Microwave Abalation in NC

http://legacy.charlotteobserver.com/health/story/528711.htm

At noon in Operating Room 4 at Carolinas Medical Center, Dr. David Iannitti starts his second liver operation of the day.

The patient is sedated, and Iannitti slits the man’s abdomen, making an incision that curves to the right like a hockey stick.

The surgeon and his assistant grip the man’s ribs with a device that looks like something built with an Erector Set. They crank his chest open, creating a cavity the size of a bathroom sink.

“There’s his liver right there,” Iannitti announces. “That’s a beautiful looking liver.”

The self-described “Liver Guy” should know.

A renowned surgeon from New England, Iannitti came to work at Carolinas Medical Center in 2006. He was wooed by doctors and administrators who share the goal of building a program that will attract other liver specialists, increase the hospital’s prestige and bottom line, and offer more treatment options for patients who haven’t had many.

Since Iannitti’s arrival, the number of liver operations performed at CMC has jumped from 26 in 2005 to 202 last year.

Because of Iannitti (pronounced eye-uh-NIT-ee) and the medical personnel he has helped recruit, patients with liver disease can now get a wider range of treatments, from medicines to surgery to transplants, without leaving the Charlotte area.

Among the new options is a treatment for advanced liver cancer called microwave ablation that Iannitti pioneered at Brown University in Rhode Island. It’s the procedure he used that day in OR 4, to burn away liver tumors with microwave energy.

He had done the surgery more than 100 times since 2003.

But on that day in February 2007, he was unusually excited.

It was the first time he’d done the procedure in the Southeast.

And it was the realization of a dream.

Like the Carolinas Heart Institute, which focuses on diseases of the heart, the hospital’s new effort is aimed at a specific organ — that flat, triangular blob beloved by the Liver Guy.

A Carolinas first

The man whose liver tumors Iannitti tackled in that premier procedure was Kevin Heslin.A Boston native who moved to Charlotte from Atlanta in 1999, Heslin knew his prognosis “wasn’t all that great” when he met Iannitti in September 2006.

Heslin had gone to his doctor for a routine colonoscopy that summer. At 48, he was two years younger than most patients who get the test routinely. But a former doctor had mistakenly ordered a colon screen for Heslin when he was 38. So, even though he wasn’t having symptoms, Heslin decided to get his colon checked again 10 years later.

The results gave him the shock of his life: Not only did he have colon cancer, but it had spread to his liver.

Surgery followed to remove the colon tumors. Then came 10 weeks of chemotherapy. But the tumors on his liver presented a bigger challenge. They couldn’t be surgically removed because there were too many and too spread out. And chemotherapy wouldn’t kill them.

Heslin’s surgeon referred him to the new Liver Guy in town.

Iannitti had been waiting for someone like Heslin, a local patient whose cancer could benefit from microwave ablation.

Heslin and his wife, Barb, were impressed by the surgeon’s experience and his confidence that this procedure was the best way to treat cancer that has metastasized, or spread, to the liver.

Without it, Heslin’s chance of surviving five years — the time generally used to measure a cancer cure — was less than 1 percent. With microwave ablation, his odds rose to 25 percent. Still not great, but better than the alternative.

The Heslins approached surgery, on Feb. 13, 2007, with hope and humor.

Barb ordered balloons with apropos Valentine’s Day messages: “Be My Liver Boy” and “I Can’t Liver Without You.”

On the day of the operation, Kevin used a black Sharpie to draw an arrow on his abdomen, pointing to his liver. He added a note to his surgeon:

“Treat it like your own.”

Pulling and searching

After 30 minutes in OR 4, Iannitti was beginning the hard work of freeing up the liver by cutting ligaments that normally hold it in place.

Standing on a stool for better leverage, Iannitti plunged his gloved hands, up to his elbows, into Heslin’s belly and tugged on the reddish brown liver.

Colon, stomach and heart are just inches away.

“Ooomph,” the doctor grunted as he leaned in to pull.

The 42-year-old Iannitti weighs 215 pounds and is 6 feet tall, but it was all he could do to free the liver from its cocoon. It was as slippery as a wet water balloon.

The chief surgical resident applied cautery, cutting ligaments and unleashing the smell of burned meat.

As Iannitti stepped down, he shrugged his shoulders to stretch. Pulled muscles are an occupational hazard.

“Now we need to start finding the tumors,” he announced.

Holding an ultrasound probe about the size of a TV remote control, Iannitti roved around his patient’s liver. A snowstorm of images appeared on the monitor overhead. Dark spots on the ultrasound pictures showed him the tumors.

Iannitti started with an easy one, on the exposed surface of the liver. With the ultrasound as his guide, he stuck three long thin antennae, like kabob skewers, in the middle of the lesion.

“Ten minutes at 45 watts,” Iannitti told the nurse.

She switched on the microwave generator and the surgeon heard a familiar crackling sound, like Rice Krispies in a bowl of milk. As minutes passed, a thin curl of white smoke rose. The golf ball-sized tumor turned black.

“Everything in the middle there,” Iannitti pointed, “is getting completely cooked.”

New specialists recruited

Iannitti’s arrival at CMC signaled a change in its approach to liver disease.”He is somebody you build around,” said Dr. Todd Heniford, a CMC surgeon who trained with Iannitti at Cleveland Clinic. “He energizes those around him.”

Before Iannitti, most Charlotte-area patients who needed major liver or pancreas surgery traveled to other cities.

That’s because CMC had no faculty doctors who specialized in caring for liver patients who didn’t need transplants. The hospital depended on community doctors who are also busy with private practices.

With his hiring, Iannitti was the first CMC surgeon who operated on the liver or pancreas daily and exclusively. He and Dr. Daniel Hayes, CMC’s liver transplant surgeon for 15 years, have since brought in about a half dozen more liver specialists.

The first recruit was Dr. Mark Russo, a hepatologist who deals with nonsurgical aspects of liver disease. Russo had an established career at UNC Chapel Hill medical school when Iannitti convinced him to move to CMC.

“He’s very persuasive,” Russo said. “It was very obvious that Charlotte’s a big enough city, it should be a major player in liver disease.”

With more doctors, more patients are staying in — and even traveling to — Charlotte for treatment of liver disease.

CMC is one of only four centers in the United States where microwave ablation is available. Since the first procedure on Kevin Heslin, Iannitti has performed about 20 in Charlotte.

In total, liver patients at CMC — surgical and nonsurgical — rose from 150 in 2006 to more than 700 in 2007.

Razor-thin margin for error

One hour into Heslin’s operation, Iannitti had burned away the four easiest-to-reach tumors.

The remaining three lay dangerously close to the vena cava.

This, the largest vein in the body, sits behind the liver and drains into the heart, only an inch away. One nick and Heslin could lose liters of blood in a few minutes.

But Iannitti was undaunted. He’s confident and gregarious enough to have invited a newspaper reporter and photographer into the OR for this first microwave ablation in Charlotte. He’s at the top of his field, giving lectures around the world, but he still brings a childlike wonder to each day’s work.

To get to Heslin’s final tumor, he reached deep into Heslin’s belly. With one hand, Iannitti held the liver still. With the other, he stuck the three antennae into the tumor.

“OK. Fire it up,” he said.

Iannitti’s cupped hand remained inside Heslin’s abdomen, holding the liver still, as the microwave generator worked.

“It’s pretty toasty in there, I can tell you that,” he said after a few minutes.

Before the allotted time, Iannitti decided to cut the heat. Having done more than 100 of these operations, he knew instinctively when enough was enough, how black the tumor should look, how hard it should feel, how it should smell.

When he finished, nurses counted all the gauze sponges that stuffed Heslin’s belly to absorb blood and keep the surgeon’s field of vision clear.

The sponges were pink, not red.

After two hours of surgery on an organ that handles so much blood, Heslin barely lost any.

An active life resumes

Six weeks after his operation, Heslin returned to work full time as a human resources executive at Goodrich.

He has since traveled to England a half dozen times on business, and he works out every morning at the gym in his office building.

Last year he traveled to Idaho for fly fishing with buddies. In January, he and his wife, Barb, took their two grown children scuba diving and kayaking in the Caribbean.

He continues on chemotherapy, as he will indefinitely. And he gets CT scans every three months.

A year later, his scans are clear. But Heslin and his doctors watch worriedly as results of one blood test change gradually, indicating cancer could have returned. To make sure, Iannitti recently took another look at Heslin’s liver and abdomen when he repaired a hernia. Again, no cancer.

Although Heslin feels healthy and confident, he lives with uncertainty.

If the cancer comes back, doctors say it will probably be in the first two years.

If that happens, depending on the size and location of tumors, Heslin will try microwave ablation a second time.

And Iannitti will be there.