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Surgery Double Issue

SPRING 2012

Mount Sinai General + Robotic + Metabolic, Endocrine & Minimally Invasive + Orthopaedics + Transplant + Vascular + Otolaryngal + Cancer + Colorectal + Neurosurgery + Cardiothoracic

SCIENCE & MEDICINE The Magazine of the Mount Sinai Medical Center

surgeons FOREFRONT at the

Mount Sinai’s surgeons are at the forefront of new techniques, innovating and leading the way towards less invasive, more precise procedures with minimal hospital stays and shorter recovery times. Meet 30 of them right here.

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Michael L. Marin, MD Vascular surgery page 12

Kalmon D. Post, MD Neurosurgery page 22

David B. Samadi, MD Prostate surgery page 18

Joshua B. Bederson, MD Neurosurgery page 24

Celia Divino, MD General surgery page 25

Every surgery is a complete story that begins and ends

INNOVATORS

with the patient. Innovation tells these stories through a sharper focus, in fewer words, with less drama, and—more likely than ever before—a positive outcome. If “our patients are our heroes,” as one surgeon says, our surgeons transform their stories—wielding their innovative tools with power, confidence, expertise, and, as you will see, great humanity and compassion.

Randolph M. Steinhagen, MD Colorectal surgery page 38

Christina Weltz, MD Breast surgery page 45

Paul Hank Schmidt, MD Breast surgery page 45

Joel Bauer, MD Abdominal surgery page 50

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Sander Florman, MD Transplantation surgery page 40

Andrew Hecht, MD Spine surgery page 46

Stephen Gorfine, MD Abdominal surgery page 50

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Eric M. Genden, MD Head and neck surgery page 18

William B. Inabnet III, MD Endocrine surgery page 18

Evan Flatow, MD Orthopaedic surgery page 28

Sharif H. Ellozy, MD Vascular surgery page 35

Daniel Labow, MD Surgical oncology page 32

Myron E. Schwartz, MD Surgical oncology page 34

Aman Patel, MD Vascular surgery page 35

Juan Rocca, MD Transplantation surgery page 40

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Peter Faries, MD Vascular surgery page 35

Barry Salky, MD Colorectal surgery page 38

Marcelo Facciuto, MD Transplantation surgery page 40

Sean McCance, MD Spine surgery page 46

Brian Katz, MD Abdominal surgery page 50

Raja Flores, MD Thoracic surgery page 20

Elisa R. Port, MD Breast surgery page 45

David Adams, MD Cardiothoracic surgery page 48

Mark Reiner, MD Abdominal surgery page 50

Edward Chin, MD General Surgery page 52

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Mount Sinai SCIENCE & MEDICINE Volume III, number 1

04

President and Chief Executive Officer, The Mount Sinai Medical Center

Kenneth L. Davis, MD

57

Anne and Joel Ehrenkranz Dean, Mount Sinai School Of Medicine Executive Vice President For Academic Affairs, The Mount Sinai Medical Center

Dennis S. Charney, MD Senior Vice President, Development, The Mount Sinai Medical Center

Mark Kostegan, FAHP Editor

Celia M. Regan Associate Editor

Travis Adkins

53

Editorial Assistant

Vanesa Sarić Contributors

Philip Berroll Sara Daniels Don Hamerman Michael Hirshon Andrew Lichtenstein Kenneth Lin Kristin Lund Josh McKible Sima Rabinowitz Matthew Septimus Katie Quackenbush Spiegel Design

Message 03 Mount Sinai and surgical innovation

News 04 Koch commits $10 million to food allergy research + Neurology residency gets high marks + NIH gives $3.4 million to study personalized medicine…and places School of Medicine 17th in overall funding + Summit at Mount Sinai examines US News rankings + Drs. Fuster and Sharma have new appointments + SciMed program opens new admission doors + Med student a “Survivor” + ¡A tu Salud!

Taylor Design Mount Sinai Science & Medicine is published two times annually by the Office of Development, The Mount Sinai Medical Center, for an audience of friends and alumni. We welcome your comments; please contact us at magazine@mountsinai.org, or call us at (212) 659-8500. Visit us on the Web at philanthropy.mountsinai.org

Surgery Stories The history of Mount Sinai is full of surgical firsts. Throughout the magazine, watch for some of the many milestones that have given Mount Sinai’s surgery program a name for the ages. PLUS: In a letter to the editor about our last issue, “Global Impact,” Mount Sinai’s archivist, Barbara J. Niss, reminds us of one of the medical center’s most historic contributions to global health—the Hiroshima Maidens Project. Read about it on page 7.

Faculty 08 Ten receive honors and recognition + Spotlight on 20 new recruits + Researchers investigate genetics of stent failure, links between diabetes and food toxins, genetics of mental illness, and new target for preventing heart failure

Giving 53 Fundraising breaks records + Strong start to 2012 + Marathoner races for WTC programs + Mount Sinai Celebrations: Annual Boards of Trustees Dinner; new developments in MS, brain research, prostate cancer, and cardiovascular disease; Noble Deeds Society honors the Cullman family; young professionals gather; first annual salute to the Dubin Center

Alumni 58 Profile alumnus Dr. Jeffrey Flier + Note from the director + Alumni Association presents awards+ Dr. Laitman sends a message

Back cover photo: Don Hamerman

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Mg

MESSAGE The history of Mount Sinai is inseparable from the history of surgical innovation. Our very first patient, who was admitted to what was then called The Jews Hospital in June 1855, underwent successful surgery. And when Dr. Arpad Gerster literally wrote the book defining aseptic and antiseptic principles in the 1880s, he set the standard for Mount Sinai’s monumental knowledge enterprise: Our doctors don’t just read the books—they write them. For all of our 160 years, Mount Sinai surgeons have charted new

Message from

the President the Dean

&

paths and been placed squarely at the forefront of surgical advances. This special double issue of Mount Sinai Science & Medicine focuses on surgery and plots those historic battles right alongside the most profound accomplishments that began or were perfected at Mount Sinai and are happening right now, including laparoscopy, HIPEC, mitral valve repair, robotic surgery, and ever-more refined minimally invasive techniques. There are more than 600 surgeons at Mount Sinai; each of our surgical departments leads its field. They use the most advanced procedures, approaches, and instruments—many of them pioneered right here. We have room in this issue for only a small fraction of the accomplished men and women who are currently practicing surgery at Mount Sinai; our issue could easily have filled the space many times over. Past, present—and future: Innovation is so ingrained in Mount Sinai that we are planning to establish an innovation laboratory for our surgical trainees and faculty, one that will ultimately change the way surgery is practiced. We are continuing to invest in order to ensure that our surgeons stay right where they belong: at the forefront.

Kenneth L. Davis, MD President and Chief Executive Officer, The Mount Sinai Medical Center

Dennis S. Charney, MD Anne and Joel Ehrenkranz Dean, Mount Sinai School of Medicine Executive Vice President for Academic Affairs, The Mount Sinai Medical Center

Our surgeons use the most advanced procedures, approaches, and instruments— many of them pioneered right here.

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NEWS Koch Commits $10 Million to Food Allergy Research A $10 million gift by David H. Koch to the Jaffe Food Allergy Institute, one of the largest gifts in the Institute’s history, will create the David H. and Julia Koch Research Program in Food Allergy Therapeutics, which will be the hub for geneticsbased drug discovery work for food allergy at Mount Sinai. Mr. Koch is the executive vice president of Koch Industries and a major supporter and advocate Dr. Sampson

for medical research.

“This program has the potential to deliver the first therapies and cures for food allergy.”

Mount Sinai Science & Medicine / SPRING 2012

– Hugh Sampson, MD, director of the Jaffe Food Allergy Institute

The new program will build on the promising

work already underway at Mount Sinai, including the development of a vaccine for the treatment of

David H. Koch

peanut allergies, and will also further the Institute’s

Robin Platzer/FilmMagic/Getty Images

recruitment of leading scientists to establish a robust team dedicated to food allergy therapeutics.

Hugh Sampson, MD, the internationally

of The Mount Sinai Medical Center. “Breakthrough

renowned director of the Jaffe Food Allergy Institute,

therapeutics such as these will change the face

said that Mr. Koch’s gift strengthens Mount Sinai’s

of children’s health,” he said. “Mr. Koch’s visionary

position as a global leader in food allergy thera-

philanthropy brings us one step closer to that goal.”

peutics. “Right now, the only recourse for patients

who have food allergies is to avoid those foods,” said

medicine in food allergy. Dr. Sampson and his team

Dr. Sampson. “This program has the potential to

are the best at what they do, but the most exciting

“This is a remarkable time for science and

deliver the first therapies and cures for food allergy.”

discoveries are yet to come,” said Mr. Koch. “My hope

is that children who suffer from life threatening food

The research conducted by the program will

be especially significant for children’s health,

allergies will have their lives transformed from the

according to Kenneth L. Davis, president and CEO

therapies that originated from this work.”

High Marks for Neurology Residency Program

Dr. Sealfon

According to a recent study published in the Archives of Neurology, Mount Sinai School of Medicine’s neurology residency program is ranked third in the country by number of neurologists who continue in academic neurology. “These results attest to the love of teaching, discovery, and academic neurology that has been transmitted to Mount Sinai School of Medicine residents over the years,” said Stuart Sealfon, MD, Glickenhaus Professor and Chair of the Department of Neurology. “We have a strong culture of teaching and training and look forward to continuing this great tradition.”

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$3.4 Million from NIH for Groundbreaking Study of Personalized Medicine

Dr. Bottinger

A team of researchers at the Charles R. Bronfman Institute for Personalized Medicine has been awarded a $3.4 million grant from the National Institutes of Health to undertake the largest study of its kind: The researchers will identify genetic markers of disease for each patient enrolled in the study and enter them into Mount Sinai’s new electronic medical records system following safety and security guidelines. Physicians treating the study’s patients will be able

MSSM Climbs in NIH Funding Mount Sinai School of

TH AMONG ALL US MED SCHOOLS

to access this genomic information electronically to create a personalized course of treatment. “So far the genomic information of individual patients has been limited to the laboratory and research setting,” said Erwin Bottinger, MD, who directs the Bronfman Institute and is Irene and Dr. Arthur M. Fishberg Professor of Medicine. “This will allow us for the first time to bring that critical individual genetic-disease risk information to the patient setting.”

Mount Sinai Hosts Summit Discussing U.S. News & World Report Rankings Deans and other academic leaders from some of the

Medicine ranks number

country’s top medical schools convened at Mount Sinai in

17 among all U.S. medical

October for a lively, candid discussion with the editors of the

schools in funding awarded

influential annual “Best Medical School” issue of U.S. News

by the National Institutes

& World Report. Attendees debated the methodology of the

of Health—the highest

magazine’s ranking system and its relevance, among other

ranking in its history—

topics. “The rankings impact those of us who run medical

according to the most

schools,” said Dean Dennis S. Charney, who organized and

recent report from the Blue

chaired the event. “We knew it would be interesting to invite

Ridge Institute for Medical

leaders from the top medical schools to discuss the rankings,

Research, the industry’s

and U.S. News graciously embraced that idea. I think it took

definitive source of data.

a little courage to hear what the deans have to say.”

The medical school’s NIH funding increased more than 35 percent to $254 million and total federal funding (including funds awarded through the American Recovery and Reinvestment Act) increased nearly 28 percent to $309 million, a growth rate that outpaced peer institutions such as Duke University and Stanford University. Underlying the success was a sharp rise in the number of competitive proposals submitted to the NIH by Mount Sinai faculty, which is due in part to the school’s success in recruiting leading researchers and scientists over the past several years. “This ranking reflects the extraordinary efforts of Mount Sinai investigators and their teams,” said Dennis S. Charney, MD, the Anne and Joel Ehrenkranz Dean of Mount Sinai School of Medicine. “I’d like to congratulate all of them on this impressive achievement.”

Pictured: (from left) Dean Charney; Robert Alpen, MD, dean, Yale University School of Medicine; Jules Dienstag, MD, dean for medical education, Harvard Medical School; Nancy C. Andrews, MD, PhD, dean, Duke University School of Medicine; and Robert N. Golden, MD, dean, University of Wisconsin-Madison School of Medicine & Public Health

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NEWS

New Appointments for Valentin Fuster, MD, and Samin K. Sharma, MD “I look forward to working with Mount Sinai leadership to make an indelible impact in clinical research and on the diagnosis, treatment, and ongoing care of our patients.”  – Valentin Fuster, MD

Two of Mount Sinai Heart’s most esteemed physicians, Valentin Fuster, MD, and Samin K. Sharma, MD, have been named to new leadership positions. Dr. Fuster, director of Mount Sinai Heart, has been appointed Mount Sinai’s first-ever physician-in-chief, a role in which Dr. Fuster will have a broad mandate to elevate all aspects of patient care at the medical center. “I look forward to working with Mount Sinai leadership to make an indelible impact in clinical research and on the diagnosis, treatment, and ongoing care of our patients,” said Dr. Fuster.

Dr. Sharma, the director of Mount Sinai’s renowned

Cardiac Catheterization Laboratory, has been appointed director of clinical cardiology, dean of international clinical affiliations, and president of the Mount Sinai Heart Network. He will be responsible for operational issues related to cardiology at the main campus and throughout the Mount Sinai network and will work to develop and implement growth strategies for cardiology. “Mount Sinai Heart is already a recognized leader in cardiology,” said Dr. Sharma, who as the newly appointed dean of international clinical affiliations will also work to develop relationships and affiliations Dr. Sharma (L)

worldwide. “We will build on that success by continuing

and Dr. Fuster

to deliver the superior patient care that has made us one of the most acclaimed programs in the nation.”

Mount Sinai Science & Medicine / SPRING 2012

Wanted: Computational Science Majors A new early admissions entrance track for undergraduate students majoring in the computational science fields of engineering, computer science, genetics, or mathematics will advance Mount Sinai’s mission of training the next generation of translational biomedical researchers. The SciMed program allows up to 10 students per year from those disciplines to apply to Mount Sinai without first taking traditional pre-med requirements or the Medical College Admissions Test (MCAT). “We want science-oriented students to come to medical school better prepared to make breakthrough discoveries,” said David Muller, MD, Marietta and Charles C. Morchand Chair in Medical Education and dean for medical education. “SciMed removes the barriers that often stand in the way of truly innovative thinking.”

Student Wins “Survivor” Sophie Clarke, a first year student at Mount Sinai School of Medicine, won first place in the CBS TV show “Survivor: South Pacific” on December 18. Ms. Clarke took home a prize of $1 million. “I’d been looking forward to medical ©Survivor: South Pacific school for years, but the prospect of winning “Survivor” and becoming a new millionaire proved to be very distracting in my first semester,” said Clarke. “Plus the competition took an enormous physical and emotional toll on my body. So balancing that with school was difficult. But I’m looking forward to coming back, focusing on my studies and taking full advantage of all of the opportunities here at Mount Sinai.”

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New TV Program Aimed at Latino Community ¡A tu Salud! (For Your Health!), a weekly Spanishlanguage program

Watch ¡A tu Salud! at: mountsinai.org/latino

featuring Mount Sinai physicians and patients discussing key health issues, is the latest initiative in the medical

center’s ongoing campaign to serve the healthcare needs of the Latino community. The program, which premiered January 7th, airs Saturdays on local New York City station Telemundo Channel 47 and includes features such as “Pregunte al Dr. Guzmán,” a question-and-answer segment with Eliscer Guzmán, MD, assistant clinical professor of cardiology. “This series was inspired by Mount Sinai’s commitment to the Latino community,” said Wayne Keathley, president and chief operating officer of The Mount Sinai Hospital. “By providing Latino families with knowledge and the right tools, we will be able to engage and empower them to lead healthier lives, and ¡A tu Salud! allows us to do just that.” The hospital was recently ranked the best in New York City by the readers of El Diario, the most widely-read Spanish language newspaper in the city.

Eliscer Guzman, MD, with show host Yamila Constantino

Hiroshima Maidens Project LETTER TO THE EDITOR Re: The “Global Impact” issue of Science & Medicine No feature about Mount Sinai’s global impact would be complete without a reference to the Hiroshima Maidens project, carried out at The Mount Sinai Hospital from 1955–56. This project, organized by Norman Cousins, was funded through public donations. Twenty-five women were brought to Mount Sinai for treatment to restore function and appearance to bodies that had been injured in the nuclear blast in Hiroshima. The Mount Sinai surgeons—Arthur Barsky, Sidney Kahn, and Bernard Simon— donated their services. A Mount Sinai Trustee, Alfred Rose, donated the use of a four-bedded room for 18 months. The girls lived with Quaker families in the tri-state area between surgeries, of which over 125 were performed. With money remaining from the donations, surgeons were brought to Mount Sinai from Japan to receive advanced training in plastic surgery. They formed the beginning of the field of modern plastic surgery in Japan.  – Barbara J. Niss, Archives & Records Management Division

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Fa

Fa FACULTY

FACULTY

Recognition

&Awards

Jonathan Halperin Appointed Chair-Elect by ACC

Award, while the ACC honored him with its Gifted Educator

Annapoorna Kini, MD

Jonathan L. Halperin, MD, director of Clinical Cardiology

Award during the 61st Annual Scientific Sessions meeting in

Rosanne M. Leipzig, MD, PhD

Services in the Zena and Michael A. Wiener Cardiovascular

Jagat Narula, MD, PhD

Chicago.

Institute and the Robert and Harriet Heilbrunn Professor of

From left to right: Jonathan L. Halperin, MD Patrick R. Hof, MD

presented Dr. Narula with its Distinguished Physician

Medicine, was appointed chair of the American College

William Oh Elected to ASCI

Samuel Sidi, PhD

of Cardiology’s Task Force on Clinical Competence and

The Tisch Cancer Institute’s William Oh, MD, the Ezra M.

Mary V. Solanto, PhD

Training.

Greenspan Professor in Clinical Cancer Therapeutics, was

Patrick Hof Takes Helm at Journal of Comparative Neurology

Investigation.

William Oh, MD Samin K. Sharma, MD

Theresa A. Soriano, MD, MPH

The Friedman Brain Institute’s Patrick R. Hof, MD, the Irving

Samin Sharma Wins Awards from AHA, NECO

and Dorothy Regenstreif Professor of Neuroscience and

Samin K. Sharma, MD, director of clinical cardiology, dean

vice chair for the Department of Neuroscience, was named

of international clinical affiliations, and president of the

editor-in-chief of the Journal of Comparative Neurology, the

Mount Sinai Heart Network, received the American Heart

primary scientific journal for neuroanatomy and systems

Association’s 2011 Award for Achievement in Cardiovascular

neuroscience.

Annapoorna Kini Hailed by AHA

Science and Medicine and the National Ethnic Coalition of Organization’s 2011 Ellis Island Medal of Honor.

Annapoorna Kini, MD, associate professor of cardiology

Samuel Sidi Awarded Searle Scholarship

and director of the Cardiac Catheterization Laboratory,

The Tisch Cancer Institute’s Samuel Sidi, PhD, assistant

was named a Rock Star of Science by the American Heart

professor of oncological sciences, was one of 15 winners

Association for her wide-ranging contributions to interven-

selected by the Searle Scholars program, which recognizes

tional cardiology.

promising young scientists nationwide.

Roseanne Leipzig Named to NBME

Mary Solanto Recognized as Innovator

Rosanne M. Leipzig, MD, PhD, Gerald and Mary Ellen Ritter Mount Sinai Science & Medicine / SPRING 2012

elected to membership in the American Society for Clinical

Professor of Geriatrics and Palliative Medicine, has been appointed to the National Board of Medical Examiners, an organization that provides the national standard

Mary V. Solanto, PhD, associate professor of psychiatry and director of the Attention Deficit Hyperactivity Disorder (ADHD) Center, was honored with the Innovative Program of the Year Award from Children and Adults with ADHD

assessment for health care practitioners in preparation for

(CHADD) for developing an approach to treating adults

medical licensure.

with ADHD using cognitive-behavioral therapy.

Jagat Narula Honored by Two Top Organizations

Theresa Soriano Receives Cuniff-Dixon Physician Award

Jagat Narula, MD, PhD, Philip J. and Harriet L. Goodhart

Theresa A. Soriano, MD, MPH, director of the Mount

Chair in Cardiology and director of cardiovascular imaging,

Sinai Visiting Doctors Program and associate professor of

was recently recognized by the two most respected institu-

medicine, received the prestigious Hastings Center Cunniff-

tions in cardiology, the American Heart Association (AHA)

Dixon Physician Award for her work in improving end-of-

and the American College of Cardiology (ACC). The AHA

life care for patients.

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New RECRUITS The Mount Sinai Medical Center welcomes the following new recruits. 1 Emilia Bagiella, PhD, professor in the Center for Biostatistics, Department of Health Evidence and Policy, and director of the CTSA Biostatistics, Epidemiology and Research Design program; previously at Columbia University Mailman School of Public Health.

2 Joshua Brody, MD, director of lymphoma immunotherapy and a member of the Tisch Cancer Institute; previously at Stanford University Medical Center.

3 Hearn Jay Cho, MD, PhD, assistant professor in the Division of Hematology and Medical Oncology and a member of the Tisch Cancer Institute; previously at Weill Cornell Medical College and New York University School of Medicine.

4 Michael J. Donovan, MD, PhD, professor in the Department of Pathology and director of experimental pathology and the biospecimen bank; previously at Aureon Biosciences.

5 Ke Hao, ScD, associate professor in the Department of Genetics and Genomic Sciences; previously at Rosetta Impharmatics and Merck Research Labs.

6 Harvey Hecht, MD, associate director of cardiovascular imaging; previously at Lenox Hill Hospital.

7 Andrew Kasarskis, PhD, vice chair, Department of Genetics and Genomic Sciences, and co-director, Institute for Genomics and Multiscale Biology; previously at Pacific Biosciences.

8 Patricia Kovatch, associate dean for scientific computing; previously director of the National Institute for Computational Sciences at the University of Tennessee and Oak Ridge National Laboratory.

9 Janina Longtine, MD, vice chair of Molecular Pathology and Genetics program in the Department of Pathology; previously at the Brigham and Women’s Hospital.

10 Ruth Loos, PhD, professor and program director, Genetics of Obesity and Related Metabolic Traits Program at the Charles R. Bronfman Institute for Personalized Medicine; previously at the Institute of Metabolic Science in Cambridge (England).

11 Bojan Losic, PhD, associate professor, Department of Genetics and Genomic Sciences and Institute of Genomics and Multiscale Biology; previously at the Ontario Institute for Cancer Research.

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11

2

12

3

13

14 Hirofumi Morishita, MD, PhD, assistant professor of psychiatry and a member of the Child Health Development Institute and The Friedman Brain Institute; previously at Children’s Hospital Boston.

4

14

15 Anne Schaefer, MD, assistant professor in the Department of Neuroscience and Department of Psychiatry and a member of The Friedman Brain Institute; previously at Rockefeller University.

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15

6

16

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17

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18

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19

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12 Roberto Lucchini, MD, director of the Division of Occupational and Environmental Medicine in the Department of Preventive Medicine; previously at University of Brescia (Italy).

13 Milind Mahajan, PhD, director of genomics core facility and associate professor in the Department of Genetics and Genomic Sciences; previously at Yale University.

16 Daniel Soffer, MD, FACC, co-director of carotid and endovascular services and associate professor of medicine, Mount Sinai Heart; previously at Lenox Hill Hospital.

17 Ila Singh, MD, PhD, vice chair of clinical pathology and director of clinical laboratories; previously at the University of Utah.

18 Harsh Thaker, MD, PhD, vice chair for operations, Department of Pathology; previously at the University of Utah, Salt Lake City. 

19 Bin Zhang, PhD, associate professor, Department of Genetics and Genomic Sciences, and a member of the Institute of Genomics and Multiscale Biology; previously at Sage Bionetworks.

20 Jun Zhu, PhD, professor, Department of Genetics and Genomic Sciences, and a member of the Institute of Genomics and Multiscale Biology; previously at Sage Bionetworks.

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FACULTY

Research Roundup Discovery of Gene Variants Could Prevent Deadly Coronary Stent Complication

Several Common Genetic Variants Found to be Associated with Mental Illness

A team of Mount Sinai researchers has identified several gene

An international research consortium led by Mount Sinai

variants contributing to early stent thrombosis, a devastating

researchers has discovered several common genetic variants

and often deadly complication after coronary stent implantation

that contribute to a person’s risk of schizophrenia and bipolar

in people with coronary artery disease. Led by

disorder. Two just-released studies provide new

Jean-Sebastien Hulot, MD, PhD, associate professor of

evidence that 11 genomic regions have a strong

medicine in the Division of Cardiology and director of

correlation with mental illness, including six areas

pharmacogenomics and personalized therapeutics at

not previously discovered. The findings provide

the Cardiovascular Research Center, the team found

fresh insight into the causes of these diseases and

that three of these variants were associated with

may lead to new, more effective treatment options.

impaired sensitivity to the common blood thinner clopi-

The data are published in the September 18 issue

dogrel, and a fourth affects a blood platelet receptor

of Nature Genetics. “Schizophrenia and bipolar

11

involved in platelet aggregation and clot formation. “Now that we have a clearer understanding of the mechanism behind the development of stent thrombosis, we can take preventive measures to protect our

genomic regions

patients from this deadly complication,” said Dr. Hulot. The study was published in the October 2011 issue of the Journal of the American Medical Association.

New Study Shows High Levels of DiabetesRelated Food Toxins in Infants Mother-to-child disease transmission is a subject of extensive research, especially with respect to obesity and diabetes, which now affect people at a much

Mount Sinai Science & Medicine / SPRING 2012

younger age. The mother’s blood is a common route of

Two studies provide new evidence that eleven genomic regions have a strong correlation with mental illness.

disorder are debilitating illnesses affecting millions of people around the world, and existing therapies for these people are ineffective as long-term options,” said Pamela Sklar, MD, PhD, chief of the Division of Psychiatric Genomics in the Department of Psychiatry, professor of psychiatry, and lead author on the bipolar study. “We have been hard at work trying to determine genetic risk for these diseases so that we can intervene earlier and develop new therapies with which to treat them. Through this research, we are an important step closer to making that possible.”

Promising New Target Identified for Treating and Preventing Heart Failure

transmission, but little is known about the nature of

Investigators led by Roger J. Hajjar, MD, Arthur and

factors transmitted that could be involved in the recent

Janet C. Ross Professor of Medicine and director

profound increase in diabetes. A team led by Helen

of the Wiener Family Cardiovascular Research

Vlassara, MD, director of and professor in the Division

Laboratories, have identified a new drug target that

of Experimental Diabetes and Aging, and Jaime

may treat or even prevent heart failure. The team

Uribarri, MD, professor of medicine, found that modern

discovered that SUMO1, a so-called “chaperone”

foods carry harmful compounds, called AGEs, that

protein that regulates the activity of key transporter

multiply during heat-processing of nutrients. AGEs

genes, was decreased in failing hearts. The research

have been shown to trigger inflammation, damage to insulin-

is part of the team’s larger project evaluating the transporter gene

producing cells, and insulin resistance, conditions that can

SERCA2a in patients with severe heart failure. “Our experiments

lead to diabetes. Since these substances are carried via the blood,

over the last four years, beginning with the discovery of SUMO1

they can be transported to the fetus, meaning exposure to AGE

as an interacting protein of SERCA2a, have shown that it plays a

begins prior to birth. AGE levels can also be further increased as

critical role in the development of heart failure,” said Dr. Hajjar.

soon as the infant is fed industrially-processed formulas, containing

“In fact, SUMO1 may be a therapeutic target at the earliest

AGEs at levels twenty fold or more than maternal milk. Infants

signs of development, and may be beneficial in preventing its

with high AGE levels were found to have abnormal levels of plasma

progression, a much-needed advance for the millions suffering

insulin, a marker of insulin resistance and predictor of diabetes.

from this disease.”

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W

e may do it very well, but very little we do in medicine is perfect. At the leading edge is a physician who knows there is no room for complacency, that there can be a better way, and who starts on that journey towards innovation. Surgical innovation can mean a more enhanced, robust cure through technological improvements: Today you may be able to live for a year after surgery; tomorrow’s new innovations can give you five years. Or it can mean perfecting the technical parts of a primary procedure: The outcome may be just as good as it was before, but perhaps there’s less pain, a shorter recovery time, a smaller scar, and greater ability, sooner. The true advances move medicine forward. Identifying a real need is central to innovation. The truth is that innovators must have drive and passion and ideas and confidence, but they also have to be young and maybe, just maybe, a little bit stupid. Once you know the ramifications and magnitude of what could happen, you lose a little of your courage, because innovation also means risk-taking. Experience makes you better, but it also dampens your aggressiveness. Take me. Twenty years ago, I performed the first minimally invasive surgery to repair an aortic aneurysm. I had finished my training—I’d been a “real doctor” for all of three months. A patient who came to see me with a painful aneurysm was inoperable,

INNOVATION terribly sick with more than a dozen dangerous conditions that gave me just two choices: to operate conventionally and watch him die, or not to operate— and watch him die. All I could think of was, “What else could we do? How could I find someone else who’s being innovative?” Naïve as I was, I found and called a surgeon in Buenos Aires who was using a brand-new procedure that he’d tried on just six patients. We performed the surgery on my patient, who lived for more than two years. Innovation saved his life. I was the first person in the country to do these procedures, and perhaps I cringe a little at some of the choices I made at 30. But what I learned from those procedures, year after year, has saved countless lives since that time, and that’s also part of how new technology evolves. Innovation may not always favor the first person who received it, but others who follow? Absolutely. Every one of the surgeons in these pages is an innovator whose brilliance has been sharpened by experience, even as experience may soften the drive to innovate. They may not always tell you, but I know no good surgeon who doesn’t look back from case to case—from complication to complication— and learn and grow and improve with the experience. That’s what it means to be at the forefront.

By Michael Marin, MD Professor and Chairman of the Department of Surgery Two of the tools shaping surgical innovation at Mount Sinai: a stent graft, and the gifted hand of Dr. Marin

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TIME LESS

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Photography by Andrew Litchenstein Written by Travis Adkins

1  The details Two days before: Dr. Marin talks to Mr. Michael about what to expect. 2  Waiting 5:30 am: Mr. Michael on the morning of the surgery.

3  Surrounded by family 6:30 am: Mr. Michael and his daughters, Marguerite Beaser (L) and Marianne Culich, just before the surgery. 4  Human touch 7:15 am: Dr. Marin prepares Mr. Michael for what is to come.

Vascular surgery

nnovative technical breakthroughs are the new reality, but at the end of the day, surgery will always be about the oldest principles of medicine: the inviolable trust between patient and physician. Judgment shaped by experience. Compassion tempered with wisdom. The best-laid plans set aside when the moment dictates. Science & Medicine was privileged to document a Mount Sinai surgery, when Michael Marin, MD, chairman of the Department of Surgery, performed a life-sustaining procedure on Marvin Michael, a 93-year-old retired lawyer. Our photography chronicles the experience before, during, and after Mr. Michael’s minimally invasive stent graft surgery, an innovative technique Dr. Marin pioneered 20 years ago.

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5  Locked and loaded 7:30 am: Dr. Marin scrubs in. 6  Everything in place 7:30 am: Tools are at the ready. 7  Absolute focus 9:30 am: Dr. Marin (with vascular surgery fellow David O’Connor, MD) watches the monitor displaying the stent’s progress.

8  A change of plans 11:30 am: Encountering a complication that demands different tactics, Dr. Marin devises a new approach within minutes.

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Vascular surgery

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9  Team effort 1:00 pm: After six hours, the surgery nears completion.

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10  Outcome 1:45 pm: Dr. Marin tells Mr. Michael’s daughters that the operation is a success.

11  Game over 2:00 pm: In the locker room afterwards, Dr. Marin prepares for the rest of his day. 12  Good to go The next day: Mr. Michael leaves the hospital to face the next phase: recuperation.

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Vascular surgery

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T RA NSF ORM E RS David B. Samadi, MD

Transforming Prostatectomy

MOUNT SINAI SURGERY MILESTONES

18

Mount Sinai Science & Medicine / spring 2012

85 Arpad G. Gerster is first to suggest that surgery spreads cancer; three years later, writes first textbook in US on aseptic and antiseptic principles.

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Howard Lilienthal devises many instruments including the first useable metal detector for surgery; a rib spreader; a guillotine to cut the first rib; and a silver wire for use as suture material in the presence of an infection. c.

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Prostatectomy—the removal of a diseased prostate gland—has long been considered one of the riskiest of medical procedures. Because the prostate is surrounded by nerves which control sexual and excretory functions, the slightest error can leave a patient both impotent and incontinent. But through the use of robotics, David B. Samadi, MD has been able to perform more than 3,800 robotic prostatectomies—2,200 of them taking place at Mount Sinai—with amazing results: “Ninety-seven percent of patients retain continence,” he says, “and eighty-five percent retain sexual function. Ninety-five percent stay only one night in the hospital. Pain is minimal.” As Chief of Robotics and Minimally Invasive Surgery and Vice Chairman of the Division of Urology at Mount Sinai, Dr. Samadi, a urologist, performs almost 15 robotic prostatectomies a week, using a procedure he has dubbed SMART (Samadi Modified Advanced Robotic Technique). The main advantages of the technique, he says, are the ability of the DaVinci® system to handle the prostate without disturbing “the delicate, sensitive nerves” around it, and to give him a clear, precise view. “In open surgery, you use ‘the touch factor’ because you can’t see the detail of the procedure,” he notes. “With the SMART technique, I can see the detail—so I can perform a precise operation.” As one of only a handful of surgeons trained in open, laparoscopic, and robotic techniques, Dr. Samadi provides the skills of three separate surgical disciplines. He combines a complete understanding of traditional open surgery with less painful, minimally invasive laparoscopy, and advanced robotic technology—and he performs every surgery himself.

Meet three surgeons whose use of robotic and other minimally invasive procedures is transforming their specialties—and patient lives. Surgeons of Mount Sinai have been leaders in the use of the DaVinci® robotic system and other minimally invasive techniques. Here are three who are defining—and refining, over and over again—how surgery is practiced.

97 % 85 % 95 % With the advances in robotic prostatectomies, 97% of patients retain continence, 85% retain sexual function, and 95% leave the hospital after 1 night.

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In typical open surgery for head and neck tumors, patients have to undergo a 12–14 hour procedure. With the use of robotics, the patients’ surgery lasts only about 2 hours.

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With traditional removal of a diseased thyroid gland, patients were left with a 4 to 6 inch scar on the front of the neck. Now, through the use of robotics, scars are down to only 1 to 2 inches in length.

written by PHILIP BERROLL PHOTOGRAPHY by DON HAMERMAN

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Eric M. Genden, MD

William B. Inabnet III, MD

Minimizing thyroidectomy

Eric M. Genden, MD is no stranger to innovative surgical procedures—he was the first surgeon in the United States to perform a jaw transplant. So it’s not surprising that he has been a pioneer of robotic surgery in his field of specialty, cancers of the head and neck. “It’s made a remarkable impact on our ability to take care of patients with these cancers,” says Dr. Genden, “without making large incisions and doing surgeries that take up a huge amount of time and resources.” Dr. Genden, Chairman of the Department of Otolaryngology and Chief of the Division of Head and Neck Oncology, performed his first robotic surgery in 2006 and has since done close to 250 such procedures. The biggest advantage of the robotic procedure, he says, is its relative simplicity: “In the typical open surgery, patients have to undergo a 12-to-14-hour procedure to get to the tumor, and they’re usually in the hospital for 10 to 12 days. Using the robot, we’re able to remove the tumor in about two hours—and patients usually go home the next day, eating and drinking, and swallowing.” Dr. Genden notes that the robotic technique “is being adopted widely, not only across the U.S. but now in Europe and Asia—because people are seeing that this has a tremendous effect on both the quality of patient outcomes and the cost of care.”

As Chief of the Division of Metabolic, Endocrine and Minimally Invasive Surgery, William B. Inabnet III, MD leads a team that has performed more laparoscopic surgeries than at any other hospital in New York City. Dr. Inabnet and his team performed the first robotic thyroidectomy at Mount Sinai in 2010, and are strong advocates of both robotic and non-robotic minimally invasive procedures to remove part or all of a diseased thyroid gland. In the most common procedure, a laparoscope with a tiny, high-definition video camera is inserted into a remote incision, so that he and his team have a bigger, clearer view of the operative field on a television screen. “Minimally invasive endoscopic thyroidectomy promotes teamwork,” says Dr. Inabnet, “because all members of the team can follow each step of the operation in real time.” There is also a cosmetic advantage: the patient is left with a one-to-two-inch scar in the axilla (underarm), as opposed to a visible scar on the neck in a traditional operation. “Every year,” he notes, “we graduate two minimally invasive endocrine surgery fellows who have learned these techniques at Mount Sinai. We’re training the next generation of minimally invasive thyroid surgeons.” More information can be found at mountsinai.org/memis.

MOUNT SINAI SURGERY MILESTONES

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92 Emil Gruening: Performs first successful mastoidectomy in the US.

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Howard Lilienthal is the first surgeon in US to perform a successful staged abdominal colectomy for colitis.

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Sydney Yankauer develops the first of many important operative instruments, a wire mesh anesthesia mask. He goes on to refine suction devices, clamps, an endoscope and bronchoscope, and many otolaryngeal operative instruments, and also performs the first successful removal of a foreign object via bronchoscopy in New York State.

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Robot-assisted surgery

Streamlining head and neck surgery

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Thoracic surgeon Raja M. Flores does innovative work that respects both body and spirit.

Authenticity

Mount Sinai Science & Medicine / spring 2012

Written by Sima Rabinowitz

Dr. Raja Flores has patients—often with devastating lung and esophageal conditions—who want the impossible. And that’s OK with him: He’ll find ways to deliver just that. From the smallest incisions to what he calls “a big, crazy operation,” Dr. Flores has earned a reputation as an intrepid pioneer, whose work transcends pure technique. He tempers his recognized expertise with a profound understanding of his patients, honoring the nuanced, profoundly complex relationship between innovation and the vigilance and compassion needed to tailor treatments to each patient’s hopes and needs. Steven and Ann Ames Professor of Thoracic Surgery, Chief of Surgery and Director of the Thoracic Surgical Oncology Program, Dr. Flores has developed and perfected surgical techniques that have created new standards of care and investigated complementary treatments and therapies with dramatic implications for the early detection, diagnosis, and treatment of lung cancer (carcinomas and sarcomas), mesothelioma (cancers that result from asbestos exposure), and esophageal cancer. And he has saved lungs—and lives—and possesses expertise and knowledge with the potential to alter approaches to thoracic surgery in remarkable ways. Dr. Flores came to Mount Sinai in 2010 from Memorial Sloan-Kettering Cancer Center, where he

spent ten years conducting studies that changed the surgical management of pleural mesothelioma cancer and developing a revolutionary approach to excising tumors of the lung, the VATS lobectomy (Video Assisted Thoracic Surgery). “I chose this field because I’ve always been drawn to helping patients facing the most devastating and difficult conditions. I’m convinced that we can triumph over the odds,” he says. “I understood that Mount Sinai intended to establish itself as a clear leader in the field of lung cancer research, prevention, and treatment, and I was compelled to help lead this effort.”

Stubborn disease/creative solutions Lung cancers stubbornly remain the leading cause of cancer deaths for adults in the US. At Mount Sinai, Dr. Flores has helped established one of the world’s largest VATS lobectomy practices and teaching programs in the world. VATS, a minimally invasive approach to treating lung cancer, allows access to, and removal of, diseased segments of the lung through three small incisions—helping patients avoid the trauma of conventional open surgery, which requires opening the chest between the ribs or even the removal of a rib. Dr. Flores continues to refine the technique and to work on education and

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“Technical expertise and an authentic connection to each patient go hand in hand. They’re part of a comprehensive effort.”

Honoring the individual Dr. Flores’s close, personal attention to patients is a persistent quality of his practice: He makes it a priority to understand their individual conditions and concerns. “I knew she wanted to dance,” he says of a patient with carcinoid tumor he recently treated, a professional stage performer in New York City. Told by every surgeon she consulted she would lose her lung, she came to Dr. Flores with what seemed to be a hopeless situation. Images of the tumor did appear to indicate, he explains, that it was unlikely the whole lung could be saved. Nevertheless, based on past experience, Dr. Flores thought he might be able to save a portion of the organ. During the lung resection procedure, he discovered a way to excise the tumor completely and save the entire lung. The patient is now healthy, cancer-free, and “dancing up a storm.” “Technical expertise and an authentic connection to each patient go hand in hand. They’re part of a comprehensive effort,” says Dr. Flores. “We have to balance the patient’s desires for her life with her health and what we believe is in her best interests. In the operating theater, knowing what my patient truly wants for herself drives me to seek a solution that can beat the odds.” Dr. Flores knows what he wants, too. To perfect innovative surgical techniques for lung cancer, esophageal cancer, and mesothelioma; to advance research in order to develop complementary targeted therapies to improve quality of life and outcomes; and to contribute on multiple levels to the prevention, detection, and treatment of diseases that persist as some of the most severe and devastating. And above all—metaphorically, at least—to keep all of his patients dancing.

MOUNT SINAI SURGERY MILESTONES

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Alexis Moschcowitz develops new operation for femoral hernia repair, sometimes called the Moschcowitz operation.

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Edwin Beer develops the Beer Cystoscope; three years later, publishes first report on a new method of destroying benign tumors of the urinary bladder by electric current (fulguration).

Thoracic surgery

training initiatives to ensure that future physicians will develop the specialized skills to perform the surgery. But Dr. Flores knows that the technical expertise is just part of what it takes for successful surgery. In his keynote speech at the School of Medicine’s 2011 White Coat Ceremony, he told new medical students and their families about performing a VATS procedure in China: He had not been able to get to know the patient before operating, and realized this wasn’t acceptable. “The best surgeons perform an operation driven by the patient’s desires for himself and our professional understanding of what’s in their best interests. We’re not technicians. We’re treating a person, not just a disease.” Dr. Flores is also an innovator in the treatment of esophageal cancer. For both laparoscopic (minimally invasive, video assisted) procedures and conventional open surgery, the primary concern with esophageal cancer is post-surgical complications: They are often more devastating than the disease itself. Dr. Flores, whose complication rate is among the lowest in the country, cites experience—the specialized technical skill developed over time—and acute attention to his patient’s needs and circumstances. “Complications with esophageal cancer surgery are very common and extremely challenging,” he says, “In the case of esophageal cancer, innovation is not as much about tools and technologies as it is about an overall approach. It’s about what’s required to execute a procedure flawlessly.” The treatment of mesothelioma is another specialty that drives Dr. Flores to innovate; he continues to investigate and perform lung-sparing therapies and to research multimodality management of malignant pleural mesothelioma. While initially promising, his investigation of intraoperative chemotherapies (chemotherapies administered during surgery) demonstrated that more research is needed to design effective treatments using this approach. But other groundbreaking work is part of his mesothelioma arsenal. He is currently reviewing data from more than 6,000 patients to compare and evaluate treatment and outcomes in the mesothelioma population. Treatment of mesothelioma is of special significance at Mount Sinai, where there is a history of prominence in occupational medicine, as well as such critical health initiatives as those involving 9/11 rescue workers. Research is an essential component of Dr. Flores’s work at Mount Sinai. He has just launched a new Translational Thoracic Surgery Lab, a basic science facility dedicated to the investigation of the cellular mechanisms that may lead to the development of targeted therapies to complement surgical procedures for lung cancer, mesothelioma, and esophageal cancers and to improve patient outcomes by reducing the recurrence of tumors post-surgery. The new lab will also conduct investigations with animal models to test innovations in minimally invasive surgical techniques.

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Written by Travis Adkins

Illustration by Michael Hirshon

THE

A brilliant pituitary surgeon—a pioneer in his field who still sets the standard—lives by his art.

MOUNT SINAI SURGERY MILESTONES

19 Mount Sinai Science & Medicine / spring 2012

08 Surgeon Leo Buerger describes Buerger’s Disease: thromboangiitis obliterans.

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Charles Elsberg: Develops first practical positive pressure anesthesia technique (endotrachial anesthesia) allowing Howard Lilienthal to perform a drainage of an empyema.

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Kalmon D. Post, MD is an avid collector of modern art who favors abstract expressionism and color field pieces. But it’s another contemporary art movement, minimalism, that best suggests how Dr. Post has crafted his own career: Less is more. Over more than 30 years as a preeminent neurosurgeon specializing in pituitary tumor surgery, Dr. Post has helped to transform complex and debilitating treatments into minimally invasive procedures. And in so doing, he’s become an artist of the minimalist school. Move over, Mark Rothko.

Changing the Pituitary Game The pituitary gland is located underneath the brain, just behind the nose. For much of the twentieth century, craniotomies—“go in through the top of the head, lift the brain out of the way, and take the tumor out,” as Dr. Post described it—were the standard surgical treatment for pituitary tumors. Dr. Post’s contributions to pituitary tumor surgery began early in his career, when

he became one of the early adopters of a revolutionary new transsphenoidal surgical approach. The transsphenoidal approach to pituitary surgery, which involves inserting surgical instruments through the nose to reach the brain, was first explored almost a century ago by such surgeons as the famed “father of modern neurosurgery,” Harvey Williams Cushing. But the technology of that era limited surgeons in what they could see as they worked, and so the procedure fell out of practice for decades. Then, in the 1950s, French neurosurgeon Gerard Guiot—one of the few surgeons who had continued to champion the procedure—adapted new imaging technologies such as fluoroscopy that enabled the transsphenoidal approach. The first surgeons to begin utilizing the approach, Dr. Post included, used microscopes; since then, endoscopes have become the preferred device. “The results were spectacular,” said Dr. Post, who knows a game-changer. “It changed the whole field.” To cite just one example, craniotomies have a one percent to two percent morbidity and mortality rate; the comparable rate for the transsphenoidal approach is less than one-tenth of one percent. “It’s a dramatically significant improvement in regard to safety and hospital stay,” said Dr. Post. “Compared to a craniotomy, hospital stay is a fraction of the time. The patients never hit the ICU. They’re out of bed that day like nothing’s happened.”

The Transsphenoidal School Perhaps artistic movements are less the invention of a solitary genius than the cumulative effect of many visionaries all pursuing the same idea. The same can be said of medical advances. In Dr. Post’s case, you could think of him as a champion of the transsphenoidal school of surgical arts.

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Since becoming one of the first surgeons in the United States to begin employing the new technique after learning it from Dr. Guiot’s collaborator Jules Hardy, MD, Dr. Post has been one of the leaders chiefly responsible for making the transsphenoidal approach the standard procedure for pituitary tumor surgery: It now accounts for more than 90 percent of cases. He is one of just three neurosurgeons in the country to have performed the surgery more than 3,000 times and is a coauthor of the field’s definitive textbook, The Pituitary Adenoma. He has been involved with numerous clinical trials that have yielded guidelines for successful patient outcomes. Along the way, as the former chairman of Mount Sinai’s Department of Neurosurgery, he has trained 38 residents, including more women neurosurgeons than any of his peers in the country; created a clinical center for skull base surgery at Mount Sinai; and expanded the department’s ICU ward, among other accomplishments. One of his proudest achievements, he says, has been his cross-disciplinary collaboration with his colleagues in Mount Sinai’s endocrinology program. Because the pituitary regulates much of the body’s hormone production, pituitary tumors can wreak havoc on the hormonal system and cause potentially deadly disorders such as acromegaly, in which an excess of hormones leads to runaway growth. Dr. Post’s investigations into the most effective treatments for certain kinds of invasive pituitary tumors that cause acromegaly established the criteria for defining cure and remission in those cases. For that landmark piece of work and others, Dr. Post was awarded the Endocrinologist of the Year award from Mount Sinai’s Department of Medicine—a rare distinction for a non-endocrinologist.

Next Masterpiece?

WHY ROTHKO?

Kalmon D. Post, MD Chairman Emeritus and Leonard I. Malis, MD/Corinne and Joseph Graber Professor, Department of Neurosurgery; Professor, Department of Medicine

Neurosurgery

“What sets Mark Rothko apart from most other artists is the boldness of his vision, the discipline of his technique, and the purity of his artistry. He manages to create a magnificent, evocative image in which color is its own justification, without a single unnecessary element. The precision of surgery and the ability to know when to stop is similar to the art of Rothko. In surgery, the beauty of the normal anatomy is stunning and by removing a tumor, it is restored. This is a bonus added to the very satisfying feeling of helping another person.”

Like the artists he admires, Dr. Post is always seeking the inspiration for his next masterpiece. He’s particularly enthusiastic about advances in drug discovery. “There will be medicines found for some pituitary tumors to stop their growth and shrink them, which will negate the need for surgery,” he predicts. “We’re advancing the understanding of the disease and what needs to be done.” He’s also optimistic about progress in minimally invasive technology—and with good reason, since he has helped shape the field’s continuing evolution. By virtue of having grown up with endoscopy as their milieu, Dr. Post said, the next generation of neurosurgeons will find it second nature, just as he came to regard microscope technology as an extension of his capabilities. “Microscope development occurred during my youth as a neurosurgeon, so it’s part of me,” he said, an artist speaking about the tools of his trade. “I don’t feel like I’m operating unless I have a microscope.”

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CURRENT IMAGING

FUTURE IMAGING

Live and in COLOR Joshua B. Bederson, MD, Chairman of the Department of Neurosurgery, describes how a powerful new imaging technology will give neurosurgeons a crystal clear advantage.

Mount Sinai Science & Medicine / spring 2012

MOUNT SINAI SURGERY MILESTONES

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Alexis Moschcowitz devises a surgery for the repair of rectal prolapse.

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Howard Lilienthal: Performs first pulmonary lobectomy for inflammatory disease; also known as the first successful pulmonary lobectomy for suppurative disease.

“On the left is an image of a brain, obtained before surgery and viewed midoperation, using our current technology. Neurosurgeons rely on images like this during surgery to navigate through the brain, but such technology conveys a relatively limited amount of information and cannot account for changes that occur during the operation. Now look at the right: an image of the same patient obtained with more advanced techniques and showing important motor fibers that control movement of the arm and leg. The difference is dramatic but this technique is not accessible at the most critical moment, during the operation, and cannot be updated in real time as the operation proceeds.

“Soon the Department of Neurosurgery will be equipped with advanced technology to see the brain in mid-operation with the same level of detail as we do before and after surgery, and to account for shifts in the position and shape of the brain that occur during surgery. A collaboration with one of the industry’s leading companies and the Department of Neuroradiology, the technology uses sophisticated GPS-like navigation devices, sliding gantry intraoperative imaging, 3D angiography, and other components that allow neurosurgeons to view— in real time—the results of the procedure. The benefits for patients are immediately clear. “Mount Sinai will be one of the first medical centers in the country to combine this technology with intraoperative biplane cerebral angiography. We already have some of the best neuroimaging specialists in the nation; now we’ll have the intraoperative technology to match that expertise.”

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Laparoscopic surgery pioneer, educator, researcher—Dr. Celia Divino balances all, but still keeps her equilibrium. And her eye on patient safety.

balancing act Written by Philip Berroll Photography by Don Hamerman

General surgery

elia Divino, MD picks up a tiny plastic rake and slowly, calmly pulls it back and forth across a miniature sandbox on her desk. “It’s a Japanese garden,” says this pioneer in minimally invasive gastrointestinal and hernia procedures. “When you’re stressed out, you rake it and it relaxes you. It’s kind of Zen.” It’s easy to see how Dr. Divino—one of the first practitioners to perform laparoscopic hernia surgery—would be interested in stress reduction, though hard to imagine her stressed out. Her life is a kind of tightrope walk, involving a dizzying array of responsibilities. While she maintains an active surgical practice, befitting a surgical innovator, she also serves as Chief of Mount Sinai’s Division of General Surgery; Professor of Surgery at Mount Sinai Medical School; Vice Chair of Quality and Education; Program Director of the General Surgery Residency Program; and head of the groundbreaking Surgical Simulation Center, where both new and experienced surgeons learn the latest robotic surgery techniques. “When I was in medical school,” she recalls, “it was my dream to be what was called a ‘triple threat’—a person who does research, teaches, and has an active practice. I feel fortunate to be able to do all three.” In her work, Dr. Divino also engages in another kind of balancing act: While teaching and advocating for innovative surgical procedures, she firmly believes that no new technique should be introduced without taking issues such as patient safety and quality of care into account. “With any new procedure, I think that people should resist a bit when they have doubts regarding safety—after all, we’re doctors, we can’t endanger our patients,” she says. “So there has to be quality control, and appropriate credentialing. Not everybody can just go out there and start doing this.”

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Dr. Divino has won several awards from Mount Sinai for her accomplishments in the laboratory, the classroom, and the operating room, including the Arthur A. Aufses, Sr., Prize in Surgery, the Dr. Robert Paradny Teaching Award in Surgery, the Physician of the Year Award, and the Surgical Attending of the Year Award.

Today’s ‘heresy’ may be tomorrow’s standard procedure

Mount Sinai Science & Medicine / spring 2012

“ When I was in medical school it was my dream to be what was called a ‘triple threat’—a person who does research, teaches, and has an active practice. I feel fortunate to be able to do all three.”

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How does Dr. Divino preserve her equilibrium? By conserving her energy, keeping her sense of humor— and practicing a kind of synergy, where her experience in one area complements and enriches her work in another. For example, take her position at the Surgical Simulation Center (SSC), a state-of-the-art facility where surgical trainees and experienced surgeons alike can learn and practice techniques using laparoscopic and endoscopic simulators: working at a computer-based tabletop and manipulating robotic instruments as in an actual operation, while monitoring their progress in the digital image of the “patient” on a screen. It’s a process with many similarities to minimally invasive surgery; and there is a clear overlap among Dr. Divino’s advocacy for the center, her role as an educator, her quality-control concerns, and her experience performing minimally invasive surgeries such as the innovative hernia procedure. “There were a lot of pioneers across the country, but I particularly focused my interest on many aspects of hernia surgery—not just inguinal [groin] hernias but ventral [abdominal] hernias,” she recalls. “I looked into it from a more academic standpoint; I did a lot of studies on it, on the durability, safety, and outcomes of this procedure. And I still have an interest in pushing the envelope and trying to see if there are other efficient ways of doing the surgery, with better outcomes.” For patients who are good candidates, she cites several advantages for laparoscopic hernia surgery over traditional procedures. “With a laparoscopic procedure, you have a smaller incision than in open surgery. You still have a dissection, of course, but with much less pulling and tearing, so there’s considerably less trauma. And the recovery time, the possibility of wound infection, the durability—all are much better.”

Dr. Divino makes a similar case for the laparascopic approach in her other major field of interest, gastrointestinal surgery. “For gastrectomies, small bowel resections, colon resections for both benign and cancerous growths—you have the same differences in technique and in the effect on the patient,” she says. “Or look at cholecystectomy [gallbladder removal]—that used to be a three or four day hospital stay when it was performed as an open procedure. As recently as 1992, people thought the idea of doing it in such a way that the patient could go home the same day was crazy—it was heresy. But we’ve since proven that when you do it laparoscopically, it’s a fourhour—not four-day—stay in the recovery room. Colon cancer, gastric cancer, small bowel cancer, all of them can now be approached using minimally invasive techniques with the same outcomes in terms of survival and adequacy of resection. And that is really important.” Not surprisingly, Dr. Divino has often encountered initial objections to new techniques—and not only on the grounds of patient safety. “It can be harder for people who have done it a certain way to adapt to what is quite a steep learning curve,” she observes. “Do you want to start from scratch again when you’re able to do this and you’ve been doing it safely for 20 years? But I think our responsibility as leaders in the field is to reassure them—to say, ‘I don’t care if you’re at this stage of your career, you can still learn it if you want to.’” It’s in that spirit that she declares the SSC “open to everybody—not only to train new doctors, but also those who have been in the profession for some time.”

The video game advantage Dr. Divino feels that in one regard, the current generation of surgical students does have an advantage: Their experience with video games gives them a leg up. “One of the most difficult things in doing laparoscopic surgery is that you can only work in two dimensions, as opposed to three dimensions when you’re doing open surgery,” she explains. “In laparoscopy, you have, at the

BALANCING ACT

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most, four degrees of freedom: You go this way or that way, or up, or down. You can’t turn the instrument around there because it’s a fulcrum. “But kids who do video games, they’re used to playing in two dimensions,” she continues, “so it’s second nature to them. Studies have shown that kids who play video games have better hand-eye coordination. Even my son, who naturally has played on the Wii, the Xbox, etc., has been asking to use a surgical simulator to prove to me that he would be good with it,” she says with a hearty laugh. “And I say, ‘We’re not having a simulator at home!’” The educational process has changed in other ways since she began teaching. “The mass of knowledge is expanding, but we have less time to teach it in the hospital because of the regulations that have been put in,” she notes. “Interns can’t work more than sixteen hours at a stretch or have too many calls. You have to supplement their operating room experience because they can't stay there all night long anymore. So you think of innovative ways to get the message across. When we teach our curriculum, we actually give them Web-based modules and reading materials to study. We are also able to teleconference our teaching conferences to other hospitals, so they don’t have to physically be here. And on balance, I think it’s for the best.” Dr. Divino has also made the concept of team training, which emphasizes the kind of collaboration and teamwork that takes places in an actual operating room, a core part of the Surgical Simulation Center and of the overall curriculum. Again, she stresses the importance of patient safety and the quality of care. “There’s a lot more emphasis on those factors,” she says. “That emphasis has always been there, but now there are a lot more requirements and oversight. It’s no longer that cowboy mentality of residents, operating by themselves, making crazy decisions. And that has to play a part in education.”

Some things don’t change

Unfinished revolution For all her pioneering efforts in surgical research and development, Dr. Divino has also broken new ground in another sense: as a female surgeon and surgical educator in what had long been a male-dominated bastion of medicine. She considers it to be “revolutionary, even unbelievable” how much things have changed since she began her medical career. And while acknowledging that “there’s still a long way to go for female surgeons—we have plenty who are assistant professors, but very few who are at the tenured, full professor level,” Dr. Divino also notes that “forty-five to fifty percent of the applicants to surgical residency are highly qualified women from the best medical schools—some more qualified than the men. It used to be maybe twenty percent. The number of women in the American College of Surgeons, the number of women in residency programs—they’ve all gone up.” But in her view, the rest of the country is just following Mount Sinai’s lead. “We were always ahead of the curve here,” Dr. Divino says, “because of Dr. Arthur Aufses [Chairman of the Department of Surgery from 1974-1996], who was one of the trailblazers in bringing in a lot of women.” Dr. Aufses, who is currently Professor of Surgery and Professor of Health Policy in Mount Sinai School of Medicine, agrees with Dr. Divino’s assessment. “About a third of the surgical students at the School of Medicine are women,” he notes. “That’s real progress—though when you consider that for many, many years we’ve had fifty percent or more women overall as medical students, we’ve still got a way to go to make it really equal in surgery.” Dr. Aufses is not surprised by the success of his former protégée. “Every once in a while, you see somebody and you know they’re going to be a star,” he says. “Celia was destined to be a star from the beginning.”

MOUNT SINAI SURGERY MILESTONES

19 15 Surgeon Richard Lewisohn describes the minimum amount of citrate required to prevent blood from clotting, making indirect transfusion possible and practical, allowing blood to be stored for later transfusion. Paved the way for modern blood banking.

19

Richard Lewisohn: Publishes first paper in US about new surgical procedure for duodenal ulcers, the gastrectomy. These operations, many performed by A. A. Berg beginning c1920, became the accepted technique after a period of sharp controversy.

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19

Howard Lilienthal: Publishes textbook on thoracic surgery that becomes a standard reference.

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General surgery

But there are also some unchanging lessons that Dr. Divino has always imparted to her students. “First of all, don’t lose track of why you’re here, and that’s the patients; they come first. Two—and this goes hand-in-hand with number one—you have to take ownership of your patients. Make sure that nothing falls through the cracks, and that all the people on your team know what’s going on. Three, you have to have a passion for what you do, or else you’re not going to do a good job. Fourth, keep on learning, whether it’s on the floor or by reading. Fifth, always maintain a certain amount of professionalism, whether it’s not wearing jeans on a Saturday even if you’re so tempted, or always being respectful of the patient’s race or religion, or the way you talk to your colleagues on a different service. And finally, before you do anything, stop and think. Because medical errors are unforgivable—and if you just stop and think for a moment, it may save a patient.” Dr. Divino also wants her students to be

knowledgeable on the subject of global health. Born and raised in the Philippines—she came to the United States to study at University of California-Davis and UC-Berkeley—Dr. Divino is acutely aware of the differences between Western health care and health care in the developing world. Under her leadership, surgical trainees have traveled to communities in Southeast Asia, Haiti, and elsewhere to teach and help set up health care programs, and all senior surgical residents participate in a month-long surgical rotation in the Dominican Republic. “Having come from that culture, I think our goal should be sustainability,” she says. “We try to go there and train the surgeons, the local people, not to do it our way, but to improve how they do it, or teach how we do it so that they’re able to do it on their own. We don’t convince them that the way to do it is using these fancy machines, because nobody there can afford them.”

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Meet Mount Sinai’s  Evan Flatow, MD,  the very definition of  the world’s best shoulder replacement surgeon.

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DO

ER written by Katie Quackenbush Speigel photography by Andrew Lichtenstein

Dr. Brigance’s appointment is at 3:00. For the last several years, he and his wife have traveled to New York from Paducah, Kentucky to see Dr. Flatow at

pioneered several shoulder replacement systems and minimally invasive rotator cuff repair techniques, and completes between four and 12 operations each week. He conducts groundbreaking research into tendinitis and repetitive use injuries. And as Chair of the Leni and Peter W. May Department of Orthopaedics, he runs

1. [noun] One who does. 2. [renown] Dr. Evan Flatow. one of the largest, busiest, and most innovative departments in the United States, with patients ranging from professional athletes and weekend warriors to active baby boomers and day laborers. Oh, and he trains several shoulder surgery fellows every year, providing the kind of highly competitive training required to specialize a surgeon’s career. You could fairly say he’s kind of busy. the suggestion of many leading orthopaedists they’d consulted in the south. Nearly a decade ago—years before he came to Mount Sinai as a patient of Dr. Flatow— Dr. Brigance, a retired urologist who is fit and tanned at 73, underwent a shoulder replacement surgery, which ultimately failed. Dr. Flatow was able to fix it in a second “revision replacement” operation in 2006, retaining the artificial socket but revising the ball and stem and liberating the nerves and soft-tissues from scar. “At the time, I asked the doctors, ‘Isn’t there anybody in the South I can see? I don’t want to go all the way to New York City,’” said Dr. Brigance. “But we’re glad we came—we’re very grateful to Dr. Flatow. I’ve played golf pain-free for four years now. And of course we’ve fallen in love with New York.” Dr. Brigance is a typical patient for Dr. Flatow, whose clinical interests are in shoulder disease (like tendinitis and arthritis), fractures, and tendon tears. Dr. Flatow said that while he sees young athletic patients such as baseball pitchers and tennis players, most of his patients are active people in their 50s and 60s whose injuries, surprisingly, tend to be more severe. In Dr. Brigance’s case, his failed shoulder replacement surgery a decade ago left him unable to lift his arm more than 20 degrees, golf, pick up his grandchildren, or even pour a glass of milk from a gallon jug. And he was in terrible pain every day. “We have natural degeneration of the tendons as we age, and later in life, tendons can tear right off the bones,” Dr. Flatow said. “As many as sixty percent of the tears surgeons fix re-tears later, especially if the patient is older, because the tendon doesn’t heal. Sort of like if a tree is pulled out by a storm, and the roots are left in the sun. If you replant it, the tree just doesn’t take.”

MOUNT SINAI SURGERY MILESTONES

19

29 Moses Swick: Introduces Uroselectan as first radioopaque media for visualization of the urinary tract, while on traveling fellowship sponsored by Mount Sinai.

19

Harold Neuhof and Arthur Touroff: Describe development (with Coleman Rabin and Ameil Glass) of the early one-stage surgical drainage technique for putrid lung abscess.

36

Orthopaedic surgery

But you’d never know, talking with him. He’s calm and easy-going; he speaks without urgency and doesn’t seem hurried or preoccupied. Tall and genial, and claiming to be the “least athletic orthopaedist you’ll ever meet,” Dr. Flatow wears a bow tie every day. So how did he decide to become Dr. Flatow, the globally renowned, highly sought-after shoulder surgeon with the jam-packed schedule? “Proust said we usually make the most important decisions of our lives for the silliest of reasons,” Dr. Flatow said recently, when we had a rare opportunity to shadow him for an afternoon. “In medical school, you pretty quickly sort yourselves out. Internists are brilliant thinkers, but may be less dextrous. Surgeons are the doers—they are tactile, good with their hands, very precise and visual; in their spare time lots of surgeons make models, fix cars, do carpentry,” Dr. Flatow said, seated at his desk. He moves the joint on the metal artificial shoulder he keeps in his desk drawer as he speaks. “And many of us are impatient—we don’t have to treat someone for years with medicine to make them better. I replace a shoulder, and a week later the patient has less pain than they have had for twenty years. I don’t have a creative bone in my body, but I can sculpt, very precisely, and I like instant gratification.” So do his patients.

Internationally renowned in the field of shoulder surgery, Dr. Flatow

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DOER

“I like to say that minimally invasive surgery to fix your shoulder and keep you active is much more cost-effective than heart surgery, down the road.”

MOUNT SINAI SURGERY MILESTONES

19

Arthur S.W. Touroff: Working with Harry Vessel, report first successful surgical treatment of patent ductus arteriosus complicated by subacute Streptococcus viridans endarteritis.

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John H. Garlock: First successful resection of a middle third esophageal carcinoma, i.e. the first successful resection with re-establishment of continuity without a gastrostomy. Prior successful reports all were done in stages.

Mount Sinai Science & Medicine / spring 2012

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19 51

Surgeons Albert S. Lyons and George Schreiber establish a first-ever patient self-help group of Mount Sinai ileostomy and later also colostomy patients.

So, supported by a grant from the National Institutes of Health, Dr. Flatow and his team are conducting basic science in the laboratory with stem cells, genes, and the world’s first animal model of the tendon fatigue overload he sees in his patients. “We have a great tradition at Mount Sinai: We have a superb orthopaedics department and extremely talented surgeons who can deal with the most complex cases,” said Dr. Flatow. “But Mount Sinai is a very unusual institution because the medical school and the hospital are so closely intertwined, with one leadership group for both institutions. So we have the best clinicians, who treat very complex injuries, working with the best scientists, who are trying to develop ways of repairing the joints and bones. The traditional surgery for the spinal disk, for example, is to cut it out, or to fuse it. Here at Mount Sinai, our spine team is trying to learn how to repair it, re-growing it with stem cells and artificial tissues.” Dr. Flatow’s own basic science investigations are aimed at understanding how tendon degeneration happens in the first place so that scientists can identify ways to treat or biologically reverse that process, rather than just mechanically repairing it. They may also be able to develop treatments that prevent tendons from ever degenerating in the first place. “Many of my patients are baby boomers who want to stay active—people who want to keep playing sports into their older years, people who don’t want to be sidelined,” Dr. Flatow said. “They come here because they really want to get excellent treatment, but treatment that’s also not going to slow them down.” The rise of minimally invasive and arthroscopic surgical techniques has made such instant gratification an easier feat to accomplish for patients and surgeons alike. Dr. Flatow said that when he was a resident, almost all surgeries were done through large “open” procedures. Although he said he completes several open surgeries every week (which are required in the case of a failed total shoulder replacement like Dr. Brigance’s), when minimally invasive techniques are an option, they’re an excellent choice.

“If you can have the same operation done through a tiny incision with less dissection of the soft tissues, with less inflammation and swelling and less chance of infection, you’re just better off,” Dr. Flatow said. And patients can even go home the same day. His clinical research has produced new minimally invasive and arthroscopic techniques for repairing fractures, and several shoulder replacement systems— artificial joints—that are now in use all over the world in arthritis patients. Dr. Flatow and his team have also published articles in major medical journals comparing minimally invasive procedures to traditional open surgeries both in terms of outcomes and cost effectiveness. “These are all fundamental questions that aren’t well understood and that afflict millions of people around the world,” said Dr. Flatow. Often, he said, a painful shoulder prevents activity, resulting in a sedentary lifestyle—and dangerous health conditions like obesity, type 2 diabetes, and heart disease. “I like to say that minimally invasive surgery to fix your shoulder and keep you active is much more cost-effective than heart surgery, down the road.”

In his 30 minutes with Dr. Brigance, Dr. Flatow carefully examined his patient’s shoulder joint at work, evaluating the joint and positioning the arm at different angles. “We had to dig this out of scarring; the nerves were all stuck,” said Dr. Flatow. Dr. and Mrs. Brigance nodded, almost with pride, remembering how bad the arm had been before they saw Dr. Flatow. “This was a hard operation—seven hours—not a minimally invasive procedure; we had to really cut him open.” Dr. Brigance described for the surgeons-in-training, who had crowded into the exam room to learn from the expert at work, how he hadn’t had pain or any movement problems since Dr. Flatow repaired his shoulder replacement in 2006. He said he was thrilled to have use of his arm back again, let alone the ability to golf and carry a suitcase. Then he described how, beginning a few months earlier, he had begun to experience aching in his arm that lingered for several days after playing a round of golf.

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“Well, if I do that, I’ll drop it at 250 feet,” said Dr. Brigance. Everyone in the room laughed. “And I probably shouldn’t be doing any heavy housework or anything like that.” His wife batted his arm; the fellows looked relieved. “Well, that’s my suggestion: let it rest over the winter, try playing some golf in the spring. Do the things you like to do,” said Dr. Flatow. “We gave you a good arm, and it’s fun to use it. But if it’s not working, we’ll reevaluate it next year. That’s what I would suggest.” “That’s kind of what I thought I’d hear, but I wanted to hear you say it,” said Dr. Brigance, shaking hands with Dr. Flatow. They agree, for now, to be patient.

After the appointment, in the hallway of the clinic, Dr. Flatow said, “ Dr. Brigance is an excellent example of the tertiary cases we were talking about. I’ll probably see twenty patients sort of like him in the clinic today— active older people who don’t want to slow down.” He studied a new chart outside the exam room containing his next patient, asked his fellows if they were ready to move on, and said, with his hand on the doorknob, “But of course this is just one piece of what I do.”

C All in a day’s work: Dr. Flatow trains surgery fellows while conducting a follow-up exam on Dr. Brigance.

MOUNT SINAI SURGERY MILESTONES

19 51 Neurosurgeon Leonard Malis develops first automated apparatus for cerebral angiography.

19

Samuel Rosen: Reports new operation that relieved deafness in otosclerosis by mobilizing the stapes.

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Orthopaedic surgery

“So I quit playing golf as a last resort,” Dr. Brigance said. “Of course, I can survive like this, but I just can’t do everything I want to do.” On a computer screen, Dr. Flatow scrutinized x-ray images of the shoulder joint taken the day before, asked Dr. Brigance many questions, and talked through his deductive medical reasoning with his shoulder fellows. The couple waited patiently, listening to the students’ questions and periodically nodding as the doctor detailed his observations. Then Dr. Flatow stepped back from the exam table and gave the opinion the Brigances had traveled from Kentucky to hear. “The good news is I don’t see anything that looks urgent or that we need to do something about right now,” said Dr. Flatow. The Brigances looked relieved. He explained that since he had ruled out other possible problems, it looked like the socket, retained from Dr. Brigance’s original failed operation, might be wearing out. In socket deterioration, polydebris, or tiny wear particles, surround the artificial joint and the bone resorbs slightly, the joint moves more, and the patient can feel a bit of pain. “The treatment for that is to do just what you’ve done—not push it too hard. You’re still a hell of a lot better than you were before,” said Dr. Flatow. Dr. and Mrs. Brigance nodded their heads and murmured in agreement. “Well, you started out with a defective arm anyway,” said Dr. Brigance. “Yes, you’re right; you had the previous surgery that failed, and the axillary nerve was caught, and you had the scarring,” said Dr. Flatow. “This wasn’t the first time I got to build the car. And it’s not that we can’t do anything—we definitely can.” He explained how he could replace the entire shoulder joint with a new one, but that Dr. Brigance probably wouldn’t want to do that since the ache he experienced after golfing wasn’t really limiting his lifestyle. Instant gratification has to be worth the recovery. “You’re not going to harm your arm by using it, and a little pain is ok,” Dr. Flatow said. “Some people play golf without driving; they play with a buddy, who drives—and wherever he drives you drop your ball and just pitch it down the fairway.”

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Written by Sara Daniels Illustration by Josh McKible

Expanding the Arsenal A breakthrough new chemotherapy treatment—with Mount Sinai leading the way—against advanced peritoneal cancers.

I

MOUNT SINAI SURGERY MILESTONES

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Isadore Kreel and colleagues are first to describe “postperfusion syndrome” after open heart surgery, a new procedure.

Mount Sinai Science & Medicine / spring 2012

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69 Norman Simon develops a successful afterloader for brachytherapy, internal radiation therapy with an implanted source of radioactivity.

In July 2007, Dr. Daniel Labow, associate professor of surgical oncology, performed Mount Sinai’s first Hyperthermic Intraperitoneal Chemotherapy (HIPEC) treatment—an aggressive, intraoperative procedure during which a concentrated liquid chemotherapy solution is heated and circulated throughout the abdominal cavity to target cancer cells directly—on a young woman who had been diagnosed with metastatic stomach cancer. Today, Dr. Labow, who joined Mount Sinai in 2004, has 160 patients in his HIPEC series—one of the largest in the country—and patients seek him out specifically for this expertise. “We’re at about 50 operations a year now,” Dr. Labow says. Only a handful of institutions across the U.S. offer the HIPEC treatment; in fact, when Dr. Labow began performing the treatment at Mount Sinai, it wasn’t yet available in the northeast. “Most cancer surgeons don’t do it,” Dr. Labow explains, “because it’s a major investment in time and technique. It’s labor intensive, and you need to be skilled in all areas of the abdomen.” Though awareness and performance of the procedure is not yet widespread, HIPEC is a “new

tool in the kit” for surgical oncologists, according to Dr. Labow, because it offers patients with cancers of the peritoneal or abdominal cavity (including cancers of the colon, stomach, appendix and other intraabdominal organs) a targeted treatment option that attacks the cancer cells directly. This is a breakthrough against cancers that often go undetected until they are advanced, limiting their treatment options. HIPEC also shortens recovery times and spares patients the daunting physical side-effects of chemotherapy. “Traditional chemotherapy doesn’t penetrate peritoneal cancers well and you can’t be sure it’s circulating throughout the abdomen,” Dr. Labow said. “HIPEC evolved from the need to expose every single surface to the chemo. It’s not a pinpoint target, but it’s getting the chemo closer to where it’s needed.” HIPEC has already become the standard of care in treating appendix cancer, and has shown clear success in treating some appendix and colon cancers. And HIPEC has been used successfully as a treatment for ovarian cancer: “I’m working with gynecological oncology to really launch that aspect of our program,” said Dr. Labow. There have also been some early efforts to use HIPEC in the chest cavity to treat mesothelioma, a cancer along the lining of the chest cavity. HIPEC gains may seem relatively modest, given the severity of disease in eligible patients. “Usually patients are stage 4 so their survival rates are in the six month to a year range before treatment. We’re close to doubling that,” Dr. Labow said. But these improvements are significant and promising. For patients with pseudomyxoma perotinei, a low grade tumor of the appendix that emits toxic mucus into the body too slowly for traditional chemotherapy to have an effect, “we can get survival rates of decades now. It’s made a big difference,” Dr. Labow notes.

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1

2

1 CHECKING IN The surgeon determines a patient’s eligibility for HIPEC based on evidence that he or she will be physically strong enough to endure the strains of surgery, that the disease is contained in the abdominal cavity, and that he will be able to get an “optimal debulking,” meaning that he will be able to remove all or most of the large tumors through surgery prior to administering HIPEC. 2 REMOVING THE TUMORs During cytoreductive surgery, performed using traditional or laparoscopic (minimally invasive) techniques, the surgeon painstakingly removes the visible tumors from affected organs. Removing the tumors may involve organ resection, or the removal of part or parts of an affected organ.

HIPEC: STEP BY STEP 3

4

109°

109°

3  inserting the catheters Once the remaining tumors are the size of a sesame seed or smaller, the surgeon inserts two inflow catheters under the diaphragm in the upper abdomen, as high up as possible. The drainage catheters are inserted near the pelvis. The surgeon temporarily closes the skin to provide a watertight surface.

+2 HRS

4  setting the temperature

5

6

The catheters are connected to a bypass machine, which heats the liquid chemotherapy solution to between 41 and 43 degrees Celsius (105.8 – 109.4 degrees Fahrenheit) for optimal tumor penetration and cytotoxicity (ability to kill harmful cells). 5  circulating the solution The solution is circulated throughout the abdominal cavity for two hours or more in order to expose every single surface to the chemotherapy.

109°

Surgical oncology

HRS ++22 HRS

6  follow-up chemo In the weeks following surgery, traditional intravenous (IV) chemotherapy treatment is often administered to improve outcomes.

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Nearly 25 years ago, Dr. Myron Schwartz and his colleagues at Mount Sinai made history by performing the first liver transplant in New York State.

Pushing Limits Interview by sara daniels

It was a groundbreaking procedure that revolutionized care for patients with advanced liver diseases, and helped catapult Mount Sinai’s liver transplant program to the second largest in the world. Today, Dr. Schwartz remains a leader in transforming surgical care options for liver cancer patients as the director of surgical oncology, associate director of liver transplantation, and Henry Kaufmann Professor of Surgery at Mount Sinai. We recently caught up with Dr. Schwartz—on his way to rehearsal for Francis Patrelle’s “The Yorkville Nutcracker”—to ask about his insights into how the surgical field for liver cancer has evolved over the past two decades. And, of course, about ballet.

Q: Why has transplantation remained the standard of care for liver cancer patients for so long? It has to do with the way the disease develops. Liver cancer typically develops over time from another disease of the liver that causes cirrhosis, such the Hepatitis B and C viruses. As time went by it became clear that liver transplant is a good option because 90 percent of people that have liver cancer have liver disease as well, so you could treat both the disease and the cancer.

Q: Your work has been shifting away from transplant toward alternative surgical options such as liver resection, which removes affected parts of the liver rather than the whole organ. Why is resection preferable to transplant? There are drawbacks to transplantation. Patients in New York, for example, are usually looking at a year-long wait before a liver becomes available. Liver resection doesn’t require a donor, so we can intervene sooner to isolate and remove sections of the liver that contain tumors. We can do this laparoscopically as well. Liver cancer is really one of the last frontiers of laparoscopy. Right now we’re at about 16 to 20 percent of resections that are laparoscopic.

Q: What advances do you anticipate will do the most to drive new approaches to treating and preventing liver cancer? Advances in imaging have been critical to driving advances in minimally invasive treatments. More than 50 percent of cases of this disease are curative with early detection but when we started out we had ultrasounds and basic CT scans that couldn’t show liver cancer. Since the 1990s, the advanced CT and MRI allow us to survey at-risk patients. We used to find tumors by accident during surgery—we never find them by accident anymore. Early detection means earlier interventions in a disease that is so often advanced before it’s detectable. But the field is also focused on curing the diseases that develop into cancer, namely Hepatitis C.

Q: Surgeon by day, ballet dancer by night? How long has ballet been a hobby for you?

Visit artsbeat.blogs.nytimes.com and search for Myron Schwartz to read: “The Nutcracker Chronicles: The Doctor Will Dance for You Now”

I’m by no means a serious dancer, but I first took ballet lessons in 1999 and this December marked my fourth performance in “The Yorkville Nutcracker” at the Kaye Playhouse at Hunter College. I performed as the Chinese consul. Being part of the creative process is a great feeling. The most exciting part this year, though, was having my wife Diana dance opposite me as Mrs. Theodore Havemeyer. Our six-year-old daughter Hari also took part. It was great fun.

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SURGEONS

Photography by Andrew Lichtenstein

specialist in aortic aneurysm repair, Dr. Ellozy is the principal investigator for several different clinical trials examining potential new treatments for the disorder. Dr. Patel is a leader in minimally invasive treatment of brain and spinal disorders that replace long and difficult traditional surgeries with low-risk interventions—allowing patients to go home the same or the following day. The three surgeons discussed their clinical interests, the value of cross-disciplinary collaboration, and even what kind of music they like during surgery.

Vascular surgery

Interview by Travis Adkins

cience & Medicine recently sat down with Peter Faries, MD, chief of the Department of Surgery’s Vascular Division; Sharif H. Ellozy, MD, also a surgeon in the Vascular Division; and Aman Patel, director of the Endovascular Neurosurgery and Interventional Neuroradiology Program in the Department of Neurosurgery, for a far-ranging conversation. Each of these three talented surgeons brings a unique clinical focus to the area of expertise that unites them: the vascular system. An expert in aortic aneurysm repair, Dr. Faries is also a pioneer in the treatment of carotid artery disease for the prevention of stroke. Another

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THREE SURGEONS

Science & Medicine: Talk a little bit about how and why you each started to pursue your specialty. Aman Patel: I was a neurosurgical resident at UCLA and I knew I wanted to do vascular neurosurgery, which is mostly aneurysms. I told the head of cerebral vascular surgery that I wanted to complete a fellowship year with him, and he suggested that instead I approach the radiology department about completing a fellowship there. This was almost 12 years ago, and at that point there were not that many neurosurgeons doing interventional radiology—in fact, probably only a few in the country. Peter Faries: Aman, how did you feel that your expertise as a neurosurgeon, and not a neurointerventionist, was going to advance the care in that field? In other words, you’re bringing two really distinct skill sets and a similar knowledge base to bear. What’s the advantage of that over going straight into neurointervention?

Above: As a researcher Dr. Faries leads an NIH-funded laboratory investigating the use of stem cells to treat aortic aneurysms. Below: Drs. Faries, Patel, and Ellozy work closely to bring new approaches in vascular surgery to their patients.

Dr. Patel: I could already see that more and more of the vascular disease in the brain was going to be treated via endovascular procedures [procedures performed by entering the body through blood vessels rather than through open surgery] but not everything, and certainly not serious complications that arise when things go wrong. By learning endovascular techniques, when I see patients with aneurysms I can say these are the options: “We can do an open surgery and clip the aneurysm or we can do it via endovascular means, but this is what I would do for your aneurysm.” I’m not restricted by being able only to perform one or the other. Dr. Faries: In all areas, the field has moved in a direction of doing procedures either percutaneously [through needle punctures to the skin rather than through incisions] or with a minimum of physiologic disruption. Our practices have evolved from doing everything as

an open procedure to doing more and more minimally invasive procedures. Sharif Ellozy and I can each say that that we employ the same sort of approach that you describe, Aman; we can provide the optimal method of treatment without being tied down to “I only do surgery, so I’m going to recommend surgery.” Dr. Patel: What I basically tell patients is that the goal is to treat your disease in the least invasive way possible. But the first goal is to treat the disease, so I’m not going to use a less invasive approach if it’s going to be a non-optimal treatment. So it’s optimal treatment in the least invasive way possible. Dr. Faries: Sharif, when you see somebody who could be a candidate for open repair or an endovascular repair, how do you decide what approach to take? Sharif Ellozy: It depends on the patient. Some patients are good candidates for both, and in that case, I offer both options. I have my personal preference, but I let them decide; more often than not, they’ll go with a less invasive approach. The technology’s evolved now to the point where in appropriate anatomy, the durability is equivalent to an open repair. There are still trials ongoing, but it’s now fairly clear that early results [of endovascular surgery vs. open surgery] are better and the long-term results are just as durable. Dr. Faries: If we look at the evidence of the trials there’s a good amount of data that suggest that people do better with the endovascular approach, provided their anatomy is suitable. And if we examine the evidence of our eyes, the patients seem to do so much better in terms of how they tolerate the surgery, how they recover from surgery, and how they do in the long term. It’s not surprising when we look at practices across the country that more and more patients are treated that way.

Science & Medicine: Techniques and technology developed to treat neurovascular disorders have shown the potential to be effective for treating other vascular disorders, and vice versa. What are your thoughts on the importance of crossdisciplinary collaboration? How does it inform your clinical focus? Dr. Ellozy: What I find most stimulating about being in a place like Mount Sinai is that are a lot of smart people who have access to a lot of different technologies. For example, Juan Rocca, a transplant surgeon in the Recanati/Miller Transplantation Institute, is investigating new laparoscopic approaches for kidney transplants that are based on a laser-assisted technology originally developed for intracranial bypass operations [operations to increase blood flow in the brain]. You get stimulated by seeing these different

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techniques and thinking of possible uses in your own practice. For more about Dr. Rocca’s procedure, see p. 44. Dr. Patel: There are a lot of specific, concrete examples of collaboration. For example, Sharif and I are on several institutional review boards together. Among the most valuable kinds of collaboration are the little things that happen on a daily basis. I might be walking down the hall and Sharif will say, “I have this patient with this problem—do you have any ideas on how to handle this treatment?” Dr. Faries: It’s very important, as you develop new techniques, to monitor your results and demonstrate that what you’re doing is benefiting the patient. We have a program [that Dr. Patel started] to review carotid stenting to look at outcomes, potential complications, and how to ensure the safety of the procedure itself. And that type of monitoring is critical to the development of new techniques. Its importance can’t be overstated. Dr. Ellozy: At Mount Sinai, the first line of therapy for treatment of visceral aneurysms and splenic aneurysms [aneurysms in the artery that supplies blood to the spleen] has become endovascular. All these techniques have been adopted from embolization [blocking a blood vessel to reduce pressure on an aneurysm] of intracranial work primarily. Certain diseases are rare enough that you can’t do good randomized control clinical trials. You have to rely on the experience and judgment of people in other fields who have used the devices, take their advice, and apply it elsewhere. Dr. Patel: Likewise, our intracranial stenting and angioplasty started with coronary work and some of our thrombectomy [removal of a blood clot] techniques started with peripheral thrombectomies. Devices have been adapted for smaller vessels, but it’s a similar approach. Dr. Faries: The collaboration goes beyond any individual case. We couldn’t do carotid intervention, whether it’s open or endovascular, without having a neurointerventionist with the ability to potentially treat a patient who develops an intracranial thrombus or another complication along those lines. That’s what allows the procedure to be done safely or maximize the safety with which it’s done. For all of us to be able to do our jobs, surgeons sometimes need to rely on each other. Fortunately issues don’t arise very often.

Dr. Patel: Some people like music to relax them. I hate music in the OR; I can’t stand it. If I were to play something, though, it would probably be punk rock. Dr. Faries: Sharif prefers rap and hip-hop. Dr. Ellozy: I usually play music in the OR, particularly if it’s a long case. But I ask the patient first and play something that they like. Dr. Faries: If they’re under general anesthesia, it doesn’t matter. Dr. Patel: Sometimes I hear Neil Diamond coming from Dr. Faries’ operating room. Dr. Faries: (Laughs) There you go. Sharif, I’ve always admired the amount of preparation you do for surgery, so I’d like to hear you talk about that. Dr. Ellozy: A little bit of stress makes you function better. Too much stress, you decompensate and you can’t function well. Maybe it’s my obsessive compulsive disorder, but you want to try and control everything that you can so that if unexpected things happen, you’ve been able to anticipate and adapt. My routine for preparation is to make it as simple as possible and try to minimize all the odd and unexpected things. A lot of research has been done into the advantages of a team-based approach, like a flight crew preparing for takeoff. Dr. Patel: The key is that you make it not stressful but rather a matter of being prepared. That’s how most of the stress arises: from unexpected things. You can’t predict everything, but you can know the major pitfalls and be ready for them. Dr. Faries: I think the point that Sharif touched on, the team concept, is essential. It’s not just the surgeon and the surgeon’s assistant. It’s the scrub technicians who set the operating room up, the nurses who prepare the patient leading up to surgery, the nurses who manage the patient post-procedurally. You really rely on high-level performance in every aspect to ensure a good outcome for the patient.

MSSM SURGERY MILESTONES

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Mount Sinai has its first woman surgery resident.

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Angelos Papatestas, Daraius Panveliwalla, Demetrius Pertsemlidis, Michael Mulvihill, Arthur H. Aufses Jr. are first to show the association between estrogen receptors and obesity in breast cancer patients.

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Vascular surgery

Dr. Patel: We’re still behind on devices for preventing and treating strokes. Cross-disciplinary collaboration needs to happen more frequently in the medical community if we want to change that. If I add up all the number of aneurysms in the country, it’s still a tiny fraction of the number of strokes. At Mount Sinai we probably do a total of about 30-40 acute stroke interventions per year compared to over 100 aneurysms per year—and yet there are 30,000 ruptures in the country per year and more 700,000 strokes per year.

Science & Medicine: Performing surgery has to be one of the most intense, stressful experiences imaginable. What’s your state of mind right before you perform surgery? What do you do mentally to prepare?

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Drs. Salky and Steinhagen know that innovations in colorectal surgery can preserve dignity and function, while transforming quality of life for their patients.

Mount Sinai Science & Medicine / spring 2012

“I was a big believer from the beginning because I saw the potential good … the difference is like night and day.” – Dr. Salky

Written by Sima Rabinowitz Photography by Don Hamerman

ot many patients want to talk about gastrointestinal disease. The symptoms can be relentless, even embarrassing, and the diseases themselves can strike fear, for good reason. The many patients who suffer from colorectal diseases and conditions may experience frequent, sometimes daily—even hourly—distress. Every swallow, every meal can result in a perceptible, often unpleasant—sometimes severe, potentially fatal—response or reaction. And some of these conditions lead to more serious illnesses, such as cancers of the colon or rectum (colorectal cancers). Although GI disorders are extremely common, with millions of sufferers ranging from children to older adults in the United States and across the globe, procedures to correct these conditions can be extraordinarily complicated. Mount Sinai has long been home to true innovators in gastrointestinal research and clinical care, and surgeons have pioneered and perfected techniques in both innovative (minimally invasive and laparoscopic) and conventional (open) surgeries to ameliorate patient suffering and improve outcomes. With more than 600,000 surgeries performed annually in the U.S. alone for colorectal diseases, the need to continue to focus effort in this area is unquestionable. “Above all, patients want to survive and live well,” says Randolph M. Steinhagen, MD, Mount Sinai’s Chief of Colorectal Surgery and Professor of Surgery. “At Mount Sinai, we possess the range of expertise and technologies to provide patients with the full complement of treatments best suited for their individual needs. And at some point in the near future we will likely be able to combine open and innovative laparoscopic techniques to offer the advantages of both approaches in a single procedure.”

historic leadership Dr. Steinhagen’s confidence in Mount Sinai’s capacity to excel and innovate is built on a history of widely recognized leadership in the research and treatment of gastrointestinal diseases, from the first abdominal colectomy (colon resection) for colitis performed in the United States in 1901 and the first description of Crohn’s disease in 1932, to the current work in the relatively young field of laparoscopic surgery of Barry Salky, MD, Franz W. Sichel Professor of Surgery in the Division of Metabolic, Endocrine, and Minimally Invasive Surgery—among the least invasive surgical techniques. Laparoscopy was first used to diagnose and treat certain gall bladder and gynecological conditions—Dr. Salky was the first surgeon in New York City to perform laparoscopic gall bladder surgery in 1991—and involves different devices: cameras that provide extremely clear and precise visualization, and sophisticated instruments that allow surgeons to make several tiny incisions through which to view and remove tumors, rather than by opening the abdomen with a single large incision. While the procedure typically takes longer than conventional surgery and requires highly specialized skills, there is a great deal of evidence that laparoscopic surgery can provide significant benefit in terms of patient experience, including shorter lengths of stay in the hospital, less pain (and consequently less pain medication), faster return to normal bowel function, reduced risk of obstruction or related complications, speedier return to normal activity, and minimal scarring. As important as its short-term post-operative benefits, laparoscopy has been proven to be as effective from a medical perspective as open surgery in the treatment of colorectal conditions, including certain colon cancers. In fact, Dr. Salky

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and his team at Mount Sinai participated in the most significant clinical trial to date in this field, comparing the clinical outcomes of colectomies performed with both approaches in nearly 900 colon cancer patients at 48 institutions in the US and Canada. Rates of cancer recurrence and metastasis were nearly identical for open and laparoscopic surgery. One of the first surgeons to promote and perform laparoscopic surgery for IBD (inflammatory bowel disease), as well as for colorectal cancers, Dr. Salky is enthusiastic about the extraordinary improvements in both techniques and instrumentation over the last 20 years since he helped pioneer the field. “I was a big believer from the beginning because I saw the potential good for patients, and the difference is like night and day. After ‘lap surgery’ for Crohn’s disease, for example, some patients now go home from the hospital in just one day, rather than seven. That’s a huge difference for patients.” Nevertheless, laparoscopic surgery is not always the recommended approach, for example in the treatment of rectal cancer. While clinical trials in the US and Europe are underway comparing surgical approaches for the treatment of colorectal cancer, the procedure has not yet proven to have significant benefit over open surgery. And few surgeons, says Dr. Steinhagen, possess the skills to perform the surgery well.

innovating open surgery “We have improved open surgical techniques considerably over the last few years, and we have learned a great deal from our colleagues who specialize in laparoscopic approaches,” says Dr. Steinhagen. “We’re now performing open surgery with minimal scarring. And the outcomes of laparoscopic procedures have helped us understand the importance of reducing length of stay in the hospital after surgery and of returning patients more quickly to their normal activities and routines. These advances help create a much more pleasant experience for patients who undergo surgery of any kind.”

future advances

minimally invasive surgical techniques for colorectal conditions and diseases. Mount Sinai School of Medicine was among the first in the country to recognize laparoscopy as a distinct specialty within general surgery and it maintains an exemplary simulation training facility in laparoscopy ( for more about surgical simulation, see p. 17). The School of Medicine continues to innovate, including experimental work in single-incision laparoscopic procedures. Mount Sinai is also one of the most active training sites in the country for laparoscopic surgery. “I am unbelievably proud of the work we have done to educate laparoscopic surgeons,” says Dr. Salky. “We have trained more than forty postdoctoral fellows who are now practicing around the country.” Dr. Steinhagen, himself a dedicated, award-winning educator, is convinced that the treatment of colorectal conditions will continue to be of great interest to Mount Sinai’s students, fellows, and residents. “Few medical students, even those interested in becoming surgeons, begin their careers planning to specialize in colorectal surgery. But, if you’re interested in an area of practice and research where quality of life for patients really can be dramatically improved, it’s hard not to be captivated by the potential of colorectal surgery,” he says. “There are so many challenges and so much variety. Colorectal surgery is scientifically interesting and medically important. We love what we do because we know we can really affect a patient’s life every single hour of every single day.” Dr. Salky agrees. “These diseases are common, but each patient’s experience is unique, intimate, personal. When we focus on what’s best for patients, almost anything is possible.”

MOUNT SINAI SURGERY MILESTONES

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Lewis Burrows and Paul Tartter suggest that perioperative blood transfusions reduced immunity and led to the increased recurrence of colorectal cancer; subsequently confirmed and extended to other malignancies and led to fewer transfusions.

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Barry Salky and colleagues first to successfully treat splenic cyst via laparoscopy.

Colorectal surgery

Drs. Salky and Steinhagen are optimistic about what’s on the horizon for the treatment of colorectal disease in both “lap” and open approaches: new and experimental procedures that will improve patients’ experiences from alleviation of daily distress to positive long-term outcomes. Advances in robotics that continue to provide significantly better visualization of the pelvis, enabling more precise and accurate surgical procedures; a technique called TEMS (Transanal Endoscopic Microsurgery) that will allow removal of tumors with no abdominal incision at all; and related surgical techniques that require no external incisions whatsoever— all these are in development. And both surgeons are confident about Mount Sinai’s ongoing leadership in the development of successful,

“We love what we do because we know we can really affect a patient’s life every single hour of every single day.” – Dr. Steinhagen

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Mount Sinai Science & Medicine / spring 2012

Sometimes medical innovation arises from social necessity.

Everyday written by TRAVIS ADKINS photOGRAPHY by Andrew Lichtenstein DON HAMERMAN

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The Recanati/Miller Transplantation Institute (RMTI), established in 1998, is a pacesetter for the highest standards in transplantation: They have performed 6,000 liver, kidney, pancreas, and intestinal transplants with many “firsts” to their credit. The newly created Center for Living Donation, endowed by a generous gift from the Zweig family, is dedicated to ensuring donor safety and to making living donation an increasingly viable option. Because of national shortages of deceased donor organs, living donation is the innovation that is saving lives. “Living donation changes everything—it can be the difference between life and death,” says Sander S. Florman, MD, director of the RMTI. “It’s our responsibility to provide the very best care possible for all our patients, but we actually raise the bar even higher for our living donors.” Dianne LaPointe-Rudow, DNP, the Center’s director, adds, “Living donors are healthy people who should not otherwise be patients in the hospital—except that they are literally lifesavers. It takes very special people to actually give a piece of themselves to help other human beings.”

Transplantation

Lifesavers

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EVERYDAY LIFESAVERS

“I would do it again,” she says. “I would never second-guess my choice.” – Damitra Avery-Parker

Kidney Donation: Sister to Sister

MOUNT SINAI SURGERY MILESTONES

19 Mount Sinai Science & Medicine / spring 2012

87 Randall Griepp performs the first successful arterial switch operation for transposition of the great arteries and the first successful complete correction of hypoplastic left heart syndrome in the New York area.

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Mount Sinai surgeons including Charles Miller and Myron Schwartz perform the first liver transplant in New York State—a success.

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Davinya Avery looks both younger and older than her 30 years. Younger, when she’s joking and laughing with her sister and kidney donor, Damitra AveryParker; older, when she’s talking about the monthly doctor visits she endured since she was diagnosed at 19 with glomerulonephritis, a chronic kidney disease. “I used to get a physical once a year so I could play sports in high school,” Davinya says. “Then after I was diagnosed, it was doctor’s visits every month, sometimes every two weeks, constant blood work, medication, hospitalization.” Just speaking about the grueling regimen seems to tire her out. “A lot of stuff that hit me all at one time,” she says. Damitra nods her head in silent support. As soon as she was diagnosed, Davinya’s three sisters volunteered to become donors, yet she waited 10 years before going through with it. “At first, I was scared,” she admits. “But as time passed, I knew I wanted to marry and have children—to move on with my life.” All three sisters were tested, and two came back as a match. Damitra—the oldest sister, and a mother of three—settled the question of who would be the donor with the same pragmatic, irrefutable logic that a big sister might use to stake her claim to ride in the front seat of the car. “I’m the oldest, I’ll go,” she says. Less than six months later—after a whirlwind of MRIs, ultrasounds, blood work, nutrition work, as the RMTI team prepared both sisters for what to

expect—the two surgeries took place in March 2012. (Davinya’s surgeon was Michael J. Goldstein, MD, Surgical Director of Kidney Transplantation; Damitra’s was Juan Rocca, MD, Surgical Director of Live Donor Kidney Transplantation.) Two weeks after the surgery, both sisters were recovering well. “I thank Damitra every day from the bottom of my heart,” she says, turning to her sister. “It’s a powerful thing. I want to thank you for giving me a second chance.” Damitra shrugs off the notion that she did anything special. “I would do it again,” she says. “I would never second-guess my choice.”

“Currently nearly 100,000 Americans await a deceased donor kidney. The harsh reality? Most will never get one. The risk of heart attack and stroke increase dramatically for those on dialysis and the vast majority of these people are unable to work or enjoy life—transplantation can be liberating for them. On average, deceased donor kidneys last seven years while a kidney from a living donor lasts more than fifteen.” – Dr. Florman

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“I slept straight through the night before the surgery—I had so much confidence in the team.” – Edward Dowling

Liver Donation: Daughter to Father

straight through the night before the surgery—I had so much confidence in the team.” Edward and his daughter underwent their procedures in September 2010, and have since recovered fully. Katie serves as a mentor for people considering becoming living donors through RMTI. “I try to help people realize that living donation works,” she says. She tells them that they’ll have many, many people on their side. “It’s not just the donor and the recipient— it’s family, friends, neighbors, all the nurses, the doctors, the social workers. Everyone plays such an important role in that process.” Katie looks at her father. “I think we each played our role pretty well.”

“About 17,000 people await liver transplantation in the US; roughly one out of every nine lives in New York State. Those in need of a liver transplant have no dialysis option; they either get transplanted or die. Last year, some ten percent nationally, and nearly fifteen percent in New York, died without a transplant. Living donation offers an important, life-saving option for these patients.” – Dr. Florman

Transplantation Transplants

Like many parents, Edward Dowling never talked to his children about his health problems. But when he told his daughter Katie Dowling two years ago that he needed a transplant, it was the first she’d heard that he had liver disease—and that there was such a thing as living donation for liver transplantations. Yet she agreed without hesitation to get tested, as did her sister and brother. “To me there was a selfish reason for it—he’s my dad, and I wanted him to be here with us,” she says. Edward, a retired Port Authority police lieutenant, still speaks in the direct cadence of a cop—but when he talks about Katie, his voice fills with pride. “Right away Katie volunteered to be the donor,” he says. He outstretches his hands in the universal gesture for beats-the-hell-outta-me; then he gazes at his daughter and for a moment looks as if he’s cradling something tenderly. “What can you say?” Yet Edward was difficult to convince: Katie’s health was far more important to him than his own. But he says the Mount Sinai team, everyone from the coordinators to the surgeons, reassured him. (Dr. Florman performed his operation, and Marcelo Facciuto, MD, Director of Live Donor Liver Transplantation, performed Katie’s.) “I never doubted the outcome, otherwise I would have never let them do it,” Edward says. “I slept

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EVERYDAY LIFESAVERS

Innovation in Transplant Surgery A Breakthrough 50 Years in the Making While minimally invasive surgery has become the standard for procuring kidneys from living donors, transplantation— attaching the kidney to the recipient—has remained stubbornly resistant to the introduction of comparable techniques. Neither laparoscopic nor robotic-assisted surgeries satisfactorily enable surgeons to perform vascular anastomoses (reconnecting the donated kidney vein and artery) in a timely manner, resulting in unacceptable damage to the organ. Using standard open surgery, transplant surgeons are able to complete the extremely delicate and difficult work of suturing the kidney’s blood vessels by hand within 30 minutes. In contrast, attempts with both the laparoscopic and robotic-assisted techniques have required, on average, 60 minutes, and the higher technical demands of these approaches can increase the rate of vascular complications. The net effect, says Juan Rocca, MD, Surgical Director of Live Donor Kidney Transplantation, is that kidney transplantation surgery for the recipient remains “essentially unchanged from its original design.” Dr. Rocca is the primary investigator of a research team exploring an exciting new approach to perform vascular anastomoses that may make minimally invasive kidney transplantation feasible. The approach is based on a technique, the Sutureless Excimer Laser-Assisted Non-Occlusive Anastomosis (SELANA) currently used for neurosurgical procedures to bypass cerebral aneurysms without interrupting blood flow. The technique is sutureless with a titanium clip for the apposition of blood vessels and uses a laser to create the connection. If successful, the technique—which has shown promising early results in the lab—could make the vascular implantation of the kidney a faster, simpler, and safer procedure, ultimately allowing for laparoscopic or robotic-assisted surgery to become the procedure of choice.

Dr. Rocca recently performed a sutureless anastamosis between two blood vessels, using a specialized catheter and laser device.

Mount Sinai Science & Medicine / spring 2012

Minimizing the Incision

Traditional incision

Dr. Facciuto’s incision

Traditional incision includes Dr. Facciuto’s and extends across the right side dividing the abdominal wall muscles.

Live donor liver transplantation “Clearly, safety must is one of the most technically remain paramount demanding procedures performed for our donors and at Mount Sinai, for both the this technique allows donor and the recipient. Marcelo Facciuto, MD, RMTI’s Director of good exposure.” Live Donor Liver Transplantation, –Dr. Facciuto has mastered a technique enabling him to perform the donor surgery through a small midline incision: None of the abdominal muscles is actually divided, there is less pain, faster recovery, and better cosmesis than when a traditional, much larger incision is made under the right rib cage that divides all of the abdominal wall muscles. “Clearly, safety must remain paramount for our donors,” Dr. Facciuto says, “and this technique allows good exposure.” His donor liver procedures have been associated with impressively little blood loss or complications—and donors who are grateful for the outcome.

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Warriors Photograph by Don Hamerman

For many surgeons, the satisfaction of immediately and decisively repairing a problem is what drew them to their field. But with breast cancer, even a completely successful procedure is often just one victory in an ongoing battle. So Science & Medicine asked the surgeons of Mount Sinai’s Dubin Breast Center: what does it mean when the operation is only the beginning of care?

Christina Weltz, MD

Assistant Professor, Surgical Oncology Associate Director of Surgery, Dubin Breast Center

Elisa Port, MD

Chief of Breast Surgery, Co-Director, Dubin Breast Center “As a breast cancer surgeon, you walk into someone’s life at one of the most critical junctures and help them make these critical decisions with their family members and their loved ones, and that bond never goes away. It’s really an incredibly privileged role to be the one to support them through what may be one of their darkest hours and help them see that they’re going to be OK. I have patients whom I saw for the first time when I was pregnant with my daughter; now, ten years later, when I see them they always ask me about her, and it’s just unbelievable for me to realize that they’re doing great and that they’re back to their normal lives. It’s one of the most gratifying experiences a surgeon can have.”

Assistant Professor Surgery

“Breast cancer care takes many different stages, and many times a patient’s journey begins with the surgeon. We’re one of the first caregivers patients see, and one of the first to tell them they have cancer. Because we’re there right from the start, we develop a relationship with our patients that goes beyond the surgery. There are many other aspects to care that come after surgery, and we help them make many important decisions and educate them about their disease and the treatment. We meet them at a time when their life has hit a wall, and things are breaking down for them, and we step in and help them get through that difficult time.”

Breast Surgery

“There are definitely elements with breast cancer surgery that are different from other surgeries; one of the most pronounced differences is the psychological component. Every surgery is a stressful event, but we’re frequently dealing with a healthy young woman who received this diagnosis out of the blue, and it’s a heavy blow, amplified by all the media attention breast cancer receives. Sometimes more knowledge can make something harder, and so a huge part of our job is being something of a psychologist and social worker and providing emotional support. It’s challenging, but also rewarding, to be there not only as a doctor, but also as a person.”

Hank Schmidt, MD

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Show and tell: Dr. Hecht demonstrates a lateral interbody fusion cage.

Mount Sinai Science & Medicine / spring 2012

Tool Kit ToolKit Minuscule objects and man-made tissue are among the powerful new tools in the spinal surgery kit.

Written by Philip Berroll Photography by Don Hamerman

At first glance, it doesn’t look very impressive: a metallic rectangle, maybe half the size of a typical mobile phone, that could just as easily be mistaken for a spare part to a washing machine. But in the skilled hands of Andrew Hecht, MD, and Sean McCance, MD, the co-directors of spine surgery in the Leni and Peter W. May Department of Orthopaedics, this unassuming little piece of hardware is actually one of the devices that has revolutionized spinal surgery over the last ten years, speeding patient recovery and significantly reducing some of the risk and many of the tough side effects of spinal surgery. Called the lateral interbody fusion cage, the device is inserted between the patient’s vertebrae through a minimally invasive procedure, enabling surgeons to enter the patient’s body through a small incision, avoiding the major back muscle. It is a major advance in the field and emblematic of the innovations that are changing the way spinal surgery is performed. “With this technique there’s less scarring and less risk of side effects,” explains Dr. Hecht. “It has enabled us to greatly reduce morbidity for patients.” The procedure to insert the lateral interbody fusion cage also relies upon another innovative device, a tubular retractor that enables surgeons to enhance

their view of the spine without the invasiveness of traditional surgery. “Instead of making a larger incision and dissecting all the way down to the spine,” Tubular Retractor Dr. Hecht explains, “we make a small incision and, through a series of dilators, insert what is basically a tube. Then, with the use of a microscope, we're able to look down the axis of this tube and see things that we normally see with open surgery. Some of these tubes at the very bottom can be expanded or dilated further to improve visibility. “This allows us to avoid the extensive dissection, the tissue exposure, of open spine surgery. We’re minimizing the muscle damage, shortening the length of stay, and minimizing the post-operative pain, particularly in the short term. The patient can be out of the hospital and getting on with life much more quickly.” “It allows us to perform the same, or better, surgery but with a smaller incision,” says Dr. McCance, noting that the device is particularly beneficial for older patients with scoliosis and for young patients.

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Big Advantages/Small Devices The lateral interbody fusion cage and tubular retractors are just some of the breakthrough devices and technologies that have transformed some spinal surgery operations once considered high-risk into minimally invasive procedures now commonly performed on both elite professional athletes and people in less physically stressful lines of work. “Minimally invasive techniques have had a very positive impact on our field in the last decade,” says Dr. McCance. “They’ve given us the ability to address a broader array of pathologies with less morbidity.” Dr. Hecht also cites prosthetic cervical disc replacement, used to treat patients suffering from herniated discs, as “a very advantageous development.” He and the other members of his surgical team, Sheeraz Qureshi, MD and Samuel Cho, MD, have frequently performed this procedure. “It’s a big advantage over traditional fusion treatments, where the disc is removed and the surgeon performs a fusion with a bone graft and a titanium anterior Prosthetic disc fixation plate,” he says. “With prosthetic replacement, motion is preserved—patients can start moving right away, they don’t need to wear a brace. As a result, we don’t worry about problems such as muscle atrophy above or below the area where they would have had a fusion.” It isn’t just the typical patient who benefits from the new treatments—it’s also big-time athletes. In addition to his work at Mount Sinai, Dr. Hecht is the spine surgical consultant to the New York Jets, the New York Islanders, and numerous collegiate teams, and he directs the National Football League’s retired players’ spine care program at Mount Sinai (one of only five medical centers across the country designated by the NFL as a program partner). This work has given him a unique perspective on the growing applicability of minimally invasive spinal surgery. “A lot of these techniques,” Sean McCance, MD

says Dr. Hecht, “are applicable to many different groups of patients.”

From Cages To Cells

“The lateral interbody fusion cage has enabled us to greatly reduce patient morbidity.” — Dr. Hecht

BMP sponges

MOUNT SINAI SURGERY MILESTONES

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Richard Stock (Rad. Onc.) working with Urology staff, develops an ultrasound-guided technique to insert radioactive seeds into the prostate to treat prostate cancer; eliminates time consuming pre-planning and allows for optimal seed placement.

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Spine surgery

Both Dr. Hecht and Dr. McCance wax enthusiastic about something else—neither a device nor a procedure, but a substance: Bone morphogenetic protein (BMP), a molecule which can literally grow bone. Dr. McCance says that BMP can be used as a replacement for iliac crest, a major segment of the group of bones around the pelvis, from which bone material is often used in grafts. “Studies suggest that it holds up just as well. So it’s been a step forward in saving some patients the need to harvest their own bone.” The recent breakthroughs in minimally invasive techniques have given surgeons the ability to gain deep access through small incisions—and that critical advance is what really makes BMP such a promising therapy, as Dr. Hecht points out. “We’re able to achieve a solid fusion through a tiny incision, only a centimeter or two long, by inserting BMP, where in the past you’d have these massive incisions. For certain types of patients, this is a very effective treatment.” The two surgeons are closely following the development of other minimally invasive techniques that could prove useful in their work. For example, Dr. McCance predicts that more surgeons will be inserting screws in the spine percutaneously [through wires and tubes] during procedures, rather than the traditional approach of insertion through an incision. “So if you have a sick patient who maybe can’t tolerate a full open surgery, you can do part of it percutaneously and part of it open,” he says. “That’s another minimally invasive technique that potentially is a step forward for patients.” Dr. Hecht is working closely with his colleague James Iatridis, PhD, an internationally acclaimed spine researcher, to develop novel therapies that can treat spinal problems at the cellular level. Their investigations are exploring stem cell-based biomaterials and other methods to repair degenerated or injured discs biologically. “This research could lead to new treatments that eliminate or significantly defer invasive surgical procedures,” says Dr. Hecht. Dr. Hecht believes that minimally invasive surgery— and an innovative tool kit that seems to grow both smaller and bigger at the same time—has enhanced the success of his practice and the personal satisfaction he takes from his work. “For both cervical and lumbar surgery, we’ve showed a substantial ability to help people,” says Dr. Hecht. “Mount Sinai has one of the largest spine services in Manhattan, and has emphasized treating patients with all kinds of spinal disorders, and trying to get them back to a full life. I think the kinds of surgeries we’re doing, and the outcomes we’re having, are testament to that.”

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Interview by Sara Daniels  Photography by Don Hamerman

quarterback

Mount Sinai Science & Medicine / spring 2012

d

David Adams is rarely still: He has multiple educational and medical missions planned for 2012, gives an average of 25 invited lectures a year, and typically performs 12 mitral valve repair operations a week at Mount Sinai, where he is Marie-Josée and Henry R. Kravis Professor and Chairman of the Department of Cardiothoracic Surgery. Yet this Duke alumnus is a Southern gentleman whose manner suggests that you have his full attention for as long as he can spare it. After an hour of our conversation, though, his extraordinary focus is less surprising; indeed, it is one of many contrasts that make Dr. Adams as disarming as he is gifted. A pioneer of the mitral valve repair procedure—and every bit as brilliant and complex as the surgeries he manages—Dr. Adams literally helped write the textbook on mitral valve repair and is liberal with his praise for his highly skilled team and collaborators. Just as his work demands encyclopedic knowledge and extreme technical precision, his vision shifts seamlessly from the micro to the macro, from the delicate work of repairing damaged valves to shaping an educational mission that extends across media and regional and national borders. And his concern for patients ranges from the most intimate relationship between doctor and patient to a comprehensive Web site that brings his work and influence to a truly international patient network.

Dr. David Adams, the internationally renowned cardiothoracic surgeon, gives us a glimpse of a man of contrasts.

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Q: What attracts you to working with the

A DOCTOR WITH HEART

human heart?

Dr. Adams, co-author of Carpentier’s Reconstructive Valve Surgery, also initiated the creation of the Mitral Valve Repair Reference Center Web site to help educate patients about their hearts. “Our goal is to provide patients a valuable, robust resource,” said Dr. Adams. He cites the Web expertise and vision of Gideon Sims, director of cardiothoracic IT at Mount Sinai, as indispensable in building and maintaining the site. Visit mitralvalverepair.org.

Heart surgery is fascinating. It’s highly technical—it demands precision and an incredible working knowledge of how to manage a complex system, the heart and lungs. There’s also a really unique team model in heart surgery because of the complexity of the surgery. It takes about ten people working together and everyone has their own responsibilities. It’s quite interesting to be the quarterback of such an amazing team. And there’s the physiology of putting the heart to sleep and waking it up again. It’s a rewarding experience each and every time.

Q: Next to Dr. Alain Carpentier, you’ve been one of the most pioneering figures in the field of mitral valve repair. Why is it so important to repair rather than replace? Well, valve repair is really the gold standard. An animal valve won’t last the rest of your life, and metal valves commit a patient to a lifetime of anticoagulation. The emerging data tell us that intervening early—in patients who are often young, healthy, and asymptomatic— improves their chances of staying healthy over the long term. Of course, that means the stakes for them, and for us, are higher, and the native valve must be preserved to get the real long term benefit.

Q: That’s a lot of responsibility to shoulder. Does it ever get to you? I keep a box of tissues on my desk because invariably patients or family members get emotional every week facing the prospect of heart surgery; these are younger patients, many with young children of their own, in the middle of their lives. Physiology is on your side with younger patients, but there’s an inherent pressure to be perfect when you’re intervening in low risk patients.

Q: Your work starts with a hyper-focus on each patient but you seem equally passionate about educating physicians and patients. What are you most proud of in your role as educator?

Q: Your educational mission frequently takes you around the world to perform surgeries and educate physicians, particularly in developing nations. To give you some perspective, more than eight hundred surgeons from sixty-six countries attended the 2011 American Association for Thoracic Surgery Mitral Conclave, which I directed. There’s a lot of interest in this field and our team is committed to leading this educational effort internationally. We are establishing relationships in developing countries and helping them develop high level skills by making repeat visits to the same institutions. The goal is to raise the skill level of a group of surgeons and their teams. We do as many surgeries as we can on these visits, too. Last year we operated on ten patients in Thailand and the Dominican Republic. There’s a high burden of rheumatic mitral valve disease in young children in developing countries. It really touches your heart to see them. We teach the surgeons and their teams how to do these complex operations in young people with end stage diseases, how to care for them around surgery.

Q: What does “Mission Accomplished” look

MOUNT SINAI SURGERY MILESTONES

19

Richard Stock, K. Chan and M. Terk et al. devise a new technique for performing interstitial implants in the treatment of gynecologic malignancies.

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like to you? The goal is for Mount Sinai to be a leader in the field and to expand our valve reference center model across the country. Over the next ten years we have an opportunity to really establish ourselves as a visionary center in this field. With the recruitment of Dr. Jagat Narula as director of Cardiovascular Imaging, one of our main goals is to build a 21st century valve center for diagnosis and total care of patients with mitral valve disease. This isn’t something you win overnight. We’re just getting started.

20 03

Warren Sherman and Valentin Fuster (co-PIs): first cellular transplant for congestive heart failure (autologous skeletal myoblast transplantation) in US done by Sherman; a new approach to heart failure treatment, trying to replace non-functional heart tissue with actively contracting muscle; retrieve immature cells from the leg.

Cardiothoracic surgery

Well, I can’t overemphasize that Carpentier’s Reconstructive Valve Surgery—the textbook I co-wrote with Dr. Carpentier and Dr. Farzan Filsoufi—is the world reference book in the field of mitral valve disease. The three of us handwrote the book during three-day sessions over almost eight years and about fifty international flights between Paris and New York. The first edition sold out on pre-release on Amazon—that’s how high the demand is for knowledge in this field. We’re also extremely proud of our Mitral Valve Repair Reference Center Web site; it is recognized by peers around the world as an educational source.

We wanted to educate the patients, not talk down to them; we simplified the language a bit, but we used our own medical texts and papers and drawings to put it together. We wanted to make our own bodies of work available to patients, whether they come to Mount Sinai for treatment or not.

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THEN & NOW Dr. K atz

Dr. B

auer

written by kenneth lin photography by andrew lichtenstein

Dr. R

MOUNT SINAI SURGERY MILESTONES

Mount Sinai Science & Medicine / spring 2012

20 05

Eric Genden performs the world’s first successful composite tracheal transplant, using a method he developed that allows patients to breathe and speak without a tracheotomy.

20 06 Otolaryngist Eric Genden and Alex Greenberg, DDS (Dentistry) perform one of the first successful total jaw transplants in the country; first in New York State.

Dr. G

einer

Four distinguished Mount Sinai surgeons—whose experience adds up to a century of medical practice—weigh in on how their field has evolved. “Surgery has changed a lot in the last thirty years,” says Joel Bauer, MD, a top Crohn’s and chronic ulcerative colitis surgeon and one of four esteemed surgeons whose practices have evolved during one of the richest periods of surgical innovation at Mount Sinai. “When you look at an overview, the changes in technology and patient care have been amazing.”

Preoperative Diagnostics THEN: “When I first got to Mount Sinai in the late 1970’s, MRI and CT scans were not yet used in the institution, and ultrasound was relatively new,” recalls Mark Reiner, MD, a leading laparoscopic surgeon who specializes in repairing hernias, “so diagnoses were made purely on barium studies, x-rays, and clinical judgment.”

orfin

e

NOW: “Today, we almost never operate without a clear preoperative diagnosis,” says Brian Katz, MD, Dr. Reiner’s partner at the Laparoscopic Surgical Center of New York, “and surgeries that we used to do have disappeared because of better diagnostic modalities.” “We’ve learned to read ultrasounds and CTs with almost as much expertise as radiologists, within our specific fields, of course, and that has dramatically changed diagnosis,” Dr. Reiner adds.

Minimally Invasive Surgery THEN: “It used to be said ‘Big surgeon­—big incision,’” says Dr. Katz. “Now they say, ‘Big surgeon—small incision.’” This is true because of Mount Sinai’s pioneering work in minimally invasive surgery. “Minimally invasive laparoscopic surgery, which involves inserting instruments into a small incision, guided by a small camera, has dramatically changed surgical practice,” adds Dr. Reiner. “Mount Sinai had the first division in minimally invasive or laparoscopic surgery in the country; Barry Salky was the division head, and I was one of the original members.” (For more about Dr. Salky, please see p. 38.)

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NOW: Today, procedures that were once thought of as major surgeries are now less disruptive to patients’ lives. “Now, I can do a surgery on a patient on Friday,” says Dr. Reiner, “and they can be back to work on Monday. In the old days, they would have been back in ten days, and they would have had a much more difficult time recovering. The recuperative time has changed dramatically.” Laparoscopy is also driving the evolution of surgical procedures. In the 1970’s and 1980’s, Dr. Bauer and his colleagues at Sinai pioneered and perfected continent ileostomy and J-pouch surgeries for patients with severely compromised colons due, primarily, to chronic ulcerative colitis. Groundbreaking at the time, these surgeries are now performed throughout the world. Taking the next evolutionary step, Dr. Bauer and his colleagues are now applying minimally invasive techniques to these surgeries as well.

Evidence-Based Medicine THEN: “Back in the day, there were many things that surgeons did that were passed down from generation to generation,” says Stephen Gorfine, MD, Dr. Bauer’s partner at Manhattan Surgical Associates, “and behind the scenes you would ask, ‘Why does he do that?’ and the chief resident would say, ‘Because it works,’ and for that reason alone, you did it, too.”

NOW: Today, Dr. Gorfine says, “The effectiveness of these procedures is being studied now. There are meta-analyses, individual studies, randomized studies that show, for example, that a lot of the innovations that came out of the minimally invasive movement are also applicable to open surgery.” Dr. Gorfine and most of his peers are now following the Fast-Track protocol that was developed for patients recovering from minimally invasive surgery. Evidence-based medicine has proven that this protocol is also safe and effective in patients who are recovering from open surgery.

THEN: “When I first came here as a resident,” recalls Dr. Bauer, “there were ICUs, but they were managed by the individual surgeons and their house staffs. They were really not much more than what our step

NOW: Intensive care units and intensive care specialists play a critical role in surgery. “Surgeons are not trained to provide intensive care,” Dr. Bauer says, “and I think that hundreds of lives have been saved in those specialist-directed ICUs. Mount Sinai was at the leading edge of that movement.” “Improvements in perioperative management are allowing us to operate on patients who are considerably sicker than before,” adds Dr. Gorfine, “and obtain better outcomes.”

MOUNT SINAI SURGERY MILESTONES

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Mount Sinai surgeons perform 250th live donor liver transplant, the most performed by any US center.

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December 17: Drs. Sharma and Adams first to perform a percutaneous implant of the Medtronic CoreValve Transcatheter Aortic Valve Prosthesis in US.

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The Culture of Surgery THEN: “Gone are the days when surgeons were giants of the earth, and nurses cowed when they entered the room,” Dr. Gorfine declares. NOW: “The approach now is more humanistic,” Dr. Gorfine adds, “and that’s a good thing because it’s better for the patients. In fact, it’s better for everyone.”

Decades of Dedication Drs. Bauer, Gorfine, Katz, and Reiner have deep connections to Mount Sinai. Dr. Joel Bauer, a clinical professor of surgery in the School of Medicine who specializes in gastrointestinal abdominal wall and minimally invasive abdominal surgery, completed his residency at Mount Sinai in 1973 and has been on the attending staff since 1975. Dr. Stephen Gorfine, clinical professor of surgery and a noted expert in the field of surgery for inflammatory bowel disease, began his career at the medical center in 1978 as a resident in internal medicine; he shares a practice with Dr. Bauer. Dr. Brian Katz, associate clinical professor of surgery and a leader in laparoscopic treatments for gallbladder removal, colon surgery, and many other procedures, finished his residency at Mount Sinai in 1982 and has been here since. Dr. Mark Reiner, a clinical professor of surgery who is part of the same practice as Dr. Katz and who has a similar clinical focus, completed his residency at Mount Sinai in 1978.

Abdominal Surgery

Perioperative Care

down units are now. Then, I would say, midway through my residency, we started having an ICU where an intensive care specialist was in charge. ICU space was dramatically expanded, and nurses were specifically trained for it.”

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Double Duty Edward Chin, MD is a trendsetter in the O.R.

and a trend spotter in research.

written by TRAVIS ADKINS WITH ADDITIONAL MATERIAL BY KRISTIN LUND PHOTOgraphy by DON HAMERMAN

Edward Chin, MD’s accomplishments can be expressed through two vastly different numbers: One, and 512. The first represents the number of incisions made by Dr. Chin and his colleague Peter Midulla, MD when they recently performed the first single incision laparoscopic splenectomy (spleen removal) and cholecystectomy (gall bladder removal) in New York State. The second represents the number of Mount Sinai patients whose outcomes Dr. Chin, an associate professor of surgery, analyzed for an important study which conclusively demonstrated that a laparoscopic donor nephrectomy (kidney removal) program can achieve a success rate that compares favorably to open surgery. Put them together and it adds up to a sizable contribution to minimally invasive surgery. Taking it to the next level

Dr. Chin, along with Dr. Midulla, assistant professor of surgery and pediatrics, performed the groundbreaking single incision splenectomy and cholecystectomy on a 17-year-old girl with sickle cell disease and gallstones. The standard laparoscopic procedure requires six to seven incisions across the abdomen; Drs. Chin and Midulla, by contrast, made a single, one-inch incision in the patient’s belly button. While the single incision technique has become increasingly common for cholecystectomy, only a handful of surgeons have attempted to apply it to splenectomy. “It’s just another level of difficulty to do a splenectomy,” says Dr. Chin. “It’s a harder

organ to access and technically more difficult than a cholecystectomy.” Dr. Chin is now investigating whether the procedure offers significant advantages over the existing technique; early results are promising. “Overwhelmingly, patients report being much happier with the single incision technique,” he says, though he cautions that much research remains to be done. “It appears that patients experience decreased pain in the short term.” Case closed

In his long-range study, Dr. Chin and his co-authors tracked outcomes of 512 Mount Sinai patients who underwent laparoscopic donor nephrectomy between 1996 and 2006. Among other findings, the study showed that, even during the program’s early stages at Mount Sinai, the low incidence of donor complications proved that the safety of the new procedure was comparable to the safety of the standard, open surgery procedure. That finding led Dr. Chin and his co-authors to conclude that laparoscopic donor nephrectomy can be performed safely at a single institution over a large number of cases and years, and can be successfully included in surgical training. “Our hope was to give other transplant programs in the country that are considering starting this program a model for achieving excellent outcomes from the beginning,” Dr. Chin says. The study’s long duration (ten years) and the size of the sample examined—also essential to the study’s accuracy and integrity—underscore the fact that Mount Sinai surgeons led the way in establishing the procedure as superior to open surgery. Today it is the standard of care. Dr. Chin is currently investigating the benefits of minimally invasive surgery for elderly patients, and examining the possibility of utilizing a singleincision technique for living kidney donation. “If it increases patient satisfaction and decreases pain after surgery, it would be really special to offer these benefits to living kidney donor patients,” he says. “Anything that has advantages to them, I’m all for.”

“Our hope was to give other transplant programs a model for achieving excellent outcomes from the beginning.” – Dr. Chin

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Gv

GIVING Mount Sinai Posts Record-Breaking Year in Fundraising Mount Sinai enjoyed the most successful philanthropic year in its history in 2011, and with more than $200 million raised during the year, the Campaign for Mount Sinai has now reached 90% of its $1 billion goal.

Trustee Generosity Tops an Historic Year Mount Sinai fundraising’s banner year achieved a 6 percent increase over 2010 and included more than 30 gifts of $1 million and above. Thanks to those historic results, the Campaign for Mount Sinai exceeded its goal for the year and surged closer to its $1 billion finishing line. The Campaign closes in December 2013. “The numbers speak for themselves, and they give testimony to the incredible generosity of our Trustees and also to the dynamic growth at Mount Sinai,” said Kenneth L. Davis, MD, president and CEO of The Mount Sinai Medical Center. “Success breeds success, and so we look forward to an even better year in 2012.”

Giants in Medicine President Davis expanded upon that theme of success

“We have transformed Mount Sinai into a world-class

at Mount Sinai’s recent annual Trustee dinner while

institution,” said President Davis. “Our faculty are the

introducing Mount Sinai Now: Achieving Excellence,

giants in medicine today.”

a special video detailing the medical center’s recent

Peter W. May, chairman of the Boards of Trustees,

progress and its future. “When we talk about excel-

affirmed President Davis’ remarks and added a word

lence at Mount Sinai, we don’t use it lightly,” said

of thanks to his fellow Trustees. “The giants of Mount

President Davis. “We use the term excellence because

Sinai are not only doctors and researchers, it’s also all of

we have crossed a threshold that makes us deserving

you who give of your time, care, and dollars and make

of the word.”

Mount Sinai, together with our faculty and researchers,

He noted several metrics that make the case for

what it is,” said Mr. May.

excellence, including the highest number of faculty

Mr. May was joined on stage by fellow Trustee Susan

members that Mount Sinai has ever had elected to the

R. Cullman, who announced her family’s endowment

Institute of Medicine (11); the fact that the School of

of the Edgar M. Cullman, Sr. Chair of the Department

Medicine is third in the country in National Institutes

of Nursing in honor of her late father, who served

of Health grants-per-investigator; and the medical

as a Trustee for more than six decades. “Dad cared

center is as one of only 12 in the country to have both

about the nurses at Mount Sinai and was their biggest

a hospital and a medical school ranked in the top 20

advocate,” said Ms. Cullman. “This endowment is

by U.S. News & World Report.

something that we’re very proud to be a part of.”

The Campaign for Mount Sinai is now at 90 percent of its $1 billion goal.

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GIVING

“This generous gift will help Mount Sinai continue transforming medicine. We are incredibly fortunate to have so many valuable, committed philanthropists as our partners.”  – Kenneth L. Davis, MD

Three Leadership Gifts Kick off 2012 As it nears its goal of $1 billion to fund strategic priori-

Institute director Bruce D. Gelb, MD, Gogel Family

ties, the Campaign for Mount Sinai began 2012 on a

Professor of Child Health and Development. “This

strong note with leadership gifts from Trustee Eric

remarkable gift will help us continue to attract the

S. Lane and Sarah Lane, Trustee Marc S. Lipschultz

very best.”

and Jennifer Lipschultz, and an anonymous, longtime

“Discovering new treatments can make a major

donor to Mount Sinai.

difference in the day-to-day life for children affected

The Lanes’ gift will provide for the recruitment of

by food allergies,” said Mr. Lane, a Mount Sinai

a leading researcher or clinician specializing in child

Trustee since 2010. “We’re pleased that we can help

health issues, particularly food allergies, to the Child

advance this important work.”

Health and Development Institute’s (CHDI) Asthma

The Lipschultzs’ gift to The Friedman Brain

of the Child Health and

and Allergy Center. The new recruit will hold the title

Institute will support a broad variety of strategic

Development Institute

of The Sarah and Eric Lane Professor of Child Health

priorities, including recruitment and ongoing

and Development.

research projects. “The Friedman Brain Institute

Bruce D. Gelb, MD, director

“The CHDI has enjoyed tremendous success

is setting the pace for the discovery of revol-

in recruiting outstanding faculty members,” said

utionary new therapies for brain disease,” said Mr. Lipschultz, who joined the Boards

Eric J. Nestler, MD, PhD, director of the Friedman Brain Institute

of Trustees in 2010. “We hope to help accelerate that momentum.” “The spirit of generosity is as essential to scientific and medical progress as is the spirit of inquiry,” said Eric J. Nestler, MD, PhD, director of the Friedman Brain Institute and Nash Family Professor and Chair, Department of Neuroscience. “Mr. and Mrs. Lipschultz are true philanthropic leaders.” The anonymous gift will benefit several areas identified as major institutional needs by the President’s Strategic Initiative Fund, including recruitment and the creating of state-of-the-art research and patient care facilities. “This is a very exciting time at Mount Sinai,” said the donor, who has been a supporter for more than 30 years. “President Davis, Dean Charney, and the entire leadership team have done an extraordinary job.” “This generous gift will help Mount Sinai continue transforming medicine,” said Dr. Davis. “We are incredibly fortunate to have so many valuable, committed philanthropists as our partners.”

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Going the Distance for 9/11 Heroes Hideki Kinoshita Races to Raise Funds for World Trade Center Health Program Mount Sinai supporter Hideki Kinoshita recently raised $5,500 for the medical center’s World Trade Center Health program, which provides screening and health care for 9/11 emergency responders, by running more than 100 miles during a 24-hour “ultramarathon.” Mr. Kinoshita, who since 2008 has run almost 100 marathons on behalf of various organizations supporting causes including pancreatic cancer, says he was inspired to run for the program after learning that it was one of the few initiatives dedicated to caring for 9/11 first responders. “Knowing that every single mile I was able to run meant more dollars for the program kept me going,” he says. Mr. Kino visited Mount Sinai to present his winnings to Michael Crane, MD, deputy director of the program, and also met one of its patients. “Meeting them Hideki Kinoshita (L) and Michael A.

made me even more motivated to help out,” he says. “My

Crane, MD, deputy director of the

goal is to continue running for the program, and convince

World Trade Center Health Program

others to join the effort.”

An Evening to Remember Trustee Richard A. Friedman and his wife, Susan, welcomed more than 80 guests into their home on November 3 for an event featuring a conversation with the researchers and physicians of The Friedman Brain Institute on their latest investigations in Alzheimer’s disease. Pictured: 1. Richard A. Friedman and Seth Glickenhaus. 2. (from left) Dean Dennis S. Charney, Eric Nestler, and Susan and Richard A. Friedman.

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MS Center Focuses on New Developments Supporters of the Corinne Goldsmith Dickinson Center for Multiple Sclerosis joined the center’s researchers and clinicians on November 17 at the Loews Regency Hotel to learn about recent developments in multiple sclerosis care and research. Pictured: (from left) Fred Lublin, Trustee Clifford H. Goldsmith, Aaron Miller, Katherine Goldsmith, and George Gillespie.

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GIVING

Honoring a Legacy of Noble Deeds Almost 200 guests gathered together October 19 at the New York Public Library for the second annual Noble Deeds Society Dinner, a celebration of Mount Sinai’s most generous philanthropic partners that included presentation of the second annual Noble Deeds Society Honorary Award to the late Edgar M. Cullman, Sr. and the entire Cullman family.

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2

3

4

Pictured: 1. Carolyn Sicher. 2. (from left) Lucy Cullman Danziger, Trustee Edgar Cullman, Jr., and Trustee Susan Cullman. 3. (from left) Trustee Jean C. Crystal and James W. Crystal, Robert Friedman, and Elissa Gretz Friedman. 4. (from left) Elissa Cullman, Edgar Cullman, Jr., Chairman of the Boards of Trustees Peter W. May, Trustee Bonnie M. Davis and President Davis, Leni May, Susan Cullman, John J. Kirby,Lucy Cullman Danziger, and Mike Danziger. 5. (from left) Katherine Goldsmith, Trustee Clifford Goldsmith, Susan R. Cullman, and Trustee Patricia S. Levinson.

5

SMART Talk About Prostate Cancer David B. Samadi, MD, vice chairman of the Department of Urology and chief of the Division of Robotics and Minimally Invasive Surgery, hosted an informative evening on October 25 at the Harmonie Club at which he discussed advances in prostate cancer treatment including his pioneering SMART (Samadi Modified Advanced Robotic Technique) surgery. Pictured: Dr. Samadi

A Friendly Crowd A November 9 event at the Hurricane Club organized by the Friends of Mount Sinai, a group of young professionals, drew a near sold-out crowd of 450 and raised funds for Kravis Children’s Hospital’s Child Life and Creative Arts Therapy program. Pictured: 1. (from left) Brian Sherman, Alan Goldfarb, Jennifer Goldfarb, Erica Frank, and Andrew Frank. 2. Elizabeth Shaoul Wilens.

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Straight From the Heart Valentin Fuster, MD, PhD, director of Mount Sinai Heart, and his colleagues Jagat Narula, MD, PhD, and Vivek Reddy, MD presented recent breakthroughs in cardiovascular imaging to more than 100 guests at a November 1 event, held at The Loews Regency Hotel. 1

Pictured: 1. Kevin G. Dunsky, MD and Jill Herman. 2. Suzanna and Alessandro Carozza.

2

Big Numbers for DBC Benefit Nearly 450 guests attended the inaugural benefit gala for the Dubin Breast Center of The Tisch Cancer Institute on December 12 at the Mandarin Hotel, contributing more than $1.5 million to support a range of the Center’s initiatives. The gala honored Dubin Breast Center founders Eva AnderssonDubin, MD and Trustee Glenn R. Dubin, was emceed by television journalist Paula Zahn, and featured performances by young musicians Caroline Jones, Charles Perry, and Charlie Siem. Pictured: 1. Eva Andersson-Dubin and Paula Zahn. 2. Dr. Andersson-Dubin and Glenn Dubin. 3. Charlie Siem and Caroline Jones.

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Annual Trustee Dinner Celebrates Accomplishment At the annual Boards of Trustees dinner, held November 30 at the Metropolitan Club, Kenneth L. Davis, president and chief executive officer, thanked the Trustees for their partnership and hailed them for their commitment to excellence—crediting them for Mount Sinai’s growing pre-eminence and accomplishment. “We have transformed Mount Sinai into a world-class institution,” said President Davis. “Our faculty are the giants in medicine today.” Pictured: 1. Trustee Frederick A. Klingenstein and Sharon Klingenstein. 2. Trustees Richard Friedman and Richard Ravitch. 3.Trustee Carl C. Icahn and President Davis. 4. (from left) Trustee David S. Gottesman, Ruth Gottesman, and Trustee James S. Tisch.

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Al

Al ALUMNI

ALUMNI High Flyer Jeffrey Flier ’72, Dean at Harvard, reflects on leadership.

Taught by the Best He had other good reasons to choose the young school, including the legacy of Mount Sinai Hospital and the quality of the faculty. “I remember getting information about Mount Sinai and the hospital, which had a strong history of graduate medical education,” says Dr. Flier. “Then I read about some of the people who were listed as initial chairs of departments, and I was impressed.” Some of those impressive names became important mentors to Dr. Flier, including Kurt Hirschhorn, MD, the famed geneticist; Henry Dolger, MD, an endocrinologist who first documented many of the long-term complications that diabetics develop from insulin injections; Panayotis G. Katsoyannis, PhD, one of the first biochemists in the world to synthesize insulin; Dorothy Krieger, MD, a leading authority on endocrine glands; and Solomon Berson, MD, whose collaboration with Rosalyn Yalow, MD, to develop the radioimmunoassay method resulted in the Nobel Prize. Dr. Flier can still recall the class that first interested him in diabetes and endocrinology, the field that became his specialty. “It was in my first-year Introduction to Medicine class,” he says. “Henry

Mount Sinai Science & Medicine / SPRING 2012

Dolger taught the course, and the theme was diabetes. He insists his career has been largely unplanned, but

Every Thursday afternoon for a couple of hours,

sometimes it looks like Jeffrey S. Flier, MD ’72, was

there was a session that looked at a different aspect

cut out for leadership. Now Dean of the Faculty of

of diabetes: the fundamental basic science of insulin,

Medicine at Harvard University, Dr. Flier was drawn

to diabetes and pregnancy, to diabetic ketoacidosis,

to Mount Sinai School of Medicine—then brand

to diabetics and amputations, to psychiatric and

new—partly because of the opportunities it presented.

behavioral aspects of diabetes. I found it to be ex-

“I was captivated by the idea that it was a new school, with a small class, and I could be involved in helping

tremely interesting.” And the influence of these legends had a direct

to shape it,” says Dr. Flier. “It seemed like an adven-

impact on the arc of Dr. Flier’s career, he says. He drew

ture with a little bit of risk, but a tremendous

upon the immunological techniques he learned while

positive upside.”

working in Dr. Hirschhorn’s laboratory for his first

A desire to shape a large institution, an adventurous

investigations into diabetes, and at Dr. Berson’s urging

spirit, and the foresight to recognize great potential:

he joined the National Institutes of Health laboratory

The qualities that brought Dr. Flier to Mount Sinai

of Jesse Roth, MD, the internationally renowned

back then serve him in good stead today, too.

diabetes researcher.

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Still Learning Every Day

Family Ties

Dr. Flier’s work at the NIH, and later at Harvard

Mount Sinai has been influential on Dr. Flier’s life

University/Beth-Israel Deaconess Medical Center,

in more ways than one: he met his wife, fellow alum

has produced major insights into the molecular

and endocrinologist Eleftheria Maratos-Flier, MD ’76,

mechanism of insulin action, the molecular mecha-

a professor of medicine at Harvard Medical School,

nisms of insulin resistance in human disease, and

while completing his residency at The Mount Sinai

the molecular pathophysiology of obesity. He has

Hospital, and his daughter Sarah Flier, MD, a gastro-

won numerous accolades, including election to the

enterologist, is also a graduate of MSSM as well as

Institute of Medicine, a fellowship in the American

the hospital’s residency program. Dr. Flier’s daughter

Academy of Arts and Sciences, and the Banting

Lydia will enter medical school next year.

Medal, the highest scientific honor awarded by the

Dr. Flier, who served on the alumni committee

American Diabetes Association.

organizing activities for the 40th anniversary of

So how did a researcher whose first love is the lab become a highly visible leader of one of the most

the class of 1972, enjoyed planning the reunion. “It will be exciting to see firsthand how the school

prominent medical schools in the world? ”Somehow

has changed since I was there,” says Dr. Flier. “When

I was the last one standing when they went down

I entered Mount Sinai, people said ‘What’s that?

the list of several hundred people,” he jokes—but

I’ve never heard of that school.’

then considers.

“They don’t say that anymore.”

It was more a natural progression rather than a

– Travis Adkins

calculated path, he says. “What ends up happening is that you get various opportunities to take on more leadership, and you can either be interested and take them on, or not,” he says. “I decided early on to follow up on those opportunities.” “In this role, I’m still learning every day,” he continues. “You have to learn the ropes, who all the parties are that you have to deal with, what the rules of the game are, and how you play the game. It’s a mind boggling set of skills, but I approach it, every day, by just starting a new day.”

“What ends up happening is that you get various opportunities to take on more leadership, and you can either be interested and take them on, or not. I decided early on to follow up on those opportunities.” – Dr. jeffrey flier

From the Alumni Director’s Desk Stephen J. DeSalvo, Director of Alumni Relations As the director of Alumni Relations, it is my

privilege to work with the proud alumni of

on the volunteers, chapter leaders, and class agents

Mount Sinai School of Medicine and The Mount

who are our greatest strength. Please visit our Web

Sinai Hospital on a variety of programs, events,

site, mountsinaiconnections.com, to learn more about

and services.

each of our initiatives and to find out how you can

Our mission is to deliver real value to all of our alumni, while strengthening your connection to Mount Sinai.

The success of our alumni community depends

participate. I hope to see you soon at one of our many upcoming events!

To that end, we have recently launched a broad range of initiatives such as regional chapters; alumni golf and tennis outings; social events in New York City; networking, volunteering, and mentoring opportunities; and specific programs that celebrate the gender

For more information about these—and all—Alumni Association programs, please contact Stephen DeSalvo at stephen.desalvo@mssm.edu or (212) 241-4694.

and ethnic diversity of our alumni.

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Al

ALUMNI

Award Season for Alumni Association The Alumni Association began 2012 with two special events paying tribute to distinguished members of the Mount Sinai community. The Annual Meeting and Awards Presentation, held in February, recognized Michael L. Brodman, MD MSSM ’82 and David G. Nichols, MD, MSSM ’77 with the Saul Horowitz, Jr. Memorial Award; Lisa Satlin, MD with the J. Lester Gabrilove Award; Elliot J. Rayfield, MD with The Mount Sinai Alumni Special Recognition Award; Adam I. Levine, MD, MSSM ’89 and Gerald Friedman, MD, PhD, MSH ’61 with the Mount Sinai Alumni Award for Achievement in Medical Education; Lynne D. Richardson, MD with The Dr. Sidney Grossman Distinguished Humanitarian Award; and Nishant Goyal ’12 (expected) with The Alumni Student Leadership Award. The Jacobi Medallion, one of Mount Sinai’s highest awards, was presented in March to a distinguished group of recipients for 2012: Avi Barbasch, MD MSH ’80; Dean Dennis S. Charney, MD; Michael L. Marin, MD MSSM ’84; Chairman of the Boards of Trustees Peter W. May; and Barbara K. Richardson, MD MSH ’81. “I would like to congratulate each award winner and thank them for their dedication,” said Jeffrey T. Laitman, PhD, president of the Mount Sinai Alumni Association, at the Jacobi Medallion dinner. “After all they have given to Mount Sinai, it is a pleasure to be able to give something back to them.” TOP (from left): Peter May, Dennis Charney, Michael Marin, and Avi Barbasch. (Not pictured: Barbara K. Richardson) BELOW (from left): Nishant Goyal, David Nichols, Gerald Friedman, Michael Brodman, Elliot Rayfield, Adam Levine, Lisa Satlin, and Linda Richardson.

A Letter from the Alumni President Jeffrey T. Laitman, PhD My name is Jeff Laitman and I’m the new President of The Mount Sinai Alumni. I’ve had the privilege of teaching and working with many of you—and/or your children, relatives and friends—over the 35 years I’ve been at Mount Sinai. My extended family has been at Mount Sinai for more than 75 years and my son, Ben, is here now as a first-year MD/PhD student. It’s wonderful how traditions continue at our home! But as all of you know, this is a tradition that comes with a high price tag—and, for many, makes scholarships absolutely essential. Our alumni have been terrific in keeping our torch ever bright, fostering relationships through events, awards, and activities. Now we need your help to enhance scholarship giving. Not all students are born with a silver stethoscope around their necks; indeed, some excellent students go elsewhere because they can’t afford it here. Over my term as your president I will work to redefine alumni awareness of and responsibilities toward scholarships. To those of you who have already committed to scholarship support—either through establishing individual scholarships or by becoming Life Members of the Alumni (funds that are directed toward scholarships)—many, many thanks. To those who have not, please consider this important gift. You can make it possible for a young student to obtain the great and glorious education that Mount Sinai offered you. Giving to your alma mater—Mount Sinai—is not a chore, not a burden, and not a luxury. It is a blessing and a moral imperative. Let us remember the oft-quoted phrase, “From those who have been given much, much is expected.” And Mount Sinai has given us all very much. Our alumni are responsible for “paying it forward” and enabling the next generation to follow in our footsteps through scholarship support. You are part of the sacred link that binds us all. Your place in the history—and future—of Mount Sinai is most special. On behalf of our Alumni Association, I look forward to working with you in the years ahead as together we ensure the outstanding students who embody the future of medicine can learn at Mount Sinai today.

Jeffrey T. Laitman, PhD President, The Mount Sinai Alumni Distinguished Professor, Mount Sinai School of Medicine

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Are you part of

THE CIRCLE?

If you are not, now is the time to join the Mount Sinai Leadership Circle and be part of our exclusive membership events. Members of the Mount Sinai Leadership Circle advance Mount Sinai’s mission: patient care, research, and medical education. Circle members receive invitations to special events during the year—such as a lecture series featuring noted experts discussing the latest medical breakthroughs and other opportunities keyed to your level of giving. For more information on the Mount Sinai Leadership Circle, please contact Al Seminsky at (212) 731-7428 or albert.seminsky@mountsinai.org.

www.philanthropy.mountsinai.org

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Non Profit Org. U.S. Postage

PAID The Mount Sinai Medical Center Office of Development One Gustave L. Levy Place, Box 1049 New York, NY 10029-6574

S. Hackensack, NJ Permit No. 897

s

F

Please contact us by telephone (212.659.8500) or email (philanthropy@mountsinai.org) if you wish to have your name removed from our distribution list for fundraising materials.

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Mount Sinai Science & Medicine Spring 2012