Q. Tell me about what are some of the procedures that we are doing here.
A. Well we’ve been very fortunate, Conemaugh Surgical Associates, actively went out and looked for two new surgeons. I’m the newest one on the block. Dr. Helling from the University of Kansas. I come from the University of Illinois prior to this, and both of us have expertise in hepato biliary and pancreatic surgery. We’ll do the full range of pancreatic surgery. We do laparoscopic pancreatic surgery, pancreatic resections for cancer, pancreatic resection surgical procedures for benign disease as well and pseudocysts, not malignant anomaly tumors of the pancreas, congenital abnormalities of the pancreas as well as biliary tract abnormalities, tumors in the liver, metastatic and primary tumors. We do just about everything short of transplantation.
Q. And is this something that prior to this people used to have to leave the area for?
A. Yes. My understanding of the history of the area for a period of time some of these surgeries were done here in a limited fashion but the vast majority of them were, patients did have to travel outside of Johnstown, the local area to do that and since, since the arrival of Dr. Helling and myself, I just looked at our records and in the last year and a half we’ve done 11 major liver resections and 22 major pancreatic resections. All of those, traditionally, would have left the region.
Q. What’s new in this area? Are there new techniques? You mentioned some of it can be done minimally invasive now.
A. Sure, in the area of, where I concentrate most of my effort which is pancreatic surgery as well as the biliary tract, there are newer techniques. For instance, the classic approach to pancreatic pseudocysts has been an open operation requiring an incision into the abdomen and then a surgical drainage of the pseudocysts around the pancreas. In certain situations now that can actually be done either laparoscopically or even endolaparoscopically. My other two partners in the practice will assist me with that and we can go into the stomach and actually drain the cysts directly back into the back of the stomach with as few small incisions onto the abdominal wall. So that’s an advent. By the same token, I know Dr. Helling done a few here already, laparoscopic liver resections. I’ve done that for peripheral lesions in the liver as well as laparoscopic pancreatic resections. So our ability to do some of these cases minimally invasive, minimally invasively has dramatically improved over the last many years and that is an advantage to these patients. In addition, the surgical techniques have become much more standardized and the recommendations of the American College of Surgeons is that an institution be doing at least 10 major pancreatic resections a year to be classified as a high volume center. We know that the results in those centers are much, are much better and so those are things that we’ve been able to add on to the care of patients in this area.
Q. What’s the benefit of being able to have it done here at home versus having to leave the area?
A. The type of techniques that we do are really tailored to the individual patient. A patient may come in and say I want this done minimally invasive because I want a small incision on my belly and that may not actually be the best approach for that patient to get the best outcome for that patient, and our surgical approaches are such that, you know, even nowadays with good anesthetic care and good pain control you really don’t see a lot of difference sometimes between the two approaches but more importantly your second question is that, you know, I come from Illinois, and I laughed when I first came here. I said, they wanted to show me a place to live and they said now we’re afraid we are going to show you a place that’s a little bit flat. I understand people here want to live up in the hills and they talked me into some place that you could see about 100 yards straight and I laughed and I said my last home, when the corn was down, I could see 15 miles straight out my front window. The difference in geography here means that if I try to go 30 miles even down to Somerset or north up towards Indiana, it’s a long distance at certain times of the year, trying to get around the mountains. It’s not very easy to do. I understand you call them hills here. They’re mountains to me. And for the patients to have to travel all the way to Pittsburgh or out to Philadelphia or to Harrisburg or Baltimore to get these procedures is quite a hassle because most of these patients are in the hospital for a week to 10 days. The recuperative period afterwards is on the order of about two months and so that’s a long time for a family to be committed to going back and forth to a major institution someplace else. So from a geography standpoint, for patients to get this surgery here and have the same results that they would at another University Center is a great advantage I think to the people in this area who, you know, traveling is difficult out here.
Q. What’s your level of confidence in the surgical programs here, your team and the team that works with you?
A. Well we track all of our results. I think part of Conemaugh’s credit is they went out and actually looked for people who had already had a track record. Dr. Helling and I have been doing this type of surgery combine for approximately 40 years give or take maybe a few more. And our combined experience from that we can put down our mortality rate. Our combined mortality rate for pancreatic surgery is the same as any major pancreatic center in the country. So we can easily do that. We track our complication rates. We fall well within the accepted standards that are set for University Centers. So by recruiting people in who are able to do this and building those kind of programs we kind of bring the product to us and here in Johnstown.
Q. You mentioned about removing a pancreas, can you live without your pancreas?
A. Yes you can live without the pancreas. It’s certainly not the ideal, the pancreas has two major functions. One is to produce insulin which everyone knows about and the other is to produce enzymes, proteins that help digest our food. Both of those can be replaced. So we can give you insulin, you know, diabetics get it, and we can give you pills to replace the enzymes that you just take when you eat. Not ideal obviously, but you can live without a pancreas and that’s some of the newer interventions, innovations that we now have, the ability to replace the activity of the pancreas, its physiologic activity with medications, either intravenous or injectable or pills, has made our ability to do these procedures much more feasible.
Q. And what about the liver? You can actually take portions of that?
A. Well you can take, if the rest of the liver is healthy, you can take up to 75 percent of the liver. The liver is the one chameleon organ we have in our body. It will grow back. It will regenerate itself. Now the amount of liver you can remove is dependent upon on how much liver remaining is normal. That’s the same problem with the pancreas. So, you know, if someone had a problem with their, a diffuse problem with their liver, they’ve got a global problem in the liver and they’ve got a specific thing that has to be removed, you can removed, you can’t remove as much but you can removed quite a bit of the liver in certain situations.
Q.I would have to think this is a pretty exciting time for you as a surgeon in this field.
A. Yeah it is. I just gave a ground rounds for the hospital. We cycle through and it was my turn and I talked about nonmalignant diseases of the pancreas because we always talk about pancreatic cancer and one of the quotes we all grew up with, I know Dr. Helling grew up with it too, was that the three rules of surgery are eat when you can, sleep when you can, and never never touch the pancreas, you know, because it’s a very difficult area to operate in, the complication rates are high even in the best centers. There are complications that occur with this procedure, it’s almost expected, and so surgeons kind of stayed away from that area and the results were poor. So if you combine those two together it was that way. What’s exciting is that what we’ve learned is as you gain experience if you can get into a center where you’ve got the help and support, the surgery can be done very, very effectively and at a very low mortality rate, less than 3 percent, and with that kind of results from surgery now the other physicians become more accepting of okay maybe we ought to approach this and then you can get the physicians together in a group, and I think that’s what’s happening now is that people are not as afraid of the pancreatic surgery anymore. The oncologists are getting on board with the surgeons because now they’ve got, if you send a pancreatic patient to an oncologist and they haven’t had surgery and there’s very little he can offer or she can offer, and so now we can combine our talents and move forward. So I think in the next 10 years we’re going to see a significant advancement in this area. There’s a lot of research being done, and I think we are going to make changes and it’s kind of, it is fun because I grew up with don’t ever do this and for some reason now I’m doing it and it’s fun to watch it change.
Q. I’m interested in the protocol that’s being used for brain injury with the hypothermia. What is the protocol?
A. We have a very nice protocol here. In my estimation, one of the best I’ve ever seen for the approach to brain injured patients, a real nice cooperative effort kind of spear headed by Tom Kauser out Trauma Case Manager who brought together all of the different parts that are necessary in the care of patients with brain injury, that’s the neurosurgeons here, the trauma surgeons, the ICU doctors, the nurses who actually are going to care for these patients and we actually put together, they put together step-by-step guidelines for how to manage these patients to be as aggressive as we possibly can because as we all know a brain injury, even a minor brain injury, is very devastating for people. So whatever we can do to save brain just like we used to say save muscle for the heart, we’re trying to do for the brain injured patients. It includes an aggressive approach that begins the minute the patient hits the emergency room with resuscitation efforts that are begun empirically even if we don’t know for sure what the injury is to start to prevent, to help prevent ongoing injury and save as much brain as we can. It continues on in the ICU and in the operating rooms with placement of special catheters to make sure not only the pressure inside of the brain which people have done classically for the last 30 or 40 years but also now to measure the brain oxygen levels at the tissue levels to see if the cells in the brain are getting the appropriate amount of oxygen and then a series of strategies designed towards improving that including more invasive techniques such as placing catheters to raise the blood pressure, give medications to raise the blood pressure and maintain it, giving --- the patients in order to maintain a gradient between the brain and blood to break the swelling as well as placing special catheters and devices to cool the body down because we know that the brain does better in a cool environment. We’ve all heard of people who fall into the water, cold water drownings and they come out perfectly fine because the cold water preserved the brain. And so we are doing all these things here and I think what’s been nice to see and kind of unique here is that every one of the practitioners who are involved, who are involved with caring for these patients follows the same set of guidelines. So it doesn’t matter what day of the week or time of the week or day that you come into the hospital you are going to get the same level of care from our Brain Management Team, and I think that’s a great credit for the neurosurgeons here and the trauma surgeons. I can’t claim anything for it. It all came, was coming together before I came here but it’s very similar to what I was used to where I practiced before and it’s done very, very well.
Q. And why does cooling the brain benefit a brain injured patient?
A. We know that if we could slow the metabolic rate of an organ that it has a longer time to respond to the injury and heal itself. It the brain is running full tilt, it’s kind of like your engine in your car. If you are running down the expressway at 90 miles an hour you run out of gas real fast and you can’t get anywhere. If you go slower you can go farther and so slowing the brain down allows the brain cells that are there that are partially injured to recover and those that aren’t injured to kind of sit back and wait while the rest of the brain heals itself, and that’s kind of a simplistic way of looking at it. We don’t know much more detail than that other than our observational studies from seeing patients who fall into cold water and drown and do well. So the link to hypothermia was made there.