high volume EC surgery hospitals

Good afternoon dear Sister-in-law

 Just a bit of humor here.  Not too long ago I heard an intriguing question regarding in-laws.  The question was:  Do you know the difference between in-laws and outlaws?  The answer surprised me.  The answer was:  OUTLAWS ARE WANTED!    That goes along with another little ditty I saw once.  Some of us are old enough to remember when milk came in quart and half-gallon waxed-paper cartons.  I remember when every milk carton had pictures of missing people, some young—some old, on the sides of the carton.  Now, you would have to know about those pictures to understand the saying:  “HAPPINESS IS SEEING YOUR MOTHER-IN-LAW’S PICTURE ON A MILK CARTON!”    So that’s my contribution to the “in-law-outlaw” problems that are present to this day.  Now being the MIL to 3 DIL, I would say that I’ve often pondered pasting my picture to one of those paper milk cartons, putting it in a lovely gift-wrapped box with a beautiful bow and mailing it to one or more of them.  Now I really wouldn’t do that, but I’m certain 2 out of the 3 would display it on their shelf in some conspicuous place and enjoy gazing at it.

So I must say you are the “exception” to the “in-law” question.  You’ve asked a good question and below my name I’ve provided some good information that will help you decide.  As I’ve stated before in answering others here, all hospitals are known for their expertise, or lack of it, in different types of medical diagnoses.  Did you know that the USNews&World Health report has ranked hospitals, as well as doctors according to their level of expertise in dealing with certain types of diseases?  Further, did you know that according to an April 2017 report this year, that of all the patients that came to Mayo Clinic in Rochester, MN, only 12% of their diagnoses were correct.   (See reference below)  Eighty-eight (88%) were changed in some fashion—some were absolutely wrong altogether.  So although you’ve named some well-known hospitals, those facilities will NOT all enjoy an equal ranking in the field of GASTROENTEROLOGY and GI series.  Esophageal Cancer comes under the category of Gastrointestinal diseases.

As to the questions about who coordinates the complete treatment program.  Normally the case would go like this. At least this is how my husband's treatment course followed.

....................................................................

1.      Patient consults GP for heartburn, acid reflux, difficulty swallowing, excessive weight loss, etc.

2.      GP orders an Upper Endoscopy

3.      Gastroenterologist confirms presence of cancer & sends report to the patient’s GP

4.      GP refers patient to a Thoracic Surgeon

5.      Thoracic surgeon studies reports & conducts further tests of their own to determine the stage & grade of cancer, and whether or not patient qualifies for surgery.  (I use the word “qualifies” because sadly some present with Stage IV initially.  That is a disqualifier for an esophagectomy.)  And believe me, all who are diagnosed with Esophageal Cancer hope that they will be surgical candidates.

6.      Usually the surgeon has a medical team he works with, and all the testing is done by his team of associates as to what they think is necessary prior to surgery.  In this case, someone has already conducted testing evidently close to home, but with a SECOND opinion, the surgeon will review all that work-up and will concur with all that has been done, or even order testing of their own.

 BIL will want to be certain that he is tested for HER2+ gene.  (Human epidermal growth factor receptor 2) Some patients have an “over-expressive oncogene that replicates itself much more rapidly than usual.  This causes a more rapid spread of the cancer.  If that gene is overactive, then a drug known as HERCEPTIN should be administered in addition to any prescribed chemo/radiation regimen.)

7.      Pre-op chemo/radiation treatments can be coordinated with an oncologist at your BIL’s home.   It isn’t necessary to go back to where he will be having the surgery to have his pre-op treatments. 

...........................................

 In your BIL’s case, although he goes out of town for the consult and recommendations, all pre-op chemo/radiation can be done at home prior to returning to the hospital for the actual surgery.  The surgeon and the oncologist co-ordinate and agree on the pre-op treatments.  Upon completion of the pre-op treatments a PET/CT scan is usually conducted approx. 3 weeks after the last treatment.  Chemo usually has a residual effect of up to 3 weeks after each treatment so that the maximum effect of the treatments will be evident by that time.   Usually a follow-up PET/CT scan is performed to determine final outcome.  Then after that, surgery is set up ASAP.

 Now usually during the chemo treatments, an interim scan is conducted to check the progress of the chemo that has been prescribed to test its effectiveness.  Hopefully results are good, and a reduction in the presence of the cancer will be noted.  If no progress, then the chemo combo should be reassessed and sometimes it is changed.  Hopefully, whatever is ordered will work well.  My husband has 5-FU and Carboplatin.  Pre-op tests indicated chemo had worked perfectly, and no evidence of cancer was present.  BUT even in that instance, surgery is STILL necessary.  There may be some residual cancer that was so small it wasn’t detected by the scan.  (That happens sometimes.)

 I always say “qualifies” because sometimes the cancer has already infiltrated more than one major organ.  If that is the case, the Stage will be Stage IV, and only palliative treatments of chemo and/or radiation will be prescribed.  In rare instances, the Stage will be “in situ” meaning that it has not progressed further than the initial stage of EC cancer.  Stages run from Zero to Stage IV.  So if it is the very earliest of stages, no pre-op “neoadjuvant” chemo and/or radiation treatments are ordered. 

Now however, in some instances when the patient goes to surgery, more cancer is found than the original tests indicated.  During surgery, normally a minimum of 22 lymph nodes local to the Esophagus will be examined by a pathologist to test for residual cancer.  If none is found, then no post-op (adjuvant) treatments are prescribed.  If there is any “residual” cancer found in the nodes that were removed for examination, then “post-op” treatments are prescribed.  Clinical trials have revealed that patients who undergo tri-modal treatment (chemo-radiation-surgery) enjoy the best prognosis. 

And another scenario is that patients have had the chemo and radiation prior to the surgery, and afterwards still more cancer was found in the nodes.  In that case, post-op (adjuvant) chemo is prescribed.  Cancer cells left untreated will only spread, they will not just simply dissipate.  As we know all too well, cancer can multiply rapidly.  A cell will divide—then there are 2.  Those 2 will make copies of themselves, and then there will be 4.  Then those 4 multiply and become 8.  Then 8X2=16—16X2=32—32X2=64 and you can see how it rapidly progresses.  Chemo circulates throughout the entire system in search of cancerous cells to kill.  However, it also kills good cells thus the many side effects that a cancer patient can suffer.  Radiation is designed to shrink the actual tumor itself. 

Now radiation can result in scar tissue.  That is why a follow-up PET/CT scan is scheduled usually in 3 to 4 weeks after the last chemo treatment, then a surgical date is set, because there is less scar tissue buildup.  The more scar tissue, the more difficult the surgery. 

All surgeries will not take the same amount of time.  In my husband’s case the Ivor Lewis Minimally Invasive Esophagectomy (MIE) took 7 hours.  In a case preceding his, the surgery was only 4 and ½ hours.  Dr. Luketich explained that my husband had more scar tissue to cut through than the previous patient.  So times will vary.  Now I will tell you that Dr. James D. Luketich pioneered the MIE.  He is located at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania.  The majority of esophagectomies performed at UPMC are totally laparoscopic.  So no matter where your brother-in-law decides on treatment, the first prerequisite should be that the surgeon be thoroughly proficient at performing the Ivor Lewis Minimally Invasive Esophagectomy.  There’s absolutely no reason why a patient should undergo “massive” incisions when tiny cuts are all that is necessary.  I called Johns Hopkins (443) 997-1508) and asked if Dr. Richard Battafarano performed the MIE.  The answer was YES!    (my phonetic pronunciation – “bot uh fuh ron’ o”).  The gentleman that answered the phone said, patients usually call him “Dr. B”.

You are wise to ask these questions now.  I’m certain that you can readily call up Dr. B’s office and ask about how he likes to coordinate treatments between his team and the oncologist.  I’m almost certain that he might even have an oncologist that he would recommend that practices close to your BIL’s home. 

And as always, we are sorry to have to say “welcome”, but happy to be able to give you some advice “sooner rather than later”.  As for my husband and me, your BIL has our blessings on “Dr. B” at Johns Hopkins!” 

Wishing the BIL every success,

Loretta (Wife of William, DX ECIII, T3N1M0) Nov. 2002, pre-of chemo @ home, then MIE @ University of Pittsburgh Med. Ctr. By Dr. James D. Luketich on May 17, 2003.  William is still cancer free as of this date, August 25, 2017!  Thank God for real!  It’s a miracle.

______________________________________________________________________

1.       http://www.gomn.com/news/mayo-clinic-says-get-a-second-opinion-first-ones-are-frequently-wrong/

“Mayo Clinic says get a second opinion – first ones are frequently wrong

by Melissa Turtinen April 4, 2017 12:17 pm -

If you’re diagnosed with an illness, you might want to get a second opinion.

The Mayo Clinic in Rochester did a study (published in a medical journal Tuesday) and found as many as 88 percent of patients who came to the clinic for a second opinion for a complex condition left with a new or more refined diagnosis, a news release says.

The Mayo Clinic says a different or more detailed diagnosis can change someone’s care plan “and potentially their lives.”

The study looked at 286 patients who were referred from primary care providers to Mayo Clinic’s General Internal Medicine Division in Rochester between Jan. 1, 2009, and Dec. 31, 2010. Here’s how the types of diagnostic errors breaks down:

• Only 12 percent of patients left the Mayo Clinic with the same diagnosis.
• In 21 percent of cases, the diagnosis was changed completely.
• In 66 percent of patients, their diagnosis was refined or redefined…”

_________________________________________________

2.       http://news.cancerconnect.com/cancer/newly-diagnosed/

[My note:  Please check the list of questions to ask.  Also, as your BIL has tests performed,  ask for a copies of all medical records, actual scans and accompanying reports, etc.  The next doctor will want to see them to make an accurate assessment of the patient’s prior treatments and compare them with his own criteria.  Check to be sure the doctor you want to see accepts your insurance.] 

___________________________________________________________

3.       http://news.cancerconnect.com/types-of-cancer/esophageal-cancer/esophageal-cancer-overview/

[ My note:  This site covers all the bases.  See different topics on left side of page.]

___________________________________________________________

4.       http://health.usnews.com/doctors/richard-battafarano-7665

“Overview -

Dr. Richard Battafarano is a thoracic and cardiac surgeon in Baltimore, Maryland and is affiliated with multiple hospitals in the area, including Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital. He received his medical degree from Drexel University College of Medicine and has been in practice for more than 20 years. Dr. Battafarano accepts several types of health insurance, listed below. He is one of 11 doctors at Johns Hopkins Bayview Medical Center and one of 20 at Johns Hopkins Hospital who specialize in Thoracic & Cardiac Surgery…”

_____________________________________________________________

5.  http://health.usnews.com/best-hospitals

U.S. News Hospitals Rankings and Ratings

The U.S. News Best Hospitals analysis reviews hospitals' performance in clinical specialties, procedures and conditions. Scores are based on several factors, including survival, patient safety, nurse staffing and more. Hospitals are ranked nationally in specialties from cancer to urology and rated in common procedures and conditions, such as heart bypass surgery, hip and knee replacement and COPD. Hospitals are also ranked regionally within states and major metro areas. The Honor Roll recognizes 20 hospitals with outstanding performance across multiple areas of care.

____________________________________________________

6.       http://health.usnews.com/best-hospitals/rankings/gastroenterology-and-gi-surgery

(My note:  I see that JohnsHopkins ranks 3^rd in GI Surgery---UPMC ranks 6th-----Univ. of Penn ranks 12th together with Houston Methodist in TX – I don’t see Sloan Kettering listed as one of the best hospitals for GI series.)

• Johns Hopkins Hospital - Baltimore, MD 21205-1832 - #3 in Adult Gastroenterology & GI Surgery Hospitals

Johns Hopkins Hospital in Baltimore, MD is nationally ranked in 15 adult specialties and 10 pediatric specialties.

83.6/100 - Gastroenterology & GI Surgery Score

.................................................................................................

 Hospitals of the University of Pennsylvania-Penn Presbyterian

Philadelphia, PA 19104-4206- #12 in Adult Gastroenterology & GI Surgery Hospitals

Hospitals of the University of Pennsylvania-Penn Presbyterian in Philadelphia, PA is nationally ranked in 11 adult specialties.

73.1/100 - Gastroenterology & GI Surgery Score

_____________________________________________________

______________________End of references________________