece (2:08 min) about Baby Christian:

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Posted by Stony Brook Surgery on July 17, 2018

Achieving the Highest Star Rating for Outcomes and Quality

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Our cardiothoracic surgeons: (left to right) Drs. Allison J. McLarty, Thomas V. Bilfinger, Vinay M. Tak, Joanna Chikwe, and Henry J. Tannous.

We are very pleased to announce that our Cardiothoracic Surgery Division has earned the highest quality rating of three stars from the Society of Thoracic Surgeons (STS) for its overall patient care and outcomes in isolated coronary artery bypass graft (CABG) procedures, based on the latest analysis of data from January to December 2017.

This achievement places us among the elite for heart bypass surgery in the United States and Canada.

The STS star rating system is one of the most sophisticated and highly regarded overall measures of quality in healthcare, rating the benchmarked outcomes of cardiothoracic surgery programs across the United States and Canada.

The star rating is calculated using a combination of quality measures for specific procedures performed by an STS Adult Cardiac Surgery Database participant.

The three-star rating, which denotes the highest category of quality, places us among the elite for heart bypass surgery in the United States and Canada.

Historically, approximately 10% to 15% of participants receive the three-star rating for isolated CABG surgery.

"The Society of Thoracic Surgeons congratulates STS National Database participants who have received three-star ratings," says David M. Shahian, MD, chair of the STS Council on Quality, Research, and Patient Safety.

"Participation in the database and public reporting demonstrates a commitment to quality improvement in healthcare delivery, and helps provide patients and their families with meaningful information to help them make informed decisions about healthcare."

"Knowing which hospitals have superior results is a huge advantage for patients," says Joanna Chikwe, MD, chief of cardiothoracic surgery and director of the Stony Brook Heart Institute. They can have peace of mind knowing they're getting care from one of the top-rated facilities in the nation."

"Everybody recognizes that the STS standards reflect overall best practices in cardiac surgery, and our achievement of top performance in isolated CABG surgery reflects our approach to all types of cardiac surgery," says Martin Griffel, MD, chief medical officer, Stony Brook Medicine.

Knowing which hospitals have superior results is a huge advantage for patients, who can have peace of mind knowing they're getting care from one of the top-rated facilities.

Dr. Chikwe adds: "This is a huge accomplishment by the entire cardiac team. Each year only a handful of heart surgery centers in the whole of New York State claim this top rating for outcomes and quality in coronary bypass surgery.

"This is the first time we have participated, and our team can feel extremely proud of this important recognition of the truly superb care our patients receive here.

"The quality of the team is the most important contributing factor as how a patient is going to feel, not just tomorrow but in a week's time and a year's time and in 10 years' time. We want patients to have the best quality of life and the longest life possible."

There are around 300 people on the Heart Institute team, including nurses and nurse practitioners, perfusionists, physician assistants, physiotherapists, respiratory support technicians, residents and attending physicians in the cardiac surgery operating rooms, anesthesia and critical care, cardiology and cardiac surgery stepdown floors and outpatient clinics; as well as care coordinators, dieticians, social workers, and administrative, technical, and housekeeping support in cardiology and cardiac surgery.

"Additionally, we draw heavily on the support of a wide range of services outside the Heart Institute," says Dr. Chikwe, "including vascular and general surgery, pulmonology, nephrology, neurology, radiology, and endocrinology."

The STS is a not-for-profit organization that represents more than 7,300 surgeons, researchers, and allied healthcare professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest.

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Our new state-of-the-art cardiac surgery unit — opening this fall in the new Hospital Pavilion adjoined to University Hospital — will further enhance the care provided by our Cardiothoracic Surgery Division. It will include an entirely new intensive care unit (ICU) with 10 rooms designed especially for patients having cardiothoracic procedures, plus 16 contiguous stepdown rooms. The current ICU will become new cardiac operating rooms (ORs) to go with the new hybrid ORs that are already up and running.

For consultations/appointments with our heart surgeons, please call 631-444-1820. The new STS star ratings will be posted on the STS website in August 2018.

Posted by Stony Brook Surgery on July 2, 2018

Offering a New Patient-Friendly Solution to Treat Delayed Gastric Emptying

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Dr. Salvatore Docimo Jr.

Salvatore Docimo Jr., DO, MS, of our Bariatric, Foregut, and Advanced Gastrointestinal Surgery Division, has just performed Suffolk County's first per-oral pyloromyotomy (POP) — a novel, minimally invasive procedure to treat gastroparesis.

The POP procedure, also known as G-POEM that stands for gastric per-oral endoscopic myotomy, is a newly developed treatment offering patients attractive benefits, compared with other surgical therapies for gastroparesis.

Gastroparesis, or delayed gastric emptying, is a stomach disorder in which food moves through the stomach into the intestines slower than normal. (The etymology of "gastroparesis" is: gastro- from ancient Greek γαστήρ gaster, "stomach" and πάρεσις -paresis, "partial paralysis.")

Patients often experience chronic nausea, vomiting, bloating, feeling full too soon after starting to eat, and weight loss. It is a debilitating condition, at times requiring hospitalization, and can significantly affect a person's quality of life.

Common causes include diabetes and previous surgery. Diabetes has been noted to be a cause in 30% of gastroparesis cases. However, neurological disease, collagen vascular disorders, viral infection, and drugs have all been blamed.

POP is a novel, minimally invasive procedure at the forefront of gastroparesis treatment.

Gastroparesis is believed to occur in 9.6 per 100,000 people in men and 37.8 per 100,000 people in women. A recent study has also demonstrated an increase in gastroparesis-related hospital admissions by nearly 300% over a 16-year period.

"POP is a novel, minimally invasive procedure that is at the forefront of gastroparesis treatment. We are excited to offer the POP procedure as an option for our patients," says Dr. Docimo.

Gastroparesis may result in the following complications, which, in addition to potentially problematic symptoms, justify treatment:

  • Severe dehydration: This condition is due to chronic vomiting.
  • Malnutrition: Patients tend to have poor appetites and cannot meet their daily caloric requirements.
  • Poor glucose control: Poor control over the amount and rate of food passing from the stomach to the small bowel can cause poorly controlled blood sugar levels.
  • Poor quality of life: Symptoms can make it difficult to maintain a normal quality of life and may affect a patient's work and social life.

Surgical treatment options for gastroparesis are reserved for patients with symptoms that have not responded well to lifestyle/dietary modifications and medical management.

The surgical options include implantation of a gastric electrical stimulator, placement of feeding tubes, pyloroplasty (open or laparoscopic), total gastrectomy (removal of the stomach), and the POP procedure (read more).

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The stomach showing location of pylorus (red circle); source, Henry Gray's Anatomy of the Human Body (1918). (Click on image to enlarge.)

POP is the most minimally invasive surgical option, using an endoscope (thin flexible tube). It is an alternative to more conventional pyloroplasty, in which the pylorus — a disc-shaped muscle that allows emptying of the stomach — is cut.

The cutting of this muscle aims to improve passage of food contents from the stomach into the small intestine.

With POP, there generally are no incisions made on the body, as everything is done through an endoscope that is passed through the mouth, into the esophagus, and down into the stomach.

The physician uses a small knife at the tip of the endoscope to create a tunnel to the pylorus, which is then cut, and the tunnel is closed.

The POP procedure offers an option for patients who need to avoid the problems associated with surgery. Most patients will be in the hospital for one day and require a post-procedural upper gastrointestinal study to ensure the effectiveness of the procedure.

The newly established Stony Brook Gastroparesis Center, under the direction of Dr. Salvatore Docimo Jr., offers a multidisciplinary approach that brings together experts in the areas of surgery, gastroenterology, psychology, and nutrition. The center's goal is to provide patients with digestive disorders, especially gastroparesis, a wide spectrum of diagnostic and treatment options under one roof.

Learn more about gastroparesis. For consultations/appointments with Dr. Docimo to discuss treatments for gastroparesis, please call 631-444-8330/-2274.

Posted by Stony Brook Surgery on June 25, 2018

Research by Our Bariatric Team Helps Make Weight Loss Surgery Safer

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Roux-en-Y gastric bypass showing the gastrojejunal anastomosis (red circle) where ulcers might occur.

Bariatric surgery is the most effective treatment for obesity, leading to long-term weight loss, improvements in quality of life, and reduction of obesity-associated medical problems, such as diabetes, sleep apnea, high blood pressure, high cholesterol, venous stasis disease (collection of blood in the lower limbs), and soft-tissue infections.

However, the surgery is associated with possible long-term complications.

Concerns about such complications represent a considerable barrier for eligible patients who consider bariatric surgery. One known long-term post-op complication for the Roux-en-Y gastric bypass (RYGB) procedure is anastomotic ulceration (AU). Symptoms of ulcer disease include abdominal pain (possibly severe) and nausea, among others.

The RYGB procedure, which currently is the most common bariatric procedure performed in the United States, uses a combination of restriction and malabsorption to reduce calories. During the procedure, the surgeon creates a smaller, egg-sized stomach pouch, using about 5% of the patient's stomach and separating off the rest (see illustration). The surgeon then attaches a section of the small intestine directly to the pouch.

AU is a condition in which ulcers develop where the small intestine is attached to the stomach pouch. Most ulcers of this kind respond to medical therapy, but complicated or complex lesions may require further surgery.

Tobacco-smoking has been implicated in the development of AU, but its role has not been well understood. The questions about it motivated the study just published in JAMA Surgery conducted by faculty in our Bariatric, Foregut, and Advanced Gastrointestinal Surgery Division.

A significant long-term risk of anastomotic ulceration after Roux-en-Y gastric bypass is associated with passage of time and history of tobacco use.

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Dr. Konstantinos Spaniolas

The title of the study is "Association of Long-term Anastomotic Ulceration after Roux-en-Y Gastric Bypass with Tobacco Smoking" (see preview). The first author of the study is Konstantinos Spaniolas, MD, associate professor of surgery and associate director of the Stony Brook Bariatric and Metabolic Weight Loss Center.

The aim of this study, according to the authors, was to describe the epidemiology of AU after RYGB and measure the association of tobacco smoking with long-term AU incidence.

The Statewide Planning and Research Cooperative System database of the Department of Health of New York State was used to identify 35,075 adult patients who underwent laparoscopic or open RYGB for obesity in the state of New York in 2005 through 2010.

The study found that 17.8% of patients with a history of tobacco use at the time of RYGB surgery developed AU within eight years. These findings emphasize the need for proper patient and bariatric procedure selection.

The authors conclude: "The findings of this study underline that the incidence of AU after RYGB is more common than previously reported and that it progressively increases over time.

"Despite the limitations of the retrospective design, the lack of bariatric-specific granular data, and the possibility of missing patients with AU who were diagnosed and managed exclusively outside the hospital setting, the long-term effect of tobacco use on this complication is profound.

"Such information can potentially aid in procedure selection at the time of initial bariatric surgery or guide patient selection for targeted AU preventive and surveillance strategies."

Dr. Spaniolas told Reuters Health, "The findings can be used to tailor procedure selection for patients with exposure to tobacco, potentially steering them away from gastric bypass and towards other bariatric procedures, or extending ulcer prophylaxis measures lifelong for such individuals who undergo gastric bypass.

"Additionally, [our study] reinforces the possible value of long-term bariatric follow up, specifically in an attempt to identify and aggressively treat (these ulcerations) early in their stage of development."

Studies like this conducted by our faculty demonstrate that not only do they take care of patients, they make surgery better through research. This is what sets us apart.

Stony Brook Medicine is shaping the future of bariatric surgery on multiple fronts. Reflecting the vision and leadership of its founder and director, Aurora Pryor, MD, and associate director, Konstantinos Spaniolas, MD, the Bariatric and Metabolic Weight Loss Center has become a leader nationally and internationally through advanced clinical care, research, advocacy, and mentorship of the next generation of surgeons (read more).

Read about a case of AU after gastric bypass. For consultations/appointments with our specialists at the Bariatric and Metabolic Weight Loss Center, please call 631-444-BARI (2274).

Posted by Stony Brook Surgery on June 21, 2018

REMINDER: Summer Injuries and ER Visits Are Often Avoidable

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Today is the first day of summer! For many, the summer months — when school is out and families take vacations — mean lots of fun in the sun. But with all the pleasures of the season come injuries and increased visits to the emergency room.

"During the summer, we treat more patients with injuries from burns, drownings, boating accidents, and motor vehicle crashes, than at any other time of the year," says James A. Vosswinkel, MD, chief of our Division of Trauma, Emergency Surgery, and Surgical Critical Care, and medical director of Stony Brook Trauma Center.

"We want Long Islanders to get out and enjoy the warm summer months, but to take a moment to first think about safety and precautionary measures they can take when planning outdoor activities. Many of the accidents and deaths that we see are avoidable."

Watch Fireworks from a Distance, Don't Set Off at Home, and Practice Outdoor Fire Safety Tips: Nearly 10,000 Americans are injured by fireworks each year, according to the National Council of Fireworks Safety. Most of these injuries occur during the Fourth of July holiday and include serious burns, loss of fingers, and blindness.

"Each year, we treat adults and children injured by fireworks," says Steven Sandoval, MD, director of the Suffolk County Volunteer Firefighters Burn Center at Stony Brook Medicine. He recommends enjoying public firework displays, which are handled by professionals, from a safe distance — rather than setting them off at home.

And summertime burns also result from outdoor grills, both charcoal and propane, which cause hundreds of injuries and thousands of fires every year. "In addition, we treat at least a few injuries from fire pits and campfires every summer," says Dr. Sandoval. Fire safety tips include:

  • Keep a bucket of sand and/or a garden hose nearby in case the fire grows.
  • Place the fire pit away from trees, branches, and foliage in order to prevent catching fire.
  • Be sure your BBQ is well maintained and cleaned regularly.

Dr. Sandoval reminds Long Islanders that flammable liquids, like lighter fluid or gasoline, should never be used to start a fire. "Unfortunately, the Burn Center treats flash burns to the face and torso when these agents have been used," Dr. Sandoval advises.

Closely Supervise Children around Fires: Around outdoor fires, Dr. Sandoval advises that children should be far enough away to prevent a burn injury. Remember to keep all barbecue accessories, including charcoal, lighter fluid, and propane gas tanks, well out of the reach of kids.

Keep a Watchful Eye on Swimming Children: Drowning is the leading cause of unintentional injury and death for children ages one to four, and drowning can occur in as little as two inches of water. "Parents should know that children can drown without making a sound, and that drowning deaths can occur even when children are left unattended for just a few minutes," says Dr. Vosswinkel.

Kristi L. Ladowski, MPH, injury prevention and outreach coordinator on our trauma team, provides the following water safety tips for people of all ages:

Tips to Keep Young Children Safe during Water Activities:

  • It's all about supervision: always know where your children are, and never leave them alone near water, not even for a second:
    • Designate a "water watcher" when children are swimming. The "water watcher" should not engage in any social distractions (conversation, phones, reading, etc.), they should only be watching the children in the pool for a set amount of time. Rotate the "water watcher" position so that the supervision remains fresh.
    • Install physical barriers to keep children out of pool/spa areas: fences that children cannot climb with self-latching doors.
    • Install door and/or pool alarms to notify you if a child is in or near the pool/spa.
    • Do not use flotation devices (water wing, floaties) as a substitute for supervision.
    • An adult should always be within arm's reach of infants and toddlers when they are in or around water:
      • If a child goes missing, check the water first.
      • Keep pools and spas covered when not in use, empty all other containers of water after use (buckets, inflatable pools).
      • Remove all toys from in and around the pool when not in use.

Water Safety Tips for Adults and Older Children:

  • Never swim alone, use the buddy system.
  • If swimming in open bodies of water (oceans and lakes), only swim in designated areas and obey all instructions and orders from lifeguards.
  • Do not dive into open bodies of water.
  • Never swim under the influence of drugs or alcohol.
  • Know how to safely get out of rip currents. If you're caught in a rip current:
    • Stay calm.
    • Don't fight the current.
    • Escape the current by swimming in a direction following the shoreline (parallel to shore). When free of the current, swim at an angle — away from the current — toward shore.
    • If you are unable to escape by swimming, float or tread water. When the current weakens, swim at an angle away from the current toward shore.
    • If at any time you feel you will be unable to reach shore, draw attention to yourself: face the shore, call or wave for help.

Water Safety Tips for Everyone:

  • Learn to swim.
  • Learn CPR.
  • Keep a cell phone nearby to call for help if needed.
  • Take a water safety and rescue course.
  • Keep rescue equipment nearby (life-saver ring, shepherd's hook).
  • Wear a life jacket when boating. In 2016, 80% of boating deaths were caused by drowning and 83% of those who drowned were not wearing a life jacket.

Alcohol and Water Don't Mix: According to the U.S. Coast Guard and the National Association of State Boating Law Administrators, alcohol can impair judgment, balance, vision, and reaction time. It can also increase fatigue and susceptibility to the effects of cold-water immersion. For boaters, intoxication can lead to slips on deck, falls overboard, or accidents at the dock.

"Alcohol impairs judgment and increases risk-taking, a dangerous combination for swimmers," says Dr. Vosswinkel. "Even experienced swimmers may venture farther than they should and not be able to return to shore, or they may not notice how chilled they're getting and develop hypothermia. Even around a pool, alcohol can have deadly consequences. Inebriated divers may collide with the diving board, or dive where the water is too shallow."

THE GOOD NEWS: MANY SUMMER ACCIDENTS ARE AVOIDABLE

"Overall, the good news is that many injuries that commonly occur during the summer are avoidable — or at least the risk of serious injury can be significantly reduced — if recommended safety precautions are taken," says Dr. Vosswinkel. "We encourage Long Islanders to keep safe and have a great summer!"

"But if an accident does occur, call 911 and go to the nearest emergency room," says Dr. Vosswinkel.

Learn about the Stony Brook Trauma Center and how we can help in case of summer accidents, if you live on Long Island. Visit the website of the CDC for more tips for a safe summer.

Posted by Stony Brook Surgery on June 4, 2018

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

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Winner of Outstanding Poster Competition (click on image to download & read).

This year's Research Day program took place last Thursday at Stony Brook University's Charles B. Wang Center, and was another great success, as the event continues to grow, with more research presentations and increased attendance.

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.

Opening the program, Kenneth Kaushansky, MD, dean of the School of Medicine and senior vice president of health sciences, said:

"I have attended virtually every Research Day since its inception, and I am very pleased to see the quality of research grow and the amount of research grow, together with the new horizons of research on display here today."

Stony Brook Medicine is committed to making research happen, says Mark A. Talamini, MD, professor and chairman of surgery and chief of surgical services at Stony Brook Medicine.

Our Research Day celebrates our discoveries, and also demonstrates that as academic surgeons our faculty not only has the job to take care of patients, but to make surgery better. This is what sets us apart from private-practice surgeons, Dr. Talamini is quick to point out.

Research Day demonstrates how we're making surgery better and what sets us apart.

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

The keynote speaker was Jeffrey B. Matthews, MD, Dallas B. Phemister professor of surgery and chairman of the Department of Surgery at the University of Chicago.

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Dr. Jeffrey B. Matthews

Dr. Matthews's address, titled "Truth and Truthiness in Surgery," was a thought-provoking examination of the validity of scientific evidence applied to clinical practice.

Early in his talk, Dr. Matthews made the compelling statement that "the current practice of surgery is an accumulated wisdom, mixing fact, opinion, and magical thinking in unknown proportions."

He showed that truth and truthiness — the preference for concepts or facts one wishes to be true rather than concepts or facts known to be true — coexist in the world of medicine.

He argued that it's okay to learn to trust one's gut; evidence is elusive and fluid; and knowledge is inseparable from experience.

Ultimately, Dr. Matthews stressed to the audience that evidence-based medicine inadequately accounts for the complexity of individual clinical decisions and the omnipresence of uncertainty. Experience and gut truthiness, not science alone, are essential for successful patient care.

Commenting on the purpose of Research Day, A. Laurie W. Shroyer, PhD, MSHA, professor of surgery and vice chair for research, who oversees the event, says: "Research Day shows the commitment of our department to advancing scientific knowledge in order to improve patient care and population health.

"Residents and fellows, as well as junior faculty, utilize their research projects to address important clinical questions that they face each day, fostering their curiosity and building their excitement and enthusiasm for current and future biomedical research.

"By networking at events such as Research Day, they gain new opportunities for collaborative multidisciplinary team projects. Most important, our Research Day lights the pathway for trainees to envision a future career in academics."

Research Day lights the pathway for trainees to envision a future career in academics.

All categorical residents in our general surgery residency program are 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 is moving the science of surgery forward.

The Research Day program offers continuing medical education (CME) credit; this activity is designated for a maximum of 3.0 AMA PRA Category 1 Credits™.

2018 Research Day Posters

Here are the titles/authors of the posters exhibited at this year's Research Day. Together, they demonstrate the broad range of research activity within the Department of Surgery, and the impressive productivity of our residents and students:

  • Abdominal wall reconstruction utilizing biologic meshes: comparison of outcomes and risk for readmission between three different meshes | Cary E, Jou C, Marquez J, Shih J, Klein G, Khan S.
  • ABO blood group and prevalence of pulmonary embolism | Kim P, Tassiopoulos A, Probeck K, Elitharp D, Labropoulos N.
  • Acellular dermal matrix sterility: does it affect microbial and clinical outcomes following implantation for breast reconstruction | Klein G, Singh G, Gebre M, Barry R, Trostler M, Marquez J, Huston T, Ganz J, Khan S, Dagum A, Bui D. Oral Presentation.
  • α-Gal: antibody-stimulated, macrophage-directed wound healing | Kaymakcalan O, Dong X, Jin J, Akintayo R, Galili U, Spector J.
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  • Analysis on postoperative ileus after colectomy in patient with inflammatory bowel disease under ERAS protocol: retrospective study | Choi H, Denoya P.
  • Antithrombotic agent use in older adult blunt trauma patients: prevalent and deadly | Chantachote C, Garry J, Singh G, Sikalas N, Labropoulos N. Finalist in Outstanding Poster Competition.
  • Assessment of vascularized constructs within hard and soft tissues | Singh G, Kaymakcalan O, Uddin S, Wiles B, Cordero J, Rafailovich M, Simon M, Bui D. Finalist in Outstanding Poster Competition.
  • Bedside ultrasounds in conjunction with spirometry in the assessment of diaphragm function following blunt traumatic rib fractures: a feasibility study | O’Hara D, Ahmad S, Pasternak D, Huang E, Jawa R.
  • Comparing superior versus inferior pedicle reduction mammoplasty: evaluation of clinical outcome — a single surgeon’s experience over 10 years | Bader A, Tembelis M, Marquez J, Klein G, Zhu C, Bui D.
  • Current technology and devices for port closure: review | Basishvili G.
  • Does bilateral reduction mammoplasty facilitate subsequent weight loss? | Groves D, Marquez J, Trostler M, Pamen L, Medrano C, Kapadia K, Huston T.
  • Does substance abuse increase risk for post-surgical complications in bariatric patients? | Bates A, Yang J, Altieri M, Karim S, Talamini M, Pryor A.
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  • Early ambulation after surgery in the age of fitness tracking | Weller R.
  • Early predictive factors affecting risk of pneumonia, SICU length of stay and hospital length of stay in trauma patients with isolated rib fractures | Fleury M, Masson R.
  • Endovascular thoracic aortic repair for catheter associated aortic injury during thoracentesis | Skripochnik E, Tak V, Bilfinger T, Tassiopoulos A, Bannazedeh M.
  • Estimating the incidence of stray energy burns during laparoscopic surgery based on two statewide databases and retrospective rates: an opportunity to improve patient safety | Guzman C, Forrester J, Fuchshuber P, Eakin J.
  • Examining gender disparities in surgical case volumes in the state of New York | Altieri M, Yang J, Bevilacqua L, Zhu C, Talamini M, Pryor A.
  • Impact of ongoing CPR on VA-ECMO outcomes | Rabenstein A, Fujita KJ, Chiu K, Chiu R, Seifert F, McLarty A. Oral Presentation.
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  • Incidence, outcomes and recidivism of elderly patients admitted for isolated hip fractures | Cabalatungan S, Divaris N, McCormack J, Huang E, Kamadoli R, Abdullah R, Vosswinkel J, Jawa R.
  • Increased incidence of surgical site infection with a body mass index of >35 following abdominal wall reconstruction with open component separation | Svestka, M, Docimo S, Spaniolas K, Bates A, Sbayi S, Schnur J, Talamini M, Pryor A.
  • Increased parathyroid hormone assay use not improved surgical outcomes | Ferrara A, Frenkel C, Yang J, Park J, Samara G.
  • Initial single-center experience with gallium-68 DOTATATE scans for neuroendocrine cancers | Hirai K, Lin M, Georgakis G, Chimpiri R, Matthews R, Franceschi D, Sasson A, Kim J. Finalist in Outstanding Poster Competition.
  • Investigation of the role of the etiology of deep venous thrombosis in the degree of recanalization and reflux development in the deep venous system in order to define the optimal duration of anti-coagulation after an episode of acute deep venous thrombosis | Volteas P.
  • Laparoscopic paraesophageal hiatal hernia repair in a 13-month-old infant | Sosulski A, Burjonrappa S, Coren C, Brathwaite C.
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  • Late proximal neck failure after EVAR | Ribner A, Labropoulos N, Tassiopoulos A.
  • Location, location, location! Stepping up to reach seniors for fall prevention | Ladowski K, Fantal S, Vosswinkel J, Jawa R.
  • Lung cancer and aortic aneurysms: evidence for an inherent linkage | Wiles B, Comito M, Labropoulos N, Bilfinger T. Winner of Outstanding Poster Competition.
  • Machine learning to reduce errors and time in patient admissions/consults | Connolly R.
  • Marginal ulcer continues to be a major source of morbidity over the time following gastric bypass | Pyke O, Spaniolas K. Docimo S, Talamini M, Bates A, Pryor A.
  • Outcomes of anti-reflux procedures in adolescents | Hesketh A, Yang J, Zhu C, Talamini M, Pryor A.
  • Patterns of clinical manifestations and management of intestinal aspergillosis | Yelika S, Lung B, Crean A, Denoya P.
  • Personalized medicine applications for endoscopic derived gastric cancer organoids | Lin M, Kirai K, Buscaglia J, Davis J, Powers S, Rao M, Georgakis G, Sasson A. Oral Presentation.
  • Presentation, diagnosis, and treatment modalities for cecal bascule | Lung B, Yelika S, Denoya P.
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  • Proportion of laparoscopic versus open inguinal herniorrhaphy by year and patient age: the New York state experience | Bates A, Tembelis M, Marquez J, Klein G, Zhu C, Bui D.
  • Regional patters of fluid accumulation and fat hypertrophy in patients with lower extremity lymphedema: an MRA (magnetic resonance angiography)-based staging system | Dayan J, Verma R, Shen J, Talati N, Goldman D, Mehrara B, Smith M, Kagan A.
  • Secondary intention healing after Mohs surgery: evaluation of wound characteristics and cosmetic outcomes | Liu K, Silvestri B, Huston T.
  • Sleeve gastrectomy — the first three years: evaluation of re-operating, emergency department visits and readmissions for 14,080 patients in New York state | Altieri M, Gulamhusein T, Yang J, Obeid N, Park J, Talamini M, Pryor A.
  • Spatial characterization of fibrin with an evolving venous thrombus | Chandrashekar A, Garry J, Gurtej S, Sikalas N, Labropoulos N. Oral Presentation.
  • Spontaneous celiac artery dissection complicated by gallbladder wall necrosis. A case report and literature review | Drakos P, Monastiriotis S, Skripochnik E, Esarko P, Tassiopoulos A.
  • Surgical boot camp for fourth year medical students: Impact on objective skills and subjective confidence | Bevilacqua L, Simon J, Rutigliano D, Sorrento J, Docimo S Jr., Verma R, Wackett A, Chandran L, Talamini M.
  • Surgical boot camp for fourth-year medical students: impact on surgical skills and confidence | Simon J, Bevilacqua L, Docimo S, Rutigliano D, Chandran L, Wackett A.
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  • Surgical trainee impact on bariatric surgery safety | Goldberg I, Talamini M, Pryor A, Docimo S, Bates A, Park J, Yang J, Spaniolas K. Oral Presentation.
  • The novel treatment of traumatic submandibular gland fracture with placement of sialo endoscopic stent | Svestka M, Laskowski R, Samara G.
  • The rush to pre-hospital cervical spine clearance: are we at breakneck speed? | Laskowski R, Jawa R, Mc Cormack J, Huang E, Vosswinkel J, Chaudhary N.
  • Treatment of high-risk patients with carotid artery stenosis using transcarotid artery revascularization in a single academic center | Jasinski P, Panagiotis D, Tzavellas G, Tassiopoulos A, Loh S, Koullias G, Kokkosis A.
  • Trends in diagnosis and management of cecal diverticulitis | Crean A, Lung B, Yelika S, Lung K, Denoya P.
  • The use of computed tomography versus clinical acumen in diagnosing appendicitis in the pediatric population — interim report | Lacy R, El-Gohary Y, Gulamhussein T, Scriven R, Shapiro M.
  • Use of flow-diverting stents in the treatment of complex visceral arterial aneurysms | Monastiriotis S, Jasinski P, Koullias G, Landau D, Fiorella D, Tassiopoulos A.
  • The use of indocyanine green angiography in post-mastectomy reconstruction: do outcomes improve over time? | Diep G, Schelomo M, Kizy S, Huang JL, Jensen EH, Portschy P, Cunningham B, Choudry U, Tuttle TM, Hui JC.
  • The use of radiofrequency ablation in treatment of anal fistula | Dickler C, Lee K.
Next year's Research Day will take place on Thursday, May 30, 2019, from 8:00 am to noon, at the Medical and Research Translation (MART) Building. For more information, please call 631-444-1820.

Posted by Stony Brook Surgery on May 29, 2018

Help Decrease the Number and Severity of ATV Accidents Involving Children

Summer is almost upon us and kids will be out of school! If your family enjoys riding all-terrain vehicles (ATVs), we want you to be safe. June 1-10 is ATV Safety Week, starting this Friday.

Every year children are injured riding ATVs. The American Academy of Pediatrics strongly discourages children under the age of 16 from riding ATVs because of the serious potential harm.

Despite this, many children still ride ATVs; therefore, it is important to educate children and their parents on ATV safety.

ATV safety education can help decrease the number and severity of ATV accidents involving children.

What do we know about the dangers of the use of ATVs by children and youth?

The United States Consumer Product Safety Commission collects data and reports annually on ATV-related injuries. Here's what the 2016 report, issued last December, says:

New York State ranks within the top 10 states where people (adults and children) die from ATV-related accidents.

In New York State, more than six children are injured every day due to ATV-related accidents.

From 1982 through 2016, there were 3,232 ATV-related fatalities of children younger than 16 years of age, which accounts for 22% of total ATV-related deaths.

Children under the age of 16 lack the judgement and physical ability to safely drive ATVs,
according to the American Academy of Pediatrics and American Pediatric Surgical Association.

Of the 3,232 reported ATV-related fatalities of children less than 16 years of age, 44% (1,411) were younger than 12 years of age. This mortality is disproportionately high relative to the number of children riding ATVs.

Nearly one-third of children hospitalized after an accident on an ATV suffer a traumatic brain injury.

More than 90% of ATV-related injuries involving children can be attributed to a lack of developmental skills needed to maneuver the faster, more powerful adult ATVs. Children under 16 years lack the developmental skills to safely drive adult ATVs.

What are the New York State laws?

All ATVs must be registered with the Department of Motor Vehicles (DMV) if it is operated anywhere in New York State — including on an owner's property. Registration must be renewed yearly.

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Click on image to view the ATV Safety Institute's Golden Rules.

You may not operate any ATV anywhere in New York State, except on your own property, unless it is covered by liability insurance.

No passengers are allowed on the ATV unless it is designed to carry more than one person. "Single-rider" ATVs are intended for use by a single driver and no passenger. "Two-up" ATVs are designed for an operator and one passenger only.

All riders (operator and passengers) must at all times wear a helmet approved by the US Department of Transportation (USDOT). It is also recommended that you wear a face shield or goggles, protective clothes, and footwear.

ATV use on highways is prohibited, except to cross these roads. (Public highway means any highway, road, alley, street, avenue, public place, public driveway, or any other public way). ATV use is also prohibited on public land.

You do not need a driver's license to operate an ATV in New York State, but the following restrictions apply to children under age 16:

  • Less than 10 years of age may ride an ATV only when under adult supervision, or without adult supervision only when on lands owned or leased by your parent or guardian.
  • 10 to 15 years of age may ride an ATV if they are on their parent's land and supervised by a parent, or on their parent's land and in possession of a safety training certificate earned after completing an ATV safety training course approved by the DMV.

No ATV shall be operated without a lighted headlight and taillight from one half hour after sunset to one half hour before sunrise.

Both the owner and the operator of an ATV may be held liable for injury and/or damages resulting from an ATV accident.

What are some safety recommendations?

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Dr. Erica R. Gross

Erica R. Gross, MD, assistant professor of surgery in our Pediatric Surgery Division, says:

"The increasing popularity of ATV use with its associated risk of permanent injury underscores the need for increased safety awareness among the general public.

"With summer on the horizon, now is the time to act to help prevent ATV accidents. It must be emphasized that non-fatal ATV accidents can result in catastrophic, life-changing medical problems. We need to protect our children from them.

"That's why I think the Trauma Committee of the American Pediatric Surgical Association offers an especially good set of recommendations for ATV use."

The safety recommendations of the American Pediatric Surgical Association Trauma Committee are:

1. The strongest recommendation is that children younger than 16 years lack the judgment and physical ability to safely operate motorized vehicles, and therefore should not operate ATVs of any size. However, the committee recognizes that many parents will find this recommendation unacceptable.

For those parents with children younger than 16 years who choose to allow their children to operate an ATV, the committee recommends that only ATVs designed for younger children (i.e., 900-cc engine or less) be operated, that no child less than 12 years be allowed to operate an ATV, and that these other recommendations be followed:

2. Children between ages 16 and 18 should ride age appropriate vehicles with an engine size no greater than 350 cc and should be supervised by a responsible adult. As mentioned above, children between ages 12 and 15 should only operate ATVs with engine sizes appropriate for smaller children, generally less than 90 cc.

3. ATV drivers should complete an approved and age-appropriate training course.

4. ATVs are designed for a single rider, and no passenger of any age should ever be on board. This includes the recommendation that children not ride as passengers on ATVs with adult drivers.

5. ATV operators should always wear a government approved helmet, eye protection and appropriate protective clothing.

6. ATVs are intended for off-road use and should not be used on public roads.

7. No one should drive an ATV while under the influence of alcohol or other substances that can impair judgment, insight, and reaction time.

8. ATVs should not be used after dark.

How do you know when your child is ready to ride an ATV?

The size of your child is not the only determinant. Children must have strength, skills, and good judgment to safely operate an ATV. Please review the ATV Safety Institute Readiness Checklist.

ATV Training Courses: The ATV RiderCourse is a half-day hands-on training program and is available nationwide. Please visit the website of the ATV Safety Institute, or call there at 800-887-2887 to find the program nearest to you.

ATVs are designed to be driven on off-road terrain, and are difficult to control on paved roads where they are at risk of overturning or colliding with cars and trucks.

ATV-related injuries vary depending on incident characteristics and patient populations. On-road use incurs a significant increase in injury severity. The pediatric population is significantly more likely to incur a severe injury and the presenting injury pattern differs from the adult population. Knowledge of population and presentation trends can help direct trauma care providers in the care and management of injured ATV riders. — "Increasing Incidence of All-Terrain Vehicle Trauma Admissions in the Pediatric and Adult Populations," International Journal of Orthopaedic and Trauma Nursing (2018)

Learn more from the ATV Safety Institute. Riders of all ages can take an ATV Safety e-Course. Kids and parents, watch this ATV safety video (2:19 min) from the Childress Institute for Pediatric Trauma:

Posted by Stony Brook Surgery on May 16, 2018

Understanding Pain Helps Patients Gain Control of It and Lead Normal Lives

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Dr. David K. Lam

Outside of survival, pain is the most important concern for patients with head and neck cancer. These patients may suffer debilitating pain before, during, and after their cancer treatments.

The most frequent cause of pain during treatment is chemotherapy/radiation-induced oral mucositis, which involves 80% of patients. It worsens not only their quality of life but may also limit treatment.

Oral mucositis — inflammation from damage to the tissue that lines the inside of the mouth — is probably the most common, debilitating complication of cancer treatments.

This complication can lead to several problems in addition to pain, such as nutritional problems due to the inability to eat, and increased risk of infection due to open sores in the mucosa.

Oral pain in patients with head and neck cancer often inhibits speaking, eating, drinking or swallowing, and sometimes reduces treatment compliance and dose intensity, thus limiting the potential effectiveness of cancer treatments.

Here, David K. Lam, MD, DDS, PhD, professor of surgery and chief of oral and maxillofacial surgery, answers frequently asked questions about pain associated with head and neck cancer and how this pain is managed.

A specialist in head and neck cancer, Dr. Lam is internationally renowned for his expertise in pain management and research. He is a 2018 Mayday pain fellow.

Q: What are the different types of head and neck cancer pain?

A: There are generally three major causes of pain in patients with cancer: cancer-related (93%), treatment-related (21%), and/or unrelated to cancer or its treatments (2%).

Cancer-related pain may be a consequence of cellular, tissue, and systemic changes that occur during cancer proliferation, invasion, and metastasis (spread in body). Cancer progression may result in tissue damage and/or nerve injury through various mechanisms, such as infiltration, obstruction, compression, and fracture; and consequent exacerbation of cancer-related pain.

Cancer treatments such as surgery (e.g., postsurgical pain), radiation (e.g., mucositis), and medical therapy (e.g., chemotherapy-induced peripheral neuropathy) may contribute to treatment-related pain.

Patients with cancer may also suffer at the same time from various acute and/or chronic pain conditions unrelated to cancer or its treatments, such as sprains, toothaches, arthritis, and fibromyalgia.

At Stony Brook we appreciate the uniqueness of each individual person suffering with cancer pain.

Q: What do chemotherapy and radiation do to the body that results in pain?

A: Advances in cancer treatment, such as intensity-modulated radiation therapy, have significantly reduced treatment-related side effects. However, both radiation and chemotherapy still affect normal tissues, with oral mucositis being the most common painful complaint.

Oral mucositis starts as acute inflammation of the oral mucosa and pharynx after radiation or chemotherapy exposure that results in soreness, redness, and minor ulcers; but can progress to severe mucositis with extensive ulcers and redness that make swallowing difficult or impossible.

A secondary infection may occur that results in even more extensive tissue injury. Eventually the tissues heal and fibrose (toughen), with most lesions resolving within two to four weeks after stopping radiotherapy or chemotherapy.

Q: How is head and neck cancer pain managed?

A: The optimal management of head and neck cancer patients with pain requires the identification of the likely causes of pain. If the pain is from the cancer itself, treatment of the cancer can resolve the pain.

Maintaining good oral care and nutrition is the most effective way to lower the risk and minimize the progression of oral mucositis.

Locally applied agents (e.g., ice chips, local anesthetics, artificial saliva spray), systemically applied agents (e.g., opioids, indomethacin), and oral microbial load reduction agents (e.g., anti-bacterials, anti-fungals, anti-virals) may be used for symptomatic treatment.

Q: What medicines are used to treat head and neck cancer pain?

A: The World Health Organization has developed a three-step ladder for pain management in adult cancer patients (read more). This approach of administering the right medicine in the right dose at the right time is inexpensive and 80-90% effective.

Step 1 includes non-opioid analgesics, such as aspirin, non-steroidal anti-inflammatories, and acetaminophen, for mild pain; step 2 includes opioids, such as codeine or oxycodone along with non-opioids, for moderate pain; and step 3 includes stronger opioids, such as morphine or Dilaudid, along with non-opioids, for severe pain.

Adjuvant medications such as anti-depressants or anti-convulsants may be used to decrease the anxiety and fear associated with cancer pain. Specialized treatments, such as a nerve block, where a local anesthetic is injected around a nerve can also help.

The Stony Brook difference in pain management is the multidisciplinary approach used for it.

Q: What are the side effects of medicines?

A: Common side effects of analgesics for cancer-related pain may include nausea, vomiting, itching, constipation, and drowsiness. We can change the dosage, the time the medicine is taken, or the medicine itself to reduce side effects.

Our team can also work with patients to help manage any side effects experienced with cancer pain management, including nutrition therapy, complementary and alternative medicines, and other services.

Q: Is complementary/alternative medicine effective in treating head and neck cancer pain?

A: Various complementary and alternative medicine therapies have been demonstrated to improve quality of life, sleep, mood, stress, and anxiety in cancer patients, which may indirectly alleviate cancer pain.

Acupuncture, transcutaneous electrical nerve stimulation, supportive group therapy, self-hypnosis, and massage therapy may provide relief in cancer pain. Relaxation/imagery can improve oral mucositis pain.

Q: Are there ways patient themselves can control head and neck cancer pain?

A: Maintaining an open and regular dialogue about their pain with their cancer team helps optimize pain control and minimize side effects. Patients with head and neck cancer can maintain good oral hygiene and nutrition, be well-rested, and practice self-hypnosis, massage, and relaxation/imagery to better control their cancer pain.

Q: What is new in pain research that's improving management of head and neck cancer pain?

A: Although recent preclinical models of cancer pain appear to better reflect the complex pain states observed in cancer patients and have identified various potential therapeutic targets, it is unlikely that a single treatment will target all of the different cancer pain-related symptoms in patients and that combined treatment strategies should be investigated in preclinical models.

The existence of multiple peripheral and central mechanisms in different cancers may not only provide a rational basis for the use of combination therapy in cases where a single agent is not sufficient, but may also serve to usher in the era of personalized cancer pain medicine.

Using advancements in genomics and proteomics, the development of diagnostics targeting an individual patient's unique cancer cell mediators and genetic makeup may not only provide targeted analgesic therapy but may potentially eliminate ineffective analgesics, reduce adverse drug reactions, lower costs, and improve quality of life.

At Stony Brook our physician-scientists are always working to advance pain management.

Q: What is the Stony Brook difference in treatment for head and neck cancer pain?

A: Multidisciplinary care. Through the broad training and experience of our multidisciplinary team of clinicians and scientists at the Stony Brook Cancer Center and Department of Anesthesiology Center for Pain Management, we appreciate the uniqueness of each individual person suffering with cancer pain.

The goal of our treatment is to help patients gain control over their pain and lead normal, active, and meaningful lives at home and in their community.

Our pain team includes dedicated experts in pain medicine who work closely with our patient's referring physician. Our program not only meets current standards for care of cancer pain, but also works to improve future care through education and research.

We study novel analgesic targets in preclinical and clinical studies, keep abreast of new advances, and, if appropriate, can refer patients to research studies on pain problems for which answers are still needed.

What is pain? — "Pain is an unpleasant sensation and emotional experience linked to tissue damage. Its purpose is to allow the body to react and prevent further tissue damage. We feel pain when a signal is sent through nerve fibers to the brain for interpretation. The experience of pain is different for everyone, and there are different ways of feeling and describing pain. This can makes it difficult to define and treat. Pain can be short-term or long-term, it can stay in one place, or it can spread around the body." — Medical News Today

Learn more about cancer and pain management. For consultations/appointments with Dr. Lam, please call 631-632-8975.

Posted by Stony Brook Surgery on May 7, 2018

People with Carotid Artery Disease Are at Increased Risk

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Dr. Angela A. Kokkosis with patient.

Stroke, or brain attack, can affect people of all ages and backgrounds. It is the No. 5 cause of death and a leading cause of disability in the United States.

A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures).

Every year, more than 300,000 Americans are diagnosed with blockages in their carotid (neck) arteries that carry blood to the brain. This condition can lead to a dangerous stroke.

To help protect members of our community at risk for strokes, the Stony Brook Vascular Center offers a safe, innovative procedure called transcarotid artery revascularization (TCAR).

This minimally invasive procedure treats carotid artery disease, and is clinically proven to protect against stroke both during and after the procedure.

Stony Brook has performed more TCAR procedures than any hospital on Long Island

Stony Brook was the first hospital on Long Island to offer this revolutionary procedure (read more).

Carotid artery disease is a blockage or narrowing in the arteries that carry oxygen-rich blood to the brain. These arteries are located in the neck, one on each side.

The blockage, caused by cholesterol-filled plaque, reduces the amount of blood that flows to the brain. Because the blood isn't flowing normally, blood clots can form or small pieces of plaque can break off and travel to the brain, causing a stroke.

Every year, 15 million people worldwide suffer a stroke, and carotid artery disease is estimated to be the source of the stroke in up to one third of patients.

There currently are multiple treatment options for stroke prevention. If the blockage or narrowing in the artery isn't severe, lifestyle changes and regular monitoring may be the only action required.

If the disease is more advanced, our vascular specialists provide three different treatments depending on the individual patient and degree of severity:

  • The traditional open surgery, called a carotid endarterectomy, or CEA
  • A minimally invasive procedure called transfemoral carotid artery stenting
  • The state-of-the-art TCAR procedure that reduces the risk of stroke both during and after the procedure
The TCAR Procedure

Transcarotid artery revascularization is a minimally invasive treatment performed by going into the carotid arteries to restore the flow of blood to the brain (revascularization).

The procedure is a major advance in treating carotid artery disease. Here's how it's done:

  • The procedure is performed with the patient under light sedation, in Stony Brook Hospital's hybrid operating room. It takes about 90 minutes.
  • The surgeon makes a tiny incision at the neckline just above the clavicle. The scar is so small that most people never notice it.
  • A tube, called a catheter, is placed directly into the carotid artery.
  • The catheter is connected to a revolutionary system called a neuro-protection system (NPS). The NPS temporarily reverses the blood flow away from the brain. So, if any plaque breaks loose or blood clots form during the procedure, it won't go into the brain. This means that there is almost 100% protection from stroke while the rest of the procedure is done.
  • A stent — a metal mesh tube — is implanted into the carotid artery. The stent expands and opens the artery for improved blood flow. It also stabilizes the plaque to help prevent future strokes.
  • The patient's blood flow that was reversed is filtered to ensure there are no particles in the blood. The filtered blood is then returned through a second catheter in the upper thigh, and the flow reversal is turned off so the blood flows in the normal direction.
  • After an overnight stay in the hospital to monitor blood pressure, the patient can go home and resume normal activities.

The stent that was placed in the artery stays in the body permanently, to keep the artery open and the blood flowing normally.

It has been shown that over ten years, the degree to which the artery stays open after the TCAR procedure is equivalent to the results of the CEA surgery. And because TCAR is less invasive than traditional surgery, there's a lower chance of complications.

"I can't emphasize how important this is in the field of vascular surgery," says Angela A. Kokkosis, MD, director of carotid interventions at the Stony Brook Vascular Center.

"It's a treatment revolution for people who are at risk for strokes because of carotid artery disease."

Who Is Eligible for TCAR?

To determine eligibility for TCAR, there are very strict criteria based on Centers for Medicare and Medicaid Services (CMS) guidelines as well as guidelines from the company that developed TCAR.

Generally, patients who have never had a stroke and have blockage greater than 80% but less than 100% are good candidates for TCAR.

In addition, current guidelines are that TCAR may be right for patients with carotid artery disease who are considered high risk for traditional open surgery.

Factors that make a person high risk — meaning the open surgery is not a good choice for them — include older age, anatomic issues or previous cancers or surgeries that may make the carotid blockage surgically inaccessible, and other medical conditions such as severe heart or lung disease.

Stony Brook was the first hospital on Long Island to provide the revolutionary TCAR

TCAR is appropriate for patients of any age, though people who need carotid intervention are generally older. The average age of patients treated with TCAR recently at Stony Brook has been 75. The procedure is covered by Medicare.

After a stroke, many patients lose their quality of life. By reducing the incidence of strokes and the debilitation they can cause, TCAR can preserve quality of life for people with carotid artery disease.

Due to the excellent outcomes patients are experiencing from TCAR, it is expected that the guidelines for who can get the procedure will be expanded to include a broader range of people with carotid artery disease.

Stony Brook has performed more TCAR procedures than any hospital on Long Island, and we are second in New York State in terms of number of patients treated with TCAR.

At Stony Brook, TCAR is performed by Dr. Kokkosis as well as by her vascular colleagues, George J. Koullias, MD, PhD, Shang A. Loh, MD, and Apostolos K. Tassiopoulos, MD, chief of vascular and endovascular surgery.

Non-Surgical Ways to Prevent Stroke: n Know and control your blood pressure n Don't smoke, or stop n Lose weight if overweight n Be active physically n Identify and manage atrial fibrillation n Treat a transient ischemic attack n Treat circulatory problems n Know and control your blood sugar and cholesterol n Drink alcohol in moderation, if at all n Eat a healthy diet low in sodium and rich in potassium n Know the warning signs of stroke and respond immediately.

For consultations/appointments with our specialists in stroke prevention, please call 631-638-1670. Watch this video (3:14 min) featuring Dr. Kokkosis who explains carotid disease and TCAR:

Posted by Stony Brook Surgery on April 30, 2018

It's Good for Your Health to Know about the Dark Side of the Sun

Skin Cancer ABCD + E for Evolution
Courtesy of National Cancer Institute (click on image to enlarge).

Skin cancer — including melanoma and basal and squamous cell carcinomas — is the most common of all cancer types.

The American Cancer Society estimates that in the United States this year there will be about 91,270 new cases of melanoma, the most dangerous form of skin cancer, and 9,320 deaths from it. The rates of melanoma have been rising for the last 30 years.

The number of cases of the more frequent skin cancers, basal cell carcinoma and squamous cell carcinoma, has been increasing for many years. According to one estimate, about 3.5 million cases of them are diagnosed annually (80% are basal cell).

Most of these three types of skin cancer are caused by exposure to ultraviolet (UV) light primarily from the sun. However, only a little over half of American adults use sun-protection measures.

The good news is that if diagnosed and treated early, skin cancer can often be cured. But if the disease is allowed to progress, it can result in disfigurement and possibly death.

Here, Tara L. Huston, MD, assistant professor of surgery and dermatology, and leader of Stony Brook's Melanoma Management Team, explains what can be done to help prevent skin cancer and how to detect its early signs.

May is National Skin Cancer and Melanoma Awareness Month.

Q: What should people know about protecting themselves against skin cancer?

A: Skin cancer is usually the result of sun exposure and blistering sunburns that occur in childhood and also cumulative sun exposure. The most important thing we can do is to protect our children from early sun exposure, although it's never too late to reduce your own risk for skin cancer. Eliminating ongoing sun damage is very important.

The good news is that most people with skin cancer are going to be fine. The majority of skin cancers are either basal cell or squamous cell carcinomas. Only 4% of all skin cancers are melanoma, the most serious type of skin cancer.

Q: Besides early sun exposure, what are some other risk factors for skin cancer?

A: Skin type has a lot to do with it. Fair skin, light hair, and light eyes are risk factors for melanoma. Sun exposure is by far the most common risk factor. The use of tanning salons is also a risk factor. Self-tanning lotions do not pose a risk.

Q: What are the symptoms of skin cancer, and what should people look for?

A: ABCDE is the key. This applies to new or changing moles. A is for asymmetry; B is for irregular borders; C is for color variation; D is for a diameter greater than 6 millimeters (about the size of a pencil eraser); and E is for evolution, or any change in a mole, including itching or bleeding. Any new lesion that bleeds or scabs and does not go away over four weeks should be brought to your physician's attention.

When in doubt about a mole, get it checked out … What to look for.

Q: How often should people do self-body checks for changing moles, and how often should they get clinical checkups?

A: People should be aware of their skin and look for any changing moles on a daily basis. People who don't have any history of skin cancer should have a complete skin examination annually by a physician. Those with a history of skin cancer, especially melanoma, should be evaluated at least twice a year by a dermatologist and do skin self-checks monthly. It's a lifetime of follow-up evaluations with your doctor, not just because of possible melanoma recurrence, but because of the possibility of other skin cancers as well.

Q: How can people protect themselves against the UVA and UVB rays of the sun?

A: Plan your outdoor activities before 10 am and after 4 pm. Use a broad-spectrum sunscreen with SPF of 30 or higher, and apply over all exposed skin about ten minutes before going out, and reapply every two hours, or sooner if swimming.

There is also clothing that now has UV protection in them, including bathing suits for kids. And be sure to wear a hat to protect the scalp and ears. Sun-exposed areas such as the nose and ears are very common spots where skin cancer can develop.

Q: How is skin cancer treated?

A: If you have a lesion that you're worried about, the first step is to see your dermatologist, who will remove it if it looks suspicious. Most of the basal and squamous cell cancers are handled with local removal by a dermatologist or plastic surgeon, and that's all the treatment needed.

When outside, seek shade, cover up, wear a hat and sunglasses, and use sunscreen.

If there is a diagnosis of melanoma, a melanoma surgeon will become involved, and the treatment depends on the depth of the melanoma. If it's what we call a thin melanoma, which is less than one millimeter deep (1/25 of an inch), the treatment is removal of some normal skin around the melanoma.

Once the melanoma is more than one millimeter deep or demonstrates concerning features on pathology exam, in addition to removing normal skin around the melanoma, we also sample the lymph node, because the deeper the melanoma, the greater the chance of lymph node involvement.

Q: What distinguishes Stony Brook from other centers in treating skin cancer?

A: Stony Brook provides comprehensive, multidisciplinary care to patients with melanoma. We offer screening, surgery, and the option to participate in local and national clinical trials. In addition, we conduct basic science and translational research, and also provide community education.

While clinical trials are not for everyone and participation in them is strictly voluntary, the availability of these trials serves as a hallmark of our ability to offer leading-edge treatment. For many patients, this is the only opportunity available in Suffolk County to benefit from such studies.

Several trials are currently underway at Stony Brook. We recently participated in the Multicenter Selective Lymphadenectomy Trial (MSLT 2) that evaluated the role of completion lymph node surgery in melanoma, in order to determine the optimum care for patients (see Dr. Huston's blog about it).

Our dedicated team of pathologists, dermatologists, medical oncologists, and melanoma surgeons meets once a month to review each melanoma case, and thus ensures that our patients receive the benefits of multidisciplinary care.

Editor's note: Dr. Huston and Alexander B. Dagum, MD, her departmental colleague and fellow melanoma surgical specialist, bring years of experience and excellent outcomes to the management of skin cancer. Christopher S. Bellber, MD, is a new and experienced member of the melanoma surgical team.

FREE Skin Cancer Screening and Melanoma Educational Program

When: Saturday, May 5, 8 to 11:30 am.
Where: Stony Brook Medicine Advanced Specialty Care, 500 Commack Road, Commack, NY 11725 (map/directions).

Are you 18 or older? Was your last skin cancer screening by a dermatologist more than a year ago? If so, call 631-444-4000 for an appointment.

For more information about skin cancer and its prevention, please visit the Centers for Disease Control and Prevention. Another good online resource is the Skin Cancer Foundation.

Posted by Stony Brook Surgery on April 25, 2018

Patients Should Research Their Cardiac Surgeon-Hospital Decision

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Our cardiac surgeons: (left to right) Drs. Allison J. McLarty, Thomas V. Bilfinger, Vinay M. Tak, Joanna Chikwe, and Henry J. Tannous.

Thousands of heart surgeries are performed every day in the United States. Changes in heart surgery have truly been transformative, resulting in better quality of life, better outcomes, and more people being eligible for minimally invasive approaches. The key to getting optimal results starts with choosing the right surgeon.

One of the best ways to choose a cardiac surgeon is for patients to ask their cardiologist or general practitioner who he or she thinks would be the right surgeon for the particular procedure they need to have. The cardiac surgeon they trust most to take the best care of their patient is useful information.

"The cardiologists on Long Island know all the cardiac surgeons individually. They know what each surgeon does best, what their success rates are, and how good their teams are," says Joanna Chikwe, MD, chief of our Cardiothoracic Surgery Division and director of the Stony Brook University Heart Institute.

"And these cardiologists come to visit their patients after surgery, so they really get to know the doctors, nursing staff, and hospitals."

Once a patient has a few recommendations, it's okay to "interview" each surgeon to ask:

  • How much experience does the surgeon have in treating their specific condition?
  • How many procedures has the surgeon performed to treat the condition?
  • What is the surgeon's success rate for the procedure?

It's important to note that information on the internet may be out of date, so patients should confirm what they find on it with their doctors.

Advanced Treatment at Stony Brook Heart Institute

Stony Brook Heart Institute is a leading center for cardiovascular medicine and advanced treatment options. Established in 1982, the Heart Institute successfully treats cardiac conditions ranging from heart attacks, arrhythmias, and valve disease to long-term heart failure.

Its team of cardiac specialists is dedicated to prevention and management of heart disease, providing exceptional care in state-of-the-art hospital facilities, as well as in the community and the homes of patients. The Heart Institute brings expertise to Long Island so that patients no longer have to travel outside the area to obtain the best care available.

The Heart Institute team has successfully performed thousands of coronary artery bypass operations, complex and reoperative cardiac surgery procedures, and has treated over 100 patients with advanced heart failure with ventricular assist (artificial heart) devices.

Getting optimal results from heart surgery starts with choosing the right surgeon.

Some of the greatest transformations are taking place in the way heart valve disease is being treated. For example, the Heart Institute team of cardiothoracic surgeons and interventional cardiologists now offer advanced treatment options to patients with aortic and mitral valve disease.

Stony Brook's transcatheter aortic valve replacement (TAVR) program has achieved an exceptional safety record, allowing valve surgery to be performed without conventional open-heart surgery.

This minimally invasive procedure allows the insertion of a replacement valve into a patient's defective aortic valve, resulting in a better-functioning valve and a very rapid recovery — most patients are able to go home the next day.

And, for patients needing mitral valve surgery, Dr. Chikwe and her team perform mitral valve repair — not replacement — for most patients. This less invasive approach uses a patient's own tissue to reconstruct the mitral valve, reducing stroke risk and reducing or eliminating the need for long-term blood thinners.

Most important, long-term outcomes with mitral valve repair have been shown to be superior to replacement, increasing life expectancy and quality of life. What's more, surgeons who do a lot of mitral valve procedures, like the surgeons at Stony Brook, have been found to perform safer, better mitral valve surgery (see video [2:16 min] in which Dr. Chikwe explains her news-making study about this).

For residents on Long Island, these groundbreaking new developments can provide exceptional outcomes to a wider range of people, including older and sicker patients, with greater safety and quicker recovery.

Patients should research their cardiac surgeon-hospital decision, according to A. Laurie W. Shroyer, PhD, MSHA, professor of surgery and vice chair for research, whose study to be published in May in The Annals of Thoracic Surgery found that single-center cardiac surgeons had better outcomes than multi-center surgeons, and that multi-center cardiac surgeons had better outcomes at their "home" versus "satellite" hospitals (see ePub). These findings will provide new fuel to the ongoing debate over how to assure the quality of care in healthcare networks that have multiple centers, versus one, where cardiac surgeons perform surgery.

Learn more about the Stony Brook Heart Institute. For consultations/appointments with our cardiac surgeons, please call 631-444-1820.

Posted by Stony Brook Surgery on April 4, 2018

The Multidisciplinary Appointment Makes Care Better for Patients

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Our head and neck specialists (l to r) Drs. Ghassan J. Samara and Lukasz Czerwonka with nurse navigator Gerty Fortune. (Click photo to enlarge.)

Stony Brook University Cancer Center has used the team approach for many years. Specialists from different areas — surgery, medical oncology, radiation oncology, and nursing — work closely together as a team to evaluate the best course of treatment for each individual patient.

Ghassan J. Samara, MD, associate professor of surgery and leader of the head and neck, thyroid oncology team, explains that for new patients who have been diagnosed with a head and neck cancer, a multidisciplinary appointment is set up so that these patients can see all of their specialists at the same location on the same day in one single visit.

Keeping the patient's needs and convenience in mind, our nurse navigator Gerty Fortune, RN, coordinates appointments so the patient can be seen by different specialists on the team in one block of time.

Patients can hear from all the specialists involved with their treatment and receive
all of the information about it at once.

On the appointment day, one specialist — for example, the surgeon — may explain the specifics of the procedure he will provide, and be followed by another — for example, the radiation oncologist — who will discuss that treatment approach.

In some cases, two different specialists may meet with the patient together to explain how their treatments will be coordinated.

This collaboration is particularly important in head and neck cancers because they may require consideration of complex factors to be handled at the same time, such as dental, swallowing, speech, cosmetic, and other specialized areas of treatment.

The quality-of-life benefits to patients make the multidisciplinary appointment better for them.

The multidisciplinary appointment model used by our head and neck cancer team will serve as the care model for all Stony Brook Cancer Center's teams in the near future.

Our Head and Neck Cancer Team

Cancers of the head and neck region are diagnosed and treated by our specialized multidisciplinary team of surgeons, radiation oncologists, medical oncologists, endocrinologists, pathologists, radiologists, and speech-language pathologists. Our team's focus is on malignancies of: 

  • Thyroid and parathyroid glands
  • Salivary glands
  • Aerodigestive tract, including:
    • Hypopharynx
    • Larynx
    • Nasal cavity
    • Oral cavity (mouth)
    • Oropharynx (tonsil and tongue base)
    • Sinuses
    • Skull base 

The Stony Brook Cancer Center is the only center in Suffolk County that offers patients a multidisciplinary appointment, which not only allows them the opportunity to hear from multiple specialists in one day, but allows our team to quickly establish a treatment plan and act on it.

Given the complexities of multimodality treatment for patients with head and neck cancer, the rationale for the use of multidisciplinary teams (MDTs) to define individual optimal treatment strategies on a per-patient basis is apparent. Increased use of guideline-directed approaches, reduced time to treatment and improved outcomes, which result from use of an MDT approach in head and neck cancer, have been documented.
— "Evaluation of the Benefit and Use of Multidisciplinary Teams in the Treatment of Head and Neck Cancer," Oral Oncology (2016)

Learn about head and neck cancers. For consultations/appointments with our head and neck specialists, please call 631-444-4121.

Posted by Stony Brook Surgery on April 2, 2018

Educate Yourself on the Risk Factors, Signs, and Symptoms

RESCHEDULED! Due to the bad weather, the Oral Cancer Awareness Month screening event is canceled for today. Please stay tuned for a new event date, or schedule a free screening at the Dental Care Center on any Tuesday and Thursday in April by calling 631-638-7965.

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Approximately 50,000 people in the U.S. will be diagnosed this year with oral cancer (cancer of the mouth).

One hundred thirty-two new people every day will be diagnosed with an oral cancer, and one person every hour of the day will die from it — that's nearly 9,000 deaths from oral cancer every year.

Of the people newly diagnosed with oral cancer, only about 60% will live longer than 5 years.

Moreover, many who do survive suffer long-term problems such as severe facial disfigurement or difficulties eating and speaking. The death rate associated with oral cancer remains high because the cancer tends to be discovered late in its development.

Oral cancer awareness in the American public is low. While smoking and tobacco use are major risk factors, the fastest growing segment of oral cancer patients is young, healthy, nonsmoking individuals due to the connection to the human papillomavirus (HPV). The only hope to save lives is public awareness.

"Early cancer diagnosis saves lives. If detected early, oral cancer has an 80% survival rate. The most effective way to manage oral cancer is to combine early diagnosis with timely and appropriate treatment," says David K. Lam, MD, DDS, PhD, professor of surgery and oral and maxillofacial surgery.

The fastest-growing cause of oral, head and neck cancers is HPV. In fact, if you have HPV, you're 30 times more likely to develop oral cancer.

Oral cancer can be treated when detected early. People can learn how to examine themselves for possible signs and symptoms (see instructions). If one is detected, they should see their dentist, oral and facial surgeon, or other healthcare professional immediately.

Some of the most common oral cancer signs and symptoms include:

  • Persistent mouth sore: a sore in the mouth that does not heal is the most common symptom of oral cancer
  • Pain: persistent mouth pain is another common oral cancer sign
  • A lump or thickening in the cheek
  • A white or red patch on the gums, tongue, tonsil, or lining of the mouth
  • A sore throat or feeling that something is caught in the throat that does not go away
  • Difficulty swallowing or chewing
  • Difficulty moving the jaw or tongue
  • Numbness of the tongue or elsewhere in the mouth
  • Jaw swelling that makes dentures hurt or fit poorly
  • Loosening of the teeth
  • Pain in the teeth or jaw
  • Voice changes
  • A lump in the neck
  • Weight loss
  • Persistent bad breath

If any of these oral cancer signs or symptoms are present for days or weeks, your doctor may recommend tests to check for oral cancer. As with any cancer, having your cancer diagnosed as soon as possible will help ensure that any treatment is as effective as possible.

Free screening for oral cancer will be provided on Monday, April 2, in front of Stony Brook University Hospital within the School of Dental Medicine's Mobile Dental Clinic, a specially equipped mobile van, between 9 am and 4 pm. Additional free screenings will be available on Tuesdays and Thursdays throughout April at the Stony Brook Dental Care Center by calling 631-638-7965. Early detection is key!

Screening takes less than 10 minutes. A clinician looks over the inside of the mouth to check for white patches or mouth sores, feels the tissues in your mouth to check for lumps or other abnormalities, and uses a state-of-the-art non-invasive scope device that emits a harmless, bright blue light to see mouth tissue changes not visible under normal white light examination.

For consultations/appointments with our oral cancer specialists, please call 631-632-8975 for Dr. David K. Lam and 631-444-8410 for Dr. Lukasz Czerwonka and Dr. Ghassan J. Samara.

Posted by Stony Brook Surgery on March 21, 2018

Communicating Science and Improving Care of Pain: Responding to the Cry for Help

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Dr. David K. Lam

David K. Lam, MD, DDS, PhD, professor of surgery and oral and maxillofacial surgery, is one of twelve experts in pain science and care to be selected as fellows of the Mayday Pain and Society Fellowship.

Dr. Lam and the other fellows in June will attend a four-day, intensive workshop in Washington, DC, where they will learn skills to effectively communicate and advocate for the translation of scientific research and evidence-based best practices in pain care and management.

"The need for the expert voices of pain researchers and clinicians to improve pain care in the U.S. and Canada is greater than ever," says Christina Spellman, executive director of the MAYDAY Fund.

"The Mayday Fellowship will help this year's fellows develop the skills to bring their knowledge of the latest in pain research and evidence-based care to the public, healthcare practitioners, and policymakers.

"Their messages will help shape conversations about access to care, pain research, emerging pain treatments, clinical practice improvements, disparities in care, and the progress that is being made in knowledge about pain and its impact."

The leadership of the MAYDAY Fund believes that public education and the support of quality science are essential to improving the way that pain is understood and treated.

The MAYDAY Fund was established in 1992 to further Shirley Steinman Katzenbach's commitment to social and medical causes. The trustees decided to adopt her special interest in the treatment of pain as the fund's mission.

The name MAYDAY commemorates the date of her birth, and is the international word signaling a cry for help, taken from the French "m'aidez" or "help me."

About Dr. Lam — a Unique Physician

Dr. Lam joined our faculty and practice last fall as section chief of oral and maxillofacial surgery, and holds a joint appointment in the School of Dental Medicine, where he is professor and chairman of oral and maxillofacial surgery. He contributes a new dimension to the care provided by Stony Brook Surgical Associates.

Board certified in oral and maxillofacial surgery, Dr. Lam specializes in the comprehensive surgical management of patients with cancer, pathology, pain, and trigeminal nerve injury.

Dr. Lam comes to Stony Brook from the University of Toronto, where he headed the Department of Oral and Maxillofacial Surgery since 2013.

As a member of Stony Brook Surgical Associates, Dr. Lam will practice at the Stony Brook Cancer Center. His clinical interests and expertise, which demonstrate his multidisciplinary experience and training, are:

  • Maxillofacial oncology
  • Facial trauma
  • Reconstructive surgery
  • Trigeminal nerve injuries
  • Oral and maxillofacial pathology
  • Head and neck surgery
  • Pain management

"I can channel knowledge from science to the patient's bedside and back again because I split my time and interests between clinical practice and research."

An active scholar as well as clinician, Dr. Lam has to date more than 50 publications to his credit. In a personal statement about his work as a pain specialist, Dr. Lam says:

"Being a surgeon and a neuroscientist provides me with a unique perspective on pain management, both focal and global. It is the perspective I gain in helping an individual patient that allows me to potentially help populations of patients.

"I can channel knowledge from science to the patient's bedside and back again because I split my time and interests between clinical practice and research.

"This allows me to play an important role in bridging the bench-to-bedside translational gap since I can readily translate my research results into the clinic and develop research questions based on clinical issues I encounter in practice.

"As a result, my research and clinical programs are closely integrated, and my research addresses the many challenges I face in the clinical management of patients with a focus on pain from head and neck disorders, cancer, trauma, and trigeminal nerve injury."

Dr. Lam earned his MD at the University of California, Davis (2013) and his DDS and PhD at the University of Toronto (2001 and 2008, respectively).

He completed his residency training in oral and maxillofacial surgery and anesthesia at the University of Toronto, and his fellowship training in maxillofacial oncology at the University of California, San Francisco Medical Center.

"My unique multidisciplinary experience and training in medicine, dentistry, anesthesia, neurophysiology, and surgery allows me to ensure optimal care for patients with evidence-based and solutions-focused management, as well as innovative therapies." — Dr. David K. Lam

Learn more about trigeminal nerve pain. For consultations/appointments with Dr. Lam, please call 631-632-8975.

Posted by Stony Brook Surgery on March 13, 2018

Dr. Andrew T. Bates

Hernias are a common health problem, with more than one million hernia repairs performed each year in the United States. Approximately 800,000 are done to fix hernias in the groin, and the rest are for other types of hernias in the abdomen.

A hernia occurs when there is a weakness, or opening, in the muscle and connective tissue that surround the belly area. Patients may feel a slight bulge, discomfort, or pressure as organs push out through this weakness.

While hernias are a common problem, their true incidence is unknown. It is estimated that 5% of the population will develop an abdominal wall hernia, but the prevalence may be even higher.

About 75% of all hernias occur in the groin. The prevalence of hernias increases with age. The likelihood of a life-threatening strangulated hernia, in which the blood supply to the bulging part of the intestine is cut off, also increases with age.

Here, Andrew T. Bates, MD, director of the Stony Brook Comprehensive Hernia Center, answers frequently asked questions about hernias and their treatment.

Q: What exactly is a hernia?

A: The abdomen is held together by a layer of tough connective tissue called fascia. A hernia is a gap, or weak spot, in this fascia that allows internal contents of the abdomen to sneak through.

Q: What are the symptoms?

A: Possible symptoms include: a slight bulge or lump in the affected area; a lump on either side of the pubic bone where the groin and the thigh meet; burning, gurgling, or aching sensations where the bulge is; a heavy feeling in the abdomen; pain or discomfort (usually in the lower abdomen), especially when bending over, coughing or lifting.

Sometimes the person doesn't feel any symptoms at all, and the hernia is discovered during a routine physical or a medical exam for an unrelated problem.

Q: How does a hernia happen?

A: Some hernias are present at birth and lie dormant for years, suddenly "popping out" during straining or pushing. Other hernias develop slowly from accumulated strain, such as repeated heavy lifting. For most patients, it's a combination of the two.

The abdominal wall has several natural weak spots, such as the belly button and the groin (in men), and hernias sometimes happen there. If you have ever had abdominal surgery, your old incision is a place where a hernia could form.

Hernia repairs done by experienced surgeons like ours provide the best results
with low recurrence rates and minimal post-op pain.

Q: Are hernias dangerous?

A: They can be. A hernia can become an emergency medical situation if abdominal contents, especially intestine, herniate through the gap and become stuck. If that happens, the stuck contents can cut off their own blood flow.

Typically, if a hernia is painful, the pain rarely resolves without surgery and will probably get worse.

For patients with a hernia that does not bother them, we must make the decision whether or not to perform surgery. We do know that a significant percentage of patients who have no pain now will develop symptoms later on and require repair.

Q: How are hernias fixed?

A: When it comes to hernias, one size certainly does not fit all. Hernias in the groin often require different surgeries from those on the abdominal wall.

Depending on the size, location, and configuration, your surgeon may use various prosthetic meshes or closure techniques. The most appropriate repair for your hernia may be a traditional open surgery, laparoscopic or even robotic.

The best way for your surgeon to advise you is to have a detailed conversation about your medical and surgical history and perform a complete physical exam.

Q: What type of repair is best?

A: Research has shown that what matters most is your surgeon's experience with a particular technique. The best open surgeon is better than a mediocre laparoscopic surgeon, and vice versa.

Traditional and laparoscopic surgeries produce similar and excellent outcomes when performed by a well-trained surgeon.

Q: Is it bad to use surgical mesh in repairing hernias?

A: In short, no. Hernia mesh is very different than the mesh discussed in some advertisements that can alarm patients. (See my more detailed response about the mesh question.)

Although non-mesh options exists, using a prosthetic mesh for hernia repair is the standard of care in most cases. Using a patch made of surgical mesh lowers the chance of the hernia coming back after surgery, which has been proven consistently by several research studies nationwide.

Most meshes are permanent and will become incorporated in the abdominal wall, adding permanent strength.

Suturing the patient's own tissue back together, without using a mesh patch, is done in the procedure called the Shouldice repair.

Our experienced hernia experts work together as a team to design the best treatment plan possible so patients can get back quickly to their normal lives and daily activities.

Q: Can a "hernia belt" sold in medical supply stores help?

A: This is called a hernia truss. It provides pressure on the hernia so it does not pop out. Although this can prevent an emergency, it does not fix the underlying problem and surgery is still recommended.

Q: What is a "sports hernia"?

A: A sports hernia is actually a ligament/tendon injury in the groin. It may mimic the discomfort of a true hernia. Depending on severity and type, these hernias can be treated via surgery, anti-inflammatory medication/injections, or physical therapy.

Q: What is the advantage of having a hernia repair done at Stony Brook?

A: The advantage is two-fold: academic and comprehensive. By having your repair at an academic institution like Stony Brook Medicine, you take advantage of a surgery faculty that utilizes the newest techniques and, in many cases, is driving the field forward.

Our surgeons present their work at national societies, and have published countless articles about their research projects in respected surgical journals. As academic surgeons, we are committed to making surgery better.

"Comprehensive" means that all of your needs are addressed under one roof, delivered by a collaborative team dedicated to excellent patient outcomes.

Our center includes open, laparoscopic, and robotic surgery specialists. We work closely with plastic surgeons for those patients that may require complex repair.

We have also integrated pain management specialists into our treatment protocols for those patients suffering from debilitating hernia-related pain. When patient care is seamless as done here at Stony Brook, outcomes improve.

The Stony Brook Comprehensive Hernia Center — distinguished by Stony Brook Medicine's multidisciplinary approach to patient care — offers a wide range of options to diagnose and treat most types of hernias. Our experienced hernia experts work together as a team to design the best treatment plan possible so patients can get back quickly to their normal lives and daily activities. Patients can see our hernia specialists at our Suffolk County offices in Centereach, East Setauket, Smithtown, and Commack.

For consultations/appointments with our hernia specialists, please call 631-638-0054. Visit the website of the Comprehensive Hernia Center for more information about it.

Posted by Stony Brook Surgery on March 7, 2018

March Is National Colorectal Cancer Awareness Month! Colorectal cancer screening saves lives. If everyone 50 years old or older were screened regularly, as many as 60% of deaths from this cancer could be avoided.

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

Colorectal cancer — also known as colon cancer — is the second leading cause of cancer-related deaths in the United States. It affects both men and women. Every year, more than 140,000 Americans are diagnosed with colorectal cancer, and more than 50,000 people die from it.

Awareness of colorectal cancer and its common signs is well worth it, because when detected early this cancer can be treated effectively.

Here, Paula I. Denoya, MD, a member of the faculty of our Colon and Rectal Surgery Division, answers frequently asked questions about colorectal cancer, with special attention to its common warning signs, detection, and treatment.

Q: What is colorectal cancer?

A: Colorectal cancer arises from the lining of the colon or rectum, usually from cells that secrete mucus. In many cases, it starts out as a polyp, which is a premalignant, benign lesion or an overgrowth in the lining of the colon. If left alone, a polyp can grow into cancer. However, with screening, polyps can be detected and removed, thus preventing cancer altogether.

Q: What are the signs and symptoms?

A: Colorectal cancer is often symptomless, which is why screening is so important. Some people do experience telltale signs, however. Ten warning signs of colorectal cancer are:

  • Blood in stool
  • Persistent diarrhea
  • Persistent vomiting
  • Cramping abdominal pain
  • Persistent bloating
  • Unexplained weight loss
  • Decreased stool size
  • Unexplained fatigue
  • Change in bowel habits
  • Incomplete emptying of bowel

Anyone experiencing these symptoms should speak with their primary care physician.

Q: Who is at risk?

A: According to the American Cancer Society (ACS), colorectal cancer is the third most common cancer in men and women. Gender does not seem to be a factor, but age is, and risk increases after age 50.

People considered to be at higher risk include those with a family history of polyps, colon cancer, or uterine cancer; individuals with inflammatory bowel disease; anyone with a personal history of polyps; and persons with inherited syndromes such as familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer.

The ACS recommends that people undergo screenings starting at age 50, with a follow-up every 10 years if no polyps are detected. Individuals at high risk should start screenings earlier and have more frequent follow-ups.

Colorectal cancer can be prevented, and it is extremely curable if caught early.

Colon Anatomy | From Gray's Anatomy (1918)
The colon, as depicted in Gray's Anatomy (1918;
click on image to enlarge).

Q: How is colorectal cancer detected?

A: Colonoscopy is considered the gold standard because it is the only test that can identify and treat polyps in the entire colon. Further, if a polyp is detected during screening, it often can be removed and biopsied at that time, eliminating the need for additional procedures. (See our 2012 blog post, "New Report Affirms Lifesaving Role of Colonoscopy: Death Risk Is Cut in Half.")

While people often dread undergoing a colonoscopy, it is important to know that recent changes make it a gentler experience. For example, Stony Brook uses many different kinds of bowel preparations — some are even in pill form. The patient's physician will determine which preparation the patient will best tolerate.

In the past, patients remained awake for the procedure, but now, with innovations in anesthesia, patients undergo a short, fast-working, and deep sedation that has minimal side effects including no memory of the procedure.

Stony Brook offers additional screening methods, including flexible sigmoidoscopy, barium enemas, fecal occult blood testing, and CT colonography, also known as virtual colonoscopy.

Virtual colonoscopy was invented at Stony Brook in the 1980s. While less invasive than a traditional colonoscopy because it uses a CT scan to look at the lining of the colon, it still requires bowel preparation. It is generally used with patients who may have an existing colon blockage or for whom a colonoscopy carries risks, for example, from anesthesia. Unlike a colonoscopy, in which a polyp can be removed during the screening procedure, during a virtual colonoscopy, if a polyp is detected, the patient will need an additional procedure to treat and biopsy it.

Q: If cancer is detected, how is it treated?

A: Colorectal cancers respond well to treatment, and often treatment is relatively uncomplicated. About 30% of cases can be treated with surgery alone. Cancers in later stages respond well to chemotherapy and radiation, and overall, the five-year survival rate approaches 65%.

Colorectal cancer is treatable — know your options.

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Q: What distinguishes Stony Brook's approach?

A: Stony Brook Medicine offers the latest protocols and treatments for colorectal cancers — delivered by a multidisciplinary team — including the new transanal endoscopic microsurgery, a less invasive procedure than the traditional approach for reaching lesions high up in the rectum.

We are renowned leaders in the use of minimally invasive laparoscopic surgery for treating colorectal cancer, which offers patients considerable benefits.

Using the da Vinci® Si robotic surgical system, our surgeons offer patients another option beyond traditional open surgery and laparoscopic procedures. The major advantage of this minimally invasive technique is that it provides surgeons with enhanced visibility and mobility.

This improves accuracy, provides cleaner "margins" (which means that no cancer cells are seen at the outer edge of the tissue that was removed) and helps ensure that all the lymph nodes (difficult to see and reach by conventional methods) can be removed during the procedure.

Benefits to the patient having robotic surgery include less bleeding, less scarring, less pain, and a lowered risk of infection.

In addition, we are working to advance the practice of medicine through clinical trials and testing. We currently are participating in a multi-institution trial run by the American College of Surgeons Oncology Group to pioneer a minimally invasive laparoscopic treatment for rectal cancers.

For standard treatment approaches, we work closely with oncologists, radiologists, pathologists, and other specialists on the colorectal cancer multidisciplinary team at Stony Brook University Cancer Center to provide comprehensive cancer care to our patients.

If you are over age 50 and have not yet had a colonoscopy, schedule one soon by calling Stony Brook's Direct Access Screening Colonoscopy Program at 631-444-COLON (2656) . You can request an appointment online, too.

Americans of African descent are approximately 40% more likely to die from colon cancer, compared to individuals who are of Caucasian descent. Because of this health disparity, researchers from Stony Brook University have created a partnership with SUNY Downstate and Cold Spring Harbor Laboratory to launch a program to assess gastrointestinal cancer biology in patients. Watch video (4:55 min) that explains.

Watch this 1-minute video featuring Meryl Streep who explains why screening for colorectal cancer is a smart thing to do:

Watch this News 12 LI news clip (1:55 min) featuring Minsig Choi, MD, director of medical oncology at Stony Brook Cancer Center:

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Posted by Stony Brook Surgery on February 8, 2018

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Dr. Christopher S. Muratore

Pediatric surgeons specialize in the diagnosis, preoperative, operative, and postoperative management of surgical problems in children, and they operate on children whose development ranges from before birth through the teenage years.

Of the estimated 4 million babies born in the United States annually, about 120,000 (3%) have a complex birth defect.

Some medical conditions in unborn children are possibly life-threatening or just not compatible with a good quality of life unless these problems are corrected surgically, often requiring multiple operations over a period of time.

In cooperation with maternal-fetal medicine specialists and radiologists, pediatric surgeons use ultrasound and other technologies such as MRI during the fetal stage of a child's development to detect and clarify possible abnormalities.

Prenatal diagnosis of a surgically correctible problem may lead to fetal surgery in select cases, if the condition threatens the fetal gestation. An increasing number of fetal surgical techniques are currently being developed.

Fetal evaluation and management is provided at Stony Brook Children's Hospital to treat a range of conditions and birth defects before delivery, further showing how Stony Brook Medicine leads the way in patient care.

Here, Christopher S. Muratore, MD, professor of surgery and Knapp Swezey chair in pediatric surgery, who is a specialist in prenatal/fetal surgery, answers frequently asked questions about it.

Q: When was prenatal surgery developed?

A: Prenatal surgery has evolved over the past three decades into a multidisciplinary and collaborative medical specialty better regarded as fetal medicine or fetal diagnosis and management.

During this time, physicians committed to fetal medicine and fetal surgery have learned the power of a cooperative community dedicated to improving outcomes for patients diagnosed with fetal anomalies.

Through these collaborations several multicenter, randomized, controlled clinical trials had been successfully completed which has allowed clinicians to accurately identify complex anomalies, stratify their severity, and provide consultation for expectant families identified with a fetus who has an anomaly to be given accurate outcomes, so that they may make the most informed decisions about her pregnancy and delivery plans.

Q: What conditions can now be treated with prenatal surgery?

A: Prenatal surgery represents a spectrum of fetal interventions that can be performed on the fetus to correct a life-threatening situation or to prevent the progressive physiologic organ damage that occurs from a congenital anomaly.

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Fetal MRI of 21-week fetus with congenital diaphragmatic hernia, showing abnormal liver (*) and bowel (**) in chest. (Click to enlarge.)

Conditions now treated with prenatal surgery include airway and lung malformations, diaphragmatic hernia, twin-to-twin transfusion syndrome, select heart defects, spina bifida, and unique tumors, among others.

Historically, fetal surgery involved a maximally invasive operation on the mother, who is the innocent bystander, to open the womb in order to gain access to the fetus and operate on the fetus while still connected to the placenta.

Techniques used in fetal intervention have evolved to more minimally invasive procedures through keyhole surgeries in the mother and the womb, using tiny incisions, to access the fetus and surgically correct the congenital anomaly in question.

Philosophically, fetal therapy has moved away from the historic idea of correcting the anatomic issue to a strategy of manipulating the fetal physiology in most cases to alter the developmental consequences of the congenital anomaly.

These fetal interventions have become important options for the fetus that would otherwise not survive gestation, or that would endure significant problems after delivery.

Stony Brook Children's fetal medicine team allows for families on Long Island
to get the very best care close to home for their unborn child.

Q: What is the role of advanced fetal diagnostic testing?

A: Without question, advances in fetal imaging and diagnosis have allowed clinicians to more accurately identify complex anomalies prenatally and to stratify their severity.

Prenatal ultrasound is routinely used as initial fetal survey imaging which oftentimes may identify a worrisome fetal anomaly. Fetal MRI is often used to better clarify or define the anomaly in question.

Both techniques have evolved significantly over the past 30 years to allow excellent identification and accurate diagnosis.

Q: How is prenatal surgery performed? Is it open surgery or laparoscopic?

A: The goal of prenatal surgery was always to correct a known or identified congenital anomaly that would be life-threatening to the fetus or pose significant health problems to the baby once delivered. The idea of correcting such a lesion prenatally to allow for normal development has always been the Holy Grail.

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Fetal MRI of fetus with abdominal wall defect (*), i.e., gastroschisis. (Click to enlarge.)

Early attempts at prenatal surgery were generally maximally invasive through an open surgery on the mother and opening of the uterus or womb, termed hysterotomy. This poses a significant risk to the continuation of pregnancy, oftentimes leading to prenatal delivery and prematurity of the baby, as well as complications for the mother.

Over the years, with the development of laparoscopic surgical technique and skill sets, physicians have utilized a more minimally invasive approach to correcting the fetal anomaly. Called fetoscopic surgery, mini keyhole incisions can be used to create tiny incisions in the uterus to attempt correction of the fetal condition with a camera inserted into the womb.

Today, some conditions still require open hysterotomy and open fetal surgery for very select situations.

The approach to the fetus can also be purely minimally invasive through the mother, through the uterus into the womb, with a catheter inserted into the fetal chest or abdomen to attempt correction of a problem. Oftentimes this will be done under ultrasound guidance for fetal imaging and monitoring.

Q: What kind of special technology is required to do prenatal surgery?

A: The most important special technology required to do prenatal surgery is a team of multidisciplinary individuals with expertise, who are dedicated to collaboratively working together, bringing all of the available resources and knowledge to the family and fetus to provide the best diagnostic accuracy to develop a prenatal and/or postnatal management plan.

Specific technology includes a 3-D and 4-D ultrasound, fetal MRI, and fetal echocardiography. Miniaturized surgical telescopes, catheter-delivery access, and laser technologies also are important instruments to a multidisciplinary fetal management team.

Q: Is fetal analgesia necessary during prenatal surgery?

A: Many intravenous anesthetics given to the mother will be transported across the placenta to the fetus. Other anesthetics can be given directly to the fetus, generally similar to an intramuscular injection.

Techniques in fetal intervention have evolved to more minimally invasive procedures
to access the fetus and surgically correct congenital anomalies.

Q: What is image-guided fetal surgery?

A: Oftentimes a fetal condition that needs to be addressed might be a mass or space-occupying lesion such as a cystic fluid collection that can significantly harm the fetus if not drained or decompressed.

Under such circumstances, ultrasound guidance through the womb can allow for access through a needle incision in the mother and the womb to allow passage of a catheter under ultrasound guidance into the fetal mass in question.

Q: How is the multidisciplinary approach used in prenatal surgery?

A: The multidisciplinary approach used in a fetal care team is built up on the strategy that each medical specialty brings a specific set of expertise to the table to allow for the best outcome for the fetus and family. Generally speaking, the fetal care team comprises a director or team leader with a number of co-directors to manage the fetal treatment program.

A dedicated fetal care coordinator or nurse navigator is essential to provide streamlined concierge service to the family and help coordinate the many subspecialty visits and consults that are required. An active fetal care database is also essential for continuity and careful examination of patient outcomes.

Core members of the fetal care team include maternal-fetal medicine specialists and pediatric cardiologists who also perform fetal echocardiogram to examine fetal heart conditions. (Read about Stony Brook's maternal-fetal medicine specialists and pediatric cardiologists.)

Fetal surgeons are often pediatric surgeons or a perinatologist/maternal-fetal medicine specialist.

Genetic counselors are essential to the team and family education. Pediatric radiologists and neonatologists also are key members of the interdisciplinary team.

When a fetal intervention is deemed necessary, the inclusion of an obstetric and pediatric anesthesiologist familiar with fetal surgery and physiology is crucial.

Additional specialists such as neurologists, neurosurgeons, urologists, and orthopedic surgeons should be part of the extended care team as necessary.

Finally, by no means last, a social work specialist provides essential continuity care and rounds off the multidisciplinary care team to assist the prenatal and oftentimes postnatal transition for the family.

Q: What is the advantage of having prenatal surgery done at Stony Brook Children's Hospital?

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In utero fetoscopic view of the fetal left hand. (Click to enlarge.)

A: The advantage of having a dedicated multidisciplinary fetal medicine team at Stony Brook Children's allows us to provide education to Long Island families whose fetus is identified to potentially have a condition that requires prenatal or postnatal care.

As pregnancies are always exciting and stressful times, the diagnosis of a possible worrisome fetal condition really requires a dedicated team to quickly determine the level of fetal concern and assist the family with understanding and education. This is best done in an environment that's close to their home, their friends, their family, and their resources.

It's very disrupting for the family to have to pick up and drive many hours or move to another location, as well as to have multiple interruptions in work and/or school or day care arrangements.

Thus, having Stony Brook's fetal medicine team available to provide consultative services prenatally allows for families on Long Island to get the very best care for their family close to home for their unborn child.

Another important advantage of Stony Brook Children's is that, as part of an academic medical center, we are dedicated to making fetal medicine better and to advancing prenatal surgical care through research and innovation. This is what distinguishes us from other hospitals in our region.

Maternal-fetal surgery is performed on two patients, the pregnant patient and the fetal patient. Ethics is therefore an essential dimension of maternal-fetal surgery. From its beginnings in only a few centers, various procedures have become available in highly specialized centers in developed countries. Innovation and research have played an indispensable role in the development of maternal-fetal surgery and will continue to do so. — Seminars in Fetal and Neonatal Medicine (2017)

Click here for more information about prenatal surgery. For consultations/appointments with Dr. Muratore, please call 631-444-4545.

Posted by Stony Brook Surgery on January 11, 2018

Dr. Andrew T. Bates

Hernias are a common health problem, with more than one million hernia repairs performed each year in the United States. Approximately 800,000 are done to fix hernias in the groin, and the rest are for other types of hernias in the abdomen.

A hernia occurs when there is a weakness, or opening, in the muscle and connective tissue that surround the belly area. Patients may feel a slight bulge, discomfort, or pressure as organs push out through this weakness.

However, many patients may have this opening/weakness even if organs aren’t actively pushing through. Over time, this bulge or area of weakness can grow in size. Occasionally, intestine can become trapped in the hernia, which requires emergency medical attention.

Not only are there different kinds of hernias, different methods and surgical approaches are currently used to repair them. Today, a "mesh" product is commonly used in hernia repairs.

Hernia mesh has been around for over 50 years, and earlier versions of it have long been regarded as the "gold standard" to use in repairs. However, some websites today make claims that mesh is unsafe, and that repairing hernias without mesh is better.

Here, Andrew T. Bates, MD, director of the Stony Brook Comprehensive Hernia Center, answers frequently asked questions about hernias and the mesh used to repair them.

Q: Must a hernia be repaired?

A: All hernias have the potential for trapping abdominal contents, such as intestine, which is why we typically recommend repair in patients who are acceptable surgical candidates.

Not all hernias, though, are the same, and so we often employ a different approach based on the location of the hernia, such as groin or abdominal wall.

In the case of groin (inguinal) hernias, surgeons in the recent past advocated for "watchful waiting" for hernias that were not particularly bothersome.

However, based on newer research, we now know that a large percentage of these hernias will later become bothersome and require repair, possibly emergent, and therefore we advocate for repair.

Q: Does hernia repair require mesh?

A: Not necessarily, but usually. In the right patients, some groin hernias can be repaired without mesh and still have acceptable success rates. Additionally, some small hernias at the belly button can be repaired with suture alone. Most repairs, though, do utilize prosthetic mesh to achieve a successful repair.

When patient care is seamless as done here, outcomes improve.

Q: What exactly is mesh?

A: The term "mesh" is used to describe a flat sheet of prosthetic material that is used to cover, or "patch," a hernia.

Q: Are there different kinds of mesh? How are they different?

A: There is a sizable industry devoted to a large array of hernia meshes. Some are made of various plastics; some are made of biologic materials. Some are permanent and some are designed to degrade over time.

The most common type of mesh is made of a plastic material and closely resembles a window screen in appearance. Some meshes are also made with protective coatings that allow them to be placed in the abdomen near the abdominal organs.

Q: What are the advantages of using mesh in hernia repair?

A: Decades ago, hernia repairs were performed by simply suturing the hernia closed. For some types of hernias, this repair resulted in 25-50% of hernias later returning. Mesh changed that. By using mesh, the chance of hernia recurrence dropped to the low single-digits.

Q: Does mesh cause problems in hernia repair?

A: In most cases, using mesh is the acceptable standard of care. However, there can certainly be complications related to the mesh.

Q: What specific problems are associated with mesh?

A: Mesh is a foreign body that your body incorporates to help strengthen the repair. However, being a foreign body, it can also become infected if it becomes contaminated either at the time of surgery or later. This may require mesh removal.

Mesh placed inside the abdomen can also lead to scar tissue, or adhesion, formation that can predispose patients to bowel obstruction down the road.

However, all patients who have had surgery in the abdomen also form these adhesions, so this is not a problem specific to the mesh itself.

Most brands and models of mesh have excellent safety profiles.

Q: Why are mesh companies being sued now?

A: There are many sizes and shapes of mesh, all with different strengths and flexibility. Some lightweight meshes were removed from the market after cases of breakage were reported, but most brands and models of mesh have excellent safety profiles.

There were also other surgeries that used mesh, such as vaginal sling surgery, which regrettably had a high complication rate but is a completely different surgery altogether. In the vast majority of cases, complications are the result of surgical technique and not the mesh used.

Q: When mesh is required, is traditional open surgery or minimally invasive laparoscopic surgery better?

A: This is impossible to answer because every patient is different and every hernia is different. What is right for one patient may not be best for another.

For this reason, an individualized approach is key. What our research has shown is that surgeon experience with a particular technique is the most important factor, whether it is laparoscopic or open.

Q: What do the latest major scientific studies say about mesh? Is there a consensus?

A: In most hernias, mesh is the standard of care. This is what the science clearly indicates, and it is backed up by well-designed clinical trials as well as retrospective studies.

Q: What is the advantage of having a hernia repair with mesh done at Stony Brook?

A: The advantage is two-fold: academic and comprehensive. By having your repair at an academic institution like Stony Brook Medicine, you take advantage of a surgery faculty that utilizes the newest techniques and, in many cases, is driving the field forward.

Our surgeons present their work at national societies, and have published countless articles about their research projects in respected surgical journals. As academic surgeons, we are committed to making surgery better.

"Comprehensive" means that all of your needs are addressed under one roof, delivered by a collaborative team dedicated to excellent patient outcomes.

Our center includes open, laparoscopic, and robotic surgery specialists. We work closely with plastic surgeons for those patients that may require complex repair.

We have also integrated pain management specialists into our treatment protocols for those patients suffering from debilitating hernia-related pain. When patient care is seamless as done here at Stony Brook, outcomes improve.

The Stony Brook Comprehensive Hernia Center — distinguished by Stony Brook Medicine's multidisciplinary approach to patient care — offers a wide range of options to diagnose and treat most types of hernias. Our experienced hernia experts work together as a team to design the best treatment plan possible so patients can get back quickly to their normal lives and daily activities. Patients can see our hernia specialists at our Suffolk County offices in Centereach, East Setauket, Smithtown, and Commack.

Learn more about inguinal hernias. For consultations/appointments with our specialists at the Stony Brook Comprehensive Hernia Center, please call 631-638-0054.

Posted by Stony Brook Surgery on January 3, 2018

Our Trauma Chief Recognized as Asset for Suffolk County and Our Community

James A. Vosswinkel, MD
Dr. James A. Vosswinkel

James A. Vosswinkel, MD, chief of our Trauma, Emergency Surgery, and Surgical Critical Care Division, and medical director of the Stony Brook Trauma Center, has been chosen the 2017 Times Beacon Record News Media "Person of the Year."

Published last Friday, the TBR article announcing the high honor, titled "Stony Brook Trauma Care Surgeon Is an Asset for Suffolk County," opens this way:

When they come to him, they need something desperately. He empowers people, either to help themselves or others, in life and death situations or to prevent the kinds of traumatic injuries that would cause a crisis cascade.

Dr. James Vosswinkel, an assistant professor of surgery and the chief of trauma, emergency surgery and surgical critical care, as well as the medical director of the Stony Brook Trauma Center, is driven to help people through, or around, life-threatening injuries.

Vosswinkel speaks to people in traffic court about the dangers of distracted driving and speeding, encourages efforts to help seniors avoid dangerous falls and teaches people how to control the bleeding during significant injuries, which occur during mass casualty crisis.

For his tireless efforts on behalf of the community, Vosswinkel is a Times Beacon Record News Media Person of the Year.

"If you are transferred because of the seriousness of your trauma or the location of your trauma and you end up at Stony Brook, you can be well assured that you'll receive state-of-the-art care."

Kenneth Kaushansky, MD, senior vice president, health sciences, and dean, Stony Brook University School of Medicine, says: "Dr. Vosswinkel is the quarterback for developing all the resources and making sure the quality of those individuals is up to very, very high standards.

"He's a very fine trauma surgeon, who has assembled a team of additional fine surgeons. If he's ever needed, he's always available, whether he's on call or not."

Mark A. Talamini, MD, MBA, professor and chairman of surgery, and chief of surgical services, Stony Brook Medicine, says: "Dr. Vosswinkel will come to the hospital to help a member of his team at any hour of the night. When his people need help, he's there."

Scott Coyne, MD, chief surgeon and medical director of the Suffolk County Police Department, has only good things to say about Dr. Vosswinkel, who recently was promoted to chief consulting police surgeon by the SCPD:

"He's a very valuable adjunct to our police department. If you are transferred because of the seriousness of your trauma or the location of your trauma and you end up at Stony Brook, you can be well assured that you'll receive state-of-the-art care. Dr. Vosswinkel is one of the leaders in the delivery of that surgical care."

About Dr. Vosswinkel

Born and raised on Long Island, Dr. Vosswinkel received his medical degree from the SUNY Upstate Medical University in 1995, and completed his residency training in general surgery at Stony Brook. Subsequently, he gained fellowship training in trauma/surgical critical care at Yale University.

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Dr. Vosswinkel, in 2000, when a resident here.

As a resident here, Dr. Vosswinkel in 2000 was the first to receive the David J. Kreis Jr. Award for Excellence in Trauma Surgery, an annual award given to a senior (fourth-year) surgical resident by the Trauma, Emergency Surgery, and Surgical Critical Care Division in honor of the late Dr. Kreis, the founding chief of our trauma and surgical critical care service, who served with distinction on our faculty from 1986 until his untimely death in 1989.

On completing his training at Yale, Dr. Vosswinkel returned to Long Island and joined the faculty of our Department of Surgery in 2002 as a traumatologist and general surgeon. Over the next decade, he distinguished himself with his clinical skills and leadership, and in 2013, he was appointed chief of the Trauma, Emergency Surgery, and Surgical Critical Care Division.

Dr. Vosswinkel was instrumental in overseeing Stony Brook's recent verification as a Level 1 Regional Trauma Center by the American College of Surgeons (read more). Stony Brook is Suffolk County's only Level 1 Trauma Center for both adults and children, which is the highest level of trauma care possible.

Over the last few years, Dr. Vosswinkel has earned recognition from several groups. He was named the Physician for Excellence in 2016 by the Suffolk Regional Emergency Medical Services Council (read more).

Last September, for his exceptional leadership at the Trauma Center, Dr. Vosswinkel was invested as the Lillian and Leonard Schneider Endowed Professor in Trauma Surgery — the first endowed professorship in the Department of Surgery (read more).

"What's different about Dr. Vosswinkel," says Jane E. McCormack, RN, BSN, our trauma program manager, is that "a lot of people talk about working harder, but he does it. He's an intense guy who is very passionate about what he does."

Read the article written by Daniel Dunaief about Dr. Vosswinkel published in the Times Beacon Record. Learn about the many lifesaving programs provided by the Stony Brook Trauma Center.

Posted by Stony Brook Surgery on January 2, 2018

Our Thyroid Specialists Use a Multidisciplinary Approach to Managing Thyroid Disorders

The Thyroid Grand | January Is Thyroid Awareness Month
The thyroid is just below the Adam's apple.

An estimated 20 million Americans suffer from a thyroid disorder, and many more go undiagnosed every year. Now is a good time to become aware of your thyroid and its relationship to your health — and how best to take care of it.

Thyroid nodules and enlarged thyroid glands are common problems, and they can harbor cancers within them. They require proper evaluation and treatment.

When detected, patients with these thyroid disorders are usually referred for further work-up to an endocrinologist, or to an experienced head and neck surgeon, like one of the head and neck surgeons at Stony Brook Medicine.

January is national Thyroid Awareness Month that aims to bring to the public's attention the need to take good care of this important tiny gland in the neck.

Following a thorough work-up, the patient may need to undergo thyroidectomy (removal of part or all of the thyroid gland) for several reasons — for removal of thyroid cancer, removal of part of the thyroid gland for definitive diagnosis, treatment of a hyperactive thyroid gland, or an enlarged thyroid gland that is causing breathing or swallowing difficulties.

The thyroid gland is a small, butterfly-shaped gland located in the base of the neck just below the Adam's apple. Although relatively small, the thyroid gland influences the function of many of the body’s most important organs, including the heart, brain, liver, kidneys, and skin. Ensuring that the thyroid gland is healthy and functioning properly is important to the body's overall well-being.

Surgical intervention is the gold standard in thyroid cancer; there are no other options to cure it.

Since thyroid cancers are highly curable, it is extremely important for the patient to undergo proper treatment and close follow-up. The initial treatment for most thyroid cancers is removal of the thyroid gland, and sometimes removal of lymph nodes which may contain metastatic cancer.

In the hands of a highly-skilled, experienced surgeon, the procedure can usually be done on an outpatient basis and with a low risk of complications. Depending on the type of cancer, some patients may require treatment with radioactive iodine after surgery.

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Our thyroid specialists, (l to r) Drs. Lukasz Czerwonka, Melissa M. Mortensen, and Ghassan J. Samara.

Also essential is close follow-up by the patient's endocrinologist for tumor surveillance and regulation of the thyroid hormone.

Our thyroid specialists take a multidisciplinary approach to providing care for patients with thyroid disorders. The team of physicians consists of surgeons, endocrinologists, radiation oncologists, radiologists, and pathologists.

Management decisions are often made jointly among the team members. Such a team approach has ensured long-term successful outcomes for our patients at Stony Brook Medicine.

Hyperthyroidism is a sustained overly active thyroid gland, which may result in anxiety, nervousness, rapid heartbeat, weight loss, and high blood pressure. The causes of hyperthyroidism include Grave's disease and toxic nodular goiter. This condition is treated with medications, radioactive iodine, or thyroidectomy.

The advantage of surgery is that the condition can be treated quickly and effectively, minimizing the risk of recurrence. In the past, non-surgical treatment has been the primary approach to patient care because of potential complications associated with the surgery. Now, with surgical expertise and advances in technology at Stony Brook Medicine, more patients are undergoing surgery with minimal complications.

In the past, goiter was treated with medication, but that was proved not to be effective. Patients with goiter now have surgery to alleviate the pressure symptoms on the trachea and the esophagus.

Thyroidectomy is performed for nodules and cancer of the thyroid gland. It is also performed in some patients with overactive thyroid glands.

Stony Brook Medicine provides patients state-of-the-art thyroid care using the multidisciplinary team approach, distinguished by highly experienced surgical specialists capable of treating all forms of thyroid conditions.

The thyroid gland is a small, butterfly-shaped gland located in the base of the neck just below the Adam's apple. Although relatively small, the thyroid gland influences the function of many of the body’s most important organs, including the heart, brain, liver, kidneys, and skin. The blue paisley ribbon icon is the universal symbol of thyroid disease awareness and advocacy. Paisley was chosen because it resembles a cross-section of thyroid follicles, the tiny spheres that the thyroid gland is made of.

Perform the do-it-yourself thyroid neck check. Watch this video (1:00 min) about thyroid awareness from the American Association of Clinical Endocrinologists:

Posted by Stony Brook Surgery on January 4, 2016

Williams Practiced Medicine and Poetry Together throughout His Career

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Dr. William Carlos Williams with patient.

"By the Road to the Contagious Hospital," by America's great poet-physician William Carlos Williams (1883–1963), is ultimately a celebration of renewal. The poem is also the record of one particular experience in Williams's life as a physician; namely, driving from his home in Rutherford, NJ, to an infectious disease hospital in Passaic.

Williams lived his entire life in Rutherford, the town where he was born and raised. It is where he maintained his medical office in his home — where most people knew him simply as "Doc" without knowing he was a widely published author and leader of American modernism.

"By the Road to the Contagious Hospital" is the first poem in Williams's book, Spring and All (1923). In this poem he applied his clinical gaze to the landscape before him, as winter was giving way to spring. He had been trained to observe carefully. This training is reflected in the fine images and detail seen in all his poetry.

And as critic Herbert Leibowitz points out, the poem shows how Williams "listened to the acoustic properties of words with the same care and skill he devoted to the beating of a patient's heart." He was skilled in patient care indeed, and in the lobby of St. Mary's General Hospital in Passaic, there's a plaque honoring him (he was co-director of its pediatrics department for nearly two decades).

Here, we honor him with the poem itself — for its hopeful vision — at the start of our new year:

By the Road to the Contagious Hospital

By the road to the contagious hospital
under the surge of the blue
mottled clouds driven from the
northeast — a cold wind. Beyond, the
waste of broad, muddy fields
brown with dried weeds, standing and fallen

patches of standing water
the scattering of tall trees

All along the road the reddish
purplish, forked, upstanding, twiggy
stuff of bushes and small trees
with dead, brown leaves under them
leafless vines —

Lifeless in appearance, sluggish
dazed spring approaches —

They enter the new world naked,
cold, uncertain of all
save that they enter. All about them
the cold, familiar wind —

Now the grass, tomorrow
the stiff curl of wildcarrot leaf

One by one objects are defined —
It quickens: clarity, outline of leaf

But now the stark dignity of
entrance — Still, the profound change
has come upon them: rooted, they
grip down and begin to awaken

[Listen to WCW reading his poem]

William Carlos Williams practiced pediatrics and obstetrics for over 40 years. A physician of great integrity, he regarded allegiance to humanism as important as excellence in medical science. He now serves as a role model, and medical students read him (The Doctor Stories) to learn how he worked at getting the right picture of patients — much like artists do with paint on canvas, and photographers do with cameras — beyond Michel Foucault's clinical gaze.

Williams's concurrent practice of medicine and poetry is illustrated by the literary use of his prescription pad, as shown here in notes for his epic masterpiece, Paterson.

At Stony Brook School of Medicine, Williams is read in the Center for Medical Humanities, Compassionate Care, and Bioethics. Established in 2008 to succeed the Institute for Medicine in Contemporary Society, the center is dedicated to furthering the school's long tradition of emphasizing humanism in medical education, and serving as "a place where the human side of medicine is elevated, examined, and revered."

See "William Carlos Williams (1883–1963): Physician-Writer and 'Godfather of Avant Garde Poetry,'" in the Surgical Heritage series of The Annals of Thoracic Surgery. For books by Williams, visit New Directions.