UAB MedCast

Multidisciplinary Evaluation and Treatment of Pituitary Tumors

Additional Info

Audio Fileuab/ua140.mp3
DoctorsVaughan, Brooks;Riley, Kristen
Featured SpeakerBrooks Vaughan, MD | Kristen Riley, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6191
Guest BioBrooks Vaughan, MD is a Doctor of Medicine in Endocrinology, University of Alabama at Birmingham.

Learn more about Brooks Vaughan, MD

Dr. Riley directs the neurosurgical Pituitary Disorders Clinic. This clinic was founded in 1988 to provide multidisciplinary treatment of pituitary tumors.

Learn more about Kristen Riley, MD

Release Date: February 25, 2020
Reissue Date: February 14, 2023
Expiration Date: February 13, 2026

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Kristen Riley, MD
Professor in Brain and Tumor Neurosurgery & Neurosurgical Oncology
T. Brooks Vaughan, III, MD
Professor in Endocrinology

Drs. Riley & Vaughan have no relevant financial relationships with ineligible companies to disclose.

There is no commercial support for this activity.
TranscriptionMelanie Cole, MS (Host):   UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

This is UAB Medcast. I'm Melanie Cole. Today we’re discussing multidisciplinary evaluation and treatment of pituitary tumors. Joining me in this panel are Dr. Brooks Vaughan—he’s an endocrinologist and a professor at UAB Medicine—and Dr. Kristen Riley, she’s a professor of neurosurgery at UAB Medicine. Doctors I'm so glad to have you join us today. Dr. Vaughan I’d like to start with you. Please give us a little background on pituitary tumors, the incidence and prevalence and the different types that you see.

Brooks Vaughan, MD (Guest):   So pituitary tumors are quite common. Estimates are that between 15 and 20% of normal people if they were placed in a good MRI scanner would be found to have a small pituitary adenoma. These are benign tumors that in most people don’t cause any significant problems. However, a percentage of them get large enough that they may cause trouble with vision changes. That can be one way that patients come to attention to physicians. The other way they sometimes come to attention is that these tumors can make hormones that cause clinical syndromes that lead patients to be evaluated by us.

Host:   Dr. Riley as we’re talking about the clinical presentation. When patients come to you or are referred to you, what’s indicated in the workup? How does it involve an endocrine evaluation, imaging, ophthalmology evaluation. What studies do you perform? Tell us about that.

Kristen Riley, MD (Guest):   Dr. Vaughan and I see patients together in a multidisciplinary clinic, which is quite useful because these patients do require a variety of investigations. When we can work together we can do that most efficiently. Generally patients come to us, most often they have already had imaging such as an MRI scan, but sometimes we need to obtain a focused MRI scan to specifically look at the area of the pituitary as some standard sequences on brain MRIs don’t adequately visualize the pituitary. In addition to imaging, the endocrine workup is quite important. That involves a battery of lab investigations as well as clinical evaluation. That’s why it’s fantastic to have Dr. Vaughan in the clinic together with me so that we have a full evaluation of the patient. Not just by their lab work but also from clinical features that sometimes lead us to do some more detailed testing that might not be familiar to a general practitioner.

Depending on the size of the tumor ophthalmology evaluation is often quite critical. That’s generally for tumors that are larger than one centimeter and extend upward towards the optic nerve. Certainly we can see larger tumors that actually extend inferiorly away from the optic nerve. So strictly the size of a tumor by itself doesn’t tell us whether ophthalmology evaluation is needed. It’s really the size and location and direction of tumor growth that dictate whether an ophthalmology evaluation is needed. Within the specifics of an ophthalmology evaluation it’s quite important to have formal visual field testing that really gives us the best idea of a potential impact of tumor on patients vision. So the combination of radiology imaging typically with an MRI scan focused at the pituitary endocrine evaluation which is clinical and a laboratory of investigations as well as ophthalmology in indicated patients. Those really are the cornerstones of our initial evaluations with patients of pituitary tumors.

Host:  Well thank you for that comprehensive answer Dr. Riley. Dr. Vaughan, as we’re talking about some of the latest treatment options for pituitary tumors, I’d also like you to mention as you were discussing radiologic imaging for diagnostic capabilities while you're speaking about treatment options. How have some of the advances in that radiologic imaging also augmented your therapeutic capabilities for these tumors? Please speak about some treatment options—non-surgical and surgical for us.

Dr. Vaughan:   In terms of radiologic imaging, one thing that’s been very useful for us is having more advanced MRI capability. Occasionally a patient will come, and we are looking for a tumor and prior MRIs have not been conclusive. We’ve got very powerful MRIs here at UAB and occasionally can find a tumor that’s been difficult to localize before. The other thing that’s changing rapidly in terms of pituitary disease is that we have new medications for several of our more difficult to treat pituitary diseases. So specifically we have medications that can treat prolactin secreting tumors. Those medications have been around for a while. So that’s something we’ve been able to do for years.

We’re getting more advanced treatments for hormone secreting tumors that cause diseases such as Cushing’s disease, which is excess production of cortisol, and acromegaly, which is excess production of growth hormone. In the past we’ve had little to offer those patients, but now we have several medications that can treat Cushing’s disease. We have very effective medications that can treat acromegaly. In the past acromegaly was almost universally treated with surgery. Acromegaly is the state of excess growth hormone production. These days because the medications are so effective often we take a more balanced approach to these patients and are able to offer them surgery potentially. Often they're able to consider medical therapy without surgery with very good outcomes. For Cushing’s disease we literally had nothing for many years, but now we've got several medications that work although not quite as effectively as our medications for problems with growth hormone.

Dr. Riley:   I’d like to add to what Dr. Vaughan just said. Again, highlighting the importance of being seen at a multidisciplinary clinic that sees a high volume of pituitary patients. It’s really critical for me as a surgeon to be able to, as Dr. Vaughan said, offer patients a balance of treatment options. Some of the medical treatment for Cushing’s disease, some of the advances in treatment for acromegaly, the medial treatment, certainly were not present when I was in training. It really is critical to have his knowledge and expertise there. So when we see a patient we can counsel them very comprehensively about their options. Certainly obviously as a surgeon I like to do operations. If I can cure somebody with an operation, we most definitely are happy to offer that. In some cases patients require a combination approach. Really it’s critical to be able to have those conversations between the endocrinologist and the neurosurgeon in the clinic with a patient simultaneously to provide the most comprehensive care to those patients.

Host:   Dr. Riley, as you’ve mentioned the multidisciplinary approach and how important that is for these patients, tell us how your outcomes have been and the prognosis of patients. For referring physicians, what would you like them to know about the specialists at UAB?

Dr. Riley:   In our clinic, as I said, Dr. Vaughan and I see patients together. We do all the lab work in the clinic. So it’s really an efficient system to get patients comprehensively evaluated. As far as outcomes, as you can imagine most patients are quite often terrified when they hear they have a tumor within the cranium. They panic they have a brain tumor. Fortunately these patients do quite, quite well. Many patients do not require any surgery or medication. Those that do, we have a very high success rate in treating those tumors successfully for patients who have visual decline related to the tumor. Most often they have vision improvement following surgery or other treatments. From a medical standpoint, we’re quite successful in controlling hormone issues related to the tumors. Surgery, when necessary, is done endoscopically. So it’s done without cuts on the face. It’s done through the nose. Typically it’s a two night stay in the hospital. Patients are out of bed walking around the day after surgery. Generally they tolerate the surgery very well. So our patients do well and are quite pleased with the service that we’re able to offer them.

Host:   Dr. Vaughan, as we wrap up what would you like other providers to know about the importance of referral when they do get a patient that exhibits some of the clinical manifestations you’ve discussed here today? What would you like them to know about this team and referral?

Dr. Vaughan:   We know that pituitary disease because it is so complex and requires multiple specialists including ophthalmologists, radiation oncologists, surgeons, and endocrinologists that it’s best treated in a center that has all of that available. There are, in fact, guidelines that suggests these tumors should only be treated in what we call centers of excellence that have all of those services available. Dr. Riley and I really feel that this can't be done without this type of approach. I cannot tell you how many times we have changed treatment decisions based on discussion we’ve had face to face either looking at scans or looking at labs together. Many of those decisions I never would have made on my own. Generally that is in the best interest of the patient to have that discussion at one time with all the specialists that are involved in their care.

Dr. Riley:   Just to add on that, Dr. Vaughan and I are in together one day a week on Tuesdays. For the most part with new referrals we see patients within one to two weeks. Certainly there are occasions where I might see the patient without Dr. Vaughan initially if it’s quite urgent and it’s not around a Tuesday, but we’re happy to help facilitate appointments and evaluations and certainly welcome those referrals. Just to wrap up as Dr. Vaughan said, it’s really critical to have patients evaluated at a center of excellence so they can have the most up to date treatment options presented to them. Having said that, we do collaborate with the outside endocrinologists and physicians for the coordination of patient’s care. We really enjoy working with our colleagues in the community and elsewhere in the state and certainly welcome those referrals from endocrinologists and neurosurgeons in the state as well.

Host:   Thank you so much, both of you. What an excellent segment. Such an interesting topic. Thank you for explaining that comprehensive multidisciplinary approach and why it’s so important for patients with pituitary tumors. A community physicians can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Medcast. For more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB podcasts. I'm Melanie Cole.
HostsMelanie Cole, MS

UAB Outreach in Kidney and Liver Transplantation

Additional Info

Audio Fileuab/ua136.mp3
DoctorsShoreibah, Mohamed;Agarwal, Gaurav
Featured SpeakerMohamed Shoreibah, MD | Gaurav Agarwal, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6186
Guest BioMohamed Shoreibah, MD is an Assistant Professor, Hepatology.

Learn more about Mohamed Shoreibah, MD

Gaurav Agarwal, MD is an Assistant Professor, Nephrology.

Learn more about Gaurav Agarwal, MD

Release Date: January 15, 2020
Reissue Date: February 7, 2023
Expiration Date: February 7, 2026

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Mohamed Shoreibah, MD
Assistant Professor in Hepatology
Gaurav Agarwal, MD
Assistant Professor in Nephrology

Drs. Shoreibah & Agarwal have no relevant financial relationships with ineligible companies to disclose.

There is no commercial support for this activity.
TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host):  The UAB Comprehensive Transplant Institute is establishing a growing network of outreach clinics in order to provide patients throughout Alabama with convenient access to state of the art treatment options for patients with complications of chronic liver and kidney disease with treatment provided by physicians who are nationally recognized as experts in their field. Today, we’re talking about the liver and kidney transplant and outreach clinics. In this panel discussion I have with me Dr. Mohamed Shoreibah. He’s an Assistant Professor and a Hepatologist and Dr. Guarav Agarwal. He’s an Assistant Professor in Nephrology and they are both with UAB Medicine. Dr. Shoreibah, I’d like to start with you. Please tell us about the UAB Comprehensive Transplant Institute if you would.

Mohamed Shoreibah, MD (Guest): So, the Comprehensive Transplant Institute, the CPI is a multidisciplinary entity where providers take care of patients that require organ transplant evaluation and management after the process is completed. So, we assembled there a great team of care coordinators, specialized clinical providers and we provide organ transplant service for liver, kidney, heart and lungs. The Institute completed so far 15,000 successful organ transplants since 1968. And we average on yearly 400 transplants. We have the largest comprehensive program in the southeast.

Now in terms of liver transplant in particular, we are one of 20 nationally ranked programs that perform 100 or more liver transplants per year. And we have excellent survival rates that actually supersede the average nationally and the big benefit that we are able to streamline that comprehensive service under one umbrella, assembling a great team of providers and administrators.

Guarav Agarwal, MD (Guest):  I would just like to add that it gives us a great opportunity for collaboration and research and deeper understanding of immunosuppression. We also have the ability to invite speakers from around the US and other countries to share their expertise in transplants so we can learn the similarities and differences of these programs and improve our patient care and outcomes.

Host:  Well thank you for that. So, Dr. Agarwal, along those lines, those synergies and the multidisciplinary approach, how has this energized your transplant communities?

Dr. Agarwal:  So, at UAB we are about nine nephrologists that work together along with five kidney transplant surgeons and we have a very strong collaborative team. We all get together at least once a week or sometimes even more frequently and have a very synergistic and comprehensive approach to patient care.

Host:  Dr. Shoreibah, tell us about the outreach clinics at UAB. Why did you see a need for these types of clinics and how did it come about?

Dr. Shoreibah:  Sure. We’re very grateful for a great network of dedicated providers in the region who do not spare any effort in caring for their patients. And equally important to patients and their families for the faith and trust that they put in the services that we provide here. but we really wanted to make sure that we are accessible to patients who are ill and cannot travel to come and see us here at the UAB. Sometimes, those patients need to be fast-tracked into the process of organ transplant evaluation and at times, it’s very difficult for them to get to us here.

And we would like to be able to provide those relevant consultations in a timely manner in a way that’s convenient to providers and patients. It is really a vital part of our mission and I think the big benefit of doing the outreach also is to spread the message about organ transplant and how life changing of a procedure it could be, that it can be a cure for an end-organ disease.

Host:  Well that is so important. What an amazing service you both are providing to the community and while we’re talking about services, Dr. Agarwal, what types of services do you offer? Tell us about the physician services for patients with complications of chronic liver and kidney disease. As I said in my intro, that this is giving them access to state of the art treatment options for patients. Tell us how that works.

Dr. Agarwal:  So, we are currently having one outreach clinic in Mobile Infirmary where we have seen post-kidney transplant patients. We are in the process of expanding our reach with opening a facility in Huntsville very soon. We are also looking into expanding to Montgomery soon. The outreach clinics are a great boon to the patients. They reduce their travel time and we are able to identify problems earlier in these patients. One of the common complaints that we get from these patients is why I have to drive all the way to Birmingham to see someone when everything is fine, and you are just telling me so.

So, with outreach clinics, when we can review their medical records, we can ensure that their medications and labs are up to date. We can also review any problems that they may have and identify these patients to come to Birmingham for higher level of care. Sometimes we are able to intervene much earlier by seeing the patients locally. The patients are always concerned about their transplant and they want our opinion even when the things are not related to their kidneys. So, for example, they are undergoing back surgery or some other surgery; but they would want our opinion to make sure they are safe from the transplant standpoint and we can provide this easily in our outreach clinic.

I also understand that some of the region – some of the institutes in our region are also doing outreach clinics. So, this has become very important part of care for chronic kidney disease and care for our transplant patients.

Host:  Dr. Agarwal, is Telemedicine playing a part in this endeavor?

Dr. Agarwal:  So, Telemedicine is definitely a part of our outreach. We are currently having difficulty in reaching patients that live in rural areas and they have to sometimes travel long distances just to see either us or even their primary care physicians. So, we are partnering with local health authorities that the patients can go there, and we can see them via Tele-Health. So, I think Dr. Clifton Kew from kidney transplant is going to talk about it in more detail. But definitely Telemedicine has increased our outreach efforts quite a bit.

Dr. Shoreibah:  And if I may add, in the field of the hepatology also, we are looking into doing that in the future. So, we would like very much to utilize Telemedicine for that intake season, that quick access point that we need for our patients to get them the access they need to their transplant evaluation and listing here at UAB. So, we’re very excited about that and we’re definitely exploring it as an option too.

Host:  Well that’s a great point and Dr. Shoreibah as we talk about how this care model improves the way patients receive their care; how does that all work together if they are going to have some other procedure done or they do have diabetes or comorbid conditions; how is this improving that whole care model by bringing it together so that everybody knows what everybody else is doing?

Dr. Shoreibah:  Sure. So, transplant patients are a unique population to deal with and right after the transplant and even that starts early on during the evaluation process; each and every patient is assigned a transplant coordinator that has a high level of training and expertise in that area in particular, the management of the immunosuppression medications, what to do before surgery or any needed procedures and that serves as a great quick access point for all of our patients. Not only this, but we utilize also the patient portal which allows patients to send us message that we can respond to in a timely manner. So, to maintain that success and good outcome after transplant; we really depend on a very strong dedicated team that maintains that communication between us and the patients and also us and the other providers that are taking care of the organ transplant recipients.

Host:  It’s such an amazing program as I said already, and Dr. Agarwal talk about patient outcomes a little bit for us. Why is this continuum of care so important for the success of transplant patients?

Dr. Agarwal:  So, one of the unique things that we provide to our patients is we follow them for the life of their organs, and this is very important. Because these patients as Dr. Shoreibah is saying that they are unique. They need to be followed for long term to improve their outcomes. So, we do that. Not all the programs in the country follow their patients for a long term. So, we feel that it has really improved our outcomes, both short and long term outcomes and we continue to do everything we can both locally and in our outreach clinic to do everything we can to improve the survivability of both the patients and allograft.

Host:  Dr. Shoreibah, give us some future plans for the clinic. What’s your vision? What are you hoping will include when you are evaluating patients with renal failure, assessing their needs? Tell us a little bit about what your vision is.

Dr. Shoreibah:  Sure. I think that to broaden even the discussion about the vision for organ transplant; I want to share some numbers with you. In the year 2019, there were more than 113,000 patients listed for organ transplant in the US. And if you look at the number of patients that were transplanted in 2018; about a third of that number received organ transplant. So, I think our vision and future challenges that we have probably two important points. The access to the specialized care, how can we get those patients quickly to be evaluated for liver transplant and outreach is a vital part of that and we will continue to do it. But also, how to fill in the gap on the deficiency in the organs there because 20 patients on the list for organ transplant die everyday without getting what they need.

So, while you look at the population here in the US, 95% of the adults approve of organ donation and have positive opinion about it but only 58% actually signed up as organ donor. So, what can we do to bridge that gap and make sure that we have more organ availability? Probably more education and outreach to the community to make sure that people understand the importance of that.

The other thing that we are working on and pushing really forward with is trying to modify nonhuman organs to be transplanted to humans in the future. And this is a very unique concept and we really hope that it becomes successful in the future and that’s what we call xenotransplant. So, we have a very strong research program now that we are hoping to see the fruits of in the near future.

Dr. Agarwal:  I agree with Dr. Shoreibah. We are moving tremendous – we are making tremendous stride in terms of xenotransplant in terms of possibly obtaining pig organs for kidney. In terms of having more accessibility for organ donation; these outreach clinics will help us find suitable candidates who have living donors and sometimes because of the slow process of evaluation; these donors are not being able to be tapped or reached because they sometimes tend to lose interest as the process lingers on. So, with this outreach, we are trying to see if we can quickly identify suitable candidates and identify living donors to improve the number of transplants that we can do every year.

Host:  Well it is fascinating, and listeners can listen to a podcast on xenotransplantation from the experts at UAB Medicine on the website podcast page. Because we have done one and it is amazing what you are all doing there. So, Dr. Agarwal, I’d like to start with you. Do you have any final thoughts? Anything you’d like to leave other providers with that will give them more information about the liver and kidney transplant and outreach clinics available through UAB.

Dr. Agarwal:  So, I would just like to say that we are working very hard to provide great care to our patients. We are trying to provide – reduce the wait time for the patients who are referred to us. We are trying to increase our outreach, so the patients don’t have to wait as much or travel as much to UAB and they are better served and are more satisfied with their care.

Host:  Dr. Shoreibah, last word to you. What would you like the listeners to take away from this very important comprehensive approach to treatment of organ failure and transplant?

Dr. Shoreibah:  Sure, I agree with everything my colleague Dr. Agarwal mentioned. I would like to add to our referring providers that the mission that we are trying to accomplish here in the CTI would not happen and won’t be a success without their efforts there. And we are ready to help and give any opinion at any point of time. So, no hesitation picking up the phone and talking to us about any patient that we need to take care of, and we value the effort that they do out there in the community. They are really on the frontlines.

Host:  Well thank you gentlemen both of you for all that you are doing and for coming on this podcast today and sharing your incredible expertise. Thank you again. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. This concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. And please remember to subscribe, rate and review this podcast and all the other UAB podcasts. I’m Melanie Cole.
HostsMelanie Cole, MS

Transplant Telehealth

Additional Info

Audio Fileuab/ua139.mp3
DoctorsKew, Clifton
Featured SpeakerClifton Kew, MD
CME SeriesMedical Innovations
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6265
Guest BioClifton Kew, MD is the Medical Director, Kidney and Pancreas Transplant Program.

Learn more about Clifton Kew, MD

Disclosure Information:
Release Date: February 19, 2020
Reissue Date: March 6, 2023
Expiration Date: March 5, 2026

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Clifton Kew, MD
Medical Director, Kidney and Pancreas Transplant Program

Dr. Kew has no relevant financial relationships with ineligible companies to disclose.

There is no commercial support for this activity.
TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host): The University of Alabama at Birmingham is using Telehealth to treat kidney transplant patients who would otherwise travel hundreds of miles for a regular checkup. Welcome to UAB Med Cast. Today, we’re discussing the UAB Transplant’s Telehealth initiative. I’m Melanie Cole and joining me is Dr. Clifton Kew. He’s a Professor of Medicine and Surgery in the Division of Nephrology and the Medical Director of the Kidney and Pancreas Transplant Program at UAB Medicine. Dr. Kew, it’s an absolute pleasure to have you join us today. Let’s start with a little working definition of Telehealth for the future for patients, providers. It’s happening all over the country. Tell us a little bit about the evolution and what you’re doing there at UAB?

Clifton Kew, MD (Guest):  So, what we’re doing at UAB is we’re trying to bring the medicine to the patient. And Telehealth is one of the initiatives that allow us to do that. Now traditionally, we have several – well we are coming up with several outreach clinics where a physical provider drives to an outlying area and see patients. And I’ve done an outreach clinic in the Mobile area which is around 250 miles from UAB. I spent eight hours in the car to see four hours’ worth of patients. So, it’s not very efficient from our point of view but it’s a big help to the patients that live in the Mobile area, the panhandle of Florida and southern Mississippi. And patients have always said thank you for coming down because I don’t have to spend the eight hours in the car to come see you.

So, Telehealth eliminates that – it’s actually the best for both provider and patient because they go to a specified site, they see a doctor over the internet and pretty much you can almost do a complete physical exam. They have a wireless stethoscope where a nurse or other designee will place the stethoscope on the patient’s chest, and I am able to hear what’s going on in the patient 200 miles away. So, it brings the medicine to the patient and I have yet to have somebody tell me that they weren’t happy. The only complaint I got was one of the patients said she couldn’t give me a hug at the end of the visit.

Host:  That really is amazing. And how lovely is that. So, give us some other examples. So, besides patient monitoring but on demand, critical care with transplant patients especially Dr. Kew, sometimes there’s emergent situations or questions that they have. They’re worried about rejection. How do some of those things work and I’d also like you to tell us where there any barriers to starting this initiative?

Dr. Kew:  I’ll start with the last question first. So, most of the barriers were administrative. And it was trying to get on the same encrypted communication suite with the outlying sites. So, the Alabama Department of Public Health has designated their Health Department. So, there’s one Health Department in every county in Alabama. And they have designated each one of these Health Departments has its own Telehealth cart. So, it was a matter of getting UAB on their communications program so that was one barrier. Another barrier was that some of these health departments are in such rural areas, that they didn’t even have broadband internet, which is a requirement for Telehealth. So, that was another barrier. Fortunately, the number of available Telehealth sites has grown. So, we now have access to more areas as broadband is getting out and the state government actually has a dedicated task force for encouraging some of the telecommunications companies to lay cable so broadband can get to these more rural areas.

Most of the focus of the Telehealth for transplant is what we’ve termed as immunosuppression monitoring. And the reason that we’ve focused on that is that we don’t need real time blood results or lab results to determine if there’s a problem. So, we would ask the patient to get their lab work a week before the visit and then they would come and we would review the labs and identify problems, identify doses of medications that needed to be changed, update our medical records and oh you had a heart attack six months ago, okay, we’ll put that in the record so when you come back sick then we know that that happened to you.

The next phase would be doing these so-called sick clinics where somebody would come in with a kidney dysfunction and we could actually do some actual diagnostics or at least the first step to diagnostics before having them come to Birmingham to have testing done that only can be done up in Birmingham such as a kidney biopsy.

Right now, we’re focusing on the people that say why do I have to come all the way to Birmingham just for you to tell me my kidney is okay. That’s what we’re focusing on. We feel that we can still contribute to a patient’s health by looking at their levels and their labs and their cell counts. We can look for toxicities. We can look for people that are getting too much. We can look for people that are getting too little and we can stomp out some simple problems.

But ultimately, the plan is to get more sick patient type visits and some of these sites for example, one of our sites is the North Baldwin Infirmary that we do have some sites available to us that are outside the Alabama Department of Public Health so the North Baldwin Infirmary, that’s a hospital. So, if somebody comes in with a chest cold, I can get a chest x-ray. Somebody comes in with a swollen leg. I can get an ultrasound to check for a DVT. Somebody comes in with a high creatinine, I could potentially get an ultrasound of the transplant in order to make sure there’s no urinary obstruction. So, those kinds of things are a little bit difficult at the public health and what we’ve done in those cases, we just say, you just need to come up and see us in Birmingham so we can take care of the problem.

As far as inpatient goes; we have not embarked on that. That would be ideal. We have lots of people that come to emergency rooms in underserved areas. I know my general nephrology counterparts have done some of those. So, that is potentially on the radar but that’s going to be down the road a bit.

Host:  Well thank you for that answer. And as long as we’re talking about how Telemedicine is transforming your decision making scenario, and the functionality that it provides from that clinical perspective; are you seeing Dr. Kew, that it’s changing the care paradigm to the home, decreasing hospitalizations, readmissions, just really the stress on everybody?

Dr. Kew:  I think it’s less of a stress on the patient. I think once they get used to seeing a doctor over the internet, it’s much less intimidating to them. I see people for follow up of test results so, for example, a patient comes, has a kidney biopsy up in Birmingham, they go home, rather than driving all the way up a week later to get the results; I see them via Telehealth, and I’ll say okay here’s what we need to do with the results. Let me go change your medicine, let me arrange for further treatment which doesn’t necessarily have to be done at UAB. Sometimes we can send them blood tubes in the mail to check for various things and follow up. These virtual visits can really, in that scenario, prevent patients from coming back unnecessarily.

I think it’s a bit early to see what impact it has on readmissions. I’m a firm believer that if you have more eyes on patients, then there’s less of a chance that something is going to slip through the cracks. So, my expectation is is that it will. And not only that, getting readmitted to the hospital, I mean our goal is to keep people off dialysis. And I think if we can see patients more frequently, more conveniently, we can delay that. So, I think that’s really where the benefit is going to be. It’s going to be in keeping people off dialysis, keeping them with a bit better quality of life and also going back on dialysis is expensive. And if we can keep the transplant lasting longer, it’s not just good for the patient; but it’s good for the healthcare system in general.

Host:  Well you got to right where my next question was going. What about cost effectiveness and insurance implications. Telemedicine is this being embraced by the insurance companies and I would imagine why wouldn’t they?

Dr. Kew:  The answer is yes. The information that I know, Blue Cross, Blue Shield of Alabama has embraced it. They will pay for it because I think they understand that if you give access to patients to provider then you might avoid some of these downstream costs that could be avoided. Medicare has embraced it primarily in underserved areas. It may be that a patient has to drive 30 minutes to go to a place where we can see them via Telehealth but still, if you have the choice of driving 30 minutes versus two and a half hours; I don’t think the patients have to think that long at what they want to do. Medicaid of Alabama, they also reimburse so the three major payors in our state are paying for this service. And so, I think they realize that if you are able to get specialty care to places that don’t have specialists; there’s a cost savings and I think that if you have higher level of care available earlier on in the process; that you would avoid problems down the road.

Host:  Well that certainly is true and thank you. As we wrap up, and we’re talking about how this would improve the patient journey and the way they receive care, for even related conditions as you mentioned heart attack earlier. What do you see as the endless possibilities of Telehealth for the future of care and especially Dr. Kew for transplant patients? Wrap it up for us with a summary of the UAB Medicine Transplant Initiative.

Dr. Kew:  So, right now, we’re focusing on immunosuppression surveillance, just is your kidney working fine, yes, no, if it is, great, let’s make sure you are on the right medicine, let’s make sure our records are updated. We’ll see you next time. If not, if there is a problem, well then you need to have further workup. So, that’s phase one. Phase two is looking at patients that are not doing 100% well and trying to stomp out some issues and prevent some trips back to the transplant center in Birmingham and deal with it more on a local basis. Phase three and we didn’t even talk about this, I transplant evaluation which would be our third initiative.

So, for example, you have somebody that may have difficulty getting to Birmingham, but they are interested in well can I get a transplant? What are my donor options? Am I going to be limited to getting a kidney off of the waiting list? Do I have an option for a living donor? What are some of my health conditions that would not allow me to get a transplant? Plus all the educational components that our coordinator staff do. That can be done – you could have a Teleconference with a group of potential transplant recipients to teach them what’s going on with the transplant process and find people that say heh, you know, I didn’t know that somebody who was not a blood relative could donate a kidney to me.

Those are things that we can do. And then lastly is the inpatient version which I think that’s probably the furthest down the road, but I think the post-transplant, the care after transplant is number one. We are already doing it. We’re trying to figure out what a pretransplant experience would be like because patients do have to have the ability to get to the transplant center ultimately because they have to come here for surgery. So, we can never eliminate the need to come to Birmingham but what we can do is we can minimize it and for patients that are kind of on the fence, may have a health problem that may exclude them from getting a transplant; they can talk to a physician, they can get some answers to what they need to do to make themselves a transplant candidate.

So, I think there are advantages all around for transplant medicine especially in our state because we do have a population that doesn’t have a lot of resources which is something that we deal with on a daily basis seemingly, in our clinic.

Host:  Wow, it’s such a fascinating topic. What a time to be in your field Dr. Kew. Thank you so much for telling us about the UAB Transplant Telehealth Initiative. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. And please remember to subscribe, rate and review this podcast and all the other UAB podcasts. This is Melanie Cole.
HostsMelanie Cole, MS

The Use of Podcasts in Medical Education

Additional Info

Audio Fileuab/ua137.mp3
DoctorsVardas, Panayotis
Featured SpeakerPanayotis Vardas, MD
CME SeriesQuality and Outcomes
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6196
Guest BioDr. Vardas specializes in all aspects of adult cardiac surgery, with expertise in complex valve reconstructive surgery, arrhythmia surgery, coronary artery bypass grafting and transcatheter valve therapies.

Learn more about Panayotis Vardas, MD

Release Date: February 12, 2020
Reissue Date: February 2, 2023
Expiration Date: February 2, 2026

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education

Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Panayotis Vardas, MD
Assistant Professor in Cardiac Surgery

Dr. Vardas has no relevant financial relationships with ineligible companies to disclose.

There is no commercial support for this activity.
TranscriptionMelanie Cole (Host):  UAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category One credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host):  Welcome. In this podcast today, we’re discussing podcasts as a resource to enlighten the medical community and keep other providers abreast of the latest advances in medicine taking place at UAB Medicine. Joining me is Dr. Panayotis Vardas. He’s a cardiac surgeon and assistant professor at UAB. Dr. Vardas, it’s such a pleasure to have you join us today. I’d like you to start by telling us what you did with the Thoracic Surgery Resident’s Association as far as podcasts and how that all came about.

Panayotis Vardas, MD (Guest): Thank you for having me. It’s a pleasure to be here. So, we had actually with the Thoracic Surgery Resident’s Association, we have produced a very successful—probably one of the most successful projects we produced in the last, I would say, five years maybe—and all this started from a previous project of the Thoracic Surgery Resident’s Association, which is the National Association of Cardiothoracic Surgeons, and what training could become cardiothoracic surgery residents, essentially, and trainees. The first project was a book which is [the] traditional way to learn and teach. It was a book which was focused on preparing the residents for the American Thoracic Surgery Boards. That means there were topics that they will go through—clinical scenarios, high-yield topics— and review common, important clinical scenarios that actually will encounter every cardiothoracic surgeon at some point in his practice. So, when we came out with this project that had a huge success among the residents, but the common comment and concern we heard often from the large body of residents because they didn’t have a lot of time to study—they didn’t have time with a book. It takes time to sit down and go through all these chapters. So, we thought, “How can we do this better” and this is how the idea of the TSRA Clinical Scenarios Podcasts started. So, we decided to do essentially a similar project, but in audio format, that the residents can use at their free time or during time that they are doing other activities like driving, going to the gym, exercising, cooking, and absorb some of this information.

Obviously, we have to encounter different standards to go ahead with this project and one of the most important standards was quality. How can we make a podcast to have good scientific background and significant quality that can be sponsored by our association and be blessed to be released to the public, and to do this, we discussed that the foremost would be first for a useful format in terms of time should be 20 minutes or less. So, all the trainees can have—can listen to this while we’re doing something else, and the next thing was—we have to follow some guidelines how to do this podcast—means to go through a clinical scenario ask for specific questions for preoperative planning, did first during the operation, what kind of operation, and postoperative course. So, it was very standardized, and then third and most important thing, which I think gave an enormous success to our project, was to find the people to ask those questions and to produce the podcast and these people they are, of course—they’re not anybody else than really prominent authorities in our specialty that they have established themselves in traditional ways of academic prestige and academic productivity through books and publications or clinical practice in specific topics.

So, for example, in our specialty we have a surgery for an arrhythmia. We call it the Cox-Maze operation. That surgery was invented by Dr. James Cox. Guess what? We did a podcast on arrhythmia surgery and then a professor who developed the podcast and to answer all our questions was Dr. James Cox, who invented the operation. What is better than this? So, the ultimate outcome was actually a series of podcasts that have enormous success. Actually, the project was adapted by the official body of education for our specialty the Thoracic Surgery Director’s Association. It was incorporated [in] the national curriculum for our trainees, and we had also enormous success because of the format of this educational resource, and outside [the] United States, we can track down through the platform where these podcasts are listened and actually they are listened everywhere you can imagine [in the] world. You can see how popular they are –which are the podcasts that are more popular, which they listen more or how often—and this is how our project is still carrying, on and we’re still producing podcasts. Actually, recently one of the last podcasts we produced for TSRA was through our division here, the Cardiothoracic Surgery Division, where Dr. Clifton Lewis talked about robotic cardiac surgery.

Melanie:  Well, that is amazing and as somebody who does podcasts for a living, Dr. Vardas, I commend you on them, and yes, I agree with everything that you said, and it is very cool that Dr. Cox was able to be on the podcast when he invented that Cox-Maze surgery. So now tell us—because UAB does these and they do them for continuing medical education credits—so what would you like people to know about the accessibility of these podcasts and why they’re important to hear directly from the experts at UAB because these podcasts are specific from the UAB docs, but they can be heard all over the world for anyone that wants to know about the latest research and medical advancements that you’re doing there at UAB?

Dr. Vardas:  I think it’s a great project, done by a great institution like UAB. The mark of a really high quality podcast are discussing the interests of the person being interviewed, clearly indentifiing who the author and why is the author of this specific podcast clear distinction of between podcasts opinions and it's very true and very important for science. I create information and accessibility and I think all these things are part of the UAB series of podcasts which are directed two different levels of audience. One level of audience are the general population patient, so you can show to them  what UAB offers in terms of healthcare and the second audience is targeted to healthcare professionals and are a little bit more technical podcast and more scientific with more technical language that can give the opportunity to healthcare professionals and this is extermely important for big institutions like UAB because through those podcasts what really UAB offers is our point of view in terms of medical innovations not only robotics but other technologies, latest clinical trials, research studies that we're doing here and development of new procedures and different treatment approaches. It's important to offer to healthcare professionals the latest and best practices with updates on the currents policies and guildlines specialty care from specialty physicians and also it's another opportunity to offer outcomes based on initiatives that we do here for quality and improvement and based on all this the healthcare professionals, they have the opportunity to listen to our podcasts in a very easy, like we discussed, way that it's part of their everyday life and their professional credits and learn through them.

Melanie:  So, before we wrap up, what do you see happening in the future, and what do you feel is the most important aspect of these? Is it the convenience factor? Is it that it’s a way to educate people where they don’t have to necessarily watch a video, and you have to be in front of the camera and that as your said, you can do it while you’re in your car or driving or cooking or any of those things, and what are you hoping will happen with these as we go because students, Dr. Vardas, and residents and other providers and other professionals can learn so much. You’re exactly right. So, what would you like us to know, kind of give us a great summary about podcasts as a resource for the medical community?

Dr. Vardas:  I think we follow the trends. Currently, medicine will see a trend in audiovisual resources. We have books that we have in our computer system ourselves, and we have podcasts. We have videos. We have Twitter that we actually many times discuss a case about a patient without obviously identifiers and then the indication for the specific patient, but we discuss across the country. This [is] happening right now. So, I think it’s here and is going to stay here. The big challenge, I will say, is how to make this promising media and adjunct traditional training methodologies? How can we make it to be objective, guideline directed, and if it’s truly impact clinical practice, and we don’t have any research currently that shows that podcasts can impact behavior in clinical practice, and we need obviously research which should be statistically significant and which would make the comparison between what is traditional training and traditional teaching versus the new trend in teaching. So, I think it’s here to stay, but we need quality, and we need metrics to make this a valid way of teaching and perpetuat[ing] knowledge.

Melanie:  Well said, Dr. Vardas, and certainly so true, and we look forward to having you again on this podcast to discuss cardiac surgery and some of the fascinating procedures that you’re doing at UAB Medicine. Thank you so much for joining us today and sharing your expertise and really interesting information on podcasts as a resource, and a community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MIST. That concludes this episode of the UAB MedCast. It’s a podcast for physicians. For more information on resources available at UAB Medicine head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast informative, please share on your social media and be sure not to miss all the other interesting podcasts in our library. I’m Melanie Cole.
HostsMelanie Cole, MS

Textured Breast Implants and Lymphoma

Additional Info

Audio Fileuab/ua135.mp3
DoctorsDenney, Brad
Featured SpeakerBrad Denney, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6076
Guest BioDr. Brad David Denney is a native of Birmingham and graduated from Mountain Brook High School. Dr. Denney received his bachelor's degree from The University of Georgia, graduating Summa Cum Laude. He then received his medical degree from the University of Alabama School of Medicine in Birmingham.

CME Post Test Information:
Release Date: December 5, 2019
Reissue Date: November 14, 2022
Expiration Date: November 13, 2025

Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Brad Denney, MD
Assistant Clinical Professor in Plastic Surgery

Dr. Denney has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity.
TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host):  Welcome. Today we’re talking about the risk of textured breast implant associated anaplastic large cell lymphoma. My guest is Dr. Brad Denney. He’s an Assistant Professor and a double board-certified plastic surgeon at UAB Medicine. Dr. Denney, a pleasure to have you with us. Tell us a little bit about textured breast implant associated anaplastic large cell lymphoma or BIA ALCL.

Brad Denney, MD (Guest):  Sure. So anaplastic large cell lymphoma or breast implant associated anaplastic large cell lymphoma otherwise known as ALCL was first reported by the FDA in 2011 as having a possible link to textured breast implants. And since then, there has been extensive research into this topic. But basically, ALCL is a specific form or T-cell lymphoma associated with patients having textured implants. Now you mentioned lymphoma, you mentioned cancer and it can be kind of scary. I will say though, that it’s a rare lymphoma and it has a risk associated anywhere from one to three thousand to one to thirty thousand risk associated with textured implants.

Now this has only occurred in textured implants and when I say textured, what that means is there are two kinds of shells that cover an implant. There’s a smooth shell and there’s a textured shell. And the reason the implant makers developed a textured shell was to combat the phenomenon known as capsular contracture. That is in any medical device whether it’s a breast implant or a pacemaker or any kind of foreign object within a human; the human body will form a shell around that foreign object and that shell is called a capsule. Well in a breast implant over time, that capsule can become very hard and firm. It can squeeze the implant and that can cause one of two things. It can either distort the look of the breast and therefore be unaesthetically pleasing and in it’s worse case scenario, it can be painful.

So, in order to combat capsular contracture; textured breast implants were developed. The thought being that the texturization of the shell and what I mean by that is the shell is literally rough. It feels like an abrasive surface. That texturization would help break up or stop the process of capsular contracture. To this date, we have found that there is some evidence that supports that an implant placed in a sub-glandular position as opposed to a submuscular position can help decrease capsular contracture, but the data is limited.

The other reason that textured implants had become popular or have been used is because texturizing the shell of an implant helps create – you can create the implant to be shaped, to be shape like a breast so, there are some plastic surgeons who think that a textured implant is because it is shaped more like a breast as opposed to round like a ball that it will give a more aesthetically pleasing breast shape. Now, the flip side of it is after the initial report that there may be a linkage between these textured implants and ALCL after extensive research, we have found that that link is true.

It's an interesting lymphoma in that it takes ten years for the lymphoma to develop from the time the implant is placed. And we think the reason of that is, is because there is friction between the textured implant and the soft tissue. And that friction basically creates inflammation and that inflammation stirs up the T-cells and then those T-cells later change into a type of lymphoma and that’s why it takes ten years to develop this ALCL.

The good news is that it’s easily treatable and with a good prognosis after treatment. The treatment is removing of that breast capsule and removing the breast implant and that alone gives a very good prognosis with most not needing chemotherapy or even radiation after that particular treatment.

Host:  That was an excellent summary. Dr. Denney so, in the United States, are these being used in Europe? Are they being used? What does the FDA know about breast implant associated lymphoma? Tell us a little bit about what’s going on in other parts of the world and in this country as far as still using the textured breast implants.

Dr. Denney:  Over the summer, the FDA met with leaders in the field of plastic surgery from the major governing bodies of plastic surgery to discuss this topic and to come up with guidelines and rules and regulations. And it was determined as I mentioned, that the linkage and association is real, but the risk is low. Therefore, textured implants have not been banned but there is a higher degree of awareness and education for plastic surgeons to communicate with their patients. There is a higher degree of need for plastic surgeons to communicate to their patients what textured implants provide and the associated risk of ALCL.

That being said, there is one implant that has been discontinued because of its stronger association between itself and ALCL and that is the Allergan textured implant known as BIOCELL. The recommendation is that Allergan has agreed to discontinue production of that implant but patients who have a Allergan BIOCELL implant, unless they have symptoms; they need not worry. They don’t have to go to their surgeon tomorrow and have them removed. The recommendation is to only report to your surgeon if they have particular symptoms and those symptoms are unilateral swelling and usually the number one sign or symptom of developing ALCL is swelling of the breast where the implant is in question.

Other recommendations that came out of this meeting from the FDA and leaders in the filed of plastic surgery is that plastic surgeons will have a more heightened awareness to report cases of ALCL if they diagnose them. There is a database that all plastic surgeons have access to and if they find cases of ALCL, they report these cases to the database. That allows for better research into the process for us to know more about ALCL and its characteristics.

Host:  So, then based on all of that information; what should breast cancer patients considering implant reconstruction discuss with their physicians as far as benefits and risks of the different types of implants and even for women that are doing it for cosmetic reasons? What would you like them to ask their physicians and how would you like the physicians to counsel them on the different types of implants that are still available?

Dr. Denney:  If patients are considering breast reconstruction with implants or cosmetic breast surgery with implants; they should ask their surgeon whom they are seeing if they used textured implants and their reasons for using textured implants. And then in response, the plastic surgeon should explain their reason for why they use textured implants but at the same time, it’s the surgeon’s responsibility to describe and go over the data on the association between textured implants and ALCL.

Host:  It’s great information. Thank you so much Dr. Denney for joining us today and sharing your incredible expertise. Thank you again. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. If you as a provider found this podcast informative and educational, please share on your social media, share with other providers and be sure not to miss all the other fascinating podcasts in the UAB library. This is Melanie Cole.
HostsMelanie Cole, MS

Per-Oral Endoscopic Myotomy (POEM)

Additional Info

Audio Fileuab/ua122.mp3
DoctorsKondal Kyanam Kabir Baig,;Grams, Jayleen
Featured SpeakerJayleen Grams, MD | Kondal Kyanam Kabir Baig, MD
CME SeriesQuality and Outcomes
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=3502
Guest BioDr. Jayleen Grams joined the faculty at the University of Alabama at Birmingham in 2009. A native of Minnesota, Grams received her undergraduate degree from St. Cloud State University and matriculated into the Medical Scientist Training Program at the UAB. Here, she completed her Ph.D. in biochemistry and molecular biology and her M.D.

Learn more about Jayleen Grams, MD

Kondal Kyanam Kabir Baig, MD's procedural expertise is in the area of general endoscopy and advanced endoscopy including: diagnostic and therapeutic endosonography and endoscopic retrograde cholangio-pancreaticography, drainage of pseudocyst, necrosis, and abscess, and endoscopic removal or large polyps, early cancer, and therapy of Barrett's esophagus and cancer.

Learn more about Kondal Kyanam Kabir Baig, MD

Release Date: November 15, 2019
Expiration Date: November 15, 2022

Disclosure Information:
Dr. Baig has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending: Olympus Corp.
Dr. Baig does not intend to discuss the off-label use of a product. Dr. Grams has no financial relationships related to the content of this activity to disclose. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Welcome. In this panel discussion today, we’re examining how peroral endoscopic myotomy POEM has emerged as a viable alternative that can be performed in an incisionless endoscopic fashion. My guests are Dr. Jayleen Grams. She’s an Associate Professor and a minimally invasive foregut surgeon and Dr. Kondal Kyanam. He’s a gastroenterologist and they are both at UAB Medicine. Doctors thank you for joining me today. Dr. Grams, I’d like to start with you. Explain a little bit about achalasia and spastic esophageal disorders not responding to medical therapies.

Jayleen Grams, MD (Guest): Well achalasia is a primary esophageal dysmotility disorder and like other disorders, it may be a secondary disorder that is not intrinsic to the esophagus itself. And in achalasia, patients have difficulty swallowing. They have dysphagia or inability to push food down their esophagus into their stomach. We don’t know exactly what causes achalasia, but as you mentioned; there are three types of achalasia, type I, type II and type III. Type III is spastic achalasia. The other type, type I is aperistalsis and type II is pan-pressurization.

And surgery can be a primary modality of treatment for achalasia. Dr. Kyanam can probably mention the endoscopic or other gastroenterology procedures, better endoscopic procedures like dilation and Botox, but we are consulted when people need a Heller myotomy of the traditional surgical therapy for achalasia.

Kondal Kyanam, MD (Guest): And I’d like to add achalasia is basically like Dr. Grams was talking about, a disorder of what we call motility. So, it’s either empiric motility either decreased or absent so the esophagus is not propelling food into the stomach and this is unfortunately also combined with the failure of the lower sphincter to relax so the patient is not able to propel food number one and this food can get kind of stuck in the esophagus because the sphincter that protects to esophagus from the stomach doesn’t relax. And very often this results in a sensation of not being able to swallow, it is a chronic problem and then eventually gets to the attention of either a gastroenterologist or a surgeon and often we do what’s called endoscopy to evaluate the achalasia and to characterize it and then we do other tests called manometry which is measurement of pressure in the muscle layer and valve to try to figure out exactly what kind it is. So, these are all steps we would usually do before we figure out what’s the best treatment option for it.

Host: Dr. Kyanam, how has this previously been treated? And Dr. Grams mentioned the Heller myotomy. Tell us a little bit about the history of POEM and Heller myotomy and what’s different now. Why the needs?

Dr. Kyanam: So, achalasia has been traditionally quite a difficult condition to treat. Whenever we think of treatment options, we have to think of two different things and what’s the problem that we are treating and also what kind of patient has that problem. So, you have a wide variety of patients. You have young ones who are otherwise healthy and then you have older patients who have multiple medical problems like potentially a heart issue and lung issues which kind of dictate or guide us towards what treatment we can do for that.

So, the traditional treatments include like Dr. Grams mentioned, the Heller myotomy which is a surgery, but any surgical procedure obviously are concerns for cardiac issues and lung issues and the overall health of the patient. It is something we take into mind because the risks of surgery increase when they have issue with their heart or lungs. So, there are some options that we used to use. Endoscopically, one of those is an injection into the lower valve to relax it and another one is stretching it with a balloon to rupture the muscle and to stretch that area.

Both of these are effective, but they are really not long-term. They are not effective in every patient we perform it in, and the percentages of success are low and not really acceptable in this day and age. But we still continue to use these in select situations. So, this brought about the idea to some endoscopists or advanced endoscopists are people who train to perform endoscopy at a very high level of accomplishment to try to get things done that would otherwise be done surgically.

So, we came up with this thought of trying to expose the muscle fibers in the wall of the esophagus to cut them. This is what we do with the Heller myotomy, but innovators figured out that you could do this from the inside too. So, you cut the esophagus, make what we call a tunnel in the wall of the esophagus, expose the muscle layers and then carefully cut these muscle layers all the way to the extent that we think is necessary, essentially doing what we would do in the surgery but really not performing the surgery by making an incision. And then this tunnel is made through a smaller opening and once we think we have achieved what we need to separate the muscle layers, we then close the small incision in the esophagus and then come out from the mouth. So, essentially, we’ve done what was done through a Heller myotomy, but we’ve accomplished it through a small opening in the esophagus using an endoscope.

And when they first figured this out and carefully did this in the first few patients, they found that they were able to achieve very good success rates with very few complications thereby expanding this procedure to a large number of patients and potentially avoiding the complexity of an open surgery or laparoscopic surgery. And this innovation then got accepted in various different patient populations and countries. We figured out how much training would be required for this to be done, what kind of set ups were required and what to expect among the many, many countries including the United States. And it usually is done in large academic centers where we have the skills and the back up required to do this and that’s how POEM came into being.

And then once they figured out that this could be used for achalasia, they also figured out that this might be something that’s effective for other types of esophageal motility disorders using the same principles of exposing the muscles and cutting them to give relief to the symptoms that the patient has.

Dr. Grams: I would like to add in addition to what Dr. Kyanam said is that really POEM was kind of this evolution. As surgeons, we used to start doing these Heller myotomies through the chest and then as technology things advanced with laparoscopy, that is minimally invasive surgery in the abdominal cavity, we started being able to do these Heller myotomies with an abdominal approach. But it was still transabdominal, that is making these incisions on the abdominal wall. And basically, what a Heller myotomy is, cutting the muscle from outside the esophagus versus POEM which is endoluminal or from within the inside of the esophagus. And I always tell patients, there’s nothing we can do to make the esophagus work again. So, really the goal is to cut the lower esophageal sphincter and cut the muscle up on the esophagus and down on the stomach so the esophagus can drain better by gravity. And that’s what we are doing with the Heller myotomy.

The other part of the Heller myotomy is usually also doing a partial fundoplication or a partial wrap. That’s because swallowing problems or dysphagia and reflux can be opposite sides of the same coin where anything you do to help the esophagus drain better by gravity, may promote things coming back out of the stomach into the esophagus.

The other thing I wanted to mention is the person who pioneered POEM is Dr. Inoue in Japan and he did his first case in 2008 and then it rapidly spread from there. But I do think we should shout out Dr. Inoue because he really was the pioneer of this procedure and the first one to perform it.

And then the last thing I wanted to add was that one difference is that with the POEM because it’s all endoluminal and endoscopic right now; we don’t do any kind of concomitant anti-reflux or partial wrap or anything like that, although I think Dr. Inoue may be working on that now.

Host: Dr. Grams tell us what’s involved in patient selection criteria. Who is a good candidate for this procedure and why might you choose POEM over the Heller myotomy. Compare and contrast a little for us.

Dr. Grams: Patient selection for both POEM and Heller myotomy would really be the same in terms of someone who is fit to undergo an operation, someone who has been determined to have achalasia and someone who is symptomatic and needs treatment, just to simplify things. I usually offer either procedure to patients. For some patients who have severe morbid obesity, where visualization in the abdominal cavity might be difficult; might be better for POEM.

Other things would be if a patient has had multiple previous operations and we would expect something that we call a hostile abdomen that is a very difficult abdomen to get into safely, requiring a lot of adhesiolysis to get to the area of concern. Some people are doing POEM now for redo myotomies. So, people who have had a previous Heller myotomy going back into these patients can be very challenging and if you do an endoscopic myotomy; potentially can go into a plane that no one has been before and complete the myotomy.

The last big category would be type III achalasia. All types of achalasia have varying responses to Heller myotomy and POEM and it seems that type III achalasia or spastic achalasia may be best suited for a POEM over Heller myotomy.

Host: And Dr. Kyanam, are there some concerns as she was mentioning if they’ve undergone pervious endoscopic procedures? Tell us a little bit about the learning curve since this is relatively new and what you might consider as contraindications.

Dr. Kyanam: Sure. The learning curve is being worked on still but there is some evidence that suggests that first 20-30 cases should be mentored with someone who is experienced and then when you hit about number 50, is when we see that most people are able to perform it in an efficient and smooth fashion and quick time and have the least number of complications.

So, it is something that requires advanced endoscopy training so you would have a gastroenterologist who has done three years of training or a surgeon who has done a surgery and also a specialty called GI surgery and for gastroenterologists, they also generally do an extra year of fellowship called advanced endoscopy fellowship. So, you do get a lot of endoscopic skill training during these training years but there is almost always a specialized training for POEM that we achieve by going to various live animal courses and to other courses where we see experts who are already performing these procedures and they walk us through the various steps and then we get our hands on animal models and then live animal models and to produce the procedure.

They found that this system of a gradational training has been quite effective in getting people to where they can perform POEM effectively and that’s kind of the accepted way to do it now.

Criteria are still being established in granular detail. But we have a general approach on what we can do to achieve competence in performing POEM.

Host: Dr. Grams, how have your outcomes been?

Dr. Grams: So, far we are very early in our experience and so, I think the last two patients I did have been doing great. I’ve seen them both in follow up and they are very happy and have had relief of their dysphagia and neither of them required any pain medication while they were in the hospital. One of them had driven down to the beach already the Saturday after she had her operation on Thursday. So, they are doing very well. Thank you for asking.

Host: Well thank you both for telling us all about that. So, Dr. Kyanam, first last word to you. Give us a future perspective of POEM. Tell us some promising new therapies or where do you see this going in the future?

Dr. Kyanam: So, I think POEM is a revolutionary new procedure, that has just been available in the past decade and maybe for the past five or seven years, really extensively in America. I’m very excited about the future options the patients have with this procedure. It’s always important to note that choice in important. Obviously, a Heller myotomy is a very well established procedure that’s had great success over many, many years and thousands of patients.

So, I think that is always going to be something that’s available as an option for treatment of achalasia but this new innovative alternative, which is less invasive, is nonsurgical, happens through a small incision inside the esophagus obviously has a lot of appeal and has shown so far, to have very promising results that are comparable to what we’ve been doing so far. And the other exciting aspect of it is that it is somewhat more flexible. Like Dr. Grams was pointing out, we can do it in patients who had other procedures that have failed in providing them relief. We are now also able to expand this to some other indications other than achalasia where we have hypermotility disorders meaning a very vigorous contraction of the esophagus and we see early results that this is effective for that condition too.

But I do think this is a highly specialized procedure that needs to be done by a very well-trained physician and I do think this is going to be restricted to universities and will always be done in somewhat of a multidisciplinary fashion where we have a discussion about the patient even before we do the procedure about all the results and tests we do and we decide what options are best for them as a group and individual physicians then will want to help the patient. But we always have each other as a team member on standby to get this accomplished for our patients.

Dr. Grams: I would also like to add that I think in general, if you look back decades, we’ve moved from open operations to laparoscopic operations or minimally invasive approaches either with the laparoscope or with the robot. And over the next decades we are going to see things get even more minimally invasive that is more endoscopic procedures for other indications as well. And so, I think this is really a natural evolution in the treatment of achalasia to go from big open operations to the minimally invasive laparoscopic approach and now in an endoscopic approach.

Host: Then Dr. Grams, as we wrap up, please tell other physicians what you’d like them to know about achalasia, POEM, and when you feel it’s important to refer, how this can help them to be reassured with this new procedure. That this is the right option for their patients.

Dr. Grams: I think the number one thing I would like to tell referring physicians is if you have a patient who has swallowing problems and you suspect achalasia; they need to be referred to a tertiary care center. Achalasia happens in one in a 100,000 patients so it is not something that happens commonly. The second thing with achalasia is it’s really important to distinguish it from pseudoachalasia. We see patients who are referred to us for achalasia but on further evaluation, they actually have pseudoachalasia, specifically a mass or esophageal cancer that is causing a picture that looks like achalasia and a Heller myotomy or a POEM would not be the treatment for esophageal adenocarcinoma.

And so if you have a patient you suspect of having achalasia, I would refer them to a tertiary or quaternary care center. In terms of differentiating between a POEM or a Heller myotomy, I agree with Dr. Kyanam completely that this needs to be done in a multidisciplinary way with gastroenterologists. We have a conference where we meet with gastroenterologists, radiologists, thoracic surgeons, and of course us with GI surgery and we talk about these patients and what potentially would be the best intervention for them.

For some patients, they can be offer either procedure but for some patients, one or the other or neither may be the best option for them. And that really needs to be determined with a multidisciplinary team as well as with the input from the patient.

Host: Wow, what a fascinating topic. What an interesting procedure and we look forward to seeing what the future holds for people with these types of esophageal disorders. Thank you both for joining us.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician for more information and to get connected with one of our providers. This is Melanie Cole.
HostsMelanie Cole, MS

Crohn's Disease & Colitis

Additional Info

Audio Fileuab/ua119.mp3
DoctorsBurski, Chad;Morris, Melanie
Featured SpeakerMelanie Morris, MD | Chad Burski, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=3265
Guest BioDr. Melanie Morris joined the faculty as an associate professor of surgery in 2010. In 2016, she was named the chief of general surgery for the Birmingham VA hospital. A native of Tennessee, she completed her undergraduate degree at Vanderbilt University and her medical degree at the University of Tennessee Health Science Center. She completed her surgical residency in general surgery at Oregon Health and Science University and a colon and rectal surgery fellowship at the University of Texas Health Science Center at Houston. Dr. Morris is a specialist in colon and rectal surgery who is dedicated to improving surgical outcomes and surgical education.

Learn more about Dr. Melanie Morris

Chad Burski, MD joined faculty as Assistant Professor of Medicine in July 2013. He received his MD at Louisiana State University Health Science Center in Shreveport, Louisiana, and completed both his Internal Medicine residency and Gastroenterology fellowship at UAB. Dr. Burski currently serves as Program Director of UAB's Gastroenterology/Hepatology Fellowship program and is actively involed in clinical education of fellows, residents and medical students. He is also the Clinical Gastroenterology Module Director for UAB School of Medicine and is a core faculty member of the Tinsley Harrison Internal Medicine Residency program.

Learn more about Chad Burski, MD

Release Date: July 8, 2019
Expiration Date: July 8, 2022

Disclosure Information:
Dr. Burski has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending: Takeda Pharmaceuticals
Stock/Shareholder: Merck, Johnson & Johnson
Dr. Burski does not intend to discuss the off-label use of a product. Dr. Morris has no financial relationships related to the content of this activity to disclose. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Transcription

UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host): Welcome. Today we’re talking about Crohn’s Disease and colitis. My guests in this panel style discussion are Dr. Chad Burski. He’s a gastroenterologist and an Assistant Professor and Dr. Melanie Morris. She’s a colorectal surgeon and an Associate Professor and they are both at UAB Medicine. Doctors thank you so much for joining us today. Dr. Burski, I’d like to start with you. Please tell us about the current state of Crohn’s and colitis. What is the prevalence and what do you feel is different about what we know about these diseases now than say we knew 20 years ago.

Chad Burski, MD (Guest): Well thank you for asking me to be on and to talk about inflammatory bowel disease, both Crohn’s and ulcerative colitis. The prevalence of inflammatory bowel disease has probably increased over the past few years and that may attributed to people living longer but the prevalence at least for ulcerative colitis is about somewhere between 200 to 250 cases per 100,000 years. Person years that is and Crohn’s Disease is somewhere probably in the 175 to 200 cases per 100,000 person years.

Sometimes there is some graphical variation with that and over time like I said; those numbers have seemed to increase but that may be attributed to folks living longer with a longer life expectancy.

Host: Dr. Morris, I introduced you as a colorectal surgeon. Dr. Burski is a gastroenterologist. What kinds of physicians are treating IBDs these days?

Melanie Morris, MD (Guest): Yeah, thank you for that question. It’s really an honor to be here today and discuss these inflammatory bowel diseases. So, certainly gastroenterologists and surgeons, especially colorectal surgeons work very closely together in managing these patients. Usually patients first try medicines which would be managed under the gastroenterologists. And as you asked earlier, there have been really a lot of advances in the medications that the gastroenterologists have to treat these patients. Many patients can be successfully managed with medications alone and may not need surgery. However, when either complications arise from Crohn’s Disease or ulcerative colitis is not manageable with medications; then patients are referred to surgery. And colorectal surgeons really have expert special training in how to treat patients with inflammatory bowel disease.

Host: Dr. Burski, as a patient would come to you, which physical findings are related to the severity of their inflammatory bowel disease? What are you looking for?

Dr. Burski: Oh, that’s a fair question. So, it’s not a single entity or a single sign or symptom that we are sort of looking for. It’s the use of putting those signs and symptoms together. So, oftentimes depending on where their disease is located can manifest differently. For example, in somebody that has Crohn’s that only involves their terminal ileum; that may manifest as pain in their right lower quadrant. Whereas if somebody has ulcerative colitis that only involves the rectum; that may manifest more in urgency and rectal bleeding. So, to define severity that can take into a lot of accounts not just bowel habits but how they are doing systemically. How’s their weight doing? How’s their nutrition? How’s their energy level and sort of how they’re making it from a systemic standpoint whether fevers, maybe an elevated white count or signs of other active inflammatory markers or measures. So, not a single answer to that question. So, you are often looking for multiple different symptoms or signs to put together to try to define that severity.

Host: Dr. Burski, I’m going to stick with you for a second as we are talking about diagnostic criteria and diagnosis. Tell us about the role of lab testing and the role of imaging in the evaluation of inflammatory bowel diseases.

Dr. Burski: Yeah, so again, not a single lab that will diagnose Crohn’s or ulcerative colitis. There are some markers that may help you. Maybe that’s inflammatory markers, not just inflammatory markers that are specific for inflammation such as an estimated sedimentation rate or a CRP. But sometimes that could be markers of systemic inflammation such as a higher white count or a higher platelet count or markers like that. So, as far as labs go, there’s not a single lab that sort of diagnoses inflammatory bowel disease. And so you have to take those into consideration.

In regards to imaging; imaging can be very, very helpful for example, in folks with Crohn’s Disease that involves the small bowel; we often rely on imaging to try to help guide us with what the inflammation looks like and how much is involved compared to just doing endoscopy alone of the colon where we can only see the colon and not the small bowel.

Dr. Morris: And I would just like to add two things on that. One while there aren’t specific inflammatory markers that are 100% diagnostic; there is something called the Prometheus panel that I frequently find providers have not heard of that can help determine if the level of suspicion you have if a patient has Crohn’s Disease or ulcerative colitis. This can be especially helpful in patients where the diagnosis is unclear. We also use that to sort of decide – some patients we can’t tell if they have Crohn’s Disease or ulcerative colitis. They may have something we call indeterminate colitis. And the Prometheus panel maybe helpful.

The other thing I wanted to add is that we tend to get CT scans on patients when they have abdominal pain, but we want to be cautious in these patients. Because many CT scans over time result in a lot of radiation to the patient. So, that’s when we think about things like MR enterography or other modalities. So, I just want providers to be conscious of those two things.

Host: Dr. Morris, in your opinion, if there is a rise in these diseases; to what do you attribute this? Do you feel that overuse of antibiotics or genetic predisposition or sanitization? There’s theories that abound. Do you have your own?

Dr. Morris: Wow, what a great question that is. I mean we all certainly wish we knew what caused Crohn’s Disease and ulcerative colitis. And there are a lot of theories out there as you’ve pointed out. It is probably some combination of some genetic predisposition, some environmental factors. I think the few things that we know may play a role that patients can help. We do know that patients who smoke and have Crohn’s Disease have worse outcomes. Their disease is harder to manage. They are more likely to have recurrences. So we certainly suggest smoking cessation in all of our patients with Crohn’s Disease.

There’s also a lot of interesting research going on with the microbiome. So, the bacteria that all live in our guts and play a role in health and wellness. We’re still learning what those bacteria mean. But you asked a question about antibiotics and so antibiotics certainly shift the bacteria that live in our colon and so I recommend that patients take probiotics. I don’t see any harm in that. While there’s no convincing evidence; it may sort of help.

The other thing we do know is that when patients are under more stress either physically or emotionally; their inflammatory bowel disease is worsened. So, I frequently talk to my patients too about trying to find healthy ways to manage stress.

Host: What a great answer and Dr. Burski, speak about the role of colonoscopy. We are going to start to speak about treatments now and so, while you’ve talked about diagnostic criteria; speak about things like colonoscopy that would be more in your purview in the treatment of inflammatory bowel diseases. What treatments do you look to first?

Dr. Burski: Yeah, that’s a great question. So, when I think about colonoscopy obviously, I think that colonoscopy is a very useful tool to try to help define patient’s disease process. Whether that be at the time of the original diagnosis or that be at the time to try to stage their response to therapy. But the role of colonoscopy can be invaluable to try to determine whether somebody has ulcerative colitis versus Crohn’s Disease. And we often will rely on colonoscopy to help guide us not just for that diagnosis but also to help us with severity of their disease process.

So, in regards to defining therapy and sort of helping guide therapy; those become very difficult to sort of make as a standard recommendation and each individual patient becomes somewhat tailored. But we often – originally, we would only have a couple drugs that would induce remission and those medications; the standard would have been steroids at the time. We now have the addition of our anti-TNF medications such as infliximab or adalimumab or certolizumab that we are able to use not just as induction medicines but also as maintenance therapy. And so we often turn to those either steroids or anti-TNF alpha medications depending on the severity to induce remission. And once we’re in a maintenance situation; we have a few more options where we can consider thiopurine, medication such as mercaptopurine or azathioprine or if we want to continue – if we started with an anti-TNF, we would just continue with that medication.

So, the medication answer is often tailored to that patient depending on their severity of disease and whether they have Crohn’s or ulcerative colitis and people that have ulcerative colitis we do have an extra sort of medication for induction with salicylate medications or 5-ASA medications that we can use for induction and maintenance and in people with mild to moderate disease; that would be the therapy normally of choice for the very mild to moderate UC patient that we think can get under control with topical 5-ASA medications.

Host: And that’s with the goal of maintaining that remission and improving the patient’s quality of life, yes, because that is a whole big part of this goal?

Dr. Burski: Yeah, that’s a – yes ma’am, that’s a fair sort of question but yeah, I think ultimately the goal of those medications is number one priority is to improve the patient’s symptoms and their overall global feeling of health but also, we look for other certain markers of that and that would be improving their inflammatory markers, improving their fatigue, improvement in their endoscopy as well as their pathological diagnosis. So, yeah, I think when we think about those medications; we want complete remission from symptoms and as well as inflammation.

Host: Dr. Morris, what is the role of surgical interventions and when does that role come into play for the patients? What would you like other providers to know if they are referring patients to you at UAB, when does that discussion take place in their process? Because this can be a very long disease, a lifelong process. When does some kind of an intervention come into play?

Dr. Morris: Great. Thanks for that question. I’d like to address it for both the main disease processes. So, for ulcerative colitis, it’s a little more clearly defined. So, we know that ulcerative colitis only affects the colon and rectum and that we can cure patients with surgery by taking out the colon and rectum. Sometimes gastroenterologists will refer to this as failing medical management. We in surgery, don’t see it as failing because we actually have the opportunity to cure the patient. In general, if patients have ulcerative colitis, they end up having surgery because they’ve either failed their medical management, so they’ve tried all appropriate medical options and their colitis is not under control. Or there is some contraindication for them taking further medications. Or they come in where they are very sick and they’ve had sort of a toxic colitis event to where they can not get better with any medications.

Depending on how the patient presents; we take out the entire colon and rectum and that maybe done in one stage or two stages and then depending on the specific patient; they may or may not be a candidate to have what’s called a J-pouch reconstruction where we create a new rectum and sew it down to their anus so that they can eventually poop out of their bottom again. Again, some patients will not be a candidate for that and would have a permanent ostomy.

Crohn’s disease is different. We know we cannot cure Crohn’s Disease with surgery. So, we need to be very careful only to operate when there are specific complications from Crohn’s Disease such as a fistula or an abscess or a strictured area or if a patient has a very small active inflammation strictured area we may consider operating on that. But again, patients who have surgery for Crohn’s Disease or more likely to need more surgery in the future and we need to be very cautious about preserving bowel length. So, any time we are talking about surgery for Crohn’s Disease; we need to make sure that the lesions that we see that are affected with Crohn’s Disease are consistent with the symptoms that the patient is having. So, just abdominal pain alone is not an indication for surgery. There just has to be something that we see that we can fix and make better with Crohn’s Disease.

Dr. Burski: What I’d like to add is I agree with Dr. Morris and that is a great response. I think from a gastroenterology or medicine side I think it’s very important to partner with our colorectal surgery colleagues quite frequently and I guess I would urge people to involve colorectal surgery early and often in the setting of trying to guide the right steps in therapy, not always are we asking colorectal surgery to operate, we are sort of asking to get their input and get knowledge and their expertise on the options that are available not just from a surgical standpoint but from a planning standpoint and I think that Dr. Morris and her group, we have a very strong working relationship and I think it’s important that people in the community if they have a colorectal surgeon that they can partner with, that becomes very important for the longevity of the patient and the choosing of the right timing for surgery.

Dr. Morris: Thanks Chad. And they can always send them here to us too. We are always happy to partner with anyone on these complicated patients.

Host: Dr. Burski, I’d like to start with you for this wrap up. Tell us some promising new therapies for medicational intervention. Where do you see this going on the horizon?

Dr. Burski: As far as new therapies that have come out that we use and have deployed here at UAB; I think the vedolizumab is new biological therapy that is sort of specific and was developed to target specifically the GI tract. We are continuing to get new biologics that become approved and as our experience grows; we will continue to work and help decide what medication works best for the patient on an individual basis.

So, I guess at UAB, where are we going to try to help define and work towards a better overall health for our inflammatory bowel patients. UAB is working to develop an inflammatory bowel center where we can partner with our inflammatory bowel specialists as well as our colorectal specialists to help patients navigate through this complicated disease and help to get them enrolled in trials if available at that time and to help manage their whole healthcare rather than only their inflammatory bowel disease.

Host: Dr. Morris, last word to you. What do you see happening in the world of inflammatory bowel diseases, new therapies, new interventions? Where do you see it going and what is your best advice for other providers that are looking for referral?

Dr. Morris: Yeah, thanks. I think certainly, as I mentioned earlier, the microbiome is very promising. And I would say everyone should look forward to see what we learn more about innovations in the microbiome and perhaps in the future we will be treating that instead of the inflammation. Maybe the microbiome is contributing to the inflammation. We don’t know yet. Too early to say.

I think a couple of things we’re doing here on the surgical side that we’re really excited about. One, we have an enhance recovery pathway for patients that we started in 2015. It helps patients recover more quickly after surgery. It has decreased our lengths of stay without increasing any readmissions or complications and patients are happier. Part of it involves pain control, part of it involves early mobilization. We are using – we are trying to use medicines that are not narcotics because we know that’s just contributing to our opioid epidemic. So, we use multimodal pain management therapies and strategies.

So, our patients are really getting good surgical care here. We also employ many minimally invasive techniques including laparoscopic or robotic surgery whenever it is possible to treat these diseases. So, I think minimizing the impact surgery can have on our patients lives in important as we are trying to get them back to health and wellness. So, we certainly wish we had cures for inflammatory bowel disease. We don’t yet. But I think at UAB, we’re ahead of all the most current treatment strategies and we do partner really well with our gastroenterology colleagues to think about a whole care plan for these patients.

Host: Thank you both so much for joining us today and sharing your expertise in this very prevalent topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician. I’m Melanie Cole. Thanks so much for joining us today.
HostsMelanie Cole, MS

Male Infertility

Additional Info

Audio Fileuab/ua131.mp3
DoctorsKolettis, Peter
Featured SpeakerPeter Kolettis, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6016
Guest BioPeter Kolettis, MD is the Director, Urology Residency Program.

Learn more about Peter Kolettis, MD

Release Date: October 31, 2019
Reissue Date: October 21, 2022
Expiration Date: October 20, 2025

Disclosure Information:

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Peter N. Kolettis, MD
Director, Urology Residency Program

Dr. Kolettis has disclosed the following financial relationships with ineligible companies:

Share/Stockholder - GSK plc

All relevant financial relationships have been mitigated. Dr. Kolettis does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity
TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host):  Welcome. Today we’re talking about male infertility. And my guest is Dr. Peter Kolettis. He’s the Director of the Urology Residency Program at UAB Medicine. Dr. Kolettis, it’s a pleasure to have you join us today. Tell us a little bit about infertility in general. What’s the definition of it?

Peter Kolettis, MD (Guest): The definition of infertility is the inability to conceive after one year of unprotected intercourse.

Host:  How common is this among men? We hear so much about women and infertility issues. Men don’t really like to talk about this as much Dr. Kolettis. Is it pretty common in men?

Dr. Kolettis:  Yes. So, about 15% of couples are infertile and, in those couples, about half will have some male factor either just a male factor or in combination with female factor.

Host:  So, it it’s a male factor, what are some of the types of issues that a man might have that could affect his fertility whether it’s medications or stress or physiological conditions? Tell us about some of those issues.

Dr. Kolettis:  Well the most common thing that we would identify in men that come for fertility evaluation is a varicocele or dilated veins of the scrotum and that’s something that we can treat. Other medications can be the cause of infertility such as chemotherapy for malignancy, testosterone treatment is something that we see a lot of men receiving currently and this can be a relatively common reason for men to have problems conceiving. Other types of problems can be related to obstruction or blockage after a vasectomy, would be the most common cause. And then there are a lot of problems intrinsic problems with the testicle with sperm production that can’t be fixed so to speak but will cause fertility problems.

Host:  So, where in that group that you just mentioned do lifestyles fit in? Because I’m just curious as to how for men, these kinds of things affect their fertility and actually their erection or erectile dysfunction.

Dr. Kolettis:  Well they are two separate things. The things that can cause erection problems like diabetes or vascular problems don’t cause fertility problems per se. So, they are really two separate things. Now men with diabetes could have other types of sexual dysfunction such as problems with ejaculation that could affect their ability to have a pregnancy, but it doesn’t affect sperm production like other types of medical problems. Smoking can affect fertility. And stopping smoking could improve a couple’s chance for getting pregnant and that’s true on the female side as well. So, that’s one lifestyle measure that if changed could improve a couple’s chance for getting pregnant.

Recreational drugs should be avoided. Moderate alcohol is probably not a problem for fertility. Anabolic steroids are a big cause of infertility and they are really – they can really be thought of as like a high powered type of testosterone treatment when used as a drug for men with “low testosterone” can cause infertility as well. So, those are some of the things that affect fertility that are part of lifestyle.

Host: So then how is it evaluated, what tests do you typically run and who would a man see? Would they go to a reproductive endocrinologist? Would they go to fertility specialists right away? What do you tell your urology residents about getting these men into see them and then how is it evaluated?

Dr. Kolettis:  Well we do a history and a physical exam and then for laboratory testing, we do two semen analyses. That’s the initial laboratory testing and then depending on the results of those things, then we may do other testing. I’d say most practitioners that evaluate men for infertility are urologists, but it could be someone else who has knowledge and expertise in that area. The reproductive endocrinologists are on the gynecologic side and they will do the evaluation for the man’s partner, but some reproductive endocrinologists are involved in the evaluation of men as well. So, that’s the initial basic evaluation looking for a reason for the fertility problem, hopefully something that can be treated and then depending on the initial evaluation we may do other more advanced testing like hormone testing or genetic testing.

Host:  Well then, tell us, once you’ve determined based on what other tests that you performed; how is it treated? What are some of the treatment options available to men in the event that you find infertility?

Dr. Kolettis:  Well if a man has a varicocele and an abnormal semen analysis and has not been able to have a pregnancy then treating the varicocele would be accepted treatment. If a man has a correctable hormone problem, we would treat that. If a man has obstruction after a vasectomy, then that’s a little different story. We know that when we first see the man, usually if he has had a vasectomy and we can treat that but treating the varicocele and then treating the endocrine problems would be probably the two most common things.

Host:  Dr. Kolettis, how important is a psychological aspect of all of this when you are in treatment with a man and how important is it that both members of the couple be involved in the assessment and discussion of these results? Do you find that men have issues discussing this or seeking treatment? What have you seen and what have some of your outcomes been?

Dr. Kolettis:  Some men do have trouble discussing it but most men are motivated to have an evaluation and to try to understand better what the cause of the fertility problem might be and then get treatment. But like any other health problem, some people may be reluctant to talk about it.

Host:  As we wrap up, what would you like other providers to know about male infertility and when they should refer to the experts at UAB Medicine?

Dr. Kolettis:  Well we could see men at any stage of the evaluation whether they have had not testing and no examination done or if they have had some initial testing done that has shown some abnormalities or if the man just wants to get more information. So, we could see them at any, really at any point in their evaluation. Most urologists can do the evaluation as well starting with the exam and then the semen analysis testing and then any other testing after that, whatever he or she is comfortable doing and has the resources to do. But it’s important to have both partners evaluated and it’s important to do some screening of the man’s partner if they come to the office together because sometimes there will be some potential female factors that we may be the first ones to inquire about and then it’s important to have the man’s partner get an evaluation done as well. And so, working as a team can be helpful to do that working with fertility specialists. The reproductive endocrinologists can be very helpful in getting the couple evaluated.

Host: Thank you so much Dr. Kolettis for coming on and speaking about treatment options available for male infertility. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please head on over to our website at www.uabmedicine.org/physician. If you, as a provider, found this podcast informative, or you have patients you would like to refer, please share this podcast, please share on your social media and be sure to check out all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole.
HostsMelanie Cole, MS

Brow Lift and Blepharoplasty

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Audio Fileuab/ua132.mp3
DoctorsDenney, Brad
Featured SpeakerBrad Denney, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5991
Guest BioDr. Brad David Denney is a double board-certified Birmingham plastic surgeon specializing in complex wound care, hand surgery, breast and abdominal wall reconstruction, and cosmetic surgery. He is a Diplomate of the American Board of Plastic Surgery and the American Board of Surgery, as well as a member of the American Society of Plastics Surgeons, the American Society of Aesthetic Plastic Surgery, and the Southeastern Society of Plastic and Reconstructive Surgeons.

Learn more about Brad Denney, MD

Release Date: October 30, 2019
Reissue Date: October 11, 2022
Expiration Date: October 10, 2025

Disclosure Information:

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Brad Denney, MD, FACS
Assistant Clinical Professor in Plastic Surgery

Dr. Denney has no relevant financial relationships with ineligible companies to disclose.

There is no commercial support for this activity.
TranscriptionMelanie Cole, MS (Host):   UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

Welcome. Today we’re talking about brow lifts and blepharoplasty, and my guest is Dr. Brad Denney. He’s an assistant professor and a double board certified plastic surgeon at UAB Medicine. Dr. Denney, such a pleasure to have you with us today. Tell us what is a blepharoplasty or a brow lift.

Brad Denney, MD (Guest):  So a blepharoplasty is where it can be done for the upper eyelid or the lower eyelid, but more commonly for the upper eyelid. That can happen because as we age we lose collagen and elastin in our skin. So therefore our skin sags if you will. That can occur all over the body, but it can particularly occur around the eyes and in the brow. So if that happens in the eyes and if you develop really baggy skin in the upper eyelid, that skin can actually hang down and can block the peripheral vision. We can fix that in a procedure called a blepharoplasty. That’s where we excise the heavy, redundant upper eyelid skin and sometimes the brow is also heavy and sags. That can also effect vision. That’s where a browlift comes into play. Whether we do a browlift or an upper eyelid blepharoplasty at once or separate kind of depends on the patient, but they're more commonly done for the reason of that excess heavy skin effecting vision. Even if they're not cause for a functional problem, they're also done for cosmetic reasons as well.

Host:   So then how do you decide which procedure you're gonna use? Explain some of the key variables that determine whether you're going to use a blepharoplasty or a browlift or even both to get the best results for a patient.

Dr. Denney:   These procedures can potentially be covered by insurance. The way they are covered by insurance is we have to send documentation to the insurance companies that the skin of the brow or the upper eyelid is significant enough. In terms of the upper eyelid, that skin has to encroach upon the top aspect of the upper eyelid itself. In terms of the brown, the skin of the brow has to descend below the super orbital rim. That’s that bone that you feel that’s directly above your orbit. In addition to the photographs, we also have to have visual field testing from an ophthalmologist that documents decreased visual fields and improvement in the visual fields when the skin of the brow and upper eyelid is lifted.

In terms of whether a blepharoplasty and/or a browlift is performed is based upon a blepharoplasty is done if that upper eyelid skin encroaches upon the upper eyelid itself. The browlift is done if that brown skin descends below the super orbital rim, just as I mentioned with the test and the documentation that’s required from the insurance companies. I do tell patients if they don’t want the browlift, there is a chance that only doing a blepharoplasty alone could actually make the aesthetics of the brow worsen because if you take away that heavy upper eyelid skin then the brow no longer has to work hard to arch, if you will, and to suspend the upper eyelids. So therefore the brow could descend more.

In terms of the other reason to have one or both or one or the other done is for aesthetics. If patients aren’t experiencing functional deficits with their vision, if they’re unhappy with how their upper eyelids or how their brow looks, it can be done for cosmetic reasons.

Host:   Is this a quick fix or is this a long term solution?

Dr. Denney:   A quick fix would be Botox. That’s where we inject a solution that innervates the muscles in the forehead and around the eyelids. That will alleviate the deep creases in the forehead, and that is a temporary fix. But surgically, yes. A browlift and a blepharoplasty are permanent solutions. That’s the advantage of surgery.

Host:   Well it certainly is. So then speak about patient selection criteria. Is there anyone for whom this is really not an option? Give us some clinical indications and contraindications for the institution of either one of these procedures.

Dr. Denney:   Indications would be one, for aesthetics; two, to improve peripheral field vision. Now there are some contraindications. If patients have a history of dry eyes, then they would need clearance from their ophthalmologist before embarking on this surgery because both these surgeries do elevate the upper eyelid therefore exposing the cornea. With a history of dry eyes, these could make dry eyes worse. If patients have had the Lasik procedure, they need to wait at least six months to a year before embarking on the upper eyelid blepharoplasty or browlift. Patients need to be physically fit cardiovascular and they cannot be on any blood thinners. Bleeding after these operations—particularly an upper eyelid blepharoplasty—in rare cases bleeding significantly enough could lead to blindness if hematomas or post-operative bleeding are not caught or discovered early enough.

Host:   Well thank you for that because I was going to ask you about some complications to keep a watch on. So are there some technical considerations, Dr. Denney, that you’d like other providers to know about? What's involved in the procedure?

Dr. Denney:   An upper eyelid blepharoplasty is pretty simple. It’s just excision of that excess skin. We used to excise a lot of fat a few years ago as well, but we’ve tended to be more conservative with our fat resection because we found that the more fat we resect in the upper eyelid the more we actually age the patient in terms of appearance. So we tend to leave more fat than we used to. Another consideration is if the upper eyelid skin is one thing, but if the upper eyelid itself descends below the pupil then they may need to have a levator advancement or levator plication. The levator is the muscle that usually with aging has atrophied and therefore the eyelid may descend below the pupil. That’s a much more complicated procedure that would be done in conjunction with excision of the excess upper eyelid skin.

In terms of a browlift, a traditional browlift is done through a coronal approach meaning that a long incision will be made in the hairline approximately five centimeters posterior to the anterior hairline itself. There were problems with that. Patients would experience alopecia as well as paresthesia and sometimes loss of sensation of the scalp. So now we’ve advanced to where we’re now doing most of our brow lifts endoscopically in which three small incisions are placed in the anterior hairline. Of course, given that this is UAB I have to give a shout out to my mentor, Dr. Vasconez, who helped develop the endoscopic browlift.

Host:   Tell us a little bit about your outcomes, Dr. Denney, and what can a patient or referring physician expect post-operatively?

Dr. Denney:   Outcomes are excellent. Upper eyelid incisions heal extremely well as do browlift incisions. I think the most common complication or potential issue post-operatively would be asymmetry between each of the eyelids and the brows themselves. As a whole, most patients are extremely satisfied. In terms of referral, referring doctors could get in touch with the Kirklin clinic at UAB for referrals.

Host:   As we wrap up, do you have any final thoughts? What you would like other providers to take away from this episode when they are referring as far as communication with the referring physician and what you want to tell us about your team.

Dr. Denney:   If patients complain to their providers that they feel that their brows or their eyelids are heavy and they think it’s effecting their vision, then that’s a patient who would benefit from seeing a surgical provider who specializes in upper eyelid blepharoplasty or browlift. That patient may need visual field testing as those symptoms could be alleviated with these surgeries. We have an excellent team at the Kirklin clinic. We work well with our ophthalmology partners for coordination of visual field testing.

Host:   Thank you so much, Dr. Denney, for joining us today and sharing your incredible expertise. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Medcast. For more information on resources available at UAB Medicine, head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast informative, please share with your patients, share with other providers. Be sure not to miss all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole.
HostsMelanie Cole, MS

Gastric Bypass vs. Sleeve Gastrectomy

Additional Info

Audio Fileuab/ua130.mp3
DoctorsStahl, Richard
Featured SpeakerRichard Stahl, MD
CME SeriesClinical Skill
Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6305
Guest BioDr. Stahl has been a practicing bariatric surgeon for over twenty five years, and is the medical director of Bariatric Surgical Services at UAB. He has extensive clinical experience in the minimally invasive treatment of multiple gastrointestinal problems including abdominal wall hernias.

Learn more about Richard Stahl, MD

Disclosure Information
Release Date: April 15, 2020
Reissue Date: March 31, 2023
Expiration Date: March 30, 2026

Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System

The planners have no relevant financial relationships with ineligible companies to disclose.

Faculty:
Richard Stahl, MD
Medical Director of Bariatric Surgery

Dr. Stahl has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity.
TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host):  For many people, severe obesity is a matter of life and death. Many people who are seriously overweight have tried different diets, medications and professional weightloss services for years without long-term success. Today, Dr. Richard Stahl, Associate Professor and General and Bariatric Surgeon at UAB Medicine joins the show to compare and contrast the two most common types of bariatric surgery; gastric bypass and sleeve gastrectomy. Dr. Stahl, I’m so glad to have you joining us again today. Let’s set the stage a little bit for providers. What is defined as obese and what other comorbid conditions can come along with obesity that would require that discussion of bariatric surgery?

Richard Stahl, MD (Guest):  Morbid obesity is defined as a body mass index of 40 or above. Body mass index is basically a weight to height ratio, and we can also call this class 3 obesity. We would recommend bariatric surgery for people at that category, class 3 obesity or body mass index 40 or above. We’d also recommend it for patients with the body mass index of 35 to 39.9 if they had other comorbidities associated with their obesity. One of the most common ones being diabetes but there can be others also.

It’s a little bit less clear about patients with class 1 obesity which is defined as a body mass index between 30 and 34.9, though patients in that weight class that have diabetes that has been difficult to control medically; those are also patients that bariatric surgery should be considered in.

Host:  So, then let’s compare and contrast. Discuss for us the two types and for other providers, help them understand why you choose the one you do for a patient. What goes into that discussion?

Dr. Stahl:  The two main operations that are being done today are the Roux-en-Y gastric bypass or the sleeve gastrectomy. That’s not to say that there aren’t others. There are a few other operations out there but the vast majority of patients undergoing bariatric surgery are having one of these two. The gastric bypass we think of as the gold standard. It has been around the longest. We have the longest follow up with that. And the gastric bypass is basically an operation where the stomach is divided into two separate pieces with the upper part being very small, roughly one to two tablespoons in size or about the size of an egg say. And then the intestine is brought up and anastomosed to that in a looks like the letter Y fashion hence the name Roux-en-Y gastric bypass. And that makes it so the patients have less of an appetite, eat less and the food that they do eat bypasses the remainder of the stomach and the first part of the small intestine.

The other operation is the sleeve gastrectomy. The sleeve gastrectomy does not reroute any of the GI tract. Food still follows the normal route and touches all the surfaces of the GI tract. But what we have done with this operation is reduce the size of the stomach by approximately 80%. If conceptually we are making the stomach more of a narrow tube and we are preserving the very bottom part of the stomach called the antrum, but otherwise removing most of the body of the stomach. And this has become an even more popular operation in recent years and is currently done more commonly than the gastric bypass.

I will stress just because something is more common doesn’t necessarily mean it’s better. It has become more popular for a number of reasons and it is a good operation. But I don’t want to impart the suggestion that this is clearly a better operation. It’s a different operation and there are some pros and cons to each of those which I can touch on if you would like.

Host:  Well I would like you to, the pros and cons because when you are thinking about patient selection and which patients would benefit the most from either one of these; tell us why. Tell us those pros and cons and if you have some predictors of treatment response Dr. Stahl.

Dr. Stahl:  First of all, when patients come to see us; we discuss both of the operations with them and make sure they have a full understanding of the various procedures that are available. For the vast majority of patients, I’d say probably 80% of patients, we ultimately ask them to choose between the two operations once we have presented the information that we know about each of them. So, most patients actually end up making up their own mind about which ones they want to do. However, some of the things that we will point out to them, differences between the operations.

We think that the weightloss results with the gastric bypass seem to be marginally better than what they are with sleeve gastrectomy. That’s not in all studies and not 100% of the time. But in many studies, and in our own review of our data, we see a little bit better weightloss results with the bypass versus the sleeve. On the other hand, if you look at complication rates; the complication rate with a bypass is a little bit higher than what it is with the sleeve. Again, not a huge difference but there is some difference.

A bypass operation is a technically more difficult operation to do. It takes longer to do. It takes about twice as long to do the operation. And therefore, because it’s more technically challenging; it does have a somewhat higher rate of complications. So, in that sense, you would say well the sleeve gastrectomy is a little bit easier, it takes less time to do and has a little bit lower complication rate. But the trade off might be well the sleeve gastrectomy may have marginally less weightloss than the gastric bypass.

Other differences; the gastric bypass may yield some vitamin and micronutrient deficiencies. Again, these are usually not particularly severe and usually typically prevented with vitamins and such that we have the patients take. Which we also have them take for sleeve gastrectomy though the incidence of vitamin and micronutrient deficiencies for it is less. So, again, that’s another trade off between the two operations.

If we look at patients with diabetes. In the case a patient comes to us that has diabetes and that’s what they are really most interested in improving. Well, the data suggests that diabetes improvement occurs with both of these operations but there seems to be more improvement with the gastric bypass if you compare it with the sleeve gastrectomy. So, that might be a decision point for patients.

Patients that either because of their size, shape or perhaps previous surgery, we might decide it’s very difficult for us to do a gastric bypass on them because with the gastric bypass, you have to have access to and be able to mobilize quite a bit of the intestine. If they have had a number of previous operations, and therefore we would expect to see adhesions and scar tissue; then we might lean towards a sleeve gastrectomy on that patient because in a sleeve gastrectomy, we really only have to work on the stomach and not have to deal with the small intestine which might have a lot of adhesions with it. so, that might be a deciding factor for us.

On the other hand, let’s say a patient comes to see us and has really severe reflux. Now reflux is very common in the morbidly obese population. It’s usually fairly well controlled with medications so people that have just mild or well-controlled reflux we wouldn’t necessarily change their operation. But let’s say somebody comes to us who has severe reflux and their main goal with surgery is they would really like to be relieved of their reflux. Well sleeve gastrectomy may not bet the best choice for that patient because sleeve gastrectomy can sometimes yield reflux. So, that patient may be better served with a gastric bypass. So, these are all some of the issues that we consider when we ware operating on them.

Another issue that we would consider is medications that the patient either is on or has to take. If a certain medications may have dismissed absorption after a gastric bypass, and we don’t think we have that to the same degree with sleeve gastrectomy. So, a good example of that would be some patients who are perhaps undergoing weightloss surgery because they have kidney failure or liver disease or something that they feel like they might be in need of a liver transplant or kidney transplant in the future or honestly even a heart transplant in the future. Those patients we would in general, not 100% of the time, but in general, would lean more towards a sleeve gastrectomy because we know those patients will have to depend on medications to take for rejection in the future. So, that might be a deciding point for us also.

All of those are all the various considerations that we take into consideration when we are seeing patients and trying to decide and help the patients decide which operation to have.

Host:  How interesting and good points all. Not something that the patient would think about or even other providers that are counseling their patients on bariatric surgery and referring to you specialists at UAB. So, as we wrap up, what would you like other providers to know when their patients say I really think that I want to consider bariatric surgery, what you would like them to discuss with them, any technical considerations you’d like other providers to know about and just really give us your best advice as you compare and contrast these two.

Dr. Stahl:  Yeah, I think one of the messages that we would like to impart to providers and to patients alike is although we sometimes refer to bariatric surgery as being the therapy of last resort. And there’s a little bit of truth to that because we don’t think bariatric surgery is appropriate for all individuals all the time. In fact, we very much advocate if a patient is able to achieve the weightloss that they need to achieve without surgery; then absolutely do it without surgery. That’s the best way to do it.

This operation should be reserved for patients that have been unable to do that. Unfortunately, that is quite common that they are unable to do that. Patients aren’t alone when they are not able to lose that kind of weight without surgery. Most patients can’t. So, instead of us saying it’s a therapy of last resort; we usually say look try to lose weight without surgery. But if you are unsuccessful, don’t put it off forever. Don’t put it off until you are so sick that perhaps you are not even a candidate for surgery anymore.

In much the same way that diabetes or hypertension are chronic diseases and should be treated early and got under control early; we know that morbid obesity is a chronic disease and the longer somebody has it, the worse it is for them. So, it’s much better for us to intervene at an earlier stage than to wait until the patients have suffered all the ravages of the comorbidities that go along with morbid obesity. We would rather see them earlier in the process when they are somewhat healthier and can undergo an operation a little bit easier. I think that’s probably the best take home message I would like for patients and providers to have. Think about bariatric surgery earlier in the process.

Host: Wow, great information. Dr. Stahl, as always, thank you so much for joining us and sharing your expertise. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician. If you as a provider found this podcast as informative, as I did, please share with other providers, share with your patients, share on your social media and be sure to check out all the other incredibly fascinating podcasts in the UAB library. Until next time, I’m Melanie Cole.
HostsMelanie Cole, MS

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Per-Oral Endoscopic Myotomy (POEM)

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Crohn's Disease & Colitis

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Male Infertility

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Brow Lift and Blepharoplasty

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Gastric Bypass vs. Sleeve Gastrectomy

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