Breakthrough Medicine
New Procedures Easing the Aches of Pain

By Sarah Markel and Lindsay Holst / Photography by Jonathan Timmes

Never mind the traffic. Forget the cost of living. When illness strikes, having immediate access to top-of-the-line medical care makes up for many of the stresses of Northern Virginia life.

From Head to Toe: Medical technology that is changing and saving patient lives
Just over half a million doctors are currently practicing in the United States. And right in our own backyard, the latest innovations in the treatment of life-threatening illnesses are increasingly being developed and tested. Here are the doctors pushing the envelope every day in search of minimally invasive, more effective procedures that save lives.

BRAIN
Dr. William O. Bank
Washington Hospital Center; Bi-plane X-Ray
Until recently, the prognosis had been dire for patients with cerebral aneurysms and tumors in the head, neck and spine. Aneurysms in the brain are notoriously hard to detect and difficult to access. Once they rupture, the brain is flooded with blood, often resulting in death.

For those who did survive, the only recourse was open brain surgery. Dr. William O. Bank, director of neuro interventional radiology at Washington Hospital Center, has a better way. Bank combines a state-of-the-art Bi-plane X-ray, which allows him to see inside the brain from every possible angle, with endovascular procedures to treat aneurysms without traditional surgery.

“The Bi-plane X-ray has been around for 20 years,” Bank said. But only recently has the technology gone digital. “Now it is more precise,” he said. “I can look through two different directions at the same time.”
The digital Bi-plane X-ray instantly transfers brain images to the computers at Bank’s worktable, where he then measures the aneurysm to hundredths of a millimeter. After consulting with neurologists and surgeons, Banks quickly returns to the patient. Using the Bi-plane X-ray as his eyes, he threads tiny platinum coils up through the groin into the aneurysm so that blood cannot enter it.

A lover of the impressionists, he takes inspiration from the works of Monet and Van Gogh. “The practice of medicine and surgery is not an exact science. What I do is an art,” Bank said. “And I have to do it well every day.”—SM

HEART
Dr. Lowell Satler
Washington Hospital Center; Heart Valve Replacement without Open Surgery
The telltale sign of heart surgery, that pale vertical chest scar, may one day become a thing of the past, thanks to Dr. Lowell Satler, director of cardiac interventions at Washington Hospital Center. Satler is leading an investigational trial to study the safety of inserting an artificial aortic valve through a large needle puncture in the leg rather than through open heart surgery.

Currently the study is only open to elderly patients too weak to undergo surgery. “For the higher risk subset, surgery is not a good option,” Satler said. “Many patients succumb to chest pain, are hospitalized and eventually die. This is an alternative strategy.”

Pricilla O’Donnell’s 95-year-old father was one of the first patients to undergo this minimally invasive procedure. The valve replacement has given her more time with her father. More importantly, she said, it has given her dad the freedom he thought he had lost. “He is now able to walk unassisted and without oxygen. He feels like this procedure was nothing short of a miracle for him. He is really loving life now.”

Satler hopes one day that more patients will be able to undergo valve replacement via catheterization. “This has the potential to replace open heart surgery if the valves demonstrate durability.”—SM

VEINS
Dr. Richard Neville
Georgetown University Hospital; Propaten Vascular Graft and Silverhawk
Dr. Richard Neville, chief of vascular surgery at Georgetown University Hospital, has devoted his career to saving legs. Patients, particularly the elderly and diabetics, too often ignore the pain that comes from clogged arteries in the legs. Sometimes they leave it so long that the only recourse is amputation.

Neville will try just about anything to avoid taking a leg, including inventing his own procedures to create systems for blood to bypass clogged arteries. He is currently testing the Propaten Vascular Graft, a minimally invasive bypass that “tricks a vein into thinking it’s an artery,” Neville explained. Neville was the first surgeon to use the graft below the knee. He also helped develop the Silverhawk, a tool used to scrape out the clogged veins of patients too sick for bypass surgery.

“Sixty percent of what we do is endovascular,” Neville said. “That allows us to work through a small needle puncture.” Patients come from across the country to see Neville. Very rarely today does he have to tell them there is nothing he can do to save the leg. “And even then,” he said, “I can often think of something.”—SM

ABDOMEN
Dr. David Deaton
Georgetown University Hospital; Aptus Endograft
Ed Mooney’s abdominal aortic aneurysm gave him no trouble. “I didn’t have any symptoms,” said Mooney, 71, whose aorta, the main blood vessel in the abdomen, had swelled to nearly five centimeters, more than twice a normal size. Left untreated, the chances of sudden death from aortic aneurysm hover at about 90 percent.

In 2006, Mooney’s doctor noticed the aneurysm during a routine ultrasound and referred him to Dr. David Deaton, chief of endovascular surgery at Georgetown University Hospital. Deaton, who is recognized as the foremost authority in his field, is leading a clinical trial to test a new, minimally invasive approach to repairing abdominal aneurysm by stapling a synthetic vein, or Aptus endograph, to the aorta. Mooney became the first patient in the United States to receive the Aptus endograph.

“It took about three hours,” Mooney said. “I was in the hospital overnight. They let me out the next day.” Deaton explained that traditionally aortic aneurysms are repaired through open surgery, followed by several days in ICU and a week in the hospital. “With the endovascular surgery, we replace the aorta with a catheter through a groin incision. There’s no pain and less trauma to the body.”

A native of North Carolina, Deaton’s style is as relaxed and unassuming as his accent. “I like to say it’s like being able to go to California on a jet plane instead of a horse,” he joked.

For Mooney, being on the vanguard of experimental medicine gave him no qualms. “Dr. Deaton is so calm and straightforward. When he explained the procedure to me I thought, This makes sense.”—SM

Dr. Tom Fishbein
Georgetown University Hospital; Multiple Organ Transplant Surgery
When the Washington, D.C. State Health Planning and Development Agency (SHPDA) granted Georgetown University Hospital, in collaboration with Children’s National Medical Center, a Certificate of Need to allow physicians to perform life-saving small bowel transplants, doctors were able to bring hope to many cases that hadn’t seen any for a while.

In small bowel transplantation, a surgeon transplants a portion of the small intestine from either a living donor or a cadaver. The surgery can restore intestinal function when the intestine has failed due to illness or trauma and when intravenous feeding is no longer an option. Only about 100 patients receive a new small intestine each year in the United States, and Georgetown’s program is the only one of its type in the Mid-Atlantic region. Dr. Tom Fishbein, Georgetown’s director of small bowel and pediatric liver transplantation, has done as many as six organ transplants at one time and has performed small bowel transplantations in a wide range of patients, from small babies to older adults.

Fishbein is a nationally recognized surgeon and has performed approximately 20 percent of all intestinal transplants in the United States.—LH

Dr. Ali Fazel
Inova Fairfax Hospital; Endoscopic Mucosal Resection
Inova Fairfax Hospital’s Center for Advanced Endoscopy, which made a spring 2007 announcement that it would use endoscopic procedures on patients with benign and malignant diseases of the digestive tract, pancreas and bile ducts, is the first program of its kind in Northern Virginia.

In the center, a multidisciplinary team that includes surgeons, oncologists and gastroenterologists uses endoscopic techniques to treat Gastroesophageal Reflux Disease and the damage that can result from the disease; remove large colon polyps that would have previously required surgery for their removal; manage digestive cancers, primarily of the esophagus, stomach, bile ducts, pancreas and colon; and treat benign blockages, stones and inflammation in the pancreas and bile ducts. It’s a one-stop center that offers a wide range of cutting-edge endoscopic services.

The doctors use endoscopic ultrasound and techniques such as endoscopic mucosal resection (EMR) to earlier detect and remove digestive cancers. “EMR allows the endoscopist to shave off the inner layers of the digestive tract without causing damage to the deeper layers,” said Dr. Ali Fazel, the center’s medical director. “Because cancerous and precancerous legions of the digestive tract arise from the innermost layer, by shaving it off, you’re able to remove cancerous legions.” Fazel, who was in charge of a similar endoscopy program at the University of Florida, is very pleased with the program’s growth. “This is such a strong medical community, and this is just one service that happened to be lacking. We’re very happy to be able to fill that niche,” he said.—LH

NERVES
Dr. Ivan Ducic
Georgetown University Hospital; Peripheral Nerve Surgery
Dr. Ivan Ducic, chief of peripheral nerve surgery at Georgetown University Hospital, has built a devoted following among migraine sufferers nationwide. Patients who have failed one treatment after another come to Ducic because he refuses to take a routine approach to migraine pain.

“In about 25 percent of cases there are strong individual characteristics,” said Ducic, who is renowned for the extensive amount of time he devotes to puzzling out the source of a given patient’s problem.

“When you have patients who have seen a number of good specialists, and they are still continuing to have problems that affect the quality of their lives, you need to start thinking outside the box.”

Accordingly, Ducic, who has a Ph.D. in addition to his medical degree, tries to reconstruct the events leading up to nerve pain so that he can better treat it surgically. “Unless you understand the source of a problem,” he insisted, “you can’t fix it.”—SM

BLOOD
Dr. Keith Sterling
Inova Alexandria; EKOS Clot-Busting Treatment
Dr. Keith Sterling, Inova Alexandria’s medical director of cardiovascular and interventional radiology, is combining ultrasound energy with thrombolytic drug-containing catheters that administer medicine into a clot-containing vein.

The high-frequency ultrasound enhances the drugs’ ability to quickly dissolve the clot in a procedure that typically takes less than 24 hours. The tool is essentially a catheter lined with tiny transducers whose ultrasound energy pushes the drug into the clot, which the ultrasound also alters.

Sterling said that the ultrasound energy makes the dissolving process quicker and allows the doctor to use a lower lose of the clot-busting agent. The first hospital in the D.C. area to conduct this new therapy, Inova Alexandria has found great patient success with the procedure. “We use the EKOS catheter system for three main areas: blockages in arteries, veins and the brain,” Sterling noted. Sterling said the EKOS ultrasound-enhanced clot-busting procedure provides more safety and efficacy than traditional procedures, and patients are often able to leave within 24 hours “with a Band-Aid.”—LH

BONES
Dr. Andy Engh
Inova Mt. Vernon; Birmingham Hip
Someone who is 55 years old has a good chance of success with a regular hip replacement—a procedure in which the doctor cuts off the ball and inserts a metal rod into the thigh bone, which holds the new ball, lasting them the rest of their life. However, someone who is younger than 55 or more active than the typical 55-year-old is likely to eventually need a second operation.

“A high-demand, highly active patient is more likely to wear his or her hip out. These are the patients that might want to take a chance on the newer technology, which is why hip resurfacing is so appealing to high-demand patients,” said Dr. Andy Engh of Inova Mt. Vernon Hospital, which features this advanced procedure.

When using the Birmingham Hip Resurfacing procedure for hip replacement, the doctor does not cut the ball off, but rather trims the edges and puts a high-carbide cobalt chrome cap on it. Laboratory research has shown that the metal-on-metal joint may be more wear-resistant than the traditional metal-on-plastic joints, but doctors say only time will tell. “What we believe right now is that the resurfacing saves more bone—nobody will debate that it’s a bone or a skeleton-preserving hip replacement,” Engh said. “So if I do a regular total hip replacement on one 50-year-old and a resurfacing on another 50-year-old on the same day, and they both go bad 15 years down the road, I will have more bone to work with and the operation should be easier with the resurfacing patient than with the total hip.”

Dr. Mark P. Madden
Reston Total Joint Center; Joint Replacement
At Reston Hospital Center’s Total Joint Center (TJC), it isn’t unusual for a joint replacement patient to be walking the afternoon of their procedure, nor is it strange for the patient to be discharged from the hospital in just three days.

The TJC, formed in 2002 and recognized as a Center of Excellence by Mid Atlantic Medical Services, Inc., represents the collaborative efforts of orthopedic surgery, rehabilitation and anesthesia professionals.
Loraine Zolkiwsky, who had her knee replaced at the TJC in January 2007, said that the informational nature of the center made her experience “just fabulous.”

“I think half of the problem with many surgeries is that there’s this mystery aspect; all the patients know is that they have to show up at the hospital that day,” she said. “At the TJC, you had to attend a class ahead of time and everything was broken down almost to-the-minute. Nothing was a mystery when you went in.”
“We’ve got not just one mind or set of eyes looking at a problem, but four or five. It’s an organized plan rather than a hit-or-miss strategy,” said orthopedic surgeon Dr. Mark Madden.

The team Madden refers to consists of physician’s assistants, physicians, physical therapists, nurses and discharge planners. The center has features like “joint camp,” where patients attend a preoperative class with their own coach, learning to mentally and physically prepare for their joint surgery. Camp continues after surgery, as do group exercise and therapy sessions and educational classes on living with a new joint.
“For lots of people, there’s this mental block when it comes to big surgeries. But if you have the information and are mentally prepared, it really works. It can be a really positive experience,” said Zolkiwsky, who has been fully recovered from her surgery for months and feels “15 years younger.”—LH

PROSTATE
Dr. A. Daniel Laurent
Reston Hospital Center; GreenLight PVP
Previous treatment for Benign Prostatic Hyperplasia (BPH), a condition common in males over the age of 50 where the prostate becomes enlarged and puts pressure on the urethra, required patients to stay at the hospital for several days and nearly a month away from work.

“Up until approximately four years ago, the ‘gold standard’ for treatment for symptomatic BPH was the TURP, or transurethral resection of prostate,” said Dr. A. Daniel Laurent, urologist at Reston Hospital Center, which began offering the GreenLight procedure three years ago. Physicians at Reston Hospital Center said the TURP procedure posed a high risk of complications and several unpleasant side effects in patients. GreenLight PVP (photoselective vaporization of the prostate), a laser procedure offered by urologists at the center, is far less invasive than previous procedures, while providing the same favorable outcome.

“The main issue with TURP was the increased risk for bleeding both during the procedure and after,” Laurent said. “Patients were typically hospitalized for two to three days with a catheter, and even after going home were told to avoid strenuous activity and car riding for several weeks to avoid delayed bleeding, which could at times be severe. In rare instances after having a TURP procedure, men developed urinary incontinence and impotence.”

According to Laurent, the GreenLight laser procedure offers an effective treatment without an ugly aftermath. “The end effect of the procedure is identical to that of a TURP, in that a wider urinary channel is created, immediately relieving the blockage. However, the laser energy simultaneously vaporizes the obstructing tissue and seals the blood vessels. This allows an almost bloodless procedure,” Laurent said.
As such, a return to normal life can occur simply after an extended weekend of rest.

“Reston Hospital Center is unique in that it provides the GreenLight technology on a full-time basis, which offers greater flexibility in scheduling. We have had a very positive response to the treatment. The results have been excellent, and the complication rate is very low.”—LH

CANCER
Drs. John Carroll and Nadim Haddad
Georgetown University Hospital; Endoscopic Ultrasound
Short of having a family history, it’s hard to say who is considered “high risk” for pancreatic cancer, and it used to be that when doctors had any suspicions of the cancer in patients, they would use a CAT scan to get a better look.

“A CAT scan just didn’t give as good of a resolution. You would just see a density and wouldn’t know exactly what it was,” said Dr. John Carroll, a gastroenterologist at Georgetown University Hospital. “At that point, you could do exploratory surgery in advance … or just watch and wait.”

Carroll and fellow Georgetown University doctor Nadim Haddad are now using endoscopic ultrasound techniques to diagnose the cancer before the disease advances to an inoperable point. In this procedure, the doctors pass an endoscope with an ultrasound component through the patient’s mouth and into the stomach. With the standard endoscope, doctors only see the inner lining of the digestive tract; with the ultrasound imaging, they can see all the layers and surrounding structures, including the adjacent pancreas, getting close enough to look for any masses, cysts or abnormalities. Some patients’ cancers cannot be seen on the CAT scan, but are detectable using the endoscopic ultrasound imaging. “Endoscopic ultrasound has been around for a while now, but the scopes are getting better, and the needles that we use are better as well, so that when we see a small cancer, we can get a biopsy early on,” said Carroll, who began training in endoscopic ultrasound in 1997.

“The accuracy and the reliability—both from the equipment standpoint, our experience and the pathologists’ experience—it’s all a lot better.”—LH

Dr. Gregory Gagnon
Georgetown University Hospital; CyberKnife
Some cancers are inoperable. Ask Joan Schwab. A former smoker, she had already lost part of her right lung to a cancerous growth. Afterward, breathing became difficult.

So when doctors at Georgetown found cancer again, this time in the left lung, 67-year-old Schwab knew surgery was out of the question. Instead, she was referred to Georgetown’s new state-of-the-art robotic radiosurgery system called the CyberKnife. This $6 million machine delivers an intense beam of radiation to tumors from as many as 1400 different angles. For weaker patients like Schwab, or those with inaccessible cancers, the CyberKnife is their last and best resort.

“The first surgery was quite awful,” recalled Schwab, who is now cancer-free and back to walking her dog. “The CyberKnife was different. I lay down, got up and drove home. No pain or anything.”

Dr. Greg Gagnon, chief of radiation medicine at Georgetown University Hospital, leads the CyberKnife team. “This is 10 times more precise than standard radiation, and because the dose fall-off is so abrupt, we can deliver a high dose to a very small area. It’s like a knife, in a way.”

With traditional radiation, patients are exposed to a high degree of excess radiation, which causes damage to surrounding organs. “There are dosage limitations with standard radiation,” said Gagnon. “With CyberKnife, it’s so accurate that you can use a higher dose.”

Perhaps most exciting are the unexpected benefits of CyberKnife. “Some cancers, like prostate, seem to have a radiobiologic response,” Gagnon said. “They are sensitive to this intense radiation.”

For now, CyberKnife is reserved for patients who cannot undergo surgery. But Georgetown University Hospital staff members are ready for the day when they become the first choice for certain cancers; they just bought a second CyberKnife.—SM

(February 2008)