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Overweight patients who have not been successful at losing weight through diet and exercise but are hesitant to undergo weight-loss surgery now have a new treatment option. An innovative nonsurgical obesity treatment can offer greater weight loss than lifestyle modifications alone, without the risks of major surgery.

Now available at MUSC Health, ReShape™ weight-loss treatment involves two outpatient endoscopic procedures along with one year of nutrition and behavioral counseling.

While bariatric surgery has a track record of offering patients significant weight loss, MUSC gastroenterologist Gregory Cote, M.D., says many people are understandably reluctant to undergo surgery. He’s excited about ReShape’s potential to reach more people who have struggled to lose weight on their own. In partnership with the experienced interdisciplinary team of experts at MUSC Health, the ReShape intragastric balloon is one of the latest nonsurgical approaches to managing excess weight.

“Roughly two-thirds of the people in the United States are overweight or obese, and most of those people want nonsurgical treatment solutions,” Dr. Cote says. “There is a tremendous demand for treatments that fall somewhere between diet and lifestyle modification and more intense surgical interventions.”

ReShape: A New Kind of Weight-Loss Plan

Historically, most obesity treatments have fallen under one of two categories:

  • Lifestyle interventions, such as diet, exercise, behavioral, and pharmaceutical modifications, tend to be minimally effective at achieving long-term weight loss and are often insufficient for those with morbid obesity.
  • Bariatric surgery, which is an effective treatment for obesity, exposes patients to the potential for surgery-related complications. Bariatric surgery is currently indicated for those with morbid obesity who have a BMI greater than 35 with comorbid health conditions.

ReShape and other intragastric balloon procedures represent a middle-ground treatment approach: a minimally invasive nonsurgical procedure paired with an intensive behavioral program. The intragastric balloon helps jump-start patients’ weight loss while MUSC’s nutrition experts help patients learn healthy habits to sustain them into the future. Endoscopic approaches like the intragastric balloon also serve as a treatment option for those in the so-called “treatment gap”: patients with a BMI between 30 and 40.

Patients receiving this treatment undergo two outpatient procedures, both under light sedation:

  • Placing the dual balloon system: Using an endoscope through a patient’s mouth, a gastroenterologist inserts two connected balloons in the stomach, inflating them once they are in place. This 20-minute procedure helps patients feel full faster and reduces appetite.
  • Removing the dual balloon system: Six months later, a patient undergoes another short endoscopic procedure, during which specialists remove the balloons from the stomach. This procedure returns a patient’s digestive system back to its normal function, requiring them to rely on healthy habits to maintain their new weight.

To help patients ensure long-term weight-loss success, patients receive one full year of regular health coaching from MUSC’s nutrition and other medical experts:

  • First week after surgery: After balloon placement, patients receive daily phone calls from care specialists, to ensure they are tolerating the treatment well.
  • Monthly meetings: Soon after the balloon-placement procedure, patients attend monthly sessions with MUSC’s registered dietitians and medical specialists to:
    • Assess progress on behavioral changes and weight-loss.
    • Tackle individual challenges and plan for success.
    • Ensure patients have the tools and know-how to maintain eating and behavior changes long term.

“Patients keep careful track of their food intake after the initial balloon placement procedure,” explains Dr. Cote, who says the diet recommendations for ReShape are similar to the guidelines patients follow after bariatric surgery. “After the balloon removal procedure, patients continue to have monthly visits with our nutrition experts for continued close monitoring of weight and additional coaching.”

A New Approach to Obesity Treatment

Unlike bariatric surgery, ReShape does not permanently modify a patient’s digestive organs. Dr. Cote has high hopes that this procedure, though temporary, will help patients achieve significant weight-loss goals in the short term and adopt healthier habits that will benefit them for years to come.

“This procedure works under the premise that after one year, patients have achieved a durable weight-loss goal and, more importantly, have adapted to a healthier lifestyle. Our bariatric experts coach patients to help them incorporate portion control, exercise, and other healthy habits into their lives. With this guidance and support, they will hopefully minimize weight regain later,” says Dr. Cote.

MUSC Health is currently one of the few centers in South Carolina offering this nonsurgical balloon procedure. While Dr. Cote notes that MUSC’s Metabolic and Bariatric Surgery Program offers a range of surgical and nonsurgical treatment options, he says ReShape is most suitable for patients who have less severe obesity (with a BMI between 30 and 40) and obesity-related complications, such as prediabetes.

Because an endoscopic procedure has fewer risks than surgery, Dr. Cote hopes physicians will consider referring overweight and obese patients to MUSC’s Metabolic and Bariatric Surgery Program sooner.

“Determining the right type of weight-loss intervention for each patient is an individualized process. An intragastric balloon may not end up being the best fit for all patients. But by referring patients who could benefit from weight loss to our program, those patients can get connected to a comprehensive weight-loss program that offers the full spectrum of treatments for obesity,” says Dr. Cote.

For more information, contact Dr. Cote at cotea@musc.edu.

An approach to carotid endarterectomy surgery that uses local instead of general anesthesia can better manage cardiac issues and thus result in fewer future complications.

“MUSC has a long history of managing carotid artery disease and reducing stroke rates,” says Ravi Veeraswamy, M.D., chief of MUSC’s Division of Vascular Surgery.

“We're continuing that tradition now with advancements, one of which is performing carotid surgery under a local anesthetic, so a patient never needs to be put to sleep.”

Awake Carotid Endarterectomy: Basics and Benefits

Carotid endarterectomy surgery can effectively remove plaque buildup due to carotid artery disease, or stenosis, with the ultimate goal of preventing future stroke. However, stroke is a significant complication concern of surgeons when performing this procedure—and it can be tough to identify when patients are under general anesthesia.

In an awake approach, patients receive a regional anesthesia block to numb the neck, so they are awake and comfortable for the entire procedure. Using regional in lieu of general anesthesia offers multiple benefits in managing stroke and other cardiac issues.

“One main benefit to this approach is that we know in real time if there is a problem with the patient having a stroke, and we can do something about it then,” says Dr. Veeraswamy. During a general anesthesia approach, surgeons must wait until the procedure is completed and the patient is awake to ascertain whether any stroke-related complications ensued.

“The local anesthesia approach also makes it easier to manage cardiac issues, because patients never have general anesthesia,” he adds.

Besides the anesthesia approach, little else of the carotid endarterectomy surgery is modified.
“We perform the procedure the exact same way as with general anesthesia,” says Dr. Veeraswamy. “It's just more streamlined, because we avoid general anesthesia.”

Outcomes for general versus local anesthesia approaches are equivalent, though Dr. Veeraswamy believes awake carotid has the potential for lower cardiac complication rates. “The rates of stroke or carotid-related complications are similar whether patients are under general or local anesthesia. However, we believe the rates of cardiac complications might be lower with the awake procedure. It certainly gives the referring physician, the surgeon, and the patient another great alternative to general anesthesia.”

Awake Carotid Endarterectomy: The Right Candidates

According to Dr. Veeraswamy, most patients appreciate the added option of choosing general versus local anesthesia for this surgery. Some are floored by this new capability.

“They're amazed that we can operate on their neck and literally be asking them about their family while we're doing it,” says Dr. Veeraswamy.

Still, he admits it’s not for everyone. Personal preference and certain health indications make some people poor candidates for this awake approach, including patients with:

  • Claustrophobia, or a fear of confined spaces. 
  • Anxiety or unease about the idea of being awake for a specialized operation.
  • Arthritis or other health issues that limit their neck movement.

“For these patients, we strongly consider carotid stent placement or carotid endarterectomy surgery under general anesthesia,” says Dr. Veeraswamy.

Carotid Artery Disease: A Tailored Treatment Approach

Dr. Veeraswamy says that this approach is part of MUSC’s greater focus on customizing patient treatment options to individual circumstances and preferences.

“We have the ability to tailor procedures for each patient,” he says. “We can do what's best for one patient, and that may be different than what we do for another patient, because MUSC offers so many options in how we treat patients.”

For more information, contact Dr. Veeraswamy at veeraswa@musc.edu.
 

Endovascular techniques have revolutionized thoracic aortic surgery over the past decade, according to Ravikumar K. Veeraswamy, M.D., chief of MUSC’s Division of Vascular Surgery. MUSC specialists stand at the forefront of this innovation.

“Thoracic aortic surgery is where endovascular techniques have had likely the biggest impact, in terms of reducing morbidity and mortality and improving patient outcomes,” says Dr. Veeraswamy. More specifically, he says a progressive approach to endovascular thoracic surgery for aortic dissections can benefit more patients in the short and long term.

An Endovascular Approach to Aortic Dissections

Many patients with a thoracic aortic dissection, a tear in the inner layer of the aorta, are managed primarily with blood pressure control medications. The goal of this is mainly to control patients’ symptoms such as chest pain and prevent the condition from progressing to an acute state, which requires emergency medical attention and has a high mortality rate.

According to Dr. Veeraswamy, a growing body of evidence shows that placing endovascular stent grafts is a better treatment option for aortic dissections and can offer many patients both immediate and long-term benefits.

“We are very forward thinking about thoracic stent grafts for aortic dissections,” says Dr. Veeraswamy. “A lot of patients with this condition are just managed by controlling the patient's blood pressure and pain and having them follow up as an outpatient. Here, we use a thoracic stent graft to help improve the natural progression of the disease.”

Endovascular stent graft surgery repairs an aortic dissection from the inside of the vessel to improve patients’ symptoms and prevent potential long-term and life-threatening complications such as stroke.

Endovascular Aortic Dissections: Who is a Candidate?

Dr. Veeraswamy’s team has particular expertise in treating acute aortic dissections that require emergency treatment. His success treating more complicated type B dissections with this endovascular approach was recently published in The Annals of Thoracic Surgery.

“Based on my work with acute, complicated, type B dissections, which have a fairly poor prognosis, we were able to reduce the mortality and stroke rate to just under 4 percent,” he explains. “We had successful treatment in approximately 80 percent of patients — sometimes even more than that.”

Dr. Veeraswamy says he’s happy to see any patient who has a thoracic aortic problem. “We have access to new stent grafts and new techniques that may allow us to treat patients who cannot be treated at other facilities,” he explains. “We have lower profile devices, and we have the ability to treat patients who have a difficult anatomy as it pertains to the great vessels of the aortic arch or the abdominal vessels.”

Endovascular Aortic Dissections: Expertise Required

While Dr. Veeraswamy notes the benefits of treating thoracic aortic dissections with this endovascular approach, he admits it’s a technical procedure that involves many moving parts.

“This procedure is fairly complex and requires advanced imaging systems, specialized technology, and a lot of expertise on the part of the surgeons and the rest of the team,” he says.

MUSC’s vascular surgery program brings together a comprehensive team, advanced technology and expertise. Each of those components is crucial to optimize outcomes and minimize complications, says Dr. Veeraswamy. “These procedures really need to be performed at a tertiary care facility, with experienced practitioners, and a whole team of people looking after patients,” he says.

“I personally have a lot of experience treating this disease process,” he adds. “I'm hopeful that we can help the patients in South Carolina — both in the short term and long term — by utilizing the latest available technology to effectively manage aortic dissection and improve patients’ lives.”

For more information, contact Dr. Veeraswamy at veeraswa@musc.edu
 

For three of the most common hand conditions, MUSC Health’s highly skilled surgical team offers specialized and minimally invasive solutions.

Milton B. Armstrong, M.D., professor of Surgery and Division Chief of Plastic, Reconstructive and Hand Surgery at MUSC Health, details the less invasive treatment options that exist for carpal tunnel syndrome, Dupuytren's contracture and Raynaud's disease. MUSC’s surgeons have the specialized training to consistently execute successful results.

Carpal Tunnel Syndrome: Endoscopic Treatment Approach

According to Dr. Armstrong, carpal tunnel syndrome is one of the most common conditions that bring patients into his office. This condition is caused by compression of the median nerve at the wrist, causing numbness and tingling in the fingers and weakness in the hand.

For the past century, open surgery has been the primary treatment for carpal tunnel syndrome. In this procedure, surgeons make an incision on the palm, cut the ligament that covers the nerve causing the problem and then close the skin.

Over time, surgeons have attempted this procedure using smaller and smaller incisions at the wrist. Today, Dr. Armstrong says he uses a very small incision about a centimeter in length and uses an endoscope to view the ligament from the underside. A knife attached to the endoscope then cuts the ligament and the surgeon closes the skin with one or two sutures—in a procedure that can be completed in 15 minutes or less.

For patients who are a good fit for this procedure, Dr. Armstrong says the less invasive nature can make for a quicker recovery. Often, patients can return to work 10 days to 2 weeks faster than if they had undergone the open technique.

“That helps people who have jobs that require significant use of their hands for activities as well as others, such as students, who have busy lives to return to. It's a very useful procedure,” he says.

Dupuytren's Contracture: Injection Treatment

A less common hand condition that Dr. Armstrong treats, Dupuytren's contracture is primarily seen in patients of Northern European ancestry. Patients develop contractures in the palm and the fingers, which pull the fingers down toward the palm over time. While not generally painful, the condition can cause stiffness and rigidity, making movement of the fingers difficult.

Dupuytren's contracture has traditionally been treated with an open technique. In the procedure, a hand surgeon opens the skin, then separates and takes out tissue that's fibrotic, which is otherwise normal tissue that becomes problematic in certain groups of people. This can be a lengthy procedure, lasting up to 2 hours in some cases, and requires meticulous dissection of important structures, such as digital nerves and flexor tendons.

Today, Dr. Armstrong and other MUSC Health surgeons can often bypass surgery entirely with an injection treatment. “We have an enzyme, called Xiaflex, that we can inject into the contracted cord to break it up,” he says. “In many cases, we can avoid open surgery.”

Patients receive the injection and then follow up with their doctor, anywhere from 24 hours to 7 days after the procedure. The doctor then breaks up the contracture manually—no operating room necessary.

“That's been a boon for these patients, especially people who may be older or have other medical problems that make them not ideal candidates to go under anesthesia,” explains Dr. Armstrong. “We can now treat this problem without having to put a patient under an anesthetic and open the skin with a scalpel.”

Raynaud's Disease: Botox® Offers Relief

Raynaud's disease, a type of vasospastic disorder, happens when a spasm of the arteries travels to the fingers. This can either be an isolated problem, more common in young women, or an issue related to other disease processes, such as lupus.

In severe cases, patients can develop ulcers and pain in their fingers due to lack of blood flow. “In some patients where it's very severe, to the point where the tissues have died off, we have to do amputations of some parts of the fingers,” says Dr. Armstrong.

Traditionally, doctors have performed an open operation that aims to release tissues around the arteries to allow for better blood flow.

“The smooth muscles within arterial walls are controlled by little nerves, the digital nerves, and so we separate the nerves from the arteries using magnification, sometimes with the microscope,” says Dr. Armstrong. “It’s a technically demanding operation and doesn’t guarantee success. Those patients have significant pain from the surgery, and then we have to wait for days or weeks to the results of the surgery.”

Hand surgeons treating Raynaud's disease now have another treatment option to consider: Botox®, or botulinum toxin A. Commonly used to treat a host of cosmetic problems, such as wrinkles of the face and forehead, Dr. Armstrong says Botox® can be a useful adjunct for this problem.

“What we have found is that the botulinum toxin, which relaxes smooth muscles, can be injected into some patients’ hands,” says Dr. Armstrong. “It breaks up the spasm and can have as good a result for some patients as doing the open surgery.”

Carpal Tunnel and Other Techniques Require Intensive Training

These three procedures illustrate how advanced, minimally invasive approaches can offer a multitude of benefits to patients, possibly limiting the need for surgery, often with a similar or better result. However, Dr. Armstrong emphasizes the need for specialized training in performing these hand procedures.

In the division of plastic surgery alone, MUSC Health has four physicians who are fellowship-trained hand surgeons, three of whom are also board certified in surgery of the hand. All of this additional training helps guide surgeons toward the best treatment results for patients.

“Physicians should ensure they’re referring patients to a surgeon who is trained and who understands the anatomy and pathophysiology of these problems,” says Dr. Armstrong, noting that an open procedure may be the next option if a less invasive technique doesn’t offer patients sufficient relief or isn’t recommended.

When patients discuss their treatment options with an expert in minimally invasive and open hand techniques, they can ensure they receive well-rounded recommendations and effective results.

For more information, contact Dr. Armstrong at armstrom@musc.edu.
 

A new approach to breast reconstruction offers better results for more women. According to MUSC plastic surgeon Kevin O. Delaney, M.D., pre-pectoral breast reconstruction can benefit women who:

  • Are seeking reconstruction for the first time
  • Underwent reconstruction surgery years or decades ago but aren’t happy with the results or suffer side effects

If women aren’t satisfied with how their breasts look or feel after reconstruction—or have lingering pain from the procedure—this new technique may help them.

Pre-Pectoral Breast Reconstruction: What Is It?

MUSC Health provides a range of treatment options for women seeking breast reconstruction after a mastectomy. Whether a mastectomy was performed to treat or prevent breast cancer, Dr. Delaney works closely with MUSC Health’s Hollings Cancer Center team to guide women toward the best available options.

MUSC Health offers 2 main types of breast reconstruction today. Free-flap DIEP (deep inferior epigastric perforator) breast reconstruction relies on a patient’s own skin and fat tissue to rebuild breast tissue, whereas other procedures use breast implants.

As Dr. Delaney explains, pre-pectoral breast reconstruction is a new way of performing implant-based procedures, an approach MUSC Health has been offering for close to 2 years.

“We're one of the first centers in the region to perform this pre-pectoral, or subcutaneous, breast reconstruction,” says Dr. Delaney. “In this procedure, we place a breast implant just beneath the breast skin, which means we don't need to cut a patient’s pec muscles.”

Previously, surgeons would need to cut a patient’s pec (or pectoralis major) muscles in order to set the implant underneath these muscles. That’s how implant-based breast reconstruction has traditionally been performed for the past 20 to 30 years.

Breast Reconstruction Technique Offers Many Benefits

According to Dr. Delaney, the new pre-pectoral approach offers many pros and few cons. Two significant benefits to patients: a better cosmetic outcome and less pain.

“One main benefit to this approach is that the cosmetic outcome of the reconstructed breast looks a lot better,” Dr. Delaney explains. “Pre-pectoral breast reconstruction avoids what is commonly known as an animation deformity, which happens to most women who’ve had implant reconstruction under the muscle, to varying degrees.”

This animation deformity occurs when a woman moves her arms or flexes her muscles. The implant, as well as the overlying breast skin, flattens and moves towards the armpit, which many women consider undesirable, says Dr. Delaney.

Because the pre-pectoral technique eliminates the need for cutting the pec muscle, women experience significantly less pain in the short and long term. This equates to a much faster and easier recovery following the surgery. Women also don't lose any functionality of their pec muscle, which is a possibility with the traditional approach.

Dr. Delaney says this new technique is now the preferred route of implant-based breast reconstruction at MUSC. He says it’s slowly catching on nationwide but that as of now, it’s largely offered only through academic centers.

Pre-Pectoral Breast Reconstruction: The Right Candidates

Dr. Delaney assesses the best reconstruction approach on a case-by-case basis, but he says there are only a few reasons why he would recommend against the pre-pectoral approach for implant-based reconstruction.

The main caveat is if a woman has previously undergone radiation therapy to the breast. “Since the breast skin typically doesn't heal as well after it's been exposed to radiation, it makes the pre-pectoral breast reconstruction more risky from a healing and ultimately infection standpoint,” says Dr. Delaney.

However, the majority of women seeking breast reconstruction can benefit from this approach. In addition to offering current patients a better treatment option, this procedure could also benefit a wide swath of women who received breast reconstruction previously but aren’t happy with the results.

“Many women who have undergone sub-pectoral implant-based breast reconstruction in the past, whether it was 3 years ago or 20 years ago, have significant complaints,” says Dr. Delaney. “Patients come to us with tightness in their chest or up into their arm, chronic pain in that area, as well as complaints about the animation deformity and how they don't like the look of their reconstructed breasts. Those are all real complaints that we hear every day.”

Previously, Dr. Delaney says he couldn’t offer those patients many solutions. But now, with this pre-pectoral technique, he says he can significantly improve many patients’ symptoms or complaints in a straightforward outpatient surgery that takes just a few hours.

“We can remove their old implant, put their muscle back down to where it belongs anatomically, and then put a newer, better implant in below the skin,” he says. “Their pain significantly improves. Their animation deformity goes away. And they're incredibly pleased with how much better their reconstructed breasts look and feel as opposed to when they were below the muscle.”

A Better Breast Reconstruction Option Now Available

Dr. Delaney wants to spread the message that there’s a new option available for women who may fall into this category—and that their health insurance would likely cover it because it’s a part of breast reconstruction care.

“As plastic surgeons, if patients have had breast cancer treated but they're displeased with their reconstruction, we want to help,” he says. “If they’re not local, we can often talk to patients via telehealth and let them know whether this procedure might benefit them.”

For more information, contact Dr. Delaney at delaneyk@musc.edu.
 

The Musculoskeletal Institute at MUSC Health brings orthopaedics, rheumatology and endocrinology specialists under one roof to treat an array of bone and joint disorders as well as metabolic bone diseases and osteoporosis.

This multidisciplinary care model offers care and convenience benefits to patients: The team’s depth of expertise in musculoskeletal care makes the institute uniquely capable of coordinating the care of patients with complex conditions. And patients don’t have to travel to see the specialists they need—they can get all of their care in one place, saving them time and energy.

Treating Hip Pain: What Multidisciplinary Looks Like

The institute’s multi-specialty approach ensures a smooth process for both patients and doctors. Patients can easily get the services they need, and physicians can seamlessly coordinate that care.

“Our advantage as a functional unit for patient care is that the physicians within those three groups interchange and freely move patients among one another based upon the diagnoses and the needs of the patients,” says  Vincent Pellegrini, M.D., chief of the Musculoskeletal Institute and chair of the department of orthopaedics at MUSC.

Consider a patient with hip pain, who makes an appointment with Dr. Pellegrini. If he determines that a patient’s pain originates from the back, he can simply walk around the corner to a spine surgeon colleague.

“The spine surgeon would then see that patient,” explains Dr. Pellegrini. “And he may decide that day that the patient really doesn't need an operation but might benefit from injection therapy.”

The coordination continues from there: “The spine surgeon would then walk around the corner and take that patient to see a physiatrist or a physical medicine physician, who might then do a therapeutic and diagnostic injection.”

Diagnostic tests, evaluation by multiple specialists and treatment: All this could happen in the same space, on the same day, even though the patient came in for hip pain and it turned out to be a back condition. These are not “what-if” scenarios—stories like this happen daily at the Musculoskeletal Institute at MUSC Health.

Orthopaedics, Endocrinology and Rheumatology: A Triad of Care Focus

The Musculoskeletal Institute combines orthopaedics, endocrinology and rheumatology for a reason: These disciplines frequently cross over and require complex care decisions, such as physical rehabilitation.

Patients who benefit from this type of care can include:

  • An orthopaedic patient who thought he or she needed surgery but could benefit from a joint injection and a rehabilitative specialist consult
  • A patient with rheumatoid arthritis who is having severe hand pain, who could benefit from consulting with a hand surgeon and a hand therapist
  • A patient with osteoporosis who has been using Fosamax® for a long time and has unique fractures that require the collaboration of an endocrinologist (to adjust the medication and dosing) and an orthopaedic surgeon (to surgically treat the problem)
  • A patient with hip or knee arthritis who needs an orthopaedic surgeon to address inflammatory arthritis and a rheumatologist to help adjust the medication before surgery

At many centers, all of those appointments would need to be on separate days, with separate specialists. At the Musculoskeletal Institute, we bring together an extensive team to care for a wide swath of people—in a more effective, efficient way.

“With many of our patients, it can take a village to have all of the resources needed to take care of certain problems that are a little more unusual,” says Dr. Pellegrini.

Hip Pain, Osteoporosis and More: Patient and Physician Benefits

The Musculoskeletal Institute has a patient-centric focus, resulting in care that’s improved, coordinated and timely. Dr. Pellegrini says these benefits extend to referring physicians as well—particularly for complicated cases that could use an extra set of eyes from a different specialist.

“I believe most referring physicians are primarily interested in taking care of their patients in a way that’s efficient and expedient,” he says. “Because we put an array of resources under one roof, it allows us to take care of some of the more complicated patient needs that can overwhelm a smaller practice with fewer resources. Our team approach can be very beneficial in certain patient situations.”

For more information, contact Dr. Pellegrini at pellegvd@musc.edu.
 

MUSC Health Sports Medicine, a specialized group of orthopedic doctors and other medical providers within MUSC’s Musculoskeletal Institute, is passionate about providing comprehensive, personalized care to athletes. 

“We’re focused on the evaluation, diagnosis, treatment (both operative and nonoperative) and rehabilitation of injury or pain conditions in the muscles, bones and joints that impact athletes and active people,” says Shane Woolf, M.D., chief of orthopedic sports medicine at MUSC Health.

At MUSC Health Sports Medicine, patients have access to integrated care—from the time of injury until they’re back at play. Patients also benefit from the group’s concentration on education and research, which promotes best practices and novel techniques that demonstrate an expert level of sports medicine care.

Beyond Orthopedic Treatment for Athletes

What sets MUSC Health Sports Medicine apart from most orthopedic groups? According to Dr. Woolf, the answer is in the scope of what—and who—they treat. “I like to consider orthopedic sports medicine as primarily soft tissue orthopedic trauma, as opposed to general orthopedic trauma, which involves primarily treating fractures,” he says. “We all treat broken bones, but at MUSC Health Sports Medicine, our orthopedic sports medicine specialists are skilled in the repair or reconstruction of cartilage, muscle, ligament and tendon injuries and joint instability.”

MUSC Health’s sports medicine group is affiliated with numerous area sports teams, including local high schools as well as the Charleston River Dogs, a minor league baseball team, and the Charleston Battery, a USL pro soccer team. While the focus is on sports medicine, the team doesn’t discriminate based on athletic ability.

“We have experience in treating active and athletic people of all age ranges, activity levels and skill levels,” says Dr. Woolf.

Many athletes may require medical care outside of orthopedic injury issues. MUSC Health Sports Medicine coordinates that care, too. “When you’re playing a sport, even at a recreational level, many medical problems need to be managed differently compared to people who don’t engage in athletics or an active lifestyle,” explains Dr. Woolf.

Conditions such as exercise-induced asthma, diabetes and heart issues can benefit from a sports medicine focus. “Our primary care sports medicine colleague, Alec DeCastro, M.D., is skilled at helping patients with medical issues remain active,” says Dr. Woolf.

Importance of Coordinated Sports Medicine Care

At MUSC Health Sports Medicine, specialists take a big-picture approach to athlete care, coordinating among many specialties.

“We integrate with other specialists very closely,” says Dr. Woolf. “We work with referring primary care physicians as well as our colleagues in radiology, primary care sports medicine, neurology, cardiology and other divisions within our institution. We get athletes the evaluation they need, even if it’s not necessarily an orthopedic issue. We keep it personal, customizing treatment plans for each patient.

“We want to make sure that every patient is safe to play, and we use every resource within our disposal to find a way to allow them to participate in their chosen activity, safely,” adds Dr. Woolf.

Two examples of how patients benefit from this coordination:

  • Joint injuries: A patient receiving joint injections sees a radiologist for image-guided injections, to confirm treatments are reaching the area of concern. Physical therapy professionals can then assist the same patient with rehab of the joint.
  • Gastrointestinal issues: MUSC Health specialists work with the Women’s Tennis Association when athletes are in town for a tournament. When an athlete has a gastrointestinal issue, for example, she might be connected with an MUSC Health specialist for a quick evaluation. “Even though the condition isn’t a musculoskeletal problem, it still affects athletic performance, and we’re happy to coordinate that care,” says Dr. Woolf.

A Leader in Sports Medicine Research and Education

MUSC Health sports medicine specialists are also educating future sports medicine providers and promoting evidence-based care through evolving research.

“We are very much engaged in research and education for sports medicine. We’re not only evaluating and treating these problems, but we’re studying them as well to learn how to provide better care,” says Dr. Woolf.

Specialists teach a range of skills to sports medicine residents and students, from the intricacies of open and arthroscopic surgery techniques to education on the importance of rehabilitation after an injury.

Current research studies are delving into a range of sports medicine points of interest, such as:

  • Improving rehabilitation after ACL tears
  • How foot pain relates to weakness in an athlete’s core (the muscles and joints in the back, pelvis, abdomen and hips that make up the fundamental foundation of the body)
  • Identifying injuries and best treatment plans for cartilage problems in the shoulder and knee

Whatever an athlete’s medical concern, MUSC Health Sports Medicine can help coordinate care and ensure the best treatment, and the fastest recovery, for each individual.

For more information about the MUSC Health Sports Medicine program, contact 843-876-0111.

Cutting Edge-Tools and Team Expertise

Jeffery Winterfield, M.D.Until recently, catheter ablation for ventricular tachycardia (VT) has been a niche subset of clinical cardiac electrophysiology, available in only a few centers nationwide. With top-notch specialists and cutting-edge mapping technology, MUSC Health is on the frontlines of efforts to make VT ablation a more accessible treatment option for patients with ventricular arrhythmia.

Watch a video about ventricular arrhythmia with ablation.

After training under clinical cardiac electrophysiology experts at Harvard Medical School in Boston followed by his first faculty appointment in Chicago at a world-renowned ablation center, MUSC Health Health electrophysiologist Jeffrey R. Winterfield, M.D., was recruited for his experience in treating complex arrhythmias to the MUSC Health Heart & Vascular Center. At MUSC Health, he now serves as director of Ventricular Arrhythmia Service.

Dr. Winterfield explains which patients might benefit from this treatment—and why timing and technology are two key components to ensuring successful outcomes.

Ventricular Arrhythmias: The Right Tools and a Team Approach

Dr. Winterfield says VT ablation procedures, while complex, can be done safely and effectively. The key to success is performing these procedures at a medical center that has the capabilities and the expertise to manage these complex arrhythmias as well as the advanced tools necessary to ensure its safety.

Cutting-edge technology is one way MUSC Health ensures safer VT ablation procedures, says Dr. Winterfield. MUSC Health was chosen as one of only 12 phase 1a sites nationwide to launch an advanced mapping system called Ensite Precision™, recently approved by the FDA.

Traditionally in VT ablation, specialists use mapping technologies to create detailed 3-D anatomic models of the ventricular chamber of interest where an arrhythmia originated. However, that process needed to be done point-by-point and can take up to an hour.

Now, Dr. Winterfield says, the high-density mapping allows him to use a catheter with multiple electrodes to take many points around the ventricular chamber simultaneously.

The result is more precise information, much faster, often in 10 minutes. Not only does that speed up the process, but it’s also made the procedure safer.

Ventricular Arrhythmias: When to Treat With Ablation

Timing is one of the most important factors in determining which ventricular arrhythmias to treat with ablation.

“What we know is that waiting until patients are storming with ventricular arrhythmias is associated with worse outcomes and a higher risk of mortality,” says Dr. Winterfield.

Dr. Winterfield and other researchers at MUSC are investigating multiple aspects of VT ablation, and he agrees that much evidence is still emerging.

What research about VT ablation shows thus far:

  • Earlier is better: Patients fare better with earlier intervention, requiring less frequent hospitalization.
  • Less medication: After VT ablation, there is lower usage of anti-arrhythmic and other complicated medications to treat patients’ arrhythmias.
  • Less hospitalization: It leads to fewer emergency room visits and longer survival overall.

Ventricular Arrhythmias: The Right Candidate

Patients best suited for this treatment include anyone who has undergone treatment for a ventricular arrhythmia through a high-voltage device such as a defibrillator or ventricular pacemaker defibrillator.

Other patients who have had premature ventricular contractions (PVCs) could also be good candidates for ablation, particularly if they’re currently on medication that is either not desired or tolerated well.

In some cases, a high burden of PVCs may exacerbate underlying heart failure. With ablation to reduce or eliminate PVCs, heart failure symptoms and prognosis may improve for some patients.

Research has clearly shown mortality and complications for VT ablation have diminished over the past decade. Dr. Winterfield and others continue to investigate other questions, such as how early VT ablation intervention compares to anti-arrhythmic drug therapy in long-term healthcare costs.

“What we have found in one economic analysis is that healthcare costs are reduced with catheter ablation of ventricular arrhythmia,” says Dr. Winterfield.

Advanced Heart Disease: A Partnership Approach

Dr. Winterfield knows his role as an electrophysiologist is just one facet of managing patients with advanced heart disease, particularly ventricular arrhythmias. Successfully managing these arrhythmias means strong collaboration with referring physicians, especially since some patients travel long distances, sometimes from out of state, for treatment at MUSC Health.

“We're here to help the referring physicians take care of these people who have very difficult problems but carry significant risk for cardiovascular morbidity and mortality,” Dr. Winterfield says. “It is important that we work together to treat them.”

Dr. Winterfield says he keeps the communication lines open and prioritizes calls, emails and questions from referring physicians. He’s certain patients are better off for it.

To reach Dr. Winterfield, email winterfj@musc.edu.

During the past century, cardiopulmonary resuscitative techniques such as CPR and AEDs have moved from the realm of science fiction to the standard of care. Today, we are seeing the same transition with another life-saving technology, extracorporeal membrane oxygenation (ECMO), says Brian Houston, M.D., an assistant professor and medical director of mechanical circulatory support at MUSC Health.

“Today, CPR is a standard of care for both in-hospital and out-of-hospital cardiac arrest. Similarly, automated external defibrillators, or AEDs, are also standard of care for out-of-hospital cardiac arrest. Even 30 years ago, that was science fiction, but now it’s the standard treatment for patients in cardiac arrest,” says Dr. Houston. “I think ECMO is right on the cusp of that transition as well.”

As doctors continue to debate how to best deploy ECMO and which patients would benefit most, one thing is clear: MUSC Health’s ECMO care team is expertly trained to use this technology—quickly, safely and nonsurgically.

What Is ECMO?

It’s helpful to compare ECMO to other cardiopulmonary resuscitation techniques, such as AEDs. An AED is a box designed to deliver electricity to the heart after cardiac arrest and get the heart back into a normal rhythm.

AEDs have been used outside the hospital environment with great success, says Dr. Houston. Multiple public health studies have shown that they:

  • Are cost effective
  • Save lives
  • Contribute to improved out-of-hospital cardiac arrest survival rates

Except AEDs aren’t an effective treatment for all causes of cardiac arrest. Dr. Houston says, “Even if a patient has normal electrical activity or heart rhythm restored, they may not get blood flow back. Their heart may still not be functioning because something other than a heart rhythm problem caused their cardiac arrest.”

In comparison, ECMO is more comprehensive in how it treats cardiac arrest. ECMO takes over the function of the heart and lungs through large tubes, one inserted into a patient’s vein and one into the artery. An ECMO machine pulls blood out through the tube, pumps it back into the body and provides blood flow. This process oxygenates the blood by passing it over a membrane where oxygen is exchanged.

“You can have no lung or heart function, considered a complete cardiac standstill, and still have profusion of all your organs and be alive on an ECMO circuit,” says Dr. Houston.

ECMO was first deployed in 1972, born out of cardiopulmonary bypass technology, a machine that does the work of the heart and lungs during surgery. “Bypass technology is too large to be used long term, and it also has some long-term downsides. ECMO seeks to counteract those drawbacks,” explains Dr. Houston.

An ECMO machine is a small device, which makes it more portable. “The devices are now similar to the size of a lunchbox and can provide a pump and oxygenation device so that they’re more mobile,” says Dr. Houston. “We’re very much on the edge of ECMO technology right now.”

ECMO Benefits: Cardiac Arrest Survival vs. Cost

Compared to a decade ago, ECMO use has risen considerably. “In 2002, there were fewer than 400 cases of ECMO in the United States. In 2009 (the most recent data available), there were greater than 1,600 cases of ECMO use. So it’s more than quadrupled in 7 years, and I suspect those numbers have continued to rise in recent years,” says Dr. Houston.

Its benefits to patients are clear. Quite simply, this technology saves lives. “If you look at out-of-hospital cardiac arrest survival in the United States, it’s less than 8 percent. If someone experiences cardiac arrest on the street or inside their home, they have a less than 8 percent chance of being alive at 1 month.”

In comparison, when patients experiencing cardiac arrest were treated with ECMO, 40 out of 115 people in one study were alive at one year. That’s 35 percent of the participants compared to eight percent. “You’ve saved many more lives using ECMO,” says Dr. Houston.

“I think it’s hard to find any medical intervention that saves that many lives in that dire of a situation,” says Dr. Houston. “However, the flip side is looking at the 70 to 80 people who didn’t survive. They were still treated with ECMO, and ECMO is phenomenally expensive. The cost of any given ECMO run, from start to finish, is more than $300,000.”

Dr. Houston admits that while no doctor likes to think about cost, it’s a realistic piece of the public health conversation on how ECMO can best be implemented. “When we think about how to wisely use this technology as a community, we have to consider cost,” he says.

Another piece of that conversation is who benefits most from this technology. If doctors can better identify the patients who will benefit, the technology can save lives as well as costs.

Dr. Houston believes younger people who have a better chance of recovery might benefit from ECMO more than older patients with more concerning health complications.

Prompt, Expert ECMO Care at MUSC Health

Currently, only specialized ECMO centers can provide ECMO, due to the very intensive care patients require during ECMO treatment. MUSC Health is one such center.

“At MUSC, we have a highly trained group of profusionists and interventional cardiologists who specialize in ECMO,” explains Dr. Houston.

“Whereas in previous years ECMO used to require a surgical procedure, now it’s increasingly done by cardiologists through a catheter-based approach,” he continues. “This allows us to deploy it very rapidly, and our specialized team ensures expert post-deployment care, where we can expertly care for ECMO patients, from start to finish.”

To reach Dr. Houston, email houstobr@musc.edu.
 

An advanced hybrid approach to revascularize chronic total occlusions (CTO) holds much promise for patients, particularly those with a known CTO for whom medical therapies aren’t sufficient.

Interventional cardiologist Anbukarasi (Arasi) Maran, M.D., leads the CTO team at MUSC Health’s Heart & Vascular Center, which specializes in this advanced hybrid algorithm.

CTO, wherein a heart blood vessel has been closed for more than 3 months, happens gradually. This allows the heart to develop its own bypass or collateral flow to supply the muscle beyond the blockage.

Unlike the conventional percutaneous coronary intervention (PCI) CTO, which uses wire escalation techniques with access through a single vessel, the hybrid approach attempts access on both vessels.

This new approach offers multiple benefits—including significantly higher success rates. It’s a complex technique that requires the type of specialized training that Dr. Maran has.

Dr. Maran learned the intricacies of this technique from internationally renowned CTO expert William Lombardi, M.D., at the University of Washington. She now performs increasing numbers of this niche procedure at MUSC Health.

Chronic Total Occlusion: A Common Cardiac Concern

Dr. Maran estimates 10 to 30 percent of her patients present with a CTO. Patients who don’t experience success through more conventional treatments are often left to continue with medical management alone.

The problem, according to Maran, is that success rates for a conventional PCI CTO can hover around 20%.

If an attempt at opening the vessel using regular techniques fails, patients are offered only medical therapy. Yet many patients still experience significant symptoms with the medical therapies that typically come after an unsuccessful revascularization procedure.

Now, with improved technology and an advanced technique, many of those patients may have another way to achieve complete revascularization—and thus, improved symptoms and quality of life.

Treating Chronic Total Occlusion With a Hybrid Approach

In this hybrid approach for CTO PCI, Dr. Maran says she gains access via two points. This allows her to visualize the blood vessel from the native blood vessel as well as the blood vessel that’s feeding the collateral flow.

“For example, if a patient has a blockage in the right coronary artery, right-side blood vessel, and it is getting fed by collaterals from the left coronary artery: We pass a catheter and a wire into the left coronary artery; engage into the bypass vessel via the septal collaterals; get into the right side blood vessel and externalize the wire across; and then deliver stents,” explains Dr. Maran.

Improved technologies, such as superior wires, catheters and tools, allow Dr. Maran and her team to better navigate blood vessels and establish continuity of flow.

Overall, Dr. Maran describes this approach as easier to learn, safer and more successful—with a success rate around 85 percent.

The beauty of the hybrid procedure is in its fluidity. “We first try to attempt it antegrade but if that fails, we quickly switch approach and go retrograde,” she says. “The team is prepared to switch from one method to another, if necessary. We can either go through the parent vessel or come through the back through the feeding vessels into the parent vessel.”

In MUSC Health’s cath lab, a team of specialists work predominantly with CTO procedures, ensuring expertise in CTO equipment and allowing for efficiency and successful outcomes.

Patients best served by this approach include anyone who has a CTO and who has significant symptoms that are not controlled medically. Those symptoms may include shortness of breath or chest pain on exertion or low energy in spite of medication therapy.

The main risks with this approach are bleeding complications from the groin access, bleeding and injury to other blood vessels and contrast-related injury.

Complete Revascularization, Realized

Data show that complete vascularization improves overall morbidity and quality of life, says Dr. Maran. With this new technique, many more patients can realize that outcome and the improvements that come with it.

“Complete revascularization is better for the patient, and now there are options to treat chronic total occlusions,” she says.

For more information, contact Dr. Maran at Maran@musc.edu.
 

Morbid obesity in American adolescents has been steadily rising, mirroring the rise of adult obesity in the United States and other developed countries. According to recent research, bariatric surgery can provide sustainable weight loss and other health benefits to teens with morbid obesity.

“We know that morbidly obese teenagers are at high risk for becoming morbidly obese adults. From recent research available on adolescents who underwent weight-loss surgery, we now know that they can achieve good, long-term weight loss, achieving a 30 percent reduction in BMI,” says Aaron P. Lesher, M.D., an assistant professor of surgery and pediatrics at MUSC Health who specializes in adolescent bariatric surgery.

Pediatric Obesity and Bariatric Surgery

Severe pediatric obesity can affect long-term health and quality of life, and non-operative treatments have shown little effect. It’s an issue with which South Carolina healthcare providers are especially familiar.

“The latest figures are that approximately 6 percent of children under 18 are morbidly obese or have a BMI greater than 35,” says Dr. Lesher. “South Carolina has a higher prevalence of morbid obesity than the national average, and that number is increasing.”

Bariatric surgery has proven benefits for adults with morbid obesity, and healthcare providers have been performing weight-loss surgeries for decades. Still, many providers have been hesitant to perform these procedures on younger patients due to the lack of research on the treatment’s long-term risks and benefits.

“While bariatric surgery has been shown to provide durable weight loss for patients with morbid obesity, there’s been some reticence on the part of surgeons and primary care doctors to do this in adolescents because of the lack of reliable data with long-term follow-up,” explains Dr. Lesher.

That lack of data leads to questions such as:

  • How do adolescents’ long-term weight loss compare to adults’?
  • Will adolescents adhere to the dietary restrictions necessary after surgery?
  • How might adolescents be psychologically affected after surgery?
  • Will adolescents develop the same vitamin and mineral deficiencies that are sometimes seen in adults who undergo bariatric surgery?

New Data Shows Benefits of Adolescent Weight-Loss Surgery

Recently released data, such as that from a study published in The Lancet, shows an eight-year follow-up of adolescents who received bariatric treatment for morbid obesity. The results are promising.

“In comparison to diet and exercise modification, adolescents achieved significant weight loss with bariatric surgery, approximately a 30 percent decrease in BMI,” says Dr. Lesher. “One study showed that bariatric surgery resolved diabetes in 88 percent of adolescents who had the condition prior to bariatric treatment.”

According to Dr. Lesher, this data may make primary care providers more comfortable in recommending adolescents for bariatric treatment. “As surgeons acting in the best interest of our patients, we are willing to offer this service to our morbidly obese adolescent patients because of this long-term data that shows we can provide durable weight loss,” he says.

While most of the longer-term studies for adolescents have looked at gastric bypass surgery, Dr. Lesher says MUSC Health considers sleeve gastrectomy another good option for bariatric surgery in adolescents.

“We don’t have as good long-term data in sleeve gastrectomy as we do with gastric bypass, but we can extrapolate that we will achieve similar weight-loss results. We may even improve the nutritional and vitamin and mineral deficiencies that we occasionally see with gastric bypass,” he says.

According to Dr. Lesher, sleeve gastrectomy offers a slightly lower complication profile, in the immediate postoperative period. It also has a slightly lower long-term vitamin and mineral deficiency profile, because surgeons don’t alter the length of the absorbable bowel during the procedure.

MUSC Offers Expertise in Adolescent Weight-Loss Surgery

MUSC Health’s bariatric program offers extensive expertise in this area, as surgeons have been performing bariatric surgery on adolescents since 1992. The program is accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery’s Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, for both adults and adolescents. It performs the highest volume of adolescent bariatric procedures in the state.

“We were not performing many bariatric treatments on adolescents before 2007,” says Dr. Lesher. “But as we’ve seen better data, we felt that it’s increasingly safe to perform.”

Criteria for surgery mirror those for adult bariatric surgery. Ideal candidates have a BMI greater than 40, or a BMI greater than 35 with major comorbidities such as diabetes. Dr. Lesher says any teen who has a BMI greater than 40, especially those with significant comorbidities such as Type 2 diabetes and who have failed other attempts at weight loss, may benefit from bariatric surgery.

“I think that intervening earlier—before someone reaches a BMI of 50 or 60 or has more comorbidities—may give patients a better chance at long-term health improvement and better outcomes,” says Dr. Lesher.

In adolescent patients, the MUSC Health team prefers to wait until patients are at least 15, though Dr. Lesher says they consider patients as young as 13, in the cases of profound morbid obesity.

“The data suggests that we need to be performing these procedures when patients are skeletally mature,” he says. “We use X-rays to confirm that patients’ bony growth plates have fused.”

As with adults, adolescent patients benefit from MUSC Health’s comprehensive program and experienced team. “We have all of the ancillary and support staff, from pediatric surgeons to adolescent dietitians and psychologists, to achieve optimal long-term goals,” he says.

Dr. Lesher hopes pediatricians and family providers will consider bariatric surgery for young patients who might benefit from this life-changing treatment: “With this recent evidence, we can legitimately say that bariatric surgery is a safe and effective procedure. And it is, by far, the most effective way for these patients to lose weight and to keep it off. This really gives teens a chance to become healthy, productive adults and to modify their behavior and lifestyle sooner rather than later.”

For more information, contact Dr. Lesher at leshera@musc.edu.
 

Of an estimated 30 million Americans with morbid obesity, one percent or less undergo bariatric (weight-loss) surgery that could benefit them.

“There are so many patients with morbid obesity, which is a serious condition. Yet there's a huge disconnect between the number of patients who could benefit from weight-loss surgery and the number of patients who are actually receiving treatment. This surgery would significantly improve their life and reduce their comorbidities,” says T. Karl Byrne, M.D., a professor of surgery at MUSC Health.

According to Dr. Byrne, several factors, including health insurance coverage and misinformation, contribute to the low percentage of people undergoing bariatric surgery. He wants primary care physicians and patients to know that there are safe and effective bariatric surgery options.

Insurance: One Barrier to Bariatric Surgery

According to Dr. Byrne, a dearth of health insurance plans covering bariatric surgery is one key reason so few people with morbid obesity actually seek out weight-loss surgery.

Whether a health insurance plan covers weight-loss surgery (and for whom) varies with a company, policy, even state. “For example, in about half of the states in the nation, the state health plans will cover weight-loss surgery,” explains Dr. Byrne. “In the state of South Carolina, our state healthcare plan does not. Medicare and Medicaid, however, do cover weight loss surgery.”

Patients who need to self-fund bariatric surgery are significantly less likely to continue with the process. Because of that reality, Dr. Byrne says insurance status is one of the first topics broached with patients inquiring about bariatric surgery.  “If a patient’s health insurance doesn’t cover weight loss surgery, we then discuss with them a range of options for self-pay,” he says.

Lack of Information About Weight Loss Surgery Safety Advances

Another obstacle to bariatric surgery: patient education. While Dr. Byrne says family practitioners are becoming more open to discussing weight-loss surgery for applicable patients, misinformation among patients still abounds.

“There is a significant amount of myth among patients as to the safety of surgery for obesity,” he explains. “In the last several years, the mortality rates for patients undergoing surgery for obesity have dropped dramatically. Secondly, most of the cases that are performed today are being done laparoscopically, so wound complications are practically nonexistent anymore.”

When comparing data across the nation, the 30-day mortality rate after a bariatric procedure is currently zero. In fact, Dr. Byrne says weight-loss surgery today is safer than many other types of surgical procedures, such as joint replacement.

“Unfortunately, that information hasn't percolated down to our patient population yet,” he says.

MUSC Bariatric Surgery Program: A Snapshot

Strict guidelines and protocols for care as well as comprehensive bariatric surgery teams comprised of various subspecialists have helped to make these surgeries safer and more beneficial for patients. MUSC’s bariatric surgery program, an accredited center from the American College of Surgeons, offers a range of weight-loss surgery options for patients as young as 15 and as old as 75, using minimally invasive approaches.

In general, candidates for weight loss surgery include patients with a body mass index (BMI) of 40 or a BMI of 35 with a weight-related medical problem, such as diabetes. Not all patients would benefit from the same type of bariatric surgery, which is why MUSC offers options, such as:

  • Gastric bypass, previously the gold standard for bariatric surgery, a procedure that’s still common today
  • Sleeve gastrectomy, the most common weight loss surgery performed today
  • Duodenal switch, a more complicated procedure that’s shown to be beneficial for super-obese patients, or patients with a BMI of 50 or more

“The gold standard operation for weight loss has always been the gastric bypass, which is done laparoscopically now,” says Dr. Byrne. “However, that has been superseded in terms of numbers by the sleeve gastrectomy, which is now the most common weight-loss procedure performed throughout the United States.”

In sleeve gastrectomy, a surgeon removes the vast majority of the stomach, leaving a long, thin, cylindrical or sleeve-like stomach in its place. Compared to gastric bypass, Dr. Byrne says gastrectomy is more straightforward and easier to perform.

A standard laparoscopic sleeve gastrectomy procedure at MUSC today can be completed in as little as 45 minutes. Most patients stay in the hospital overnight and go home the next day. “The vast majority of patients will have that kind of experience,” says Dr. Byrne. “Likewise with gastric bypass surgery, the hospital stay has been reduced significantly. It's now a one- or two-day stay as well.”

Weight Loss Surgery’s Mounting Benefits

Increased safety, shorter hospital stays and more procedure options: Bariatric surgery has changed for the better in recent years. Still, a large percentage of patients have yet to realize it.

“That’s unfortunate,” says Dr. Byrne, “because many patients who have a bariatric procedure lose a significant amount of weight, reduce the number of medications they take and completely reverse comorbidities such as diabetes and hypertension.”

For more information, contact Dr. Byrne at byrnetk@musc.edu.
 

MUSC is known for its expertise in colorectal surgery. Virgilio V. George, M.D., an associate professor of surgery and section head for colon and rectal surgery at MUSC Health, has performed more single-site colectomies than any other surgeon in the country. This high volume means Dr. George has the expertise to perform the safest, most effective surgery for patients—and that almost always translates to a minimally invasive approach.

The colorectal surgery team at MUSC Health uses the most advanced research-based treatment techniques, including minimally invasive surgeries. In fact, Dr. George uses a minimally invasive approach for nearly all surgeries he performs at MUSC Health, leading to an easier recovery.

But Dr. George says MUSC Health also prioritizes another aspect of colorectal care that has nothing to do with technology: personalized care. It’s the compassionate approach, but it’s also evidence based. With a patient-centered approach to care that starts before patients walk through their doors, patients experience less pain and recover faster.

Colorectal Surgery: Advanced Technology, Less Invasive Techniques

MUSC colorectal surgeons use cutting-edge technology and extensive expertise to push the boundaries of what “minimally invasive” means in colon and rectal procedures. Surgeons use a less invasive approach to treat a range of benign and malignant disease, from diverticulitis and prolapses to malignant disease such as colon and rectal cancer.

“Our area of expertise in colorectal surgery is based on a minimally invasive approach,” says Dr. George. “We use this approach to access the abdominal cavity for many of our surgeries. We can also use this approach for some rectal surgeries, where we access the diseased area from the abdomen and remove the colon cancer that way.”

MUSC uses a range of techniques and technologies in its minimally invasive colorectal surgery options, including robotic, laparoscopic, single-site laparoscopy and transanal surgery.

In single-site laparoscopy, MUSC surgeons offer similar oncologic results to open surgery with even fewer incisions than conventional laparoscopy. Using advanced robotic technology, Dr. George says he has seen improvements in colectomy surgery as well as rectal surgery.

How Patients Benefit From Minimally Invasive Surgery

Often, less invasive equals less pain and a faster recovery for patients. “We know patients who have a minimally invasive procedure have less pain, the same oncologic result, faster discharge home, less incidence of hernias and wound infections and faster recovery to daily activities,” says Dr. George.

More refined surgical techniques are also translating into fewer complications for rectal cancer patients, another key benefit. Due to cutting-edge minimally invasive techniques in a specialized transanal surgery (transanal total mesorectal excision), Dr. George says MUSC Health has seen a decrease in the number of permanent ostomies needed. That means patients can maintain normal GI function and enjoy a significantly improved quality of life.

Another less invasive approach that marries the MUSC Health colorectal surgery team with GI specialists is large polypectomy surgery using a combined approach of colonoscopy and laparoscopy. This approach benefits patients who have large polyps located in the colon or the rectum, who previously would have required a more invasive open surgery to remove a portion of their colon.

Colorectal Surgery: A Personalized Approach

From the time a patient is first referred to MUSC Health until follow-up after treatment, MUSC Health takes extra steps to ensure coordinated care with a team approach. That’s first illustrated in the communication between referring physicians and colorectal service coordinators, who gather all necessary lab and diagnostic tests and patient data prior to the first appointment.

Going one step further in an approach unique to MUSC Health, Dr. George meets weekly with radiology, pathology, oncology, nutrition and other specialists to discuss all new patient cases. This ensures timely, multidisciplinary care, but it also adds a convenience factor for patients. When a patient comes for the first appointment, Dr. George is already waiting with his treatment recommendations and can get to work on a plan that targets the disease and suits the patient’s needs.

That team approach follows patients as they undergo surgery. In the hospital’s colorectal pathology unit, several specialists work toward the end goal of ensuring a smooth recovery and transition back to normal activity. Patients experience less pain, faster discharge from the hospital and ultimately an easier recovery.

The post-surgical care all patients receive emphasizes our integrated approach, making our patients’ experience as seamless and comfortable as possible. The skilled post-surgical team includes:

  • Nursing staff, who tend to patients’ individualized post-surgery concerns, both large and small
  • Dietitians, who offer post-surgery nutrition recommendations
  • Physical therapists, who help patients safely get moving after surgery
  • Pain management specialists, who keep patients comfortable from the operating table until discharge

For more information, contact Dr. George at georgev@musc.edu.

Biliopancreatic diversion, more commonly known as the duodenal switch, can offer patients greater weight loss and other health benefits compared with more popular bariatric procedures, such as gastric bypass—if it’s performed by a surgeon experienced in the advanced laparoscopic techniques.

Duodenal Switch Procedure at MUSC Health

MUSC Health is currently the only site in South Carolina offering the duodenal switch procedure, according to Rana C. Pullattrana, M.D., an associate professor of surgery who specializes in general and gastrointestinal surgery at MUSC.

MUSC’s well-respected bariatric surgery program is the oldest in the region and includes bariatric surgeons, advanced practice practitioners, psychologists, dietitians and patient coordinators. Dr. Pullatt has performed more than 700 bariatric surgeries during his career, including nearly 20 duodenal switch procedures. From the success he’s seen thus far, he hopes that number continues to rise.

“It’s a cutting-edge procedure that very few centers in the country offer,” says Dr. Pullattrana. “Less than 1 percent of all bariatric procedures done in the United States right now are duodenal switch. That shows the rarity of the procedure and why it really needs to be performed by someone who specializes in it.”

Bariatric Surgery: Gastric Bypass vs. Duodenal Switch

In a gastric bypass procedure, surgeons create a smaller stomach by dividing it into two sections, one considerably smaller. They then rearrange the intestine to connect to both sections. As a result, patients need to limit the amount of food they eat at any given time.

In the duodenal switch method, surgeons create a smaller stomach but then remove the unused portion. They reroute the digestive tract, bypassing a portion of the intestine entirely. When using this approach:

  • The pylorus remains intact, so patients do not experience dumping syndrome.
  • The volume of the stomach stays a bit larger, so patients may be able to eat more.
  • Patients may experience fat malabsorption.

According to Dr. Pullattrana, the duodenal switch is a technically challenging procedure, which may be why it accounts for such a miniscule percentage of bariatric surgeries to date.

“The first portion of the duodenum [small intestine] is surrounded by a lot of blood vessels as well as very critical structures, including the bile duct,” he explains. “A surgeon needs to be proficient with advanced laparoscopic techniques. Because this is performed on people with very high BMI, it is even more challenging.”

Duodenal switch surgery can take some surgeons 3 to 4 hours. Through their experience and expertise, the MUSC team has shaved an hour off of that, generally finishing a surgery in 2 to 3 hours. “Performing this surgery required some degree of adapting our technique to get especially skilled at it, and now we are,” explains Dr. Pullattrana.

Most patients go home after 2 days in the hospital and follow up with their doctor at regular intervals for the first year (at 1 week, 1 month and then every 3 months). MUSC Health sees patients annually after the first year, to monitor weight loss progress and ensure adequate nutritional intake.

Bariatric Surgery: Duodenal Switch Benefits

So far, results point to very effective weight loss with the duodenal switch. As of March, MUSC patients had an average BMI of 60 kg/m2 with an average weight of 388 lbs at the time of duodenal switch surgery. Average BMI after surgery dropped accordingly:

  • 54 kg/m2 at 1 month
  • 49 kg/m2 at 3 months
  • 47 kg/m2 at 6 months
  • 39 kg/m2 at 12 months

Patients’ overall health also improved. Whereas gastric bypass resolved diabetes in roughly 80 percent of patients, that number is closer to 93 percent after duodenal switch surgery.

“This is the best operation that we have for bariatric surgery,” says Dr. Pullattrana. “Like any bariatric surgery, patients do need to follow lifestyle as well as dietary and exercise guidelines.”

While the duodenal switch has traditionally been reserved for patients considered super obese (characterized as a BMI greater than 50), current opinion amongst bariatric surgeons is that
many who are a fit for other bariatric surgeries would likely benefit from duodenal switch as well.

In general, Dr. Pullattrana says ideal candidates include anyone with a BMI of 35 or greater who has another health condition (such as uncontrolled diabetes) or anyone with a BMI greater than 50 who desires a drastic weight loss.

This surgery is also an option for patients who’ve previously undergone a sleeve gastrectomy without adequate success.

Bariatric Surgery: Managing Expectations and Follow-Up

Dr. Pullattrana says duodenal switch surgery offers similar complication rates to other bariatric procedures. The most common concern is malnutrition.

Because the surgery affects nutrient absorption, patients need to eat a high-protein diet and supplement with vitamins regularly. To best manage this potential complication, Dr. Pullattrana recommends patients keep in regular contact with their bariatric specialty team, especially their registered dietitians. This includes getting nutritional lab panels every 6 months for the first 2 years and annually thereafter.

Emphasizing these post-surgery management details to patients as they’re considering the duodenal switch can help manage expectations and prevent complications in the long term.

Still, he says the potential for health improvement with this surgery is not to be understated. “This is a life-changing, life-altering procedure. Truly, we can make a dramatic difference in an obese person’s general medical condition,” he says.

For more information, contact Dr. Pullattrana at Pullattr@musc.edu.
 

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