Large Colorectal Polyp Morphology Predicts Endoscopic Management Patterns

As techniques and technology have rapidly advanced over the past decade, endoscopy has had a large impact on how many gastrointestinal (GI) conditions are treated. “One of the biggest shifts we have made clinically in terms of the number of patients treated is endoscopic resection of large colorectal polyps,” says John Levenick, M.D., Penn State Hershey Gastroenterology and Hepatology. In the past, these would have been automatically referred for open or laparoscopic resection. However, not all large polyps exhibit the same clinical features and some pose relatively greater challenges and risks during resection. Levenick and colleagues determined how well an endoscopic approach performed for management across polyp types based on gross morphology. Continue reading

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Ultrasound-based Elastography for Non-Invasive Monitoring in Chronic Liver Diseases

Non-invasive, ultrasound-based elastography devices are changing and simplifying regular monitoring for scarring and fibrosis in patients with certain chronic liver diseases, in many cases replacing the need for biopsy.1 Karen L. Krok, M.D., Penn State Hershey Gastroenterology and Hepatology, says, “In patients with an established diagnosis of chronic liver disease, such as hepatitis C or B or nonalcoholic steatohepatitis (NASH), elastography can be used to monitor fibrosis and scarring, with a level of accuracy comparable to biopsy. The procedure is quick, painless and less expensive.”

Ultrasound-based methods of elastography use a vibrating device attached to an ultrasound transducer, which is placed in an intercostal position with the patient lying supine. The velocity of vibration waves (also called shear wave velocity), expressed in kilopascals (kPa), is determined by measuring the time the vibration wave takes to travel to and bounce back from the liver. Shear wave velocity is directly related to tissue stiffness, an indicator of hepatic fibrosis (Figure). Ten successful measurements are required for the test to be reliably interpreted; a median value is generated to indicate the degree of liver fibrosis. Krok says, “It’s like bouncing a tennis ball against a soft versus hard surface. The ball will bounce back more quickly from a firm surface like pavement than it would if it were bounced against something soft, like a pillow.” Continue reading

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Gaining a Multidisciplinary Perspective Toward Chronic Abdominal and Pelvic Pain

PATIENT PROFILE: A 22-year-old female presents with recurrent episodes of nausea and vomiting, accompanied by severe, non-localized abdominal pain unexplained by infection or other illness. She has a history of appendectomy and exploratory laparoscopy. Extensive clinical laboratory tests reveal no pathology. She has comorbid generalized anxiety, treated with venlafaxine, but is otherwise healthy.

“Patients with chronic abdominal or pelvic pain may suffer for years through misdiagnoses, incomplete diagnoses and possibly multiple, ineffective surgeries. By the time they are referred to us, they are desperate for relief,” says Deborah M. Bethards, M.D., Penn State Hershey Gastroenterology and Hepatology.

In addition to gastroenterology, the Penn State Hershey Chronic Abdominal and Pelvic Pain (CAPP) Group includes health care providers from anesthesia and pain management, general surgery, gynecologic surgery, physical therapy and pediatric chronic pain. This team helps patients obtain multidisciplinary treatment that may be more effective. With many similar, mutual patients, CAPP meets monthly to discuss cases and present topics. Continue reading

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Endoscopic Suturing Device Offers Minimally Invasive Treatment for Conditions that Otherwise Require Surgery

Endoscopic suturing offers a minimally invasive, incisionless repair of gastrointestinal perforations and fistulas which often occur in critically ill patients in an emergent setting. “With the new generation endoscopic suturing device that is available, the possibilities using an endoscopic approach have dramatically broadened; we can be much more aggressive with endoscopic treatments that used to be limited by traditional suturing methods,” says Abraham Mathew, M.D., Penn State Hershey Gastroenterology and Hepatology.

Physicians at Penn State Hershey Medical Center have been using the Apollo OverStitch™ (Apollo Endosurgery, Inc., Austin, Texas) since it became available in the U.S. They have noted large gains in their ability to use an endoscopic approach for a wider range of indications, including closure of GI fistulas, perforations of the GI lumen and suturing of endoscopic stents in place to avoid migration. Patients whose stomach pouches open widely after gastric bypass surgery can have it reduced using this device. The future holds endoscopic alternatives for laparoscopic sleeve gastrectomies and gastric bypass surgeries. A video of a procedure in which Mathew and his colleagues used the suturing device was shown during the 2015 Digestive Disease Week (May 16-19, Washington, District of Columbia). Continue reading

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Novel, Minimally-Invasive Approach to Life-threatening, Complex Hepatic Abscess

In 2014, the world’s first percutaneous endoscopic debridement of hepatic abscesses was successfully performed by Matthew T. Moyer, M.D., at Penn State Hershey Medical Center. A report of the case was recently published in Gastrointestinal Endoscopy.¹ And, last October, a video of the procedure won first place in the international video forum competition at the 2014 American College of Gastroenterology Annual Conference in Philadelphia.2

Case SummaryIn a novel approach to treat a patient with life-threatening and complex hepatic abscess, Moyer explains that a multidisciplinary approach involving gastroenterologists, surgical oncologists and interventional radiologists was important, and that the approach was built on established principles of endoscopic treatment of pancreatic necrosis.3 “The successes that our interventional endoscopy group has had with endoscopic ultrasound-guided drainage and stenting of pancreatic pseudocysts as well as transluminal endoscopic debridement and washout of pancreatic abscess and necrosis inspired us to attempt adapting the technique to this patient as an alternative to high-risk open or laparoscopic hepatic necrosectomy, where mortality can be as high as 15 percent.” Continue reading

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Case Summary of Patient with Life-Threatening and Complex Hepatic Abscess

  • Male patient, 46 years-old
  • Presented with abdominal pain, acute and progressive abdominal sepsis
  • Poor response to treatment for sepsis; patient exhibited rapid decline, became gravely ill
  • CT scan revealed massive hepatic abscesses (Figure):
    • Bilateral
    • Multi-loculated
    • Solid necrotic debris
  • Placement of two 24F multipurpose drains and one 28F drain.
  • Repeat catheter exchanges and lavage protocols, limited progress in removal of necrosis
  • For left hepatic abscess, replaced 28F drain with 9mm flexible endoscope:
    • EUS-guided use of floppy endoscopic snare to removal of solid necrotic debris
    • High-volume saline lavage
    • Drain replacement
    • Repeated procedure for right hepatic abscess
  • Marked patient improvement; discharge
  • Four procedures performed over ten days with full recovery by week ten
  • Ongoing oral antibiotic treatment

Read more about the novel, minimally-invasive approach.

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Targeting Peri-Operative Hyperglycemia in Patients Undergoing Complex Ventral Hernia Repair

Early post-operative hyperglycemia is associated with greater costs in patients who have undergone complex ventral hernia repair, independent of comorbid diabetes, according to findings recently reported in the Journal of the American Medical Association (JAMA) Surgery.1

David Soybel, M.D., along with colleagues from Penn State Hershey Endocrinology, conducted a retrospective medical record review of 136 consecutive patients for whom complex ventral hernias were repaired and serum glucose levels were measured within 48 hours of surgery. In the subset of patients with post-operative elevated glucose (greater than or equal to 140 mg/ mL, n=54) or those who required insulin administration (n=69) compared to patients without these outcomes, time to first solid meal was significantly delayed and significant increases were observed for length-of-stay and hospital costs. A trend toward greater risk of surgical site occurrence was also observed (P=0.06). These findings were further supported by a sub-analysis of patients in the two most common Ventral Hernia Working Group grades 2 and 3 (Figure 1).

Post-Operative Hyperglycemia

A: Comparison between groups with postoperative serum glucose levels of less than 140 mg/dL vs greater than or equal to 140 mg/dL. B: Comparison between groups with zero or one vs two or more insulin events, defined as the number of times insulin was administered postoperatively during the hospital stay. Comparisons were performed using Fisher exact test. SSO=surgical site occurrence, including seroma, hematoma, surgical site infection, a non-healing wound, or a hernia recurrence; LOS=length-of-stay.

Soybel notes, “A really interesting finding is that nearly half of the patients [46.4 percent] who developed hyperglycemia had no history of diabetes. This supports the notion that post-operative hyperglycemia and insulin resistance are part of the metabolic response to surgery itself, and are often transient.” Continue reading

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