LEADING DIGESTIVE DISEASE CARE
00 HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
ABOUT THE UNDERWOOD CENTER
PROCEDURAL VOLUMES
Houston Methodist Lynda K. and David M. Underwood Center for Digestive Disorders provides a wide spectrum of expertise in treating and researching digestive disorders with its multidisciplinary team of gastroenterologists; thoracic, gastrointestinal and hepatobiliary surgeons; radiologists; oncologists; pathologists; and molecular pathologists. The team includes dedicated researchers who are continually seeking new prevention methods and therapies for patients.
4,127 Esophagogastroduodenoscopy (EGD) (Upper Endoscopy)
GI
2,244 Colonscopy 284 Breath Testing (Lactulose, Glucose, Sucrose, Lactose) 191
Capsule Endoscopy
Our open staff model includes practicing physicians from Houston Methodist Hospital, private practice and academia. This model allows us to unite patients with the expertise of multiple providers and specialties, and to create unique partnership opportunities in clinical care, education and research. We refer to the Underwood Center as a “virtual” institute because our specialists represent our entire digestive community.
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GI SURGERY CLINICAL TRIALS
247 Gastric Bypass 211 Gastric Sleeve 182 Colectomies
81 0.29
136 Liver Transplant
RESEARCH PUBLICATIONS
GI SURGICAL MORTALITY RATE
62 Pancreatectomies
52 Nissen/Linx Hiatal Hernia
29 Esophagogastrectomy
16 J-Pouch
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It is with great pleasure and some pride that we introduce to you the first biennial report of the Houston Methodist Lynda K. and David M. Underwood Center for Digestive Disorders. This center owes its origins and existence to the vision and generosity of Lynda and David Underwood. Their support for the center was based on fundamental principles — a dedication, above all, to the delivery of integrated care across all specialties involved in digestive disorders; a devotion to the education and training of health care practitioners, students, patients and their families; and a commitment to clinical and translational research. Thanks to their philanthropy, the Underwood Center has grown, since its inauguration in May 2013, to become one of the largest multidisciplinary programs in the region and has consistently ranked in the top 20 programs for gastroenterology and gastrointestinal surgery in the U.S., according to U.S. News & World Report. This ranking is based, primarily, on the breadth and depth of the clinical programs that we offer, clinical outcomes — our mortality rates are some of the lowest in the country for complex procedures and surgeries performed on patients of all ages and severity of illness — and constant attention to patient safety and comfort.
Eamonn M. Quigley
Houston Methodist Hospital now trains the gastroenterologists and specialist gastrointestinal surgeons of the future, and is actively engaged in cutting-edge research from bench to bedside — a truly translational program.
Chief, Gastroenterology and Hepatology, Houston Methodist Hospital
Our gastroenterology fellowship program, which recently graduated its second class, was commended by the Accreditation Council for Graduate Medical Education (ACGME) for its research productivity and focus on scholarship. The Underwoods’ generous gift has also served as a foundation for other support that has helped develop various programs within the center, such as inflammatory bowel disease, through the Fondren Foundation, or the neurogastroenterology program, through the Josephine Hughes Sterling Foundation. We also owe a deep debt of gratitude to the members of the center’s task force who have guided us through these years of rapid growth and development.
MD, FRCP, FACP, MACG, FRCPI David M. Underwood Chair of Medicine in Digestive Disorders Co-director, Lynda K. and David M. Underwood Center for Digestive Disorders
Professor of Medicine, Weill Cornell Medicine Adjunct Professor of Medicine, Texas A&M Health Sciences Center College of Medicine
Since its inception, Underwood Center physicians have published more than 200 peer-reviewed papers in some of the most prestigious journals in the field, which include research on inflammatory bowel disease, endoscopy, functional gastrointestinal disorders, various aspects of liver disease and the microbiome. Faculty, fellows and residents presented original work and invited lectures at major national and international conferences. As you will see in this report, the center provides the full range of medical, endoscopic and surgical options for the management of common and complex digestive disorders. Our specialists have access to the very latest diagnostic tools as well as the complete armamentarium of treatment options, from the very latest drugs to robotic surgeries and advanced endoscopic techniques. We place an emphasis on a multidisciplinary approach through collaboration with different specialties, including oncology, radiology and pathology. Ultimately, our center is not just about technology or pharmacology — it is about the holistic care of our patients and involves meeting their emotional needs and nutritional requirements as part of their treatment plan. The recently launched Food and Health Alliance Program reflects our commitment to the whole patient with its focus on exploring and researching all aspects of interactions between diet, health and disease. We hope that you enjoy this report and we welcome your feedback and look forward to your future participation in our many educational and clinical programs.
Wade M. Rosenberg MD, FACS Co-director, Lynda K. and David M. Underwood Center for Digestive Disorders Assistant Professor of Clinical Surgery, Weill Cornell Medicine
HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
MESSAGE FROM THE CHAIRS
02 HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
CLINICAL TRIALS Researchers at the Houston Methodist Lynda K. and David M. Underwood Center for Digestive Disorders are helping improve treatment of inflammatory bowel disease (IBD) through research that examines changes in the microbiome, treatment delivery, improvements in dosing, and drug safety and effectiveness. Some patients with IBD tend to develop nonalcoholic fatty liver disease (NAFLD), while others do not. An investigator-initiated study at Houston Methodist is designed to identify specific microbial changes associated with the development of NAFLD in patients with IBD. We hope that by understanding
the specific mechanisms of change in the gut microbiome, we will be able to treat or prevent the development of NAFLD in the future. Piano Registry We are collaborating with the University of California, San Francisco, the Crohn’s & Colitis Foundation, and other centers in a national, multisite study to evaluate the clinical care of pregnant women with IBD. The study follows women through pregnancy and delivery, and tracks development of the babies for three years. The clinical practice of Dr. Bincy Abraham, Fondren Distinguished Professor in Inflammatory Bowel Disease in the Department of Medicine, is a referral center for pregnant women suffering from IBD.
Sigmoid inflammation, ulceration and stenosis with colonoscope unable to traverse the stenotic area prior to starting clinical trial.
Changing the dosing regimen of an effective drug can sometimes produce better results for certain populations. For patients whose IBD has flared or never achieved control, we are looking to reintroduce their current medications or increase dose frequency based on the patients’ biologic drug levels to personalize and tailor their care to achieve higher rates of remission. Researchers at the Underwood Center are collaborating with scientists at the Houston Methodist Research Institute to develop nanoparticle treatment for ulcerative colitis. Early animal studies have been promising.
Sigmoid colon, healed ulceration and stenosis improved, with colonoscope able to traverse through this area after clinical trial started.
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Houston Methodist’s team of dedicated, experienced gastroenterologists, surgeons, pathologists and oncologists provide rapid and accurate assessment of pancreatic tumors. We are a high-volume center with proven surgical outcomes for our patients. Because of the aggressiveness of this form of cancer, rapid, accurate assessment is crucial. We have a multidisciplinary team on-site for diagnosis. Gastroenterologists use computed tomography (CT), endoscopic ultrasound and fine needle biopsy during diagnosis. Our GI pathologists are part of the immediate team to quickly diagnosis and help determine if a tumor is surgically resectable.
Pancreatic surgery, both the Whipple and pancreatic resection, is riskier than most surgeries because of the complex anatomy around the pancreas and the way the pancreas itself responds to operations. Houston Methodist has an extremely strong safety record and very experienced surgeons with high volumes. We are able to show excellent results — even with a higher-risk base of patients. The average age of our patients is approximately 10 years older than other centers. We do not discriminate on the basis of age. We are honored to treat any patient who is a candidate for pancreatic surgery.
Illustration of a classic pancreaticoduodenectomy. Note the antrectomy with gastrojejunal anastomosis.
“It’s the results that matter. Everything is about excellent results.” Wade M. Rosenberg, MD, FACS
HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
PANCREATIC TUMOR ASSESSMENT & RESECTION
04 HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
GASTROPARESIS Specialists at the Underwood Center provide comprehensive evaluation and tailored treatment for patients with gastroparesis, a complex and challenging condition that prevents the stomach from emptying into the intestines. SmartPill™ Study of Gastrointestinal Transit
The Underwood Center is a comprehensive treatment center for gastroparesis. We help patients with dietary management and provide expertise in medical management of the disease. Experience helps us balance the benefits and significant side effects of available medications. In addition, all advanced interventions are available to our patients. We treat gastroparesis with Botox® to the stomach, gastric electrical stimulation, peroral endoscopic myotomy (G-POEM) on the pyloric sphincter and pyloroplasty. For patients with distended stomachs, we use gastrostomy tubes (G-tubes) and jejunostomy tubes (J-tubes), which can be surgically or endoscopically placed. Gastroparesis involves damage to the vagus nerve. It primarily affects patients who have long-standing, uncontrolled diabetes. It can also result from viral infections, surgery or certain medications. Severe gastroparesis is debilitating.
Patients with gastroparesis present symptoms that are nonspecific: a feeling of fullness, nausea and vomiting. Careful and detailed evaluation is crucial because treatment for gastroparesis is specific and can be invasive. Our goal is to provide comprehensive evaluation and treatment tailored to each individual patient in our care. We use a variety of diagnostic techniques, including the SmartPill™ and the gastric emptying breath test, to reach a solid diagnosis for each patient.
The Underwood Center is supported by the Josephine Hughes Sterling Foundation. Fosso CL, Quigley EMM. A Critical Review of the Current Clinical Landscape of Gastroparesis. Gastroenterol Hepatol (N Y). 2018;14:140-145.
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While the concept of natural orifice surgery has been around for 20 years, only 1% of colorectal procedures use a natural orifice in current clinical practice. The benefits are clear: smaller incisions, fewer complications, less pain, less infection and shorter recovery. But until now, techniques have proven to be difficult. Dr. Eric Haas and his team have developed a feasible, effective, safe process for robotic colorectal resection using a natural orifice for intracorporeal anastomosis and tumor or specimen extraction.
The NICE procedure (natural orifice intracorporeal anastomosis with extraction of specimen) is reproducible with consistent results:
NICE is a procedure that can help patients suffering from diverticulitis, colorectal cancer, endometriosis and other forms of colorectal disease.
• The national average for length of stay is five to eight days. With the NICE procedure, average length of stay is now reduced to 2.3 days. • Complication rates are significantly reduced, and we have complete elimination of surgical site infections involving the skin incisions. • Readmission rates are cut in half from 14% to 6%. • Patients return to work in two to three weeks versus six to 12 weeks.
Dr. Haas’ early experience with NICE was published in the American Journal of Surgery (April 2019, Volume 217, Issue 4). He and his team have since been asked to present results and the NICE procedure itself at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference and the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). They have traveled across the country training colorectal surgeons on NICE.
By taking a minimally invasive procedure and making it less invasive, NICE has reduced pain, provided for quicker recovery and, importantly, reduced the opioid requirements for patients. In-hospital opioid use has been reduced by 50% and most patients are discharged without an opioid prescription. Those who have an opioid prescription on discharge often do not fill it.
HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
NICE PROCEDURE
06 HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
ESOPHAGEAL & GASTRIC TUMORS – ENDOSCOPIC MUCOSAL RESECTION The Underwood Center offers advanced, comprehensive care for patients with esophageal and gastric cancers. Our goal is to apply all the latest research, continuously adapt and appropriately apply this knowledge to each individual patient. Patients with early-stage cancer who have favorable pathologies can be treated with minimally invasive procedures to remove tumors in the esophagus as well as in the colon, stomach and duodenum.
Our gastroenterologists have special training and experience in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) to treat early-stage cancers.
We closely monitor patients with Barrett’s esophagus. When appropriate, we can also use EMR or ESD to remove nodularity, then perform ablation to encourage the development of normal tissue for these patients. Using surgical robotics, we remove esophageal cancers while preserving healthy organ tissue, shortening recovery time and reducing pain for the patient. When esophageal cancer is locally advanced, this surgery is combined with chemotherapy and radiation, tailored to each patient’s needs. We work with medical and radiation oncologists in the community so that chemotherapy and radiation therapy can be administered closer to home.
Treatment for stomach cancer also depends on the stage of the cancer. We perform subtotal or total gastrectomy, and remove part of the omentum, esophagus, small intestine or nearby lymph nodes, as necessary. Many patients are treated with chemotherapy or chemoradiation before surgery to shrink the cancer and make it easier to remove. Treatment after surgery may include chemotherapy alone or chemoradiation. The patient’s needs are assessed often, throughout the process of treatment. All therapies are personalized and based on the patient’s stage, goals and tolerability.
For some advanced cancers, we perform a supercharged jejunum, a complex reconstruction of the esophagus and stomach.
For patients with more advanced or involved tumors, our thoracic surgeons have fully converted to using minimally invasive robotic surgery to perform esophagectomy.
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Houston Methodist has some of the most experienced surgeons using the LINX device to treat gastroesophageal reflux disease (GERD), replacing the need for traditional open surgery that permanently alters the esophagus and stomach.
Surgeons at the Underwood Center were the first in Houston to study and use the LINX device, and participated in the CALIBER study that led to FDA approval. A ring of magnetic titanium beads, the LINX device, is laparoscopically placed near the lower esophageal sphincter (LES) to help restore an effective barrier at the gastroesophageal junction (GEJ). At rest, the beads form a ring around the esophagus, supporting the sphincter without compressing the esophagus. With natural pressure of physiologic functions, the magnetic bonds release, enabling the patient to swallow, belch or vomit. This helps reduce regurgitation, gassiness, heartburn and indigestion, greatly improving quality of life for patients. We also offer transoral incisionless fundoplication (TIF) to treat GERD. Using the TIF procedure, physicians employ an endoscope transorally to staple the stomach to the esophagus. The top of the stomach is wrapped around the far end of the esophagus and on top of the LES. This procedure is similar to a traditional fundoplication, but uses no external incisions and results in fewer side effects for patients as compared to open surgical fundoplication.
HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
ESTABLISHING THE STANDARDS FOR LINX STUDY & TRANSORAL INCISIONLESS FUNDOPLICATION
08 HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
ACHALASIA & ENDOFLIP Physicians at Houston Methodist have expertise in using advanced technology to diagnose and treat achalasia. Using the EndoFlip device, we can access a complete and detailed view of the gastroesophageal junction (GEJ) for our patients with achalasia.
Using a minimally invasive technique, our specialists can measure motility, distensibility, diameter and the crosssectional area around the GEJ, providing for more accurate diagnoses of achalasia. Achalasia is a difficult disorder to diagnose because symptoms often mimic other diseases, and manometry catheters alone often cannot pass the sphincter to gain clear sight into crucial areas.
We use the EndoFlip for diagnosis of disease and also in some surgeries as a critical guide to therapy.
Peroral endoscopic myotomy (POEM) provides our patients with a less invasive treatment for achalasia combined with the durability of surgical myotomy. To treat achalasia, our surgeons access the esophagus through the mouth using a flexible endoscope. A small incision is made in the mucosal lining of the esophagus and into the esophageal wall, where a myotomy is performed. By loosening the muscles on the side of the esophagus, the lower esophageal sphincter (LES) and the upper part of the stomach, food and water are able to pass through to the stomach. Patients are often discharged without the need for pain medicine and typically spend only one night in the hospital.
FELLOWSHIP PROGRAM & NATIONAL COMPETENCY TRAINING Houston Methodist’s ACGME-accredited gastroenterology fellowship is a three-year program with two fellows accepted per year. Because we are a large referral center for patients with complex GI disease, our fellows see a wide variety of cases and gain experience working with subspecialists as well as generalists. They are exposed to advanced technologies to safely and effectively treat disorders of the GI tract.
To grade and track our fellows, the Underwood Center has adopted identical competency measures to those of the American Society of Gastrointestinal Endoscopy. Simulation lab and inanimate hands-on training for upper endoscopy and colonoscopy help ensure competency and ultimately patient safety. Our fellows also build exposure to translational and clinical research to help patients find relief from GI disease.
High resolution manometry demonstrates panesophageal pressurization with failed peristalsis and elevated integrated relaxation pressure, or IRP. This example would be consistent with type II achalasia.
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Gastroenterologists (Medical)
Bincy Abraham, MD, MS
Sandeep Lahoti, MD
Victor Ankoma-Sey, MD
Neha Mathur, MD
Alberto Barroso, MD
Robert McFadden, MD
Ronald Colman, MD
Frank Meriano, MD
Sunil Dacha, MD
Eamonn Quigley, MD
Andrea Duchini, MD
Ali Raza, MD
Chukwuma Egwim, MD
Rachel Schiesser, MD
Gulchin Ergun, MD
Peter Schwarz, MD
Joseph Galati, MD
Akshay Shetty, MD
Lyone Hochman, MD, FACP, FRCPC
Matthew Tompson, MD
Brian Kaplan, MD
David Victor, MD
Sudha Kodali, MD
Karen Woods, MD
Fernando Urrutia, MD
Surgeons
Randolph Bailey, MD Richard Caplan, MD
Gilchrist Jackson, MD, FACS
Edward Chan, MD
Min Kim, MD
Ray Chihara, MD, PhD
Jean Paul LeFave, MD
Joshua Coursey, MD
Lee Morris, MD, FACS
Marianne Cusick, MD
Michael Reader, MD
Bidhan Das, MD
Pat Reardon, MD, FACS
Rachel Ellsworth, MD, FACS
Wade Rosenberg, MD, FACS
Nestor Esnaola, MD, MPH, MBA, FACS
Vadim Sherman, MD, FACS, FRCS
Eric Haas, MD, FACS, FASCRS
Michael Snyder, MD Nabil Tariq, MD, FACS
Ashley Holder, MD Oncologists, Pathologists & Radiologists
Maen Abdelrahim, MD, PhD, B Pharm
Kirk Heyne, MD
Garth Beinart, MD, FACP
Hector Preti, MD
Jett Brady, MD
Mary Schwartz, MD
Brian Butler, MD
Monisha Singh, MD
Blythe Gorman, MD
Dina Mody, MD
HOUSTON METHODIST LYNDA K. AND DAVID M. UNDERWOOD CENTER FOR DIGESTIVE DISORDERS
FACULTY LIST
Houston Methodist Hospital 6565 Fannin St., Houston, TX 77030 Domestic referrals: 877.790.DOCS (3627) International referrals: +1.713.441.2340 houstonmethodist.org/underwood-center
U.S. News & World Report ranked Houston Methodist Hospital No. 14 in the nation for gastroenterology and GI surgery, and among the nation’s top 20 hospitals.
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