White Plains Hospital’s Hepatobiliary Program: Academic-level, Community-based Care

By Jennifer Webster
Friday, June 15, 2018

An experienced cadre of physicians at White Plains Hospital has leveraged a high level of clinical expertise to develop a uniquely integrated Hepatobiliary Program in a regional hospital setting.

Sasan Roayaie, MD, hepatobiliary and pancreatic surgeon, utilizes ultrasound technology to examine the liver of a patient.

For Sasan Roayaie, MD, hepatobiliary and pancreatic surgeon, White Plains Hospital represents an ideal fusion of academic-level medicine and an exceptional patient experience close to home.

The comprehensive program treats all aspects of patients with liver tumors and other hepatobiliary conditions. Treatment approaches include surgery, ablation and embolization procedures, advanced endoscopy, as well as medical and radiation oncology.

“We perform major liver resections and pancreatic resections,” Dr. Roayaie says. “Some of these procedures require venous reconstruction or arterial reconstruction. That’s something that wasn’t offered here before.”

White Plains Hospital also offers streamlined access to transplant care. Procedures are performed at Montefiore Medical Center with the initial pre-transplant testing and follow-up care provided at White Plains Hospital.

The hospital has invested in technologies that make it possible to perform these complex, difficult-to-find techniques locally.

“I perform laparoscopic liver and pancreas resections as well as laparoscopic ablations of liver tumors,” Dr. Roayaie says. “White Plains Hospital has made a huge investment in a guidance system for laparoscopic ablations and in equipment for open and laparoscopic hepatic resections.”

Dr. Roayaie, whom White Plains Hospital recruited for the program in 2017, is a national leader in laparoscopic and minimally invasive surgeries for liver and pancreatic cancer; he has innovated techniques and published widely in these areas.

“Liver cancer surgery generally requires a big incision,” he says. “If you can perform the resection laparoscopically instead of through an incision under the rib, you can ameliorate what would otherwise be a difficult recovery. However, the anatomy of blood vessels inside the liver is highly variable. The surgeon may come across large vessels that, if not handled properly, can result in significant blood loss. During my career as a transplant and hepatobiliary surgeon, I have performed open resections regularly, giving me the experience necessary to perform the laparoscopic procedure safely.”

Interventional Oncology for Liver Cancer

Often, treatments for liver cancer are undertaken with the aim of shrinking a tumor prior to resection or helping a patient survive until transplant. Interventional procedures, collectively known as liver-directed therapies, including ablation and arterial embolization, may function as standalone, curative treatments or serve as bridges to more aggressive procedures.

Jonathan Schwartz, MD, Director, Clinical Hepatology, and Mark Burshteyn, MD, Director, Interventional Oncology, consult in the White Plains Hospital Center for Cancer Care.

Mark Burshteyn, MD, Director of Interventional Oncology at White Plains Hospital, was excited to join the program and to work alongside Dr. Roayaie and Jonathan Schwartz, MD. As a specialist in a comparatively new, fast-growing discipline, he has over 10 years of experience performing locoregional liver therapies.

“In the past, I have worked very closely with hepatologists and hepatobiliary surgeons as part of larger, academic liver programs; however, this time around I was excited to be part of the building process,” he says. As an example of collaboration, Dr. Burshteyn performs portal vein embolization, which blocks blood flow to a portion of the liver identified for resection. Dr. Roayaie then performs the liver resection.

“Working with surgeons, I occlude portal vein branches to induce growth and regeneration in the healthy part of the liver that will remain after the surgeon removes the diseased liver,” he says. “I perform several other advanced liver interventions, specifically in the setting of portal hypertension and portal vein thrombosis.

Portal vein thrombosis, a rare condition associated with liver disease, has traditionally been treated with anticoagulants; however, Dr. Burshteyn uses catheter-directed thrombolysis or angioplasty and stenting to restore portal inflow. Another condition associated with advanced liver disease, portal hypertension, results in ascites as well as varices in the esophagus and abdomen. Treatments include shunting via a transjugular intrahepatic portosystemic shunt (TIPSS), in which the interventionalist creates a tunnel connecting the portal and hepatic veins and then places a stent to keep the connection between the portal vein and the hepatic vein open.

To manage gastric varices associated with portal hypertension, Dr. Burshteyn offers balloon-occluded retrograde transvenous obliteration (BRTO). The intervention may be an adjunct or alternative to TIPSS. In the BRTO procedure, the interventionalist introduces a sclerosing agent to occlude dilated vessels and reduce risk of rupture.

“We can also attack tumors by introducing beads soaked in chemotherapy agents or loaded with radiation,” Dr. Burshteyn says. “These procedures are referred to as chemoembolization and radioembolization. The goal is to directly poison the tumor and starve it of its blood supply, with no side effects elsewhere in the body. In addition, we can precisely target tumors with ablative therapies including microwave ablation or cryoablation, using probes in a controlled manner to superheat or freeze the tumor, which subsequently dies and is reabsorbed by the body.”

“White Plains Hospital has a liver program to which I would be more than confident to refer a family member. Today, patients in the area can receive academic-level treatment for liver disease near home, provided by nationally recognized physicians, along with outstanding nursing care in a regional hospital setting.”
— Sasan Roayaie, MD, hepatobiliary and pancreatic surgeon

Dr. Roayaie brings unique surgical skills to provide care for patients needing complex liver, bile duct and pancreas resections.

Multidisciplinary care for liver disease also involves medical and radiation oncologists, who collaborate closely with surgeons and radiologists to tailor individual care plans. Treatment goals differ according to the patient and the disease, Dr. Burshteyn notes. For every patient, however, physicians look to maximize health, reduce disease burden and side effects, and extend life.

“For some patients, surgical resection of primary or metastatic liver tumors offers the best chance for a cure,” he says. “But many are inoperable for a variety of reasons. Their tumor may be proximate to vital areas, for example, or they may be poor surgical candidates due to multiple comorbidities. But they may still be candidates for advanced interventional treatments. For unresectable primary liver cancers, the goal is typically to help the patient survive until transplant. However, waiting lists are long, and cancer may progress while patients await a donor organ. That is where we step in with advanced liver-directed therapies.”

Collaboration for Transplant Patients

One of the program’s goals that strongly appealed to Dr. Schwartz was to provide a full spectrum of care for liver disease, up to and including transplantation. “I was drawn by the unique opportunity to help establish a cutting-edge multidisciplinary program and manage patients with liver disease and liver tumors,” he says.

The multidisciplinary team of experts provides comprehensive care for patients with liver tumors or other hepatobiliary conditions.

To fulfill this goal, White Plains Hospital collaborates with Montefiore Medical Center, which boasts a well-established and highly regarded transplant program, under the leadership of Milan Kinkhabwala, MD, Chief of Transplant Surgery.

“We provide the majority of all levels of care — inpatient management of patients with advanced liver disease, multidisciplinary treatment of patients with liver cancers and malignancies, and state-of-the-art imaging — in close conjunction with an outstanding liver transplant program,” Dr. Schwartz says. “This is a collaborative decision to have our institutions work together to make these services available locally so that we can care for patients in the community.”

Dr. Schwartz, who is on the faculty of Albert Einstein College of Medicine, divides his time between White Plains Hospital and Montefiore.

“Because I’m familiar with how things work at Montefiore, it’s a natural relationship,” he says. “I spend 20 percent of my time on the transplant ward at Montefiore and attending meetings and tumor boards to ensure we have a good liaison with the hospital to represent our patients in the transplant center.”

Transplant patients receive assessment, testing, pre-transplant care and follow-up care at White Plains Hospital, while the procedure and some pre- and post-surgical testing take place at Montefiore.

“The outstanding surgical and medical teams at Montefiore Medical Center achieve extremely good outcomes,” Dr. Schwartz says. “Our very active live-donor program has a one-year survival rate of 100 percent, and our deceased-donor recipients have a 92.2 percent one-year survival rate. These types of results inspire confidence in the innovation and superior quality of the transplant team as a whole.”

As part of White Plains Hospital’s commitment to keeping as many services in the community as possible, the hospital recently acquired FibroScan technology, making advanced testing possible locally.

“FibroScan is a noninvasive technique that measures the amount of time an ultrasound wave takes to travel through the liver, providing information about liver stiffness,” Dr. Schwartz says. “We also use the software to measure and quantify the amount of fat in the liver so that we can determine whether liver injury is due to fat inside the liver. We can look at scarring and liver fat in a noninvasive way, which is a great resource for our community.”

Dr. Schwartz treats patients with acute and chronic liver diseases, collaborating with Montefiore Medical Center for those patients requiring liver transplantation.

Dr. Burshteyn focuses on using image guidance and minimally invasive procedures to diagnose and treat liver conditions.

A Bright Future

Like his colleagues, Dr. Schwartz is excited about the comprehensive Hepatobiliary Program at White Plains Hospital. Significant investment by the hospital, paired with institutional collaboration with Montefiore Medical Center, promises an unparalleled level of local care for patients with advanced liver disease.

“White Plains Hospital is committed to providing every aspect of care,” Dr. Schwartz says. “It’s an honor and an exciting opportunity to participate in this novel program.”

For more information, visit wphospital.org.