DigestiveTrac DIGESTIVE DISEASES • SUMMER 2013
Issue 7
INSIDE THIS ISSUE: Addressing the Comorbid Conditions of Obesity with Weight Loss
Nutrition Program Complements GI Care
Integrative Therapies Offer Alternatives for Weight Loss, Symptom Relief
Patient is a Key Partner in Successful Bariatric Surgery
Three Bariatric Procedures Fulfill Differing Weight-Loss Needs
Dear Colleagues, Having reached epidemic proportions in our society, obesity is the center of many health problems that Americans experience. Statistics tell us that nearly 36 percent of adults are obese, and by 2030, that rate could exceed 44 percent. The staggering health care costs related to obesity could be reduced significantly by an overall reduction in the body mass index of our population. Comorbidities of obesity are many, including metabolic syndrome, cardiac disease, joint and back pain, depression, cancer, sleep apnea and more. In the specialty of gastroenterology, conditions including nonalcoholic steatohepatitis (NASH), gastroesophageal reflux disease, and general GI complaints such as bloating often result from obesity, or are worsened by obesity. Because of its significance as a health threat and its many comorbidities, we are dedicating this issue of Digestive Trac to the treatment of obesity. A multidisciplinary, comprehensive approach is our goal in addressing obesity alongside comorbid conditions, especially those we commonly treat including GERD and NASH. We believe the medical approach to weight loss begins with sound nutritional counseling, dietary balance, and a safe, healthy plan for reducing calories and increasing activity. Obviously, the patient’s commitment and cooperation are key. In addition to medical expertise, Avera offers the counsel of dietary, fitness and behavioral health experts. Our Integrative Medicine program offers the Ideal Living program, as well as complementary therapies such as acupuncture and mind-body movement. If lasting weight loss cannot be achieved through diet and lifestyle changes, Avera offers an experienced bariatric surgery program, which is accredited as a Level 1 bariatric center by the American College of Surgeons. This well-rounded program ensures that patients are first committed to the eating and lifestyle changes required by bariatric surgery. After surgery, the needed support is provided to help patients experience success. Lasting weight loss is a difficult goal for patients, and statistics show us that long-term success rates are much higher with bariatric surgery than lifestyle changes alone. We at the Avera Digestive Disease Institute want to partner with primary care physicians to not just treat ongoing symptoms, but to help patients experience improved health and wholeness. When patients are morbidly obese, an obvious piece of the puzzle is weight loss. As always, it is our privilege to work closely with primary care physicians for our patients’ best interest and continuity of care. Please feel free to contact us at 605-322-7797 with questions or for more information. Sincerely,
Scott L. Baker, MD, FACS, FASCRS Colorectal Surgery Surgical Institute of South Dakota Surgical Director of Avera Digestive Disease Institute
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Steven Condron, MD, MHES, FACP Gastroenterology and Hepatology Avera Medical Group Gastroenterology Medical Director of Avera Digestive Disease Institute
Avera Makes the Grade! Avera McKennan Hospital & University Health Center Achieves Top Rankings in Gastrointestinal and General Surgical Care
Healthgrades has ranked Avera McKennan the No. 1 Hospital in South Dakota for GI Services and GI Medical Treatment in 2013. Healthgrades Awards for GI care:
Top 5% in the Nation for Overall GI Services Top 5% in the Nation for GI Medical Treatment n Top 5% in the Nation for General Surgery n Ranked No. 1 in S.D. for General Surgery n Ranked No. 1 in S.D. for GI Services and GI Medical Treatment n F ive-Star Recipient for GI Procedures and Surgeries, Treatment of GI Bleed, and Treatment of Bowel Obstruction
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Addressing the Comorbid Conditions of Obesity with Weight Loss Obesity has been called an epidemic in our society, and is the center of many health problems that Americans experience. Obesity-related gastrointestinal conditions are no exception.
Dr. Steven Condron, gastroenterologist with Avera Medical Group Gastroenterology
A 2012 study released by the Trust for America’s Health and the Robert Wood Johnson Foundation finds that 35.7 percent of American adults and 16.9 percent of children are obese, as defined as a body mass index over 30. If nothing changes, by 2030 the obesity rate for adults could exceed 44 percent nationally. By 2030 costs associated with treating preventable obesity-related diseases are estimated to increase by $48 billion to $66 billion a year. Yet if average body mass index was reduced by just 5 percent by 2030, thousands of people could avoid obesity-related diseases, thereby saving billions of dollars in health care costs. Comorbidities of obesity are many, including type 2 diabetes, hypertension and high cholesterol (metabolic syndrome); cardiac disease; joint dysfunction and back pain; depression and more. It’s estimated that approximately one in three deaths from cancer each year is related to obesity, poor nutrition or physical inactivity. In the specialty of gastroenterology, conditions including NASH, reflux disease and general GI complaints often result from, or are worsened by, obesity. Nonalcoholic fatty liver disease is a condition in which fat accumulates in the liver. It is often completely asymptomatic, although symptoms can include malaise, fatigue and upper abdominal pain. The disease is most often discovered if liver enzymes test high, or the liver appears enlarged with ultrasound or other imaging tests. Nonalcoholic fatty liver disease ranges from simple fatty liver (steatosis) to nonalcoholic steatohepatitis (NASH). In its more serious forms of NASH, fatty liver disease
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can lead to significant inflammation and cirrhosis, and ultimately liver failure, liver cancer, the need for liver transplant, or death. It’s estimated that approximately 3 percent of the population have NASH, or 10 million-plus people. The usual first step is to help a patient control the elements of metabolic syndrome – high blood pressure, high blood glucose and cholesterol levels. Yet most important is weight loss.
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Gastroesophageal reflux disease (GERD) symptoms are suffered by up to 50 percent of people at some point in their lifetime, and 10 to 15 percent of the population have significant reflux disease. Left untreated, the flow of acid into the esophagus can progress to the precancerous condition known as Barrett’s esophagus, which affects between 2 and 7 million adults over 40 years of age. Barrett’s patients have a risk of developing adenocarcinoma of the esophagus that is 30 to 125 times higher than patients without this condition. Those at highest risk for developing Barrett’s esophagus are older Caucasian males with truncal obesity. As the nation’s BMI has increased, so have rates of adenocarcinoma of the esophagus. In addition, numerous general GI complaints can be attributed to obesity and poor eating habits, including gas, bloating, indigestion and upset stomach, or diarrhea.
When obesity is a suspected factor in the development or worsening of GI conditions, such patients are referred to nutrition and weight loss counseling. In treating NASH, for example, weight loss is the first-line treatment. Weight loss can contribute to a decreased mortality from risks such as type 2 diabetes, hypertension and coronary disease, and the specialists of the Avera Digestive Disease Institute recommend plans which decrease caloric intake, maintain a balanced diet and include physical activity. “When weight loss succeeds, the impact is significant upon comorbid conditions. It’s not unusual to see the need for medications literally melt away with the pounds for the treatment of conditions like GERD, type 2 diabetes, pain and hypertension,” said Dr. Steven Condron, gastroenterologist with Avera Medical Group Gastroenterology.
Universal IHC Screening for All CRC patients Lynch syndrome is the most common form of hereditary colorectal carcinoma (CRC) and is caused by germline mutations in DNA mismatch repair (MMR) genes. Identification of gene carriers currently relies on germline analysis patients with MMR-deficient tumors, but criteria to select individuals in whom MMR testing should be performed are debated. There are two main strategies for determining which CRC should be tested for microsatellite instability (MSI) using immunohistochemistry (IHC): 1. One is to use the revised Bethesda criteria, which includes age (less than 50 years old at diagnosis of CRC), histology (tumor infiltrating lymphocytes, mucinous/signet ring, and medullary type carcinomas) in individuals less than 60 years of age and a combination of the age at the diagnosis and the presence of CRC and other Lynch-associated tumors in the affected individuals and family members.
2. The other main strategy is general screening of all CRC for MSI. The Physician Advisory Board of the Avera Digestive Disease Institute has recommended adopting the second strategy. This approach addresses several problems with using the revised Bethesda System (previously adopted) including that individuals can present with Lynch syndrome at older ages, the family history of Lynch-associated tumors is not always available, and histologic features are not 100 percent predictive. Therefore, moving forward, ALL surgical resection cases of CRC will be tested for MSI by IHC as screening for Lynch syndrome. Individuals with abnormal IHC results will be referred to the genetic counselor.
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Nutrition Program Complements GI Care Because of the close relationship between nutrition and the management of gastrointestinal conditions, Avera Medical Group Gastroenterology refers GI patients in need of specialized care to the services of a dietitian and nurse practitioner through a specialized nutrition program. Nutrition consultation can be beneficial for numerous reasons, including weight loss; gastroparesis, a digestive condition characterized by delayed emptying of the stomach; celiac disease, the inability to digest gluten found in wheat, rye and barley; and irritable bowel syndrome. In addition to these outpatient needs, Dawn Johnson, RD, LN and a nutrition team also work with patients through the inpatient-outpatient transition of having a feeding tube for dysphagia.
Dawn Johnson, RD, LN
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Because the cause of weight gain, simplified, is intake of excess calories and the lack of physical activity to burn those calories, successful weight loss is a reduction of caloric intake and an increase in physical activity. Johnson said she emphasizes an approach of portion control, and not eliminating any one food group from the diet. Patients must have a diet they can live with for a lifetime. Otherwise, they will simply regain any weight quickly lost by strict regimens. The Mediterranean diet is an excellent model. It includes a balance of foods, and emphasizes foods such as fruits and vegetables, beans and legumes, seeds and nuts, healthy oils such as olive or canola oil, lean meats, fish and poultry, and whole grains. It reduces processed foods, white bread, and commercial bakery products such as donuts or cakes.
Rhonda Duncan, RN
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“It’s important for patients to realize that their metabolism slows down as they age. People tend to eat like they’re 20 when they’re 40. They either need to eat less, or increase activity to compensate for this change,” Johnson said. Specialized diets may benefit patients with certain conditions, such as irritable bowel syndrome. The low FODMAP diet was developed by researchers in Australia to reduce IBS symptoms. FODMAPs are a collection of short-chain carbohydrates found in many common foods, and the acronym stands for fermentable oligo-, di- and mono-saccharides, and polyols. The theory holds that
foods high in these carbohydrates increase the volume of liquid and gas in the small and large intestine, resulting in distention, gas, bloating and abdominal pain. Increasing activity is also important. If patients are not getting at least 150 minutes of physical activity per week, they will have difficulty losing weight by limiting calories alone. “It’s important for patients to realize that their metabolism slows down as they age. People tend to eat like they’re 20 when they’re 40. They either need to eat less, or increase activity to compensate for this change,” Johnson said. Weight loss support and behavioral interventions are other key components that contribute to weight loss success. According to numerous studies, weight loss delivers huge potential benefits for overall health, and costs the system less than treating all the comorbidities of obesity. There is not an effective, safe medication available that is widely recommended for weight loss. The first approach is to restrict calories and increase activity – involving lifestyle changes by the patient. If a patient is unsuccessful through diet and exercise, the option of bariatric surgery can be a next consideration.
Colorectal Polyp Prevention Trial The Avera Research Institute’s oncology research program is seeking patients to take part in a Colorectal Polyp Prevention Trial through the National Surgical Adjuvant Breast and Bowel Project (NSABP).
Patients are excluded from this study if:
This study includes patients who have had resection for colorectal surgery at stage 0, 1 , 2 and 3. Patients must have had the surger y within one year to participate, and be completed with any additional treatment, such as chemotherapy. Participating patients will be asked to undergo colonoscopy to remove any existing polyps within 180 days prior to randomization.
• Their tumor was located <12 cm from the anal verge • They had total colectomy or total proctocolectomy • They had familial colorectal cancer (Lynch syndrome) or familial adenomatous polyposis • They currently use statins or used statins within 30 days prior to randomization • They have used therapeutic aspirin (doses >325 mg) or NSAIDS for more than an average of three days per month
Patients will randomly be placed in either a statin group or placebo group in this study to determine whether statin drugs prevent colorectal cancer recurrence or polyp formation. The medication or placebo is taken once daily for five years.
Primary care physicians, surgeons or specialists who have patients who might qualify for and be interested in taking part in this study are encouraged to contact the Avera Research Institute at 605-322-3050.
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Integrative Therapies Offer Alternatives for Weight Loss, Symptom Relief Integrative therapies are those which complement traditional medical treatments, without adding another “pill” to a patient’s list of daily medications.
Dr. Dawn Flickema, physician with Avera Medical Group Integrative Medicine
The Integrative Medicine program at Avera was launched in 2010 with the development of the new Prairie Center, home to the Avera Cancer Institute. It is offered to cancer patients and non-cancer patients alike. Common applications include GI conditions, arthritis, musculoskeletal pain and conditions, headaches, menopause and hormonal imbalance, and more. “Some patients are looking at options besides prescription medications, or they want to find therapies that don’t have any side effects,” said Dr. Dawn Flickema, Family Practitioner with Avera Medical Group McGreevy 69th and Western. Dr. Flickema is certified in medical acupuncture. Through Avera Medical Group Integrative Medicine located at the Prairie Center, she offers her services three days a week, and will soon be joined by a partner, Dr. Sally Williams, a Family Practitioner who is receiving the same certification in medical acupuncture. Dr. Williams will provide integrative services five days a week. Avera’s Ideal Living program also falls under the Integrative Medicine umbrella. This plan significantly restricts carbohydrates, while increasing protein to feed muscle mass. Working with a health coach, patients progress through four phases. The first phase involves eating primarily Ideal Protein products to force the body to mobilize its fat stores for energy. Women lose an average of three to four pounds
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per week, and men, four to six pounds. As phases progress, patients learn about healthy eating, balance and portion control, and by the end of the fourth phase, they are eating only normal foods so they can transition into long-term maintenance of their weight loss. The approach combines a faster approach to weight loss with long-term lifestyle changes that will keep the weight off. Patients go through an intake process with a health coach to ensure the Ideal Living program is a safe, healthy choice. Acupuncture, aromatherapy, mind-body movement, guided imagery and massage are among the various integrative therapies. Goals are to reduce symptoms such as stress, anxiety, insomnia, pain and nausea. Acupuncture can helpful in weight loss alongside other strategies, as it can act to suppress appetite, or reducing
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cravings. Dr. Flickema explains that acupuncture needles are placed at points where there is a dense collection of peripheral nerves which send signals back to the central nervous system and the hypothalamus, which controls functions such as homeostasis, hormonal activities and other neurochemicals. Recent research has studied the positive impact of acupuncture upon the stomach hormone ghrelin that regulates hunger, as well as leptin, which regulates fat storage. Patients should not look to acupuncture alone as a solution to weight loss â&#x20AC;&#x201C; decreased caloric intake and increased activity are still important.
Acupuncture can be an effective option with digestive and bowel regularity complaints that do not resolve with medical approaches. The effectiveness lies in acupunctureâ&#x20AC;&#x2122;s impact on the hypothalamus, and hormonal modulation of body functions. The Integrative Medicine program can be accessed through referrals from Digestive Disease specialists and other practitioners, and Integrative Medicine physicians consult with patients initially to determine which therapies they would most likely benefit from.
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Patient is a Key Partner in Successful Bariatric Surgery When bariatric surgery is considered for weight loss, the patient is such a vital partner in the process that extensive education and assessment are required before the patient is considered as a surgical candidate. Avera McKennan Hospital & University Health Center is accredited as a Level 1 bariatric center by the American College of Surgeons. The American College of Surgeons Bariatric Surgery Center Network Accreditation Program (ACS BSCN) accredits facilities in the United States that have undergone an independent, voluntary and rigorous peer evaluation in accordance with nationally recognized bariatric surgical standards. Bariatric surgery accreditation not only promotes uniform standard benchmarks, but also supports continuous quality improvement. Bariatric surgical procedures have been shown to reduce obesity, improve mortality and decrease the health risks from chronic diseases such as cardiomyopathy and diabetes. For these reasons, the ACS BSCN Accreditation Program recognizes those facilities through accreditation that implement defined ACS BSCN standards of care, document their outcomes and participate in regular reviews to evaluate their bariatric surgical programs.
are first asked to attend a free education seminar, where they learn about the different procedures, and what it takes to be successful. Typically, insurance will consider coverage for weight loss surgery for patients who have: • A body mass index (BMI) of 30-34.9 along with one or more comorbidities, such as sleep apnea, type 2 diabetes, acid reflux or high blood pressure. These patients usually qualify for lap band surgery only. • A BMI of 35-39 with a comorbid condition for any surgery • A BMI of 40 or over for any surgery with no additional comorbidities Patients must also be old enough to have reached sexual maturity. If patients qualify, they visit with either Dr. Thaemert or Dr. David Strand with Surgical Institute, who go into depth about the different procedures.
“For morbidly obese patients, the 15-year success rate for losing weight and keeping the weight off through bariatric surgery is 50 to 60 percent,” said Dr. Brad Thaemert, surgeon with Surgical Institute. Yet without surgical intervention the long-term success rate is only 5 percent. Surgery helps with success because it suppresses appetite. Beyond that, success depends upon the patient, because it’s possible to “eat around” any weight loss surgery. Medication therapy for weight loss results in only a 10 percent loss of excess body weight, on average. Cost can be restrictive for these medications, and side effects can be intolerable. After patients are referred for weight loss surgery, or hear about it from a friends, coworkers or on the Internet, they
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If patients want to continue in the process, they are asked to have an evaluation by a dietitian concerning dietary habits, along with education on how they will need to change those habits after surgery. Potential surgical candidates also undergo a psychological assessment concerning eating habits to learn about any behaviors they need to work on in order to be successful. Most insurance companies also require that patients try a non-surgical weight-loss program for six months, to see if they can be successful without surgery. Darcie Schmidt, certified nurse practitioner with Avera McKennan Bariatric Services, educates and guides patients throughout the process. The education and follow up required depends on whether they choose lap band, sleeve gastrectomy or gastric bypass. After surgery, patients have extensive follow up to help them eat successfully. An underlying shift in thinking is one of eating to live, rather than living to eat. Patients learn to look at food as a source of nutrition and energy, rather than a cure for boredom or stress. After lap band surgery, patients can eat only about half as much food as they did before, or an average of 8 ounces of food at a meal. Patients who have had sleeve gastrectomy or bypass surgery start out at 3 ounces of food per meal and work up to 8 ounces. Sleeve gastrectomy patients consume fluids only for one week after surgery, and bypass patients consume 3 ounces of soft solids three times a day. After 12 months, all bariatric surgery patients are up to eating very similarly: 8 ounces of food at each meal. They are counseled to eat lean meats, fruits and vegetables and complex carbohydrates, and avoid highly processed foods and white, starchy carbohydrates. Foods that have a “slippery” consistency such as yogurt, gravies and sauces are not recommended for patients who have undergone lap band surgery, because this food can slip past the band, circumventing the restrictive benefits. Otherwise, patients eat “normal food.” After weight loss surgery, patients experience a “full” sensation more quickly. While the scientific reason is not known, some patients no longer have a strong hunger drive. If patients eat too much, they can vomit up food or mucus, and experience pain and discomfort. So patients learn that “cheating” on the recommended food plan isn’t worth any short-term pleasure.
Dr. Thaemert performing gastric bypass. Success with weight loss is one-third the surgery to control hunger, one-third the choice of foods and eating habits, and one-third exercise. In order to lose 100 pounds and maintain the weight loss, 50 minutes of activity, five days a week is the recommendation. That can include walking, swimming, a fitness class or biking. The goal is that the person be exerted enough to be able to have only a “yes” and “no” conversation. All patients return for an office visit seven to 10 days post surgery, then one month later. After the initial visits, lap band patients come once every month for the next 12 months, and sleeve gastrectomy and gastric bypass patients have follow-up visits every three months. Patients are also welcome to take part in a support group, and are followed for a lifetime. “There is no magic bullet for weight loss – including bariatric surgery. If patients do not follow the postsurgical recommendations, they will not lose weight, or they will gain it back. Yet the majority of patients who do take the step of bariatric surgery experience successful outcomes,” Schmidt added.
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Three Bariatric Procedures Fulfill Differing Weight-Loss Needs With the guidance of surgeons, patients who qualify for bariatric surgery have a choice between three types of weight loss surgery: lap band, sleeve gastrectomy and gastric bypass. All weight loss surgeries have a restrictive component that make them successful. Patients experience a “full” sensation with a small volume of food.
Dr. Thaemert performing gastric bypass.
The lap band procedure is the least invasive, and is performed on an outpatient basis. A restrictive band that resembles an inner tube is placed at the top of the stomach through a laparoscopic procedure. Patients have a Portacath implant under the skin, and fluid can be added or subtracted from the lap band with a specialized needle that either tightens or loosens the band. This is the safest, lowest-risk procedure, yet it also often results in the slowest weight loss. Weight loss ranges from 45 to 75 percent of excess body weight after two years. Patients have the surgery and go home the same day, and typically take a few days to a week off work, depending on their type of work. Dr. Brad Thaemert, surgeon with Surgical Institute, said lap band deserves strong consideration among the three types of procedures. “It has the lowest risk, it is reversible, and it can have outcomes just as high as the other procedures – it just may take longer.” Lap bands have been in use for a number of years. They typically do not need replacing, and the material is safe and will not be rejected by the body. In the sleeve gastrectomy procedure, 80 percent of the stomach is removed, leaving a long, narrow tube of stomach. It is not adjustable and nonreversible. While more invasive than lap band, it is less invasive than gastric bypass, as no rerouting of digestive organs is required. No permanent
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device is implanted. In addition to being smaller, the new stomach produces less of the hormone ghrelin that causes hunger, helping patients feel satisfied with less food. Patients lose an average of 33 percent of their excess body weight in the first year. The gastric bypass Roux-en-Y surger y involves stapling off the top of the stomach to form a pouch. Next, a Y-shaped section of the small intestine is attached to the pouch, bypassing a 150-cm segment of the small intestine, reducing
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food absorption. This procedure has both restrictive and malabsorptive benefits toward weight loss which make it highly effective. The size of the pouch restricts the amount of food patients can eat, and bypassing the 150-cm segment of the small intestine results in malabsorption. Gastric bypass has a high success rate, and people lose an average of 62 to 68 percent of their excess body weight in the first year. Weight loss typically levels off after one to two years, with an overall excess weight loss between 50 and 75 percent. Both the sleeve gastrectomy and gastric bypass procedures are performed minimally invasively, however, patients stay in the hospital two days, and typically take a couple weeks off work. Weight loss is generally faster and greater with these two procedures, although some patients do just as well with lap band. Lap band has less than a 0.5 percent risk for mortality due to complications, and bypass and sleeve gastrectomy procedures have a 1 percent risk of mortality. This risk is low compared to the risk presented by morbid obesity. Complications after surgery, while rare, may include bleeding, infection, a blockage or tear in the bowels, or need for further surgery. Pregnancy is not recommended for 24 months after a gastric sleeve or bypass surger y; however pregnancy is fine after lap band surgery.
LAP BAND SURGERY
Patients who lose weight and maintain weight loss experience greater quality of life emotionally and socially, and the health benefits are many. Research indicates the following health benefits accompanying weight loss: • Improved survival of obesity-related disease, especially type 2 diabetes • Decreased blood pressure • Among diabetics, lower blood sugar levels and less need for medication or insulin • Prevention of new cases of type 2 diabetes • Improvement of obstructive sleep apnea • Improvement in mobility • Improvement in mood and self-confidence • Lowered risk of heart disease • Lowered risk of many cancers, including breast, colon, kidney, pancreas and esophageal Dr. Thaemert said he has performed more than 500 weight loss procedures. “It’s the most rewarding surgery I do because it cures more conditions than any other surgical procedure. This may include d i a b e te s , b a ck p a in a n d hy p e rte ns i o n . P l u s , patients may get their social life back and re-engage in the community.”
SLEEVE GASTRECTOMY SURGERY
GASTRIC BYPASS SURGERY
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Multidisciplinary Team Includes the Following Areas of Specialty: Colorectal Surgery:
Scott L. Baker, MD, FACS, FASCRS
Gastroenterology and Hepatology:
Steven Condron, MD, MHES, FACP Cristina Hill Jensen, MD Christopher Hurley, MD Larry W. Schafer, MD, FACP Dany Shamoun, MD
General Surgery:
Scott L. Baker, MD, FACS, FASCRS Michael Bauer, MD, FACS Wade E. Dosch, MD, FACS David Flanagan, MD Thomas E. Fullerton, MD Michael Person, MD, FACS David A. Strand, MD, FACS Bradley C. Thaemert, MD, FACS Donald J. Wingert, MD, FACS
Genetics:
Kayla York CGC, MS
Hepatology:
Hesham Elgouhari, MD, FACP Mumtaz Niazi, MD
Medical Oncology: David Elson, MD Mark R. Huber, MD Michael McHale, MD Heidi McKean, MD Addison R. Tolentino, MD
Pathology:
Steven P. Olson, MD Bruce R. Prouse, MD Raed A. Sulaiman, MD
Radiation Oncology: Barbara Schlager, MD Kathleen L. Schneekloth, MD James Simon, MD
Radiology:
Sabina Choudhry, MD Brad A. Paulson, MD
Research
(Cancer clinical trials)
Transplant Surgery:
Christopher Auvenshine, DO Jeffery Steers MD, FACS
Urogynecology:
Matthew A. Barker, MD, FACOG
If you have any questions or would like to make a referral to the Avera Digestive Disease Institute, call 605-322-7797. 13
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