MedStar Health Blog

This Christmas will be extra-special for Barbara Lott. For the first time in several years, the 68-year-old Washington, D.C., resident will be cooking dinner and desserts for her family and friends, free of the arthritis pain in her knees that had kept her from standing unassisted even short periods.

Ms. Lott’s arthritis started innocently enough about 14 years ago—some occasional pain in her right knee that she attributed to having been on her feet a lot. Over-the-counter medications worked for awhile, but the pain gradually grew worse, defying cortisone shots and other treatments.

Eventually, both knees were affected. But Ms. Lott was undaunted.

“I wanted to stay active and do as much as I could,” she recalls. “As I told my friends, ‘no pity party for me!’”

Deciding to Pursue Surgery

By early 2017, however, Ms. Lott’s arthritis appeared to have gotten the best of her. With both knees now deformed by pain, she was dependent on a rolling walker to get around her house. Even her never-give-up spirit began to wane, making her dubious about pursuing surgery to correct the problem.

Ms. Lott even admits that she almost skipped her appointment to see Savyasachi C. Thakkar, MD, a specialist in adult hip and knee reconstructive surgery at the MedStar Orthopaedic Institute at MedStar Washington Hospital Center.

But she decided to go, and she’s glad she did.

“I immediately felt comfortable with Dr. Thakkar,” says Ms. Lott. “He was very friendly, yet he didn’t talk down to me.”

Diagnosis

Dr. Thakkar diagnosed Mrs. Lott’s condition as “windswept knees,” an arthritis-related deformity that leaves both knees severely out of alignment. The right side was knock-kneed and the left side was bow-legged. Due to her unique problem, Dr. Thakkar suggested performing surgery on both knees at the same time, a procedure called “bilateral total knee arthroplasty,” which would reduce surgical risks and speed her recovery. The degree of deformity required her to undergo bilateral simultaneous total knee arthroplasty, as operating on just one knee would not provide the maximum functional benefit that she could achieve.

"Everything he said made sense to me,” she adds. “I wouldn’t have done the surgery without him.”

After some initial physical therapy evaluations confirmed that her knees were strong enough for the surgery, Ms. Lott joined other orthopaedic patients for a pre-operative joint replacement class designed to educate patients about what would take place during the procedure. She also met with special social workers called Post Acute Care Coordinators (PaCC) who arranged for her rehabilitation needs and home care needs after surgery. Dr. Thakkar also made sure he and his assistant were always accessible to answer questions.

"That helped get my mind ready,” Ms. Lott says. “I wasn’t afraid at all.”

The procedure to correct the deformity in Ms. Lott’s knees lasted about three hours. Another welcome surprise awaited when she awoke from anesthesia without experiencing any post-operative pain.

“That surprised even the nurse,” she says with a laugh. “She gave me a Tylenol later on, but to this day, that’s all I’ve really needed.”

Post-Surgical Recovery Progress

Ms. Lott’s recovery unfolded exactly as planned. Within six weeks of her surgery, Ms. Lott could walk short distances without a walker. Three months post-surgery, she could walk unassisted. Her overall health improved along the way, as did her anticipation about resuming those neglected holiday cooking traditions.

"I’m able to stand, do my grocery shopping, and walk from one end of the store to the other,” Ms. Lott says proudly, adding that she also keeps Dr. Thakkar’s business card in her wallet to share whenever she hears of someone else being debilitated by arthritis in the knees and the hips.

“I know what kind of pain they’re having, and how it controls your life,” she says. “And you really don’t know how much it does until you have the surgery.”

In July 2016, I attended a bariatric surgery information session with my mom. I went to support her, but I guess I looked like I needed help, too. Someone handed me a weight-loss surgery form to fill out, and I did. I was 17.

Weight has been an issue for me for a long time, and while the thought of weight-loss surgery had briefly crossed my mind at times, I had never seriously considered it until that day.

Obesity increases the risk of multiple health problems, such as diabetes, high cholesterol and high blood pressure. These conditions run in my family. I knew if I stayed on the path I was on, those risks could become reality for me down the road. And I’d be lying if I said I didn’t want to buy cute clothes in smaller sizes.

I also had another reason to consider bariatric surgery: I plan to become a physician, and I want to follow the healthy lifestyle I recommend to my future patients. For example, if I recommend that a patient reduce carbs from their diet, I’ll have the insight to be able to say, “Here’s how I go about it.”

I know some people may raise an eye at the thought of a teen or young adult having bariatric surgery. It’s a big life decision for anyone, no matter their age. As with any surgery, there are risks. And it’s a lot of work to prepare for surgery and maintain a healthy lifestyle once it’s over. But I look at it as a chance to give myself a longer, healthier life.

Taking the first steps toward weight-loss surgery

During the MedStar Washington Hospital Center bariatric surgery information session my mom and I attended, we met the bariatric team and learned about the surgical options and the process leading up to and after surgery.

It got me thinking that I could do this. So I spent the next couple months doing loads of research. I watched countless YouTube videos of doctors discussing the surgery and people describing their experiences with it.

In fall 2016, my mom and I scheduled our initial appointment with Dr. Timothy Shope. During that meeting, we discussed the health complications obesity can cause, and he told me that I didn’t need to wait until I developed such conditions to have bariatric surgery. In my case, it was a preventive measure.

Read and watch: Learn more about Jewel’s bariatric surgery journey in this Vox story.

My mom and I both decided to have gastric sleeve surgery, also known as sleeve gastrectomy. Over the winter and spring, we underwent various medical exams and attended monthly classes that covered nutrition, diet and exercise.

I was lucky to have gone through the entire process with my mom. It was comforting to have someone who truly understood what I was going through at each step of the journey. She had her surgery a month before me, so I also got to see firsthand what I would be experiencing soon.

What others thought of my decision

Before my bariatric surgery, my program required me to see a psychologist. The psychologist I saw initially was concerned about someone so young making such a life-changing decision. However, after speaking with my mom and me at length, she agreed that I had done my research and was mature enough to know what I was doing.

That initial concern was expressed by others as well. But most people didn’t say anything to me—they told my mom. I think some people wanted her to pressure me not to have the surgery because they thought I was too young.

My immediate family and friends were extremely supportive. I was nervous about telling my friends. I worried they would think I was taking the “easy way out” or urge me to lose weight on my own without surgery. When I asked one of my best friends what she would say if I told her I was thinking about bariatric surgery, she responded, “I would say, ‘What time should I be at the hospital?’” I love her for that. While many friends had questions, they all accepted my decision immediately.

Surgery and recovery

Going through bariatric surgery requires a six- or seven-month preparation process. To reduce the amount of fat around the liver and spleen, I had to follow a liquid diet for a few weeks before surgery. The low-carb beverages made me feel lethargic and miserable! But I reminded myself that it was only temporary and the surgery would make a long-term impact on my health and life.

I had gastric sleeve surgery in April 2017. Eight months post-op, I feel great! That’s not to say there haven’t been bumps in the road, but they’ve all been worth it. Bariatric surgery isn’t magic. You still have to put in the work to reach your weight goal.

I mentioned that my mom encountered some people who doubted my decision to have bariatric surgery. I think she would tell other parents in this situation that they need to determine if their teen is emotionally mature enough to make such a decision, and then trust and support that decision.

If a loved one tells you they are considering weight-loss surgery, keep an open mind. Help them with their research as you may be able to uncover different angles to consider. Ask questions, but be patient and give them room to make the decision on their own.

And be supportive after surgery, but don't be the “diet police.” It’s a myth that bariatric surgery patients can never have dessert again, but that doesn’t mean they should eat the entire box of cookies. So if you see your friend or family member reaching for another cookie, gently remind them of this.

My goals going forward

I graduated from high school in June 2017, and I’m deferring college for a year to work and make money. I’m also using the time to prepare myself to become a pre-med student by using online resources to beef up my knowledge in a few subjects I’m not as strong in, such as physics. I know that by fall 2018, I’ll be pumped to get back in the classroom and start the next chapter in my life!

As for my health, the diet and exercise changes I’ve made since surgery are little by little becoming second nature. I’m seeing progress and that motivates me to continue on this path. I don’t let the short-term challenges derail me. I look forward to continuing to live a healthier, more active life—and buying new clothes!

In the 1990s, the Food and Drug Administration (FDA) approved a treatment for bladder cancer called Bacillus Calmette-Guerin therapy, or BCG, which stimulates the immune system and helps keep patients’ cancer from coming back.

Until recently, BCG was still the newest FDA-approved treatment for bladder cancer. But about one-third of patients won’t respond to BCG. This can limit patients’ treatment options to bladder removal surgery, but many people with bladder cancer are older and not able to handle such a major procedure. And many patients don’t want to undergo the surgery even if they’re healthy enough for it.

In recent years, however, we’ve begun to find alternatives to BCG. Beginning in 2015, several new therapies have been approved that have revolutionized the way we treat bladder cancer. And like BCG back in the ’90s, these treatments harness the power of the immune system to battle this disease.

As of November 2017, these immunotherapy treatments currently are approved for patients whose disease is further along and hasn’t responded well to other treatments, such as traditional chemotherapy and surgery. But we’re currently investigating new ways to use immunotherapy, as well as how to use it sooner in the disease process.

How does immunotherapy work to treat bladder cancer?

One of the ways cancer can survive and grow within the body is by deactivating the immune system. The bladder’s cells, like all cells in the body, have a system to prevent them from growing out of control. Like inserting a key into a lock, immune cells can bind to bladder cells that are growing too much and kill them without harming healthy cells.

But in cases of bladder cancer, the cancer cells can “trick” the immune system by hijacking this process. Bladder cancer cells use certain proteins to turn off immune system cells before they can destroy the cancer cells. This allows the cancer cells to grow out of control, forming tumors that can spread from the lining and connective tissue of the bladder into the muscle.

The latest immunotherapy treatments work by preventing this interaction. By stopping the cancer cells from turning off the immune system cells, we can increase the immune system’s ability to find and destroy cancer cells.

Personalized treatments for bladder cancer

There are multiple clinical trials going on with the hope of expanding our use of immunotherapy. Some examples of these potentially expanded uses include:

• Combining immunotherapy with other treatments to kill cancer cells even more effectively
• Treating someone with a new diagnosis of metastatic bladder cancer, or cancer that is spreading beyond the bladder wall
• Treating someone with immunotherapy before surgery
• Treating someone with immunotherapy before their bladder cancer spreads into the bladder muscle

Here at MedStar Washington Hospital Center, we’re participating in a clinical trial for patients whose bladder cancer hasn’t invaded the bladder muscle. In particular, this trial is examining patients who haven’t responded to BCG, the standard of care for bladder cancer approved back in 1990. Patients who don’t respond to BCG may be candidates for this new treatment, called Vicinium. Though this isn’t a form of immunotherapy, it’s an exciting approach to targeting bladder cancer cells. When we introduce Vicinium into a patient’s system, it makes its way to bladder cancer cells, avoiding healthy cells along the way. Next, it blocks the cancer cells from creating the proteins they need to survive, which causes the cancer cells to die off.

The new treatments we have available for bladder cancer and those currently being tested all are part of a growing wave of personalized medicine in cancer care. Until very recently, although we customized each patient’s particular treatment strategy for that patient, we’ve had the same sorts of treatments available to choose from.

Many researchers are studying information we can get from the patient during the first bladder cancer biopsy to see if we can recommend particular treatments based on whether the patient will benefit from them. For example, if we could identify whether a patient is likely to benefit from the chemotherapy treatment, we could know whether we should recommend that or go straight to surgery. Like immunotherapy, this is another way we can tailor care to the individual patient.

The field of bladder cancer treatment has made great strides forward in the last few years. In the next five to 10 years, it could look radically different than it does today. I’m excited for the chance to help more of my patients, and I’m eager to see what happens next.

Dominic Nwanji has loved playing basketball since he was a child.

“It means everything to me,” says the 28-year-old. “When I play, any stress, concerns, deadlines or anything going on in my life takes a back seat. I am able to relax.”

Things came to a screeching halt on the court for Dominic during a game at his local YMCA. Two players tried to cut him off as he was heading for the basket. Dominic skidded to a stop so suddenly that his knee buckled as he twisted to pass the ball, causing him to fall to the floor in pain.

“When it first happened, I thought it was just a bad knee tweak but the pain didn’t subside,” Dominic says. “Then I realized, maybe this isn’t something simple.”

Dominic had a torn anterior cruciate ligament (ACL), an injury common among athletes. The ACL and posterior cruciate ligament (PCL) are tissues that hold the knee together and stabilize it in different directions.

Dominic was told he needed reconstructive surgery at his first consultation in North Carolina, where he lives. So he traveled to Washington, D.C., where he has family and went to MedStar Georgetown University Hospital, part of the MedStar Orthopaedic Institute. He was shocked when William F. Postma, MD, chief of Sports Medicine in the Department of Orthopaedic Surgery at MedStar Georgetown, told him that instead of reconstructing his ACL, he could possibly repair it.

“I hadn’t even heard of a repair,” Dominic says. “So, I asked Dr. Postma to explain the procedure to me a few times before ultimately deciding it was my best option.”

“The gold standard is still to reconstruct ACL injuries and at MedStar Georgetown we perform all kinds of reconstructions,” Dr. Postma explains. “But a repair can be an alternative for some individuals and the type of tear Dominic had is amenable to that. Most people are not candidates for it because of the location of the tear, but for patients that are, there are some benefits.”

The ACL attaches to bone in two places—the tibia (leg bone) and the femur (thigh bone). In a repair, strong stitches help anchor the ligament back onto the bone, leading to a faster recovery of about four to six months and more natural-feeling knee movements.

“Repair techniques are now done arthroscopically with a small camera and better instruments so we can see what we are doing without harming a lot of other tissue,” says Dr. Postma.

Dr. Postma says that all of his patients to date have had successful repairs. That has certainly been the case for Dominic, who was back on the court six months after his repair surgery.

“It is easy to become discouraged because the recovery process challenges you in ways that you are naturally unaccustomed to,” Dominic says.

“However, your confidence rises as you keep a positive attitude and notice your progress from week to week. People have actually told me I’ve gotten better as a player since the surgery,” he says with a laugh.
“I feel just as happy on the court as I did before the injury. It hasn’t held me back at all.”