With the merger of Mount Sinai and South Nassau Communities Hospital, a comprehensive array of tertiary-level interventional endoscopic treatments and techniques is now available to patients on Long Island.
Frank Gress, MD, Director of Interventional Endoscopy at South Nassau Communities Hospital and Senior Faculty Member at Icahn School of Medicine at Mount Sinai, was already part of an advanced interventional endoscopy team when he began work in his home community of Long Island — Mount Sinai boasts some of the nation’s top specialists in digestive diseases and is ranked ninth in U.S. News & World Report for gastroenterology and gastrointestinal surgery in 2018–19.
When Dr. Gress was offered the opportunity to establish a state-of-the-art interventional endoscopy program at South Nassau Communities Hospital, he jumped at the chance. It paired with his devotion to caring for patients from Long Island and his lifelong interest in advancing the field of interventional endoscopy.
“Mount Sinai approached me last year, when I was serving as Clinical Chief of Gastroenterology and Chief of Interventional Endoscopy at Columbia University Medical Center,” Dr. Gress says. “They made an exciting offer for me to come out to Long Island and build a Center of Excellence for interventional endoscopy there.”
Frank Gress, MD, Director of Interventional Endoscopy at South Nassau Communities Hospital and Senior Faculty Member at Icahn School of Medicine at Mount Sinai, consults with a patient.
Dr. Gress was intrigued because few centers on Long Island offer a full range of cutting-edge, state-of-the-art interventional endoscopy services. He set about building a state-of-the-art academic program, one featuring the same procedures and services and high-quality care found at top academic centers. To develop such a program would be a complex undertaking, involving acquiring the latest technology and recruiting highly trained staff.
“I was excited about doing this,” Dr. Gress says. “It was an outstanding opportunity to build something entirely new from the ground floor. This doesn’t happen very often — when an institution is willing to provide the support and resources to build a much-needed clinical program from the ground up. Most hospitals on Long Island don’t offer the full range of advanced endoscopy services that we now do at South Nassau. It was also great to work collaboratively with both South Nassau and Mount Sinai and their team to transform interventional endoscopy at South Nassau.”
Dr. Gress and Scott Silverman, MD, review the procedure with a patient.
A History of Innovation
Interventional endoscopy differs from conventional endoscopy in several key ways. Standard endoscopic procedures, including upper endoscopy and colonoscopy, have been the mainstay of gastrointestinal endoscopy for decades.
“The roots of interventional endoscopy go back to the early days of endoscopic retrograde cholangiopancreatography, or ERCP,” Dr. Gress says. “The ERCP procedure and the tools we use for it were developed in the 1970s and have evolved over the intervening decades into a state-of-the-art technology for treating mainly biliary and pancreatic disease.”
ERCP involves multiple interventional endoscopic treatments of the bile ducts, gallbladder and pancreas, including the placement of stents and drainage tubes for obstructions, removal of stones, treating strictures, as well as performing biopsy. ERCP is used to treat gallstones, acute and chronic pancreatitis, and cysts and tumors of the bile ducts and pancreas in a minimally invasive approach without surgery. However, the ERCP procedure was just the start of what has evolved into modern interventional endoscopy.
“In the mid-1990s, endoscopic ultrasound [EUS] came on the scene,” Dr. Gress says. “EUS lets us combine endoscopy and ultrasound by means of a transducer on the tip of an endoscope. With that approach, we can image the deeper layers of the GI tract and surrounding structures, identifying suspicious lesions and taking tissue samples.”
The EUS procedure has emerged as an interventional tool that can not only aid in the diagnosis and visualization of almost any GI tract structure, but also treat specific GI issues, including draining pancreatic collections, the bile ducts or pancreatic duct, and even the gallbladder. In addition, there are interventional techniques available to access the bile duct or pancreatic duct in patients where ERCP fails or is not possible, provide celiac blocks for pain control, and place markers called fiducials for radiation treatment, to name just a few.
ERCP and EUS have allowed an increasingly broad number of procedures that previously were available only surgically to be performed in an extremely minimally invasive fashion. Dr. Gress’ training uniquely positioned him to bring these latest approaches to Long Island.
“After completing my fellowship in general GI, I became interested in advanced procedures like ERCP and new, emerging endoscopic technology,” he says. “That was just as EUS was being developed. The ability to combine endoscopy and ultrasound and actually intervene on the spot for patients with certain GI disorders, such as tumors and other pancreatobiliary issues, intrigued me so much that I decided to do an interventional endoscopy fellowship. The field has continued to evolve over the past 20 years.”
Drs. Gress and Silverman, Jennifer Rodgers, NP, and Kyle Colquhounk, PA, discuss the surgery plan.
With this evolution in innovation comes a host of unique techniques/treatments to address even the most complex GI issues in a minimally invasive manner. South Nassau is the only place on Long Island where all of these sophisticated diagnostic and treatment procedures are offered in a state-of-the-art setting with the same level of quality available as an academic tertiary care center. Some of these treatments include:
Endoscopic fundoplication. When patients with GERD cannot find relief through medication or dietary changes, endoscopic treatment may relieve their symptoms. While laparoscopic surgery is the traditional route for treatment of GERD, endoscopic fundoplication — also known as transoral incisionless fundoplication — offers the same results and may lead to fewer complications. The technique works by passing the gastroscope and surgical device into the stomach via the mouth, and the upper part of the stomach is wrapped around the esophagus and sutured into place, as in a conventional fundoplication.
Celiac plexus blocks. Patients with uncontrolled abdominal pain, often from cancer or chronic pancreatitis, may benefit from a celiac plexus block. In a procedure lasting 20 minutes or less, the interventionist administers this block through EUS, using a needle introduced through the endoscope to administer a nerve-block injection.
Optical coherence tomography (OCT). OCT has been primarily used to diagnose conditions of the eye, but it also has gastrointestinal implications. Resembling ultrasound but using light rather than sound waves, the technique enables “depth-resolved images with near-microscopic resolution,” according to a review in Diagnostics.
“We can use OCT to detect GI cancer in early stages,” Dr. Gress says. “It can help us manage conditions such as Barrett’s esophagus as well.”
Laser endomicroscopy is essentially a small microscope placed on the tip of a catheter probe that can be inserted through the endoscope, allowing the interventionalist to view cells within the body.
“We can look at cells in real time and identify early signs of cancer or dysplasia,” Dr. Gress says. “We can then treat these patients with other kinds of interventional technology.”
Drs. Gress and Silverman perform an interventional endoscopy in South Nassau’s endoscopy suite.
Radiofrequency ablation (RFA), cryotherapy and beyond. “We can treat Barrett’s esophagus and early cancers of the stomach and esophagus via RFA or cryotherapy,” Dr. Gress says. “This is the wave of the future of endoscopy.”
Lastly, innovations in interventional endoscopy allow physicians to drain gallbladders internally, through the use of special stents, without the need for external drains and tubes. Luminal-apposing metal stents (LAMS) allow the interventional endoscopist to get beyond the GI tract wall to manage difficult-to-access diseases and infections. This has been coined “Third Space Endoscopy.” Larger in diameter than typical biliary stents, LAMS permit an endoscope to pass into areas such as pancreatic fluid collections, so the physician can drain abscesses and remove necrotic tissue without the need for surgery or external drainage.
“There is no doubt in my mind that the future of interventional endoscopy is bright and will continue to evolve. In the future, we will likely be removing the gallbladder in a similar approach,” Dr. Gress says.
South Nassau’s Program
This new service line to South Nassau Communities Hospital means patients will be able to obtain up-to-date minimally invasive diagnostic and therapeutic procedures, close to home, without the need for an expensive, daylong trip to Manhattan. Patients with any kind of GI disorder can receive diagnosis and treatment at South Nassau.
Dr. Gress thanks a patient as he leaves South Nassau following his procedure.
Diagnostic procedures often return a negative result, allaying a patient’s fears of cancer, Dr. Gress says, but an early positive diagnosis is also promising, as cancers found at the earliest stages are most amenable to treatment. And recent, advanced endoscopy techniques enable even minute cellular changes to be detected and eradicated.
“We are a comprehensive program providing leading-edge diagnostic and therapeutic techniques and approaches,” Dr. Gress says. “Not everyone will need a therapeutic procedure, but it comforts the patient to know they do not have a serious illness. And if there is a need, we can immediately follow up a diagnostic procedure with treatment delivered at the same location.”
Endoscopy at South Nassau Communities Hospital is particularly safe, Dr. Gress explains, both because of the inherent minimally invasive nature of the procedures and the care and diligence of the highly qualified endoscopy staff South Nassau has assembled.
South Nassau’s endoscopy team: Jennifer Fuentes, RN; McDonough; Stephanie Mesiti, RN; Rossy Acevedo, central sterile tech; Josephine Miller, RN; Christine Alejandro, central sterile tech; Jessieta Ducos, RN; back row, left to right: Irene Ficaro, RN; Colquhounk; Rodgers; and Dr. Gress
For one thing, the possibility of avoiding surgery is a key component of the relative safety of interventional endoscopy — patients need not run the risks involved with even the safest minimally invasive surgeries.
“Surgery has been the traditional avenue for a lot of patients,” he says, “and that approach is still very important, but we as interventional endoscopists take pride in helping patients without surgery whenever possible.”
This makes certain treatments available to patients who are not good surgical candidates, expanding the range of therapeutic options physicians at South Nassau are able to offer.
And secondly, the high quality of the physicians and staff at South Nassau assures patients they have come to the right location for their procedure.
“It’s important for patients to feel comfortable at the center they choose,” Dr. Gress says. “They have to have confidence in the physician, the hospital, the unit and the staff. At the South Nassau interventional endoscopy center, patients can feel very comfortable with us; we have expert staff and state-of-the-art equipment, and we deliver high quality with high marks in patient satisfaction.”
Part of that quality arises from the close collaboration with Mount Sinai. In addition to Dr. Gress, South Nassau’s pancreatobiliary surgeon and many oncologists are also on staff at Mount Sinai, and South Nassau continues the academic tradition of having regular multidisciplinary GI conferences, including representatives from gastrointestinal surgery, radiology, pathology and oncology, and other subspecialties as needed, to discuss each patient case and share ideas and devise the best treatment plan for each patient on an individual basis.
“This is similar to our approach in the city,” Dr. Gress says. “It’s very helpful in the management of our patients’ conditions.”
South Nassau has also invested heavily in equipment to enable physicians to perform advanced endoscopic diagnostic and therapeutic procedures: the Spyglass visualization system, the Confocal Laser Endomicroscope and more. The ongoing investments represent South Nassau’s commitment to its physicians, patients and the Long Island community as a whole.
“I get the most satisfaction from taking care of patients in situations in which I can make a difference using minimally invasive endoscopy techniques — advanced techniques through which patients can obtain good outcomes without the need for surgery.”
— Frank Gress, MD, Director of Interventional Endoscopy at South Nassau Communities Hospital and Senior Faculty Member at Icahn School of Medicine at Mount Sinai
Part of the Community
Dr. Gress and his colleagues are building relationships with Long Island gastroenterologists, general practitioners and internists who are aware of South Nassau’s cutting-edge interventional endoscopic capabilities, delivered in a high-tech setting.
“Many physicians refer their patients to help them obtain the highest quality and state-of-the-art care, with minimally invasive procedures to manage many gastrointestinal disorders like reflux disease, for example,” Dr. Gress says. “Or they may have ordered an imaging study for another condition and note a pancreatic mass or cyst, so they send patients our way for further evaluation.”
Referrals come about through the new program’s reputation for excellence and its comprehensive array of advanced interventional endoscopic procedures, but patients stay because they like the treatment they receive: quality care delivered with kindness and professionalism.
“Our staff go out of their way to make patients comfortable during stressful times in their lives,” Dr. Gress says. “When they’re coming in for tests and don’t know what to expect, it can be frightening. Our outstanding team makes all the difference.”
For additional information, visit www.southnassau.org/endo.