Advances in Treating Esophageal Perforation

Decisions regarding the treatment of patients with an esophageal perforation or spontaneous rupture are usually tackled in the emergency care setting. In recent years, the viable treatment options for patients with such life-threatening problems have expanded with development of new techniques and more widespread use of collaborative care.

As an example, in a case of Boerhaave syndrome (emetogenic esophageal rupture) recently encountered at Penn State Hershey Medical Center, a middle-aged woman presented to the emergency department medical team with unrelenting, severe, upper abdominal and pleuritic lower chest pain after a long night of emesis. Contrast radiography and computed tomography revealed a distal esophageal perforation, a complex pleural effusion, and associated mediastinal air (Figure 1), prompting emergent consults to gastroenterology and thoracic surgery. Medical Center surgeons and gastroenterologists chose to deploy a removable, fully covered, self-expanding metal esophageal stent across the esophageal disruption (Figure 2). This was positioned to arrest mediastinal contamination due to leakage of esophageal contents into the pleural space and periesophageal tissues. The stent type, diameter and length are individualized to each patient; getting the right “fit” is critical to exclude the lesion and achieve stable placement.

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Advanced Endoscopic Procedures to Diagnose and Treat Gastrointestinal Stromal Tumors (GISTs)

Important advances over the last decade in our understanding of gastrointestinal stromal tumors (GISTs) have opened the door to earlier diagnosis, innovative treatment, and improved patient survival. Most often occurring in the stomach, GISTs are thought to arise from the interstitial cells of Cajal, and are marked by mutations in the c-kit proto-oncogene, which expresses CD117, linked to the potential for malignancy.

Raquel Davila, M.D., gastroenterologist from Penn State Hershey Gastroenterology and Hepatology notes, “Gastroenterologists and surgical oncologists at Penn State Hershey Medical Center routinely use endoscopic ultrasound (EUS), with or without fine needle aspiration (FNA) for GIST diagnosis and to rule out other diagnoses, such as lymphoma. EUS can delineate the gut wall layers, which is helpful to identify the location of the tumor; a GIST appears as a hypoechoic solid mass, most often in the fourth layer of the GI tract wall, the muscularis propria, and less commonly in the second or third layers [muscularis mucosae and submucosa, respectively].”

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Per-oral Endoscopic Myotomy (POEM) for Treatment of Achalasia

New approaches to treating achalasia, a neuromuscular condition marked by difficulty swallowing, successfully reduce esophageal sphincter pressure, while avoiding the need for laparoscopic surgery. The standard surgical option for achalasia is Heller myotomy, a laparoscopic procedure in which the muscles of the lower esophageal sphincter are divided to provide durable reduction in esophageal sphincter pressure. Other effective treatments include esophageal dilation with large balloons, which has high recurrence, and Botox injection, which is much less durable.

According to Eric M. Pauli, M.D., a general surgeon at Penn State Hershey Medical Center, “A newer, incision-free, per-oral endoscopic myotomy (POEM) technique shows promise as a safe, effective alternative.” In his animal lab, Abraham Mathew, M.D., gastroenterologist from Penn State Hershey Gastroenterology and Hepatology, initially developed transesophageal endoscopic dissection techniques in a porcine model specifically aimed at reaching the esophageal muscle.1 Physicians in Japan were the first to perform the technique in humans.2 POEM is now performed in a small number of centers in the United States and around the world,3 and the Medical Center was the first to use this technique in Pennsylvania. Dr. Pauli notes, “This is an exciting opportunity to treat achalasia patients using no incision; the procedure is completely endoscopic and yields intermediate-term results equal to those of a Heller myotomy.”

Per-oral Endoscopic Myotomy (POEM)

Figure 1: Sub-mucosal tunnel creation extending towards the GE junction.4
Figure 2:
Circular muscle fibers division maintaining intact longitudinal fibers beneath.4

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Measuring the Impact of Advanced Endoscopic Techniques on Diagnosis and Treatment of Gastrointestinal Cancer

When a gastrointestinal tumor is detected, defining the risk of malignancy and the potential for metastasis, and deciding how to proceed with treatment are issues of immediate concern to both the physician and the patient.

“Often, tumors are found when patients have endoscopic evaluation for problems such as longstanding heartburn or iron deficiency anemia. The lesions may be asymptomatic, but progression can occur,” says Charles Dye, M.D., gastroenterologist from Penn State Hershey Gastroenterology and Hepatology. Dr. Dye explains, “Malignant tumors, such as gastrointestinal stromal tumors [GISTs], also look similar to nonmalignant growths, such as Schwannomas or leiomyomas.”

While tumor size and location can be indicators of a tumor’s malignant potential, pairing endoscopic ultrasound (EUS) with a biopsy technique may allow major surgery to be avoided. Benign tumors can be left in place, while malignant tumors can be staged and risk-stratified to allow the best and most minimally invasive treatment approach. While immediate cytological analysis yields important information about tumor type, ancillary analyses, such as immunohistochemistry and tumor cell mitotic rate, may take several days to complete.

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Penn State Hershey joins international pediatric quality improvement program

The pediatric gastroenterology program at Penn State Milton S. Hershey Medical Center, Penn State Hershey Children’s Hospital, will begin enrolling its first patients into the Improve Care Now (ICN) network in the first quarter of 2014, making it the only hospital in central and western Pennsylvania—and just the second in the state—to become part of this internationally recognized program. ICN is a network of more than fifty pediatric gastroenterology divisions throughout the United States, Canada, and Great Britain focused on the health of children with inflammatory bowel disease (IBD), which includes patients with Crohn’s disease and ulcerative colitis. The network will celebrate its tenth anniversary later this year.

“Improving the quality of care for pediatric patients suffering from IBD always has been our goal,” said Marc E. Schaefer, M.D., M.P.H., Penn State Hershey’s physician leader for the ICN program. “By joining forces with Improve Care Now, our physicians and nurse practitioners have access to medical data to help us treat these children even more effectively.”
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Expanding the Role of Medical Simulation Technology in Medical Digestive Health Student Training

Long before they are admitted to medical school, students have well-honed studying and testtaking skills. But they often lack the skills needed to apply what they’ve learned in the classroom to the clinical setting. Emmanuelle D. Williams, M.D., director of gastroenterology training for second-year medical students for Penn State Milton S. Hershey Medical Center’s Division of Gastroenterology and Hepatology, is working to change that.

“At Penn State Hershey, all of our second-year medical students (currently more than 140) are required to participate in handling initial intake of a simulated ‘patient’ who presents to the emergency department with a gastrointestinal bleed,” said Williams. The case builds directly on classroom lectures about obtaining a medical history, monitoring vital signs and differential diagnosis.

“It’s usually a very emotional experience for the students,” said Williams. “The clinical routine begins to fall apart; they don’t get a proper history, they struggle with differential diagnosis, and professionalism is lacking. It opens their eyes to the difference between book learning and applying that knowledge in the clinic.” Continue reading

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Digestive Health Update: Thomas J. McGarrity, M.D.

The Division of Gastroenterology and Hepatology recently welcomed Karen Krok, M.D. Dr. Krok earned her medical degree and completed internal medicine training at the University of Pennsylvania. She completed a gastroenterology fellowship at Johns Hopkins University which included an additional year of transplant hepatology training. Dr. Krok returned to the Hospital of the University of Pennsylvania as a fulfilled hepatologist for the past five years. At Penn State Hershey, she serves as director of the live donor liver transplant program.

Award presentation photo

Dr. Harold L. Paz, Chief Executive Officer, Senior Vice President for Health Affairs, and Dean, Penn State College of Medicine presented the 2013 Penn State Hershey Medical Center and Penn State College of Medicine Community Service Award for Faculty to Dr. Ian Schreibman.

Transplant hepatologist Ian Schreibman, M.D., recently received the 2013 Penn State Hershey Medical Center and Penn State College of Medicine Community Service Award for Faculty. He was recognized for his ongoing contributions at the Bethesda Mission free medical clinic in Harrisburg, PA. Dr. Schreibman has volunteered many hours of service and has mentored many medical students and internal medicine residents at the Bethesda Mission.

Nurse practitioner Marjorie Lebo, C.R.N.P., received a staff community service Award for organizing the annual Colon Cancer Prevention 5K Run and Fun Walk. This event—held in June for the last seven years—has rapidly become a focal point for the racing community in central Pennsylvania. Proceeds from this event in part support colorectal cancer genetics counseling for individuals without health insurance.

The Penn State Hershey Inflammatory Bowel Disease (IBD) Center works with the Crohn’s and Colitis Foundation of America (CCFA). The IBD Center continues to serves as a major sponsor of the CCFA’s Take Steps for Crohn’s and Colitis contribution to patient awareness efforts throughout Pennsylvania.

Emmanuelle D. Williams, M.D., a member of the IBD Center, also serves on the Advisory Board for the Gluten Intolerance Group of South Central Pennsylvania. Dr. Williams is the recipient of the 2013 American Gastroenterological Association Bridges to Excellence “Recognition for Excellence in the Delivery of Quality Inflammatory Bowel Disease Care”—the only one awarded in Pennsylvania and one of eighteen in the country.

Penn State Hershey physician demonstrating endoscopy techniques to medical students

Dr. McGarrity shares endoscopy techniques as part of the 2013 Ghana Endoscopy Training Program at Korle Bu teaching hospital in Accra, Ghana.

Thomas J. McGarrity, M.D., Professor of Medicine, recently returned from an endoscopy training program at Korle Bu Hospital in Accra, Ghana. With collaborators from Mayo Clinic and Oslo, Norway, a hands-on endoscopy training is provided annually for physicians from Ghana and West Africa. The Ghana College of Medicine has also approved funding for a first-ever gastroenterology fellowship program. The first gastroenterology fellow began training in January 2013.

Finally, Abraham Mathew, Professor of Medicine, was recognized at the annual Penn State Hershey Innovation Ceremony. Dr. Mathew, in collaboration with members of the mechanical engineering department at Penn State University, was awarded two patents for endoscopic devices which will be useful in the development of new endoscopic surgical procedures including NOTES (Natural Orifice Transluminal Endoscopic Surgery).

To learn more about Penn State Hershey Gastroenterology and Hepatology, and to watch a video featuring Dr. McGarrity, please visit http://www.pennstatehershey.org/web/gi/home/aboutus .

photo of Thomas J. McGarrity, M.D.

Thomas J. McGarrity, M.D.

Thomas J. McGarrity, M.D.

  • Professor of Medicine
  • Chief, Division of Gastroenterology and Hepatology
  • Penn State Hershey Gastroenterology
  • Phone: 717-531-1441
  • Fellowship: Gastroenterology, Penn State Milton S. Hershey Medical Center
  • Residency: Medicine, Penn State Milton S. Hershey Medical Center
  • Internship: Medicine, University of Pittsburgh – University Health Center of Pittsburgh; University of Virginia, School of Medicine

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