Expanding the Boundaries for Robotic-Assisted Complex, Gastrointestinal Surgery

“Surgical oncologists in the Program for Liver, Pancreas, and Foregut Tumors at Penn State Hershey Cancer Institute, Penn State Hershey Medical Center, are using a robotic-assisted approach to complex gastrointestinal surgeries. The team performed an average of four to five such cases per month during 2013- 2014. “Distal pancreatectomy with splenectomy is the most common procedure in which we use a robotic technique. Compared to laparoscopy, we’re finding that more tumors and cysts are amenable to a robotic approach, with less conversion to an open procedure compared to a laparoscopic approach,” says Niraj Gusani, M.D., director of the Program for Liver, Pancreas, and Foregut Tumors.

Gusani has partnered with Joyce Wong, M.D., director of the Robotic Surgical Oncology Program, to implement a two-attending model for all robotics procedures. Amanda Cooper, M.D., the third member of the team, will also perform robotics procedures. Gusani notes, “Visualization is much better with the robotic platform [see Figure] versus open surgery. This is really key with very complex anatomy. Resections may be more thorough.” Wong further adds, “The robot mimics your hand movements with more precision; there is less internal manipulation. It’s a shift from ‘feeling’ to ‘seeing’.” To date, the team has performed more than thirty complex oncologic cases robotically.

Resection of gastric mass with suture repair of gastrotomy

Intraoperative view from the robotics platform during resection of a gastric mass and suture repair of gastrostomy.

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Structured Transition from Pediatric to Adult IBD Care Increases Patient Retention, May Improve Outcomes

For adolescent patients with inflammatory bowel disease (IBD) at Penn State Hershey Medical Center, a quarterly pediatric-to-adult care transition clinic has dramatically improved follow-up rates in the adult clinic, reducing no-shows to less than one percent.

“The structured transition program makes the process smoother and addresses the biggest problems that patients and parents encounter when the patient reaches 18 years-of-age,” says Emmanuelle Williams, M.D., assistant professor, Penn State Hershey Gastroenterology and Hepatology, and associate director, Penn State Hershey IBD Center. Together with Tolulope Falaiye, M.D., Penn State Hershey Pediatric Gastroenterology, Penn State Hershey Children’s Hospital, Williams has led the development of the successful program.

The process of transition begins around the age of 12. Transfer to adult care occurs at age 18. A specialized IBD nurse navigator is assigned to follow patients throughout the multi-year transition process. Older adolescents with IBD, under the care of pediatric gastroenterology, complete the Transition Readiness Assessment Questionnaire (TRAQ). At age 18, patients identified as ‘transition-ready’ are presented at a transition conference and have their first adult care visit held in the pediatric clinic location. Their former gastroenterologist performs introductions and is present the day of transfer. Continue reading

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Fecal Microbiome Transplant (FMT) for Clostridium Difficile (C. diff): Drawing Upon Wisdom of the Ancients

The successful use of fecal matter to treat severe diarrhea was first recorded more than 1,800 years ago in China. Flash forward to 2014, and the publication of controlled clinical trial evidence demonstrating the effectiveness of “fecal microbiota transplant” (FMT) to treat C. diff infection (CDI).¹ Thomas J. McGarrity, M.D., chief, Penn State Hershey Gastroenterology and Hepatology, has drawn on this evidence to treat twelve patients with recurrent or severe CDI. McGarrity explains, “We’ve administered FMT via a colonoscopic approach to patients with either three or more recurrences of CDI, or severe CDI unresponsive to conventional antibiotic treatment. Some of the patients were critically ill and faced the risk of renal failure. Within forty-eight hours of receiving FMT, clinical improvement was seen and a full recovery was eventually made in all twelve patients. None have experienced any further CDI occurrences.” Continue reading

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Pelvic Floor Disorders: Common, Undetected Problems

Pelvic floor disorders are the “Don’t Ask, Don’t Tell” of gastroenterology, colorectal surgery and urogynecology. “Patients don’t volunteer information about urinary incontinence, fecal or anal incontinence, or constipation.

Likewise, most physicians don’t ask the detailed questions needed to make the correct diagnosis,” says Deborah Bethards, M.D., of Penn State Hershey Gastroenterology and Hepatology. Bethards says, “These disorders are seen even among active younger women. A recent study showed that over one-third of female triathletes had at least one pelvic floor disorder symptom.”

According to this report, 37 percent of the women experienced anal incontinence.1 These data indicate that physicians should have pelvic floor problems high on their radar. To increase detection, Bethards stresses the importance of asking the appropriate questions. “A complaint of ‘constipation’ is an opportunity to ask about chronicity, frequency, stool characteristics, whether they strain or sit for a long time, and if they feel incomplete evacuation. Different symptoms point to distinctly different problems such as dyssynergic defecation, which can be found in up to 50 percent of patients referred to tertiary care centers for chronic constipation.2 These are problems that a change in diet or even medication won’t really address,” says Bethards. Continue reading

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Surgical Diverticulitis Associated with TNFSF15 Gene Single Nucleotide Polymorphism rs7848647

Diverticular disease is a common gastrointestinal disorder seen in over half of all United States adults over the age of sixty years, with approximately 5 percent of the population requiring surgery. According to Walter Koltun, M.D., F.A.C.S, F.A.S.C.R.S., chief, division of colon and rectal surgery at Penn State Hershey Medical Center, “We’re beginning to understand that diverticulitis is caused by a mix of genetic and environmental factors. A strong genetic component for diverticular disease was demonstrated in twin studies done in Europe, showing that about 50 percent of diverticular disease susceptibility is genetically based. We also know genetic influence is complex, and related to multiple genes.” The overall mix of genetic and environmental factors associated with the development of diverticular disease helps to explain the wide phenotypic variation physicians observe clinically, ranging from asymptomatic to life-threatening. Continue reading

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The CHARM Trial: CHemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts

CHARM image 1

76-year-old female with a 4.2cm mucinous (premalignant type) pancreatic cyst (white arrow) prior to EUS-guided chemoablation in the Penn State CHARM trial.

Pancreatic cysts are incidentally detected in 5-20 percent of patients over the age of sixty-five who undergo CT or MRI imaging, and the majority of these cysts are comprised of premalignant type mucinous cysts. While their detection may lead to early treatment or prevention of pancreatic cancer, effective and safe management poses a challenge. “Current guidelines,” explains Matthew T. Moyer, M.D., of Penn State Hershey Gastroenterology and Hepatology, “call for ongoing radiographic surveillance or surgical resection of these premalignant lesions; however, both options have significant limitations, risks, and costs.” Pancreatic surgical resection is associated with a 2 percent risk of mortality and an estimated 30 percent risk of serious complications. Continue reading

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