New procedures, devices, guidelines
Vascular Surgeons Offer Latest Technique in Aortic Aneurysm Repair
By Susan Conova
When an aortic aneurysm lies close to the arteries that supply the kidneys and intestines, some patients are sent home with little more to hold onto than hope that they won’t suffer a lethal rupture.
Although most abdominal aortic aneurysms can easily be repaired with a minimally invasive technique that installs a flexible plastic and metal stent to reinforce the arterial wall, a stent inserted into an anatomically complex aneurysm would cut off blood flow to other organs.
“About 5 percent to 10 percent of patients with abdominal aortic aneurysms have such anatomy, and it has been a struggle to treat them,” says James McKinsey, M.D., associate professor of clinical surgery and interim bicampus chief of vascular surgery. “Often they are older and more debilitated than patients with simple aneurysms and don’t fare well after open surgical repair, which has been their only option until now.”
P&S vascular surgeons can now offer these patients a better option: a new experimental stent with holes punched in the sides that can seal off the aneurysm while preserving blood supply to other organs. The device, called a fenestrated graft, has been approved by the FDA for use only at both the Columbia and Cornell campuses of NewYork-Presbyterian Hospital and two other hospitals in the country.
“The new stent gives these patients a new lease on life,” says Dr. McKinsey, who in July performed the procedure, the hospital’s first, on a 93-year-old man.
The procedure itself took about three hours, but the preparation for it took several months. Because locations of the aortic branches are unique to each patient, every graft must be custom-made. First, a special spiral CT machine measures the patient’s anatomy so that holes in the graft can be positioned. Data are then sent to the graft’s manufacturer, which designs and builds a customized graft.
Inserting the graft also takes sophisticated interventional skills to properly align the graft’s fenestrations with the patient’s arteries. Dr. McKinsey and Nicholas Morrissey, M.D., assistant professor of surgery, have completed additional training to insert these types of grafts.
“Inserting a fenestrated graft takes more time and skill than the repair of standard aneurysms, but since both are minimally invasive, there is not much difference from the patient’s point of view,” Dr. McKinsey says. “Patients will usually be able to leave the hospital in a few days and return to normal activities in two to three weeks.”
Because the fenestrated graft has not yet been approved by the FDA for general use, patients must enroll in a clinical trial to receive one. The trials will help doctors learn more about which patients will benefit most from the procedure and about any complications that might arise postoperatively. The device has been approved for use in Europe, Australia, and New Zealand.
For more information on the clinical trial or to refer a patient for evaluation, contact Diana Catz at 212-342-4102.
Adrenal Center Stresses Advanced Care, Team Approach
By Adar Novak
Minimally invasive procedures and state-of-the-art scans are just some of the tools physicians at the Adrenal Center offer patients suffering from adrenal disorders. The center, established in September 2006 by William B. Inabnet, M.D., associate professor of clinical surgery, and Tom Jacobs, M.D., professor of clinical medicine, provides advanced, comprehensive care under one roof. The center integrates medical and surgical care of patients with adrenal disorders ranging from Cushing’s syndrome and adrenocortical cancer to various adrenal tumors.
The team is now headed by James Lee, M.D., assistant professor of surgery, who was recruited back to Columbia from UCSF to become the center’s director. The center’s staff includes world-class endocrinologists, endocrine surgeons, radiologists, cardiologists, hypertension specialists, and geneticists.
“Treating adrenal disease often requires specialized knowledge and skill to provide superior care,” Dr. Lee says. “Since the Adrenal Center provides the spectrum of services from special radiologic tests to minimally invasive surgery to genetic counseling, patients and referring physicians can come to one place for the specific expertise that they need.”
Though adrenal disorders are uncommon (for example, pheochromocytoma, a tumor of the medulla of the adrenal gland, affects one person in a million), center physicians are busy. In the first year of operation, they saw about 40 patients and performed operations on 23 patients. In the center’s second year, physicians evaluated about 60 patients and the number of operations doubled. Columbia’s volume now rivals that of more established centers.
The center also sets itself apart with state-of-the-art diagnostic tests and screening. Thomas Pickering, M.D., professor of medicine, is a hypertension specialist with specific expertise in screening for adrenal tumors that may cause high blood pressure. Wendy Chung, M.D., Ph.D, the Herbert Irving Assistant Professor of Pediatrics, heads the genetic screening and counseling section and provides evaluation for a variety of rare familial syndromes. Under the direction of senior radiologists Rashid Fawwaz, M.D., professor of clinical radiology, and Jeffrey Newhouse, M.D., professor of radiology, the Adrenal Center is also one of the few places in the region that offer PET scans and MIBG scans, a radiologic test used to detect pheochromocytoma. In addition, Nicholas Morrissey, M.D., assistant professor of surgery, is one of the few vascular surgeons in the region who performs selective venous sampling. This highly specialized procedure allows physicians to measure blood levels of certain hormones directly from the adrenal glands themselves, all through a small needle stick in the leg.
The center’s surgeons John Allendorf, M.D., assistant professor of surgery, John Chabot, M.D., associate professor of clinical surgery, Dr. Inabnet, and Dr. Lee perform about 90 percent of adrenalectomies using a laparoscopic or minimally invasive approach. Drs. Inabnet and Lee gained valuable experience in Germany, where they mastered a novel technique for the laparoscopic removal of the adrenal gland without having to enter the abdominal cavity. “With this method, patients have less pain, better cosmetic results, fewer complications, and undergo a much faster procedure.”
Center physicians are planning clinical trials, including a randomized controlled trial to compare the transabdominal and retroperitoneal methods of performing adrenalectomies. The center collaborates with UCSF on a research project that evaluates genetic mutations in adrenal cancers. The center plans to create a national database to compile data on adrenal disorders and tumors, so physicians may offer patients more precise information on prognosis, recurrence rates, and where appropriate clinical trials may be under way.
“Patients like coming to a center such as ours where they can find expertise in every aspect of their disease,” Dr. Lee says. “The response to the center has been overwhelmingly positive.”
The Adrenal Center can be reached at 212-305-0444.
Comprehensive Treatment for Children with Spasticity Disorders
By Adar Novak
When Richard C.E. Anderson, M.D., assistant professor of neurosurgery and pediatric neurosurgery, performs a minimally invasive selective dorsal rhizotomy, a procedure used to sever nerves in the spinal cord that cause spasticity in a child with cerebral palsy, he relies on the help of physical and occupational therapists and neurophysiologists. The therapists are present in the OR to palpate the patient’s muscles while the neurophysiologist monitors the nerve impulses, helping the surgeon to determine precisely which nerves to cut and which to preserve.
“A team approach is central to the way we care for our patients, both during regular visits and in the operating room,” says Dr. Anderson, director of the Pediatric Spasticity Center at the Morgan Stanley Children’s Hospital of New York.
Center specialists, including pediatric neurosurgeons, neurologists, orthopedists, physical and occupational therapists, nurses, specialists in fitting braces, and social workers, treat motor disorders characterized by tight or stiff muscles that may interfere with voluntary muscle movements.
“It can be a tremendous burden on the family to try to coordinate care for a patient,” Dr. Anderson says. “Communication among doctors is also not as good when a family member is the one trying to organize the care. It’s much more efficient for everyone if one center handles the action plan.” That’s why the Columbia spasticity team meets regularly to evaluate and develop treatment plans for patients with spasticity from cerebral palsy, spinal cord injuries, or other brain injuries. Dr. Anderson’s interdisciplinary team has grown from initially caring for about five or six patients when the center was launched three years ago to caring for more than 180 children today.
The spasticity center is the only center of its kind in the Northeast in which pediatric neurosurgeons perform the selective dorsal rhizotomy using a minimally invasive one-inch incision. This method, performed at only a few hospitals in the country, reduces postoperative pain and healing time, allowing children to begin postoperative rehabilitation in two or three days instead of waiting for weeks.
The center is collaborating with the Mailman School of Public Health to create a database that collects and analyzes data about patients, such as the range of motion of their joints, muscle tone, and gait. “Our goal is to identify preoperative predictors of who would be the best candidates for selective dorsal rhizotomy, as well as to develop better functional outcome measures for these children,” Dr. Anderson says.
Other modalities the center uses for treating spasticity include intramuscular injections of Botox, oral medications, physical and occupational therapy, bracing, and orthopedic surgical procedures. Dr. Anderson also surgically implants specialized pumps that provide a more powerful way to deliver a muscle relaxant directly into the spinal fluid to avoid unwanted side effects of the medication.
“The center’s use of the latest treatments, along with coordinated, centralized care, helps patients and their families cope with what are often very difficult disorders,” Dr. Anderson says.
To schedule an appointment at the Spasticity Center, call Genevieve Chirelstein at 212-305-9606.