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Lakeland Currents your public affairs
program for north central Minnesota. Produced by
Lakeland PBS with host Ray Gildow.
Production funding for Lakeland Currents is made possible by
Bemidji Regional Airport serving the region with daily flights to Minneapolis-
St. Paul International Airport. More information available at
bemidjiairport.org. Closed captioning for
Lakeland Currents is sponsored by Nisswa Tax Service
tax preparation for businesses and individuals. Online
at nisswatax.com.
Ray: Hello again everyone and welcome to Lakeland Currents.
Where tonight we're going to be talking about the MInnesota Institute for
Minimally Invasive Surgery
in the Crosby Ironton Regional Medical Center. I guess
we don't say Crosby-Ironton but the Crosby Regional Medical Center
is the correct term? [Cuyuna Regional Medical Center] Or the Cuyuna! Sorry about
that. We get it right. My guests this evening are two surgeons
from that center. Doctor....
Howard McCollister is the Chief of Surgeons. [mmhmm]
And he has been on our show before and we appreciate your coming
back and submitting yourself to this again.
[laughter] Howard: It's nice to be here Ray. Ray: And his...to his right
is Andrew Loveitt who is the...one of the newer surgeons
at the center. Welcome to both of you. Before we get started
maybe you could just give a little bit of a background of yourselves
so we can...the viewers can have an idea of who you are.
Howard: Well, I am trained as a general surgeon
and in the course of my 40 years
of practice have been through various evolutions including
traditional general surgery then rural general surgery
and then advanced minimally invasive surgery
and now robotic surgery. So it's been quite an evolution over that period of
time. Ray: And how about you? Andrew: Sure.
I was born and raised actually in Maine.
Completed my training out in New Jersey. And then
last year I had the opportunity to come to...Minnesota
Institute of Minimally Invasive Surgery for fellowship training.
Which for those that aren't familiar is just that extra year of very
advanced specialized training. I completed that with
Doctor McCollister, Doctor Severson, Doctor Roberts and Doctor LeMieur
who are all the surgeons over there. And had a great experience
so my wife and I decided to stay here. We're lucky enough to have the
opportunity. Ray: And you were saying that you have how many surgeons now
at Cuyuna? Howard: Fifteen...surgeons I think. Ray: Fifteen surgeons.
That's incredible....for an area
the size of where you're working. I mean that really is. Howard: Well, it's
interest....it's in all surgical specialties yeah
it's especially remarkable given where we came from
30 years ago when we had 2 surgeons on the staff, so.
Ray: And how long has Cuyuna
Regional Medical Center been that center itself?
Howard: Ah.....19....oh they just
we just celebrated our 50 year
anniversary 2 or 3 years ago, so 50 years
or there abouts. Ray: Wow. So you've seen a lot of changes in your time
there, a lot of changes not only in your
medical staff but in the national health care scene
that's probably some of the biggest changes that we're all
experiencing isn't it? Howard: It's been tough keeping
up with not just the advances in surgery but the advances in
the politics and the
paper work and the regulatory environment. Those things have been
have been difficult to keep up with. It's a lot to juggle.
Ray: And Andrew, I would guess that coming from Maine you have some of the same
climate in Maine. Andrew: Very similar.
Andrew: A little snowier in Maine actually from my experience so far
but certainly a little bit colder here. I"m down from near the
ocean, so. Ray: And where did you actually take your medical training?
Andrew: So I did my medical schooling
at University of New England which is in Maine. And then my residency
program was down in New Jersey outside of Philidelphia. [Ok]
Ray: So, talk a little bit about how this
technology is changing. I mean how you used to
just cut us open...[laughs] and do the surgery
it's really really revolutionized isn't it? Howard: It really has.
And in about 1987 was where that revolution
began to take place when we started...you know
in my training. There was really very little
in the way of laparoscopic or minimally invasive surgery. And
the idea was you had to make an incision in someone's body
that was big enough for you and your assistant to get all of your hands
in to do the work. Now we do that same
surgery through just little tiny incisions and the results
have really been significant. Patients
often times, if it's not out patient surgery, only spend a day or two
in the hospital. Pain has decreased, complications are decreased.
It's been a remarkable evolution. And that has continued
over the years. And has progressed to
the point of robotic surgery as well. Which is kind of
an extension of minimally invasive surgery. Done with a machine
rather than with human hands. Ray: Talk a little bit about
you're fellowship programs. I'm not sure a lot of
us understand what that is. Howard: Well, surgical training
is very complex and getting increasingly so. In the
United States there are 172
accredited fellowship programs. Programs
that are accredited to teach advanced techniques
in minimally invasive surgery. In Minnesota there are 3
there's us, and the University of Minnesota and the Mayo Clinic.
And what we do, the concept is
to provide one year of advanced
surgical training. We're accredited to certify our
fellows in minimally invasive
surgery and in bariatric surgery and
flexible endoscopy. And Doctor Loveitt has been
going through that this past year, I'm sure he has a take
on how that all worked. Ray: And how does it
work? It must be a little awkward when you're starting
to do this kind of surgery for the first time. Andrew: It is and you know
Doctor McCollister is being humble in that we've
at MIMIS or Minnesota Institute done minimally
invasive surgery for many years. But that's not to say that there isn't
lots of old fashioned open general surgeries still being
done out there. In certain...certainly in my
training and residency I encountered that where you know
there's certainly laparoscopic minimally invasive surgery being done.
But not to the extent that we do it at Cuyuna.
It was just you know one year really
kind of polished off all my skills and added
I can't even list the number of new skills that I
gained in that short year as opposed to even a 5 year
residency that I was building on, so. Ray: So you really have
good mentorship, I mean that's really kind of how you get through this program.
Andrew: Yep, absolutely. And that was one of the
big reasons that I decided to stay is I really loved working with everyone there.
The surgeons, the staff, the hospital
it's really a nice place to be. Howard: It's... a fellowship is sort of
an apprenticeship in many way in that that it's
a very collegial environment and we're basically
committed to passing on the experience
and the knowledge that we've gained over the last 30 years or so.
Ray: And I know you do a lot of different kinds of surgeries but bariatric
surgery is one of the areas of your expertise, you want to
just talk a little bit about that? Howard: Weight loss surgery is a....
an important concept and an important part of what we
do. There are probably 40
percent of the U.S. population is obese.
And that doesn't show any signs of decreasing
anytime soon. One of the problems with that
is that there are associated illnesses that go along
with that. Things like sleep apnea,
heart disease, some types of cancer
and diabetes which has been a....
had a remarkable increase over the last
25 years or there abouts. In 1955 I
think about 1 percent of the population had type 2
diabetes. And I think this past year almost 10
percent of the U.S. population has had that so
that's 30 million people. That's a tremendously
debilitating disease and can be difficult to manage. Ray: It goes
along with obesity. Ray: That's amazing when you think about
it. It's just absolutely amazing. So when you do
bariatric surgery what is it that you're actually doing?
Howard: What we're trying to do is...
it's very difficult to effect
weight loss just on the basis of lifestyle
change alone. Because it's hard just to wake
up one morning and say, well I think I'll just change my lifestyle.
I'm gonna eat healthy and exercise regularly and stuff like that.
What weight loss surgery does is it helps people to
affect that weight loss. To
actually or that lifestyle change...to be able to
what we tell patients is is that the operation
is not gonna make them lose weight. It will help them to change their
lifestyle and that will make them lose weight.
Ray: It's....it's a mixed bag isn't
it? I have friends who have gone through that. And they
got the same old habits. Got into the same old habits
and started gaining that weight back. So as you said, it's
a lifestyle start. And you have to be
at a certain stage to be at least from
medicare or from the health insurance perspective
you have to be a certain weight certain BMI to even qualify
for that don't you? Howard: You have to have a....
you have to be morbidly obese. You have to have
a body mass index greater than 40 or greater
than 35 if there are associated illnesses like
diabetes or heart disease or joint disease or something
like that. Ray: And that BMI is pretty easy to figure out isn't it?
Howard: Yes, there are calculators all over on websites
and a variety of places. Ray: It's basically your height and your weight.
I mean that kind of gives you a rough idea doesn't it? Howard: It's based
on body surface area. And you can calculate that
based on height and weight, you get an approximation of it. Body mass
index has some....I mean it's not...it's a very rough
guide. It's not...it is not a hard and
fast number that is extraordinarily accurate.
But I think when applied to the general population
it has some validity in terms of large populations of people.
Ray: And do you have average ages
of people that do this or is it just all ages?
That you just deal with? Howard: Our center
we're accredited center of excellence and...but we're
certified for adult.
So patients younger than age 18 or there abouts
is not something that we do. That's kind of a specialized area
and there are only a couple centers in Minnesota that actually do that.
But we're focused mainly on adults
in that obese category, yeah.
Ray: So do you basically in this surgery do you go in
and reduce the size of the stomach? Is that basically what you do?
Or how does that work? Andrew: That's part of it.
There's a couple different techniques that we can do.
The two most common, one's called the Sleeve Gatrectomy
and that is where we are essentially just reducing the
portion of the stomach. The other that we do commonly is
the Roux-En-Y Gastric Bypass which is really the
classical kind of traditional surgery. And in
that...surgery we are reducing the size of the stomach
to a small pouch. And also we're
re-configuring some of the intestine.
Both of these surgeries beyond just reducing the size
which we would call a restrictive effect, meaning
you physically can't eat as much at one time. They also have very
profound hormonal effects. When we
either size part of the stomach or re-route
the direction that the food goes initially
there's immediate hormonal effects.
Often times we'll see people with profound diabetes
even by the time they're out of the hospital on a much
lower dose of insulin or the medications
which obviously hasn't become...hasn't come from the weight loss
alone, its cause of those hormonal effects that also accompany these
surgeries. Ray: So you see that diabetes changing already?
Andrew: Very quickly. Ray: Wow, that's amazing. And when you
have folks that go through this surgery do you have
a support program for them? To help them
work through this process? Andrew: Absolutely. And that's you know beyond
that's probably the most important part is the support program.
Leading up to the surgery there's certainly
insurance requirements based on
certain number of nutritional visits, certain number
of visits to various specialties
to make sure that you're mentally and physically prepared for the
surgery. But you know I would say that those
beyond being insurance requirements really should be requirements for the surgery in general
because it's a profound change to your life.
And certainly the people that do best are the people
that continue to engage in some type of support group
or keep the lifestyle modifications in mind. As
Doctor McCollister said it's....it resets your life
for 6 months to a year. And really helps you lose the weight
but beyond that you really need to continue
to continue the lifestyle modifications.
Howard: As you mentioned, it's a mixed bag. It's
some patients do better than others and the
it....mainly reflects the commitment
to the lifestyle change as necessary.
The operation is not going to make people lose weight. It will help
them to lose weight, it makes it possible for them to lose weight.
But they have to style do the...make the effort. They still have to do the work.
So it's very successful.
But not 100% successful. There are people who regain
weight. It's rare in our practice
that they regain all their weight but
it is not uncommon to
see people regain some of their weight as the years go by after
this is done. Ray: And do you do a lot of follow-up to kind of see
how successful this has been? Do you keep track
of the patients that you worked with? Howard: Oh we keep very close track
of them. We want to see them back yearly for the rest of their life.
And certainly very frequently in that first
year. But we want to keep track of the various
potential complications, nutritional complications and those types of things.
In many cases because we have so many patients come from
long distances. We work with their primary care
doctors in their own facilities. So they don't have to drive all the way
back up to see us just for a 15 minute visit.
Ray: Now is that surgery usually done minimally too then? Howard: Absolutely.
Ray: It is? Wow. And that must be
a challenge if somebody, if you see the size of some
people that are... people who are very
huge. That must be kind of a challenge to get into that
through that body fat to do that. Andrew: It can be but
they're certainly very well established techniques and
again that's why we specialize in this [mmhmm] because we've learned those techniques.
And it's completely doable.
It's um, you know
and once you're on the inside it kind of, we can get
it done. Ray: It's amazing. I was with a heart
specialist this summer whose from not from the area but
we're talking about what it's like to just if you go to the Minnesota
State Fair for example. And you see the obesity
walking down the streets. It's just really
mind boggling. I still like the old
Lone Ranger shows because they'd play those old
reruns on tv and black and white. And you hardly ever see an actor
that's overweight from the 50's and the 60's.
I mean I'm sure there were overweight people. But like you said,
not to the degree of which they are now. Howard: No it's been a remarkable
it's been a remarkable shift in the
demographics of obesity. And it has been an alarming
increase over the last 25 years thereabouts.
It tends to be regionally variable. Minnesota
is not even one of the most prominent states relative [right] to the percentage
of obese people. I think that that's a
an honor that's reserved largely for some of the southern states.
But certainly we contribute our share.
Ray: Mmhmm. How about and I know this is a huge topic
heartburn and reflux issues. Talk a little bit about
what you folks do there. Howard: That's a huge, that's a huge
area and it's very
under treated. It's one of the most common reasons why people see their primary care
doctors. And the various medications that are used
to treat that. To suppress acid
are some of the most popular and hottest
selling medications on the market particularly now that they're
over-the-counter. And what we
have we have always been done a lot of work
relative to... managing reflux
disease. But I think over the last 4 or 5 years
we have really kind of coalesced that into
a formal center. A coordinated approach to the diagnosis
and the treatment of gastroesophageal reflux disease.
It's been a very rewarding thing and we've really
had a lot of success with that and a lot of response. We
got people that come to us literally from all over the state.
And from all over the upper midwest. [inaudible] Ray: Hmm.
What are some of the techniques you use when you're treating that
reflux? Andrew: So the
I would add that the coordinated effort that we use for the reflux
is really unique. And in fact you know my family's from
Maine. I was anticipating going back there and
there's just there's nothing even similar to what they do
at the Minnesota Reflux and Heartburn Center in Crosby and in
Riverwood anywhere that I've seen. [really]
A lot of this test... the key component
to doing proper reflux surgery is the
testing and making a proper diagnosis.
And a lot of this testing can take weeks to months
in multiple various different specialties,
different hospitals, different clinic visits. Where
many times we can do it all in one day at our center.
And making that diagnosis is the key component.
Howard: That's a good point. One of the things that we try to bring to the table...
you know how it is when you go to the doctor. The doctor
says we need this test or you need to see this specialist. But you
can't see him or her for 2 weeks or 3 weeks or 2
months. And so that happens. And then they want to do testing and
that schedules for gets scheduled for 2 months down the
road or 2 weeks down or something. It's a very
cumbersome process. And what we want to try to do is to do this
efficiently. Try to do it all in one setting or in a short time frame
if we can. So that the patients needs are met on this.
Most of these people are miserable by the time they come see us.
Ray: So you come in and you've got heartburn and
reflux issues. You almost have to go down and
look, don't ya to really be able to diagnose what the problem is?
[absolutely] Andrew: That's where we start. Ray: So you can do
that? And usually take a mild sedative or something when
you do that to relax the throat? Howard: It's completely painless. It's
done with the patient sedated, basically asleep.
They don't feel a thing. It takes us about 10 or 15
minutes to do the examination and the associated testing
to gather the data necessary to understand
what's going on. We do what's a comprehensive esophageal
evaluation that starts with the upper GI endoscopy
and the various testing that's associated with that.
But there are couple other tests that we do as well to try to put
a fine point on it to make sure we understand everything there is to
understand about a persons esophagus and their lower esophageal
sphincter and the reasons why they're having reflux and figure out the best
way to manage it whether it be surgery or whether
it be with medical treatment. Andrew: And I also say if in fact they are having
reflux there's a lot of people out there on
medication for reflux that aren't don't actually have any. And the
medications not helping them. [oh really] Our goal is to
you know treat their reflux certainly if it's there but if it's not there then
to get them off of unnecessary medications. Ray: And I've read that some
of those medications can actually be harmful if you're
taking them for long periods of time. Andrew: They certainly can over time.
If you actually go through and read the little packet literature
when you get your over-the-counter medications
which I'm sure most people don't. They're really only supposed to be used for
about 2 weeks at a time. And of course we know
many many people have been on these for years and years and years.
And there's starting to be some data that there's side effects
from that. Which is not surprising. Some
correlation with kidney disease, heart disease,
some even dementia and some
even some correlation with earlier death. These are
all very preliminary studies [sure] but it's ... there
and really any medication you know it's not too surprising.
Howard: They are preliminary. But since
2010 there have been 6 black box warnings from the Food & Drug Administration
on that particular class of drugs
omeprazole and that group. And
so we pay attention to that. But I think more importantly in this age
of doctor google [laughing] the patients are paying more
attention to these types of things as well. So those are questions that we
commonly get about that. If you
.... google omeprazole I think the first
8 or 10 hits are gonna be from attorneys
because of the potential side effects that can go along with these
medications over a period of time. It's not solid data.
It's not a for sure thing but it's enough that it has our attention. We
have to pay attention to it. The other thing that we worry about with
reflux disease is that it's contribution to
esophageal cancer. The since in the last
30 years there's been a 600% increase
in the incidence of esophageal cancer. Now
that's a scary statistic particularly when you compare it
to the other forms of cancer that have been relatively stable
or mildly increasing over that same period of time. There's
an epidemic of esophageal cancer that's very alarming.
And it's preventable. It's related directly to
the incidence of reflux disease. Ray: So
I know everybody's individually different but what's
causing this reflux increase? Is it our
diet? Is it... Howard: Obesity I think plays a huge role. Ray: Obesity
is a big part of it? Howard: Right. To circle back to obesity
that I think that the anatomic
changes that go along with accumulating that much fat
inside the abdominal cavity plays a significant role in the amount of
reflux that people have. So those two particular diseases go hand in
hand. And we see that very commonly
associated with our bariatric patients. And we see in our
bariatric patients a very high incidence of reflux
disease. And in fact a number of the patients that come to see us
to be treated for reflux disease end up being treated
for their obesity. Ray: So it would be
probably fair to say that most normal
weighted people don't have this high incidence of
it anyway. Howard: I don't know if that's accurate. I would say that it's
more accurate to say that... the incidence
of reflux disease certainly increases with increasing weight
increasing incidence of obesity yeah. Ray: So
when you've identified a problem. What are some of the
treatment options that you do? Andrew: So that Dr. McCollister said
you know we can use medications. And certainly
we always try to tailor that so it's the proper regimen
based on when people are having their reflux episodes.
But certainly you know as surgeons we
would like to get them off their medications and there's numerous surgical
techniques. We specialize in one
procedure called the LINX Device. Which is a
small magnetic beads that actually go
around the lower esophageal sphincter. The lower esophageal
sphincter is the muscle that that's there that's supposed to keep the acid down the
stomach and out of the esophagus. So with that set of beads does
is that it actually reinforces that. And it's just
strong enough so that you can swallow alright but it doesn't let that acid
back up. [mmhmm] Howard: That's been a ....
really revolutionary concept in the treatment of reflux disease
mainly because it doesn't come with the
associated side effects of some of the other operations
that we do, number 1. And number 2
it is it's an outpatient operation. It's a....
very straight forward, [oh really] pretty straightforward operation. It's done
with minimally invasive surgery but again most
patients go home on the same day. So that's... good.
We do try to. Surgery typically
and reflux disease and the treatment of it is the last resort. I
mean that's if we can control peoples symptoms
and eliminate the risk of esophageal cancer
using medical treatment without surgical treatment then that's...
certainly our preference. But there are a number of patients who
don't respond to medications, who don't respond to
a lifestyle changes and the other types of things that go along with that.
And surgery is an option for those particular
patients. There are a number of patients for example whose
symptoms are fairly well controlled on medication
but they don't want to take the risk of the side effects of that medication.
Or just don't want to take the medication
and opt for surgery instead and that's a valid reason to do that.
Ray: So when you put those beads in a person, is that for life?
Howard: Yup. Unless we take it out. Ray: It is.
And what would be a reason you might take it out? Howard: In some cases
if somebody has difficulty swallowing or ongoing
difficulty swallowing that goes along with that.
Then that's one of the reasons we would do that. Typically it would not
be unusual. I think the the explantation rate for
that device is in the neighborhood of about 1%.
One out of 100 people may not be able to tolerate that
device long term. Which is similar to other types
of surgical procedures as well. Ray: So it's pretty low.
[yeah] Pretty low. So you do
gynecology,
obstetrics... what are some of the things you do there? I can't say
it but. Howard: Well we, Dr. Loveitt and I
aren't obstetricians or gynecologists.
That's a... land of mystery to us. [laughing]
But we do have partners
there that specialize in that at
Cuyuna Regional Medical Center that do an excellent job
and similar to MIMIS they
apply a wide variety of mass surgical techniques to
gynecologic disease. Ray: And you do
some work with the da Vinci Robot. Maybe could you explain to us what
that is and what kind of surgeries you do with that? Howard: Dr.
Loveitt is the chairman of that committee. I'll... pass that
off to him. Andrew: Yeah, the da Vinci Robot
misperception is that we're not controlling it. [mmhmm]
Certainly we use the robot as a tool
and we're controlling it all times. Howard: We don't turn the robot loose on the patient
to do it's own thing. Andrew: It certainly does not...so [laughing]
What that...the robot really allows us to do is
2 things. Number 1, better visualization.
When we'd perform traditional laparoscopic procedures
it's on a flat TV screen essentially.
And you really you do lack a little bit of depth perception. Now over
time with training you'd make up for that and it's okay.
The da Vinci Robot is
in stereoscopic or 3D view. So
when we look... through that lens it's like looking
inside the patients body in real perspective.
The da Vinci Robot also has what we call wristed
instruments. Traditional laparoscopic instruments are straight
and it does limit our ability to do some
things. The da Vinci Robot we control
and it has an actual wrist on the end of the instrument. So we can
suture upside down and get in finer
areas. It just allows us to be a little more
facile and operate in just a little bit more detail.
Howard: It's... laparoscopic surgery
as we've been doing for all these decades.
But it allows us to apply a little bit
the robot allows us to apply a little bit more precision to some of the
things. And that is not, that's important for
some types of operations that we do. Ray: And how many of your
surgeons are trained to do that, with the da Vinci?
Andrew: By January all 5 of us will be, so. Ray: Wow, that's
incredible. In just generally, what kind of surgeries do
you usually do with that? Gallbladder or...
Andrew: Yeah, you know any traditional laparoscopic surgery certainly can be
done. Our focus is kind of turning towards
hernias in the upper GI surgeries [oh]
that Dr. McCollister was talking about. But
any laparoscopic surgery can be done with the robot. Howard: All the
operations that we do within the abdominal cavity typically can be done
with the robot. And eventually we'll be moving in that
direction I'm sure. Ray: We're out of time.
It's really exciting work that you're doing there. And thank you for taking
the time to come and join us and share what you're doing.
Howard: It's always a pleasure Ray. [Yes] Ray: And we'll have the information for how to contact you
at the end of the show. So, thank you very much for jumping
on with us today and appreciate it very greatly. [You're welcome]
[thank you] You've been watching Lakeland Currents where were talking about what
you're talking about. I'm Ray Gildow. So long until next
time.
For more information on the Minnesota
Institute For Minimally Invasive Surgery,
see the screen.
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