 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-Saint Paul International Airport, for information available at BemidjiAirport.org. Closed captioning for Lakeland Currents is sponsored by Niswa Tax Service, tax preparation for businesses and individuals, online at NiswaTax.com. 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-Irton Regional Medical Center. I guess we don't say Crosby-Irton, but the Crosby Regional Medical Center is the correct term. Sorry about that. We get it right. My guests this evening are two surgeons from that center. Dr. Howard McAllister is the chief of surgeons, and he has been on our show before, and we appreciate your coming back and submitting yourself to this again. It's nice to be here, right? And to his right is Andrew Lovett, who is 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 yourself so the viewers can have an idea of who you are. Well, I am trained as a general surgeon, and in the course of my 40 years of practice, I've 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. And how about you? Sure. You know, I was born and raised actually in Maine. I completed my training out in New Jersey, and then last year I had the opportunity to come to the Minnesota Institute of Minimally Invasive Surgery for fellowship training, which for those that aren't familiar, is just an extra year of very advanced specialized training. I completed that with Dr. McCollister, Dr. Severson, Dr. Roberts, and Dr. LaMire, who are all the surgeons over there, and had a great experience. So my wife and I decided to stay here, and we're lucky enough to have the opportunity. And you were saying that you have how many surgeons now at Cayuna? 15 surgeons, I think. That's incredible for an area the size of where you're working. Well, it's interesting. In all surgical specialties, it's especially remarkable, given where we came from 30 years ago when we had two surgeons on the staff. And how long has Cayuna Regional Medical Center been that center itself? 19. They just celebrated our 50-year anniversary two or three years ago. So 50 years are there. 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? It's been tough keeping up with not just the advances in surgery, but the advances in the politics and the paperwork and the regulatory environment. Those things have been difficult to keep up with. It's a lot to juggle. And Andrew, I would guess that coming from Maine, you have some of the same climate in Maine. Very similar. 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. And where did you actually take your medical training? 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 Philadelphia. Okay. So talk a little bit about how this technology is changing. I mean, how you used to just cut us open and do the surgery. It's really, really revolutionized, isn't it? It really has. 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 oftentimes, if it's not outpatient 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. Talk a little bit about your fellowship programs. I'm not sure a lot of us understand what that is. 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 three. There's us in 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 Dr. Lovett has been going through that this past year. I'm sure he has a take on how that all worked. 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. It is. And Dr. McCallister's being humble and 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 surgery still being done out there. And certainly in my training and residency, I encounter that where, you know, there's certainly laparoscopic minimally invasive surgery being done, but not to the extent that we do it at Kayuna. And 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 five-year residency that I was building on. So you really have good mentorship. I mean, that's really kind of how you get through this program. Yeah, absolutely. And that was one of the big reasons that I decided to stay is that I really love working with everyone there. The surgeons, the staff, the hospital, it's a really nice place to be. It's a fellowship is sort of an apprenticeship in many ways in 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. 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? Weight loss surgery is an important concept, an important part of what we do. There are probably 40% 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 had a remarkable increase over the last 25 years or so. In 1955, I think about 1% of the population had type 2 diabetes, and I think this past year almost 10% of the U.S. population has had that. And it's 30 million people. That's a tremendously debilitating disease and can be difficult to manage. It goes along with obesity. 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? What we're trying to do is it's very difficult to affect weight loss just on the basis of lifestyle change alone because it's very hard. I just wake up one morning and say, well, I think I'll just change my lifestyle. I'm going to 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 tell patients that the operation is not going to make them lose weight. It will help them to change their lifestyle and that will make them lose weight. It's a mixed bag, isn't it? I have friends who have gone through that and they 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? 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. And that BMI is pretty easy to figure out, isn't it? There are calculators all over on websites in a variety of places. It's basically your height and your weight. I mean, that kind of gives you a rough idea, doesn't it? It's based on body surface area and you can calculate that based on height and weight and get approximation of it. Body mass index has some... I mean, it's a very rough guide. 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. And do you have average ages of people that do this or is it just all ages that you just deal with? Our center, we're a credit and center of excellence in, but we're certified for adult... so patients younger than age 18 or thereabouts is not something we do. It's kind of a specialized area. There are only a couple of centers in Minnesota that actually do that. But we're focused mainly on adults in that obese category. So do you basically, in the surgery, do you go in and reduce the size of the stomach? Is that basically what you do? Or how does that work? There's a couple of different techniques that we can do. The two most common, one is called the sleeve gastrectomy. And that is where we are essentially just reducing the portion of the stomach. The other that we do commonly is the ruin-wide 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. I mean, you physically can't eat as much at one time. They also have very profound hormonal effects. When we either at size part of the stomach or re-route the direction that the food goes initially, there's immediate hormonal effects. Oftentimes 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 their medications, which obviously hasn't come from the weight loss alone. It's because of those hormonal effects that also accompany these surgeries. So you see that diabetes changing already? Very quickly. 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? Absolutely. And that's probably the most important part is the support program. Leading you up to the surgery, the insurance requirements based on a certain number of nutritional visits, a certain number of visits to various specialties to make sure that you're mentally and physically prepared for the surgery. But 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 Dr. McCollister said, it resets your life for six months to a year and really helps you lose the weight. But beyond that, you really need to continue to continue the lifestyle modifications. As you mentioned, it's a mixed bag. Some patients do better than others. And it mainly reflects the commitment to the lifestyle changes 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 still 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. 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? 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. We don't have to drive all the way back up to see us just for a 15-minute visit. Now, is that surgery usually done minimally too then? Absolutely. It is. Wow. And that must be a challenge if somebody, you see the size of some people, there are people who are very huge. That must be kind of a challenge to get into that, through that body fat to do that. It can be, but there's certainly very well-established techniques. And again, that's why we're specializing in this, and we learn those techniques. And it's completely doable. It's, you know, and once you're on the inside, we can get it done. It's amazing. I was with a heart specialist this summer, who's not from the area, but we're talking about what it's like just if you go to this 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 play those old reruns on TV in black and white. And you hardly ever see an actor that's overweight from the 50s and the 60s. I mean, I'm sure there were overweight people, but like you said, not to the degree of which they are now. No, 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 a regionally variable. Minnesota is not even one of the most prominent states relative to the percentage of obese people. I think that that's an honor that's reserved largely for some of the southern states. But certainly we contribute our share. How about, and I know this is a huge topic, heartburn and reflux issues, talk a little bit about what your folks do there. That's a huge, that's a huge area, and it's very under-treated. It's one of the most common reasons for people to take care of 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 four or five years, we have really kind of coalesced that to a formal center, a coordinated approach to the diagnosis and the treatment of gastrosophageal 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've got people that come to us literally from all over the state and from all over the upper Midwest region. What are some of the techniques you use when you're treating that reflux? So 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 nothing even similar to what they do at the Miss River Reflux and Harper and Center in Crosby and in Riverwood, anywhere that I've seen. Really? A lot of this testing, 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. 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 two weeks or three weeks or two months and so that happens and then they want to do testing and that's scheduled for two months down the road or two weeks down the road 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 patient's needs are met on this. Most of these people are pretty miserable by the time they come to see us. So you come in and you've got heartburn and reflux issues. You almost have to go down and look. Don't you really be able to diagnose what the problem is? That's where we start. So you can do that and usually take a mild sedative or something when you do that to relax the throat. 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 called a comprehensive esophageal evaluation that starts with the upper GI endoscopy and the various testing associated with that but there are a 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 person's 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. I also say, if in fact they are having reflux, there's a lot of people out there on medication for reflux that don't actually have any and the medication is not helping them. Our goal is to treat their reflux certainly if it's there but if it's not there then to get them off of unnecessary medications. And I've read that some of those medications can actually be harmful if you're taking for a long period of time. They certainly can over time. If you actually go through and read the little packet literature when you get your over-accounted medications which I'm sure most people don't, they're really only supposed to be used for about two 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 unsurprising. Some correlation with kidney disease, heart disease, even dementia and even some correlation with earlier death. These are all very preliminary studies. It's there and really any medication is not too surprising. They are preliminary but since 2010 there have been six black box warnings from the Food and Drug Administration on that particular class of drugs. Omeprazole and that group. So we pay attention to that but I think more importantly in this age of Dr. Google, 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 eight or ten hits on that are going to 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. The other thing that we worry about with reflux disease is its contribution to esophageal cancer. Since in the last thirty years there's been a six hundred percent 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 only 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. I know everybody's individually different but what's causing this reflux increase? Is it our diet? Obesity I think plays a huge role. Obesity is a big part of it. The circle back to obesity but 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 in particular diseases going hand in hand. We see that very commonly associated with our bariatric patients and we see in our bariatric patients a very high incidence of reflux disease. 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. So it would be probably fair to say that most normal weighted people don't have this high incidence of it anyway. 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 with increasing incidence of obesity. When you've identified a problem what are some of the treatment options that you do? Dr. McCollister said we can use medications and certainly we always try to tailor that so that it's the proper regimen based on when people are having their reflux episodes but certainly as surgeons we would like to get them off their medications and there's numerous surgical techniques. We specialize in one procedure called the Lynx device which is a small magnetic beads that actually go around the lower esophageal sphincter. The lower esophageal sphincter is the muscle that's there that's supposed to keep the acid down the stomach and out of the esophagus. So what that set of beads does is it actually reinforces that and it's just strong enough so that you can swallow outright but it doesn't let that acid back up. 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 one. And number two, it's an outpatient operation. It's a very straightforward operation. It's done using minimally invasive surgery but again most patients go home on the same day. So that's good. Surgery typically in reflux disease and the treatment of it is a last resort. If we can control people's 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 the 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. So when you put those beads in a person is that for life? Yeah. It is. Unless we take it out. And what would be a reason that you might take it out? In some cases if somebody has difficulty swallowing or ongoing difficulty swallowing that goes along with that and that's one reason we would do that. Typically it would not be unusual I think the explanation rate for that device is in the neighborhood of about one percent one out of a hundred people may not be able to tolerate that device long term which is similar to other types of surgical procedures as well. So it's pretty low. Yeah. Yeah, pretty low. So you do gynecology obstetrics what are some of the things you do there? I can't say it but Dr. Leavitt and I aren't obstetricians or gynecologists that's a land of mystery to us but we do have a partners there that specialize in that at King and Regional Medical Center that do an excellent job and similar to MIMIS they apply a wide variety of advanced surgical techniques to gynecologic disease. And you do some work with a da Vinci robot maybe could you explain to us what that is and what kind of surgeries you do with that? Dr. Leavitt is the chairman of that committee I'll pass that out to him. Yeah, the Da Vinci robot misperceptions that we're not controlling it certainly we use the robot as a tool and we are controlling it at all times. We don't turn the robot loose from the patient to do its own thing on that. But what the robot really allows us to do is two things number one, better visualization when we perform traditional laparoscopic procedures it's on a flat TV screen essentially and really you do lack a little bit of depth perception now over time with training you make up for that and it's okay. The Da Vinci robot is in stereostopic or 3D view so when we look through that lens it's like looking inside the patient's 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 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. 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's important for some types of operations that we do. And how many of your surgeons are trained to do that with Da Vinci? By January all five of us will be. Wow, that's incredible. And just generally what kind of surgeries do you usually do with that like gallbladder or... Yeah, any traditional laparoscopic surgery certainly can be done. Our focus is kind of turning towards hernias in the upper GI surgeries that Dr. McAuliffe was talking about but any laparoscopic surgery can be done with the robot. 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. 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. It's always a pleasure, right? Thank you for the information for how to contact you on at the end of the show so thank you very much for jumping out with us today. Appreciate it very greatly. You've been watching Lakeland Currents where we're 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.