NewYork-Presbyterian Hudson Valley Hospital is expanding the breadth of its gastrointestinal services to ensure patients throughout the region have access to the latest non-surgical procedures and, when indicated, surgical intervention.
During the past year, NewYork-Presbyterian (NYP) Hudson Valley Hospital welcomed two board-certified gastroenterologists: Shireen A. Pais, MD, an advanced therapeutic gastroenterologist, NYP Medical Group Hudson Valley, and Frank J. Turchioe, MD, a general gastroenterologist and Clinical Director, Gastroenterology, NYP Medical Group Hudson Valley. Together with Daniel L. Feingold, MD, a colorectal surgeon with NewYork-Presbyterian Hudson Valley Hospital and Edelman-Jarislowsky Associate Professor of Surgery at Columbia University Medical Center, these physicians provide the full continuum of care for patients in Westchester and the Hudson Valley.
Drs. Pais and Turchioe specialize in the management of a variety of gastrointestinal (GI) conditions, including liver disease, hepatitis, motility disorders, inflammatory bowel disease, obesity, and diseases of the esophagus, stomach, colon, pancreas, and biliary tree. Colon cancer screening is routinely provided by the physicians. The physicians are dedicated to treating patients in the least invasive manner possible, with treatments ranging from medical weight loss to the latest endoscopic approaches to manage GI diseases. In addition, NYP Hudson Valley Hospital’s partnership with Columbia University Medical Center means patients with colorectal cancer and other complex diagnoses affecting the colon, rectum and anus benefit from the expertise of Dr. Feingold.
Developments in Endoscopic Techniques
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are among the advancements Dr. Pais offers to diagnose and treat digestive diseases.
Daniel L. Feingold, MD, Edelman-Jarislowsky Associate Professor of Surgery at Columbia University Medical Center (CUMC), discusses treatment with one of his patients at NewYork-Presbyterian Hudson Valley Hospital. Dr. Feingold is a practitioner with ColumbiaDoctors, the faculty practice of CUMC.
During EUS, physicians move an oblique-viewing echoendoscope, which is slightly larger than a traditional endoscope, through the mouth, esophagus, and stomach into the intestines. The scope features an ultrasound probe and allows physicians to visualize the layers of the gastrointestinal wall, organs adjacent to the esophagus, stomach and intestines — including the pancreas, biliary tree, left lobe of the liver, lymph nodes of the chest, the kidneys — as well as surrounding vasculature.
The first and most common indication for EUS is the staging of cancers of the GI tract, according to Dr. Pais. The tool is also beneficial in visualizing and obtaining biopsies of pancreatic lesions.
“Endoscopic ultrasound was initially designed to biopsy the pancreas, an organ that’s not well-visualized using other imaging modalities,” Dr. Pais says. “With EUS, we get a very clear, up-close-and-personal view of the pancreas — a much better view than if we were using an MRI or CT scan. The tool is effective in identifying small pancreatic tumors, cysts, and other lesions, determining whether there are strictures or narrowing in the pancreas that requires treatment, and diagnosing and grading chronic pancreatitis.”
Additionally, physicians can use EUS to perform ultrasound-guided fine-needle biopsy of lesions within the pancreas, biliary tree and structures adjacent to the GI tract. However, the technique’s usefulness is not limited to diagnosis. Dr. Pais also uses EUS to place stents and devices that drain abscesses or large pancreatic pseudocysts internally into the stomach and rectum, eliminating the need for an external drain.
A combination of upper gastrointestinal endoscopy and X-ray, ERCP is also performed through the mouth. ERCP is completed using a duodenoscope, or side-viewing scope, inserted through the mouth and esophagus into the descending portion of the duodenum. The procedure is intended to visualize the biliary tree and pancreas.
Frank J. Turchioe, MD, and Shireen A. Pais, MD, gastroenterologists, NewYork-Presbyterian (NYP) Hudson Valley Hospital, collaborate on a patient case. They are practitioners with NYP Medical Group Hudson Valley, with offices in Yonkers and Yorktown Heights.
“Utilizing non-surgical treatments whenever possible results in better quality of life for patients. There’s less morbidity and less mortality, and patients can often go home the same day. My motto is, ‘Give patients the care they need to prevent complications.’ We want patients to easily be able to get the care they need outside of the hospital with the same good outcomes.”
— Shireen A. Pais, MD, advanced therapeutic gastroenterologist at NewYork-Presbyterian Hudson Valley Hospital and a practitioner with NewYork-Presbyterian Medical Group Hudson Valley
Before the evolution of EUS, ERCP played a greater role in diagnosing diseases of the biliary tree and pancreas. Today, however, it is used mainly in disease treatment. Indications for ERCP include bile duct tumors, pancreatic tumors and strictures, chronic pancreatitis, and benign biliary strictures and bile duct obstruction.
“When we evaluate a patient in the office, we make a decision as to which modality — EUS or ERCP — will be most beneficial based on what’s going on with the patient,” Dr. Pais says. “We look at the patient’s symptoms, as well as lab and imaging findings. Abdominal pain, jaundice, an abnormal liver test, or a CT or MRI finding of a dilated duct or stones or other debris within the bile duct warrants an ERCP.”
Treatments Dr. Pais may perform using ERCP include placing stents to drain the bile duct or pancreas, removing ampullary polyps, and removing gallstones and other bile duct obstructions.
Enhanced Management of Barrett’s Esophagus
A premalignant condition, Barrett’s esophagus affects an estimated 10 to 15 percent of patients with gastroesophageal reflux disease (GERD), according to the American Society for Gastrointestinal Endoscopy. The condition commonly occurs in those who have chronic, long-term GERD and is characterized by cellular changes in the lining of the esophagus.
Dr. Pais is among a select group of physicians based in the New York metropolitan area who specialize in advanced diagnostic and therapeutic endoscopic procedures. She is assisted with a procedure by Barbara Hughes, endoscopy technician.
All patients with Barrett’s esophagus have an elevated risk of developing esophageal cancer. However, the risk of esophageal cancer in patients with nondysplastic Barrett’s esophagus is relatively low — 0.5 percent per year. For this reason, Dr. Pais recommends treating Barrett’s esophagus only in cases of dysplasia, which further increases patients’ esophageal cancer risk, unless patients have nondysplastic lesions and a family history of esophageal cancer.
Two endoscopic treatments are available for Barrett’s esophagus at NYP Hudson Valley Hospital: endoscopic mucosal resection and radiofrequency ablation. Dr. Pais has extensive experience performing radiofrequency ablation, and uses a system that is advantageous for treating Barrett’s esophagus because it comes with multiple balloon and focal catheters, enabling physicians to personalize treatment for greater precision. For example, physicians may use the 360 RFA balloon catheters during patients’ first treatment session to ablate areas that require larger circumferential treatment. Depending on patients’ needs, physicians may then use an RFA focal catheter for spot treatment during future sessions. The average radiofrequency ablation patient completes treatment in two to six sessions. Following ablation of the dysplastic tissue, patients receive high doses of proton pump inhibitors to allow the mucosa to grow back with a normal lining.
“Our goal is to completely resolve patients’ dysplasia over a period of months,” Dr. Pais says. “If they come in early and receive this treatment, their chances of survival are much greater than if they went to surgery, which is associated with significant morbidity and mortality.”
Ideal candidates for radiofrequency ablation include those with low- or high-grade dysplasia. Prior to performing radiofrequency ablation, physicians may evaluate dysplastic lesions using high-definition white light or narrow-band imaging to identify areas of altered vascularization, ulcerations and nodularity.
“If patients have flat dysplasia, they’re typically candidates for ablation,” Dr. Pais says. “However, if there are ulcerations, nodules or changes in vascularity, I don’t recommend using ablation because there’s depth involved.”
Patients with complex high-grade dysplasia or early-stage esophageal cancers that haven’t spread past the deep submucosa may be candidates for endoscopic mucosal resection. During this procedure, physicians resect lesions and send them to a pathologist for staging. If cancer is present and the cancer has invaded tissues beneath the submucosa, Dr. Pais may refer patients for surgery.
Treatment of Hepatitis and Liver Disease
There is an epidemic of liver cancer and cirrhosis among people of the baby boom generation. Says Dr. Turchioe, “More people die from hepatitis C than from any other infectious disease. Our goal is to do a better job increasing awareness and screening of the at-risk population. Advances in pharmacotherapy, such as direct-acting antivirals, have improved the virologic response rate from approximately 35 percent to close to 98 percent in 2017. Individuals with conditions such as primary biliary cirrhosis, autoimmune and drug-induced hepatitis, and non-alcoholic fatty liver disease will find knowledgeable and supportive staff to guide them through treatment.
“When patients are educated about their disease and feel comfortable talking with their physician, they improve more quickly and experience greater long-term treatment success. My goal is to make our office a welcoming place for patients so they receive care that is efficient and effective.”
— Frank J. Turchioe, MD, general gastroenterologist at NewYork-Presbyterian Hudson Valley Hospital and Clinical Director, Gastroenterology, NewYork-Presbyterian Medical Group Hudson Valley
Dr. Turchioe is Clinical Director, Gastroenterology, NewYork-Presbyterian Medical Group Hudson Valley, and provides the full range of gastroenterology services at NewYork-Presbyterian Hudson Valley Hospital, including colonoscopy and colon cancer screening. He has a special interest in inflammatory bowel disease, including ulcerative colitis and Crohn’s disease; medical weight loss; liver disease, including hepatitis; gastrointestinal motility; pelvic floor disorders; and reflux disease.
Inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis, is a lifelong condition requiring continuous care. Because these diseases are associated with periods of remission and a flare in activity, the physicians tailor the latest in biologic medications to each patient. These new medications allow the patient to maintain remission and enjoy a better quality of life.
Medical Weight-loss Services
Dr. Turchioe offers the full spectrum of medical weight-loss solutions for obese patients with body mass indices of 30 to 40 who hope to lose 5 to 15 percent of their body weight. NYP Hudson Valley Hospital is developing a new center, which will include a multidisciplinary team to enhance convenience for patients in need of a medical weight-loss evaluation, where Drs. Pais and Turchioe will see patients.
Patients who qualify for medical weight loss may begin taking one of several FDA-approved weight-loss medications and work with a nutritionist to improve their dietary and lifestyle habits.
“If patients regain weight, we adjust their medications, recommend diet and exercise changes and, if there’s a psychiatric issue, reinitiate psychotherapy,” Dr. Turchioe says. “Thanks to close monitoring and follow-up care, roughly 80 percent of patients in my practice keep the weight off.”
If an initial evaluation suggests patients may be more appropriate candidates for bariatric surgery, Dr. Turchioe may refer them to a bariatric surgeon. To provide patients further options, plans are in place to bring endoscopic weight-loss procedures, such as the gastric balloon, to NYP Hudson Valley Hospital.
Multi-faceted Approach to Motility Disorder Treatment
Motility disorders can affect the upper and lower portions of the gastrointestinal tract. Some of the most common motility disorders Dr. Turchioe sees in his practice are gastroparesis, nonspecific esophageal motility disorder, esophageal spasm, achalasia and pelvic floor disorders. Management strategies for these conditions may include dilation of the lower esophageal sphincter, botulinum toxin injections and medications to relax the esophageal muscles. In the case of pelvic floor disorders, patients may benefit from biofeedback physical therapy, dietary changes, fiber supplementation and, in the event of childbirth-related anal sphincter injury, referral to a colorectal surgeon, when indicated.
“We prioritize access to care, work as a team and achieve great outcomes. Whether patients have colorectal cancer, diverticulitis, Crohn’s disease or some other condition, we partner with their physicians to meet their needs.”
— Daniel L. Feingold, MD, colorectal surgeon at NewYork-Presbyterian Hudson Valley Hospital and Edelman-Jarislowsky Associate Professor of Surgery at Columbia University Medical Center
Dr. Feingold is a colorectal surgeon at NewYork-Presbyterian Hudson Valley Hospital in Cortlandt Manor and a practitioner with ColumbiaDoctors, the faculty practice of Columbia University Medical Center.
The Yorktown Heights office location will include a staffed motility disorders and GERD center. Through the center, which complements NYP Hudson Valley Hospital, physicians provide a full array of diagnostic services, including high-resolution esophageal and anorectal manometry. Patients with complicated esophageal reflux disorders will have access to 24-hour esophageal pH and impedance testing to help the physicians improve strategies to best meet individual patients’ needs.
Addressing Diseases of the Colon, Rectum and Anus
Dr. Feingold specializes in the management of diseases related to the colon, rectum and anus. This includes up-to-date treatment of anal fissures, fistulas and abscesses, hemorrhoids, rectal prolapse, and childbirth-related anal sphincter injury.
For treatment of chronic anal fissures that haven’t responded to usual medical therapy, for example, Dr. Feingold performs a muscle-sparing alternative to sphincterotomy that reduces the risk of fecal incontinence. Rather than cut the affected portion of the internal sphincter, he debrides and cauterizes the wound and injects Kenalog into the fissure. The technique boasts an 85 percent success rate, and Dr. Feingold has observed no cases of fecal incontinence following the procedure. Surgical management of complex anorectal fistulas may include the muscle-sparing LIFT procedure — which also minimizes the risk of fecal incontinence — while hemorrhoid management may include in-office rubber-band ligation, sclerotherapy and stapled hemorrhoidectomy in addition to conventional hemorrhoidectomy.
Dr. Pais discusses a patient’s treatment plan. Dr. Pais specializes in advanced diagnostic and therapeutic endoscopic procedures, management of Barrett’s esophagus, cancer diagnosis, staging and palliative management, treatment of superficial cancers of the esophagus, stomach, colon and rectum, and large polyp resections. Her practice also provides bariatric endoscopy and the management of postsurgical complications of bariatric surgery.
Patients struggling with rectal prolapse and associated fecal incontinence may benefit from surgery, which can greatly improve quality of life. Dr. Feingold offers transanal and laparoscopic rectal prolapse surgery. Patients’ ages and overall health — those in their 70s through 90s or who have multiple comorbidities may not be able to withstand an abdominal procedure, for example — and the potential for prolapse recurrence are among the factors used to determine what procedure is right for which patient. Other causes of fecal incontinence that may warrant surgical intervention include anal sphincter injuries related to childbirth in young women. In these cases, anal sphincter reconstruction may be recommended.
Dealing with Diverticulitis
Chronic and recurrent diverticulitis can be difficult to manage, and the decision to move forward with surgical treatment is often complex. Physicians now know that making dietary recommendations, such as eliminating nuts, popcorns and seeds from the diet, is not effective. Similarly, medications do not effectively prevent recurrent diverticulitis attacks. Whether to have surgery after recovering from a bout of diverticulitis is very confusing for patients.
“Diverticulitis causes a lot of frustration and uncertainty for patients,” Dr. Feingold says. “Complications, such as a fistula, are usually indications for surgery, but in cases of recurrent diverticulitis, there’s no universal recommendation. My role is to educate patients about their options and their risk of recurrence and of possibly needing a colostomy.”
Partners in Care
Gastroenterologists at NYP Hudson Valley Hospital frequently collaborate with Dr. Feingold to care for patients with complex diseases that might require surgery. One example of this collaboration is the team’s approach to caring for Crohn’s disease and ulcerative colitis.
The Ambulatory Surgery team at NewYork-Presbyterian Hudson Valley Hospital includes Magnet nurses and highly skilled technicians. Pictured from left: Barbara Hughes, endoscopy technician; Patrick Clarke, patient care technician; Trina Mills, MS, RN, NE-BC, Director, Surgical Services; Salvacion Delacruz, BSN, CCRN, Ambulatory Surgery; and Pamela Germinaro, BSN, RN, Clinical Nurse Manager, Ambulatory Surgery/PACU/OR. Seated: Agnes Montemayor, BSN, RN-BC, Ambulatory Surgery.
“Gastroenterologists treat Crohn’s disease with medications, but we recognize there’s no cure — only periods of remission and active disease,” Dr. Feingold says. “If patients don’t respond well enough to medication, it may make sense to go to the operating room. Ulcerative colitis is managed similarly with medications until it reaches the point that patients need surgery to remove the colon and rectum.”
Dr. Turchioe manages inflammatory bowel disease with medication at NYP Hudson Valley Hospital. Over the past 20 years, he says, the number of medical treatments has expanded from steroids to also include responsive biologic medications. However, even with advances in medical management, 67 to 75 percent of patients with Crohn’s disease and 25 to 33 percent of patients with ulcerative colitis require surgery during their lifetime, according to the Crohn’s & Colitis Foundation.
Surgical treatment of Crohn’s disease involves resecting the affected portion of the bowel, while surgical treatment of ulcerative colitis involves removing the colon and rectum, and creating a J-pouch. When necessary, Dr. Feingold performs these complex procedures at Columbia University Medical Center.
The high level of collaboration is also evident in the team’s approach to managing colorectal cancers. Gastroenterologists at NYP Hudson Valley Hospital perform screening colonoscopies. If patients have a polyp that is not amenable to colonoscopy removal or a biopsy reveals patients have colorectal cancer, Dr. Feingold performs minimally invasive colorectal surgery at Columbia University Medical Center using an enhanced recovery protocol designed to facilitate faster, less painful recovery.
Surgery is only one part of the treatment protocol for patients with colorectal cancer, so gastroenterologists, colorectal surgeons, medical and radiation oncologists, pathologists, radiologists, social workers, and geneticists from NYP Hudson Valley Hospital and Columbia University Medical Center meet twice monthly for tumor boards to review each patient’s case.
“We emphasize multidisciplinary approaches because it’s what patients need,” Dr. Feingold says. “Taking care of patients together — as opposed to focusing only on our respective specialties — promotes better outcomes.”
For more information about NYP Hudson Valley Hospital’s services and capabilities, visit nyp.org/hudsonvalley.