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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Lysosomal Acid Lipase Dificiency (LAL-D) in adults: Epidemiologic Multi-Center Study Underway

A multi-center, investigator-initiated epidemiologic study is underway [clinical trial: NCT01633489] aiming to determine the proportion of adults affected by late-onset lysosomal acid lipase deficiency (LAL-D) using definitive genetic testing.

LAL-D is an autosomal recessive disease caused by mutations in the Iipase gene that lead to decreased or absent enzyme activity. Lack of such activity causes lysosomal accumulation of cholesteryl ester in various organs, including the liver, spleen and adrenals, which leads to morbidity and mortality.1 Transplant hepatologist Karen L. Krok, M.D., Penn State Hershey Gastroenterology and Hepatology, explains, “At Penn State Hershey and other study centers in Pennsylvania, adults with cryptogenic cirrhosis or nonalcoholic steatohepatitis [NASH] who are awaiting liver transplant will have the opportunity to be tested for LAL-D. The signs and symptoms of LAL-D are similar to other common conditions; however, 10 to 15 percent of patients have no comorbid condition like hepatitis, obesity, diabetes or alcohol use to explain the disease. (Learn more about clinical features of LAL-D in adults.) Continue reading

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Clinical and Laboratory Features of LAL-D in Adults

  • Abdominal pain
  • Hepatomegaly or hepatosplenomegaly (may be mild)
  • Chronic diarrhea
  • Elevated chitotriosidase
  • Dyslipidemia
    • Elevated triglycerides
    • Hypercholesterolemia
    • Low HDL-C and high LDL-C
  • Accelerated atherosclerosis
  • Elevated liver function tests (LFTs)
  • Hepatic biopsy
    • Bright yellow-orange tissue
    • Fibrosis/cihrrosis
    • Steatosis (most often microvesicular)
    • Enlarged, lipid-laden hepatocytes and Kupffer cells

Reference: Differential diagnosis of LAL-D. from: http://laldsource.com/diagnosis-and-testing/getting-to-a-diagnosis/ Accessed May 7, 2015.

Read more about Lysosomal Acid Lipase Deficiency (LAL-D) in Adults: Epidemiologic Multi-Center Study Underway.

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Weight Loss Surgery as a Bridge to Complex Ventral Hernia Repair

Most patients with complex ventral hernias have a body mass index (BMI) greater than 35 and have undergone multiple prior hernia repair surgeries.

Ventral Hernia RepairAnn M. Rogers, M.D., director of Penn State Hershey Surgical Weight Loss, says, “For morbidly obese patients with a complex ventral hernia, it is critical to have a frank discussion about the need for meaningful weight loss to achieve lasting hernia repair success. While this can be emotionally uncomfortable for physicians and patients, it is often a life-changing, possibly life-saving conversation. Typically, trying to achieve weight loss in such patients through diet and exercise alone fails 95 percent of the time.”

Since 2012, Rogers has partnered with Penn State Hershey Gastroenterology and Hepatology using bariatric surgery for weight loss as a bridge to ventral hernia repair in appropriately selected patients. Patients must achieve a BMI less than 40 to be eligible for hernia repair (BMI less than 35 with serious co-morbid conditions). To date, a total of five patients have successfully undergone sleeve gastrectomy followed by permanent ventral hernia repair. In one notable case, a woman weighing more than 300 pounds lost more than 100 pounds with a sleeve gastrectomy, and within a few months underwent a successful ventral hernia repair (Figure 1). Continue reading

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Case Summary of Patient with Multiple Abdominal Wall Hernias

PATIENT: 41 year-old woman, 5’ 7”, 335 pounds, BMI 52

PRESENTATION: multiple abdominal wall hernias

CO-MORBIDITIES INCLUDED: hypertension, systemic lupus erythematosus with glomerulonephritis, chronic kidney disease

MEDICATIONS: chronic steroid use

SURGICAL HISTORY: colostomy, ileostomy, two hernia repairs

TREATMENT: surgical weight loss prior to attempting abdominal wall reconstruction

OUTCOME: greater than 100 lb. weight loss, successful abdominal wall reconstruction (weight at time of repair: 215 lbs.)

Read more about weight loss surgery as as bridge to complex ventral hernia repair.

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