Category Archives: Treatments

January 15, 2013 · 10:09 am

Coordinated GI Cancer Care from Diagnosis to Long-term Survival

Gastrointestinal (GI) cancers are among the most complex malignancies to treat; often, patients present with advanced disease and survival rates tend to be low. In 2005, a small group of hepatobiliary surgeons at Penn State Hershey Medical Center came together and formed the Liver, Pancreas, and Foregut Tumor Program to deliver state-of-the-art, multidisciplinary care for this difficult to treat patient population. The group has grown over the years to include four hepatobiliary surgeons: Kevin Staveley O’Carroll, M.D., Ph.D., director of the Liver, Foregut and Pancreas Program; Niraj J. Gusani, M.D., M.S., F.A.C.S.; Jussuf T. Kaifi, M.D., Ph.D.; and Eric T. Kimchi, M.D., F.A.C.S.

The multidisciplinary and coordinated nature of the program is unique to the central Pennsylvania region. Patients admitted into the program receive coordinated care from a team of surgeons, gastroenterologists, hepatologists, medical oncologists, radiation oncologists, radiologists, geneticists, and psychiatrists. Diagnostic questions are optimally clarified by modalities such as endoscopic ultrasound and computed tomography, with expert gastrointestinal pathologists providing immediate interpretation when biopsy procedures are necessary, resulting in high diagnostic accuracy with less repeat procedures. Such facets of the program allow surgeons to optimally address the challenges of tumor removal in these cases. Continue reading →

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August 20, 2012 · 4:42 pm

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection: Minimally Invasive Techniques for Resecting GI Mucosal Tumors

Major advances in the development of endoscopic devices and techniques over the past fifteen years have introduced endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) as standard of care for the safe and effective removal and/or definitive staging of mucosal lesions of the esophagus, stomach, duodenum and colon, often eliminating major surgery as first-line management. Gastroenterologists at Penn State Hershey Medical Center including Abraham Mathew, M.D., Matthew Moyer, M.D., and Charles Dye, M.D., have become leading clinicians and active researchers in these techniques, performing several hundred EMR procedures annually. Mathew explains, “EMR is the more widely used of these techniques for removal of smaller tumors or lesions [<2.5 cm]. With EMR, normal saline or hydroxy propyl methylcellulose, dilute epinephrine and methylene blue are injected into key areas of the submucosal space beneath the tumor, strategically positioning the tumor and separating it from the bowel wall; the tumor can then be resected with less risk of thermal or mechanical damage to the muscularis propria. With ESD, a more aggressive technique for removal of larger, more invasive tumors, the surgeon uses specialized devices to tunnel into the submucosal plane to dissect the tumor en block. Incisions are closed endoscopically with sutures or clips.”

A colon mass lesion in the process of being resected by ESD.

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· 4:41 pm

Addressing Patient Nutritional Needs in Complex Abdominal Surgery and Intestinal Failure

The pre-treatment nutritional status of patients with acute abdominal injury, or chronic gastrointestinal (GI) illness plays a large role in post-surgical course of recovery. Likewise, their ability to obtain nutrition after treatment significantly impacts long-term health outcomes and quality of life.

David Soybel, M.D.

Physicians at Penn State Hershey Medical Center and Penn State College of Medicine are investigating how to better detect and address nutritional needs before and after major complex GI surgery. According to David Soybel, M.D., “A significant proportion of patients with complex medical histories have pre-existing deficiencies in specific micronutrients such as zinc, copper, selenium, and magnesium. Major procedures place high demands on already compromised micronutrient stores, and often put these patients into a state of ‘micronutrient distress’ that may be associated with longer and more complicated recovery.”

Soybel’s research aims to establish methods to routinely detect and treat these deficiencies in high-risk patients, both before and after surgery. “Pre-surgical recognition of micronutrient deficiencies would provide the opportunity for micronutrient repletion and other interventions, and better prepare patients to get well post-surgery,” says Soybel. “Likewise, in acute situations, recognition of such deficiencies and rapid intervention could help patients better recover after emergency procedures.”

Gordon Lee Jensen, M.D., Ph.D.

Based in State College and one of few physicians in the country who specializes in management of intestinal failure, Gordon Lee Jensen, M.D., Ph.D., explains, “In the past, many of these intestinal failure patients would have died or become indefinitely dependent on intravenous, total parenteral nutrition (TPN). But now, because of new medications and advances in medical nutrition therapy, some can eventually come off of TPN and lead more normal lives. Today, TPN is more often a temporary supportive measure. Successful transition off of TPN depends on a number of factors. If a patient has at least 100 cm of small bowel length and a portion of intact colon (or at least 150 cm of small bowel and no functional or intact colon), and residual disease is controlled, then the odds are favorable for them to eventually adapt to enteral or oral nutrition.” Continue reading →

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· 1:15 pm

Keys to a Successful Live Donor Adult Liver Transplant Program

Transplant patient and donor at press conference

Surgeons at Penn State Hershey Medical Center, the only Medicare-approved center for liver transplantation in central Pennsylvania, performed the region’s first adult living donor liver transplant on Jestine Reider and John Kreider, brother and sister from Elizabethtown, Pa. in July 2008.

One of the greatest challenges facing patients who require a liver transplant is surviving the wait for a donor organ. Each year, nearly 16,000 patients in the United States are on the liver transplant waiting list, according to UNOS; yet only between 5,000 and 6,000 receive a transplant from a deceased donor.1 Zakiyah Kadry, M.D., said “Although liver transplant patients are stratified based on MELD scores, some die while waiting. To decrease wait times and associated mortality, some patients can receive grafts from live donors.”

In 2011, only 247 live donor liver transplants were performed in the United States, according to HRSA/ OPTN statistics.2 “Live donor programs must be UNOS-certified and require at least two surgeons trained in hepato-biliary surgery, as well as transplantation,” notes Kadry. Continue reading →

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May 3, 2012 · 8:18 am

Laparoscopic Surgery Options for IBD: When, Why, and Where?

For patients with inflammatory bowel disease (IBD), surgery is often necessary to manage symptoms and address disease-related complications. Such surgery is particularly common for patients with stricturing or fistulizing Crohn’s disease, patients with ulcerative colitis whose disease is not adequately managed with medication, and those with precancerous lesions. Surgical interventions vary according to the disease. Because Crohn’s disease can involve any segment of the gastrointestinal tract, surgical intervention is unlikely to be curative and is reserved to treat the complications of the disease such as obstruction or fistuli. As Walter Koltun, M.D., explains, “Excessive or repeated resection can potentially leave a Crohn’s patient with crippling short bowel syndrome and so alternate surgical therapies are performed such as stricturplasty, which overcomes the obstruction but minimizes resection.”

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· 8:17 am

IBD Center Advances Toward Official Announcement

Inflammatory bowel disease (IBD), has increasingly been a focus of clinical attention at Penn State Hershey Medical Center. The multidisciplinary care needed by these patients has brought together surgeons, gastroenterologists, radiologists, nutritionists, and other sub-specialists to foster the creation of an IBD center focused on providing excellence in IBD patient care and promoting access to cutting-edge research and treatments. This initiative has been directed by Walter Koltun, M.D., F.A.C.S., F.A.S.C.R.S., chief, Division of Colon and Rectal Surgery, and Emmanuelle Williams, M.D., assistant professor of medicine. Koltun explains, “The Penn State Hershey IBD Center has three major components that include a multidisciplinary patient care clinic where surgeons and gastroenterologists see patients together; educational and training programs for both medical professionals and patients; and, an IBD research program that includes benchtop basic science and clinical trials of new, investigative treatments.”
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May 2, 2012 · 8:44 pm

Chromoendoscopy for Colorectal Cancer Surveillance in IBD

Emmanuelle Williams, M.D.

Emmanuelle Williams, M.D.

Inflammatory bowel disease (IBD) is associated with a significantly higher risk of colorectal cancer than the general population. To improve early colorectal cancer detection, patients with a ten-year history of extensive colonic IBD are recommended to undergo colonoscopy surveillance at least every two years. Emmanuelle D. Williams, M.D., Penn State Milton S. Hershey Medical Center explains, “Currently recommended surveillance techniques (at least thirty-three random biopsies obtained from the entire extent of the colon) for IBD patients are time consuming and limited by a relatively low colorectal cancer detection rate where up to 25 percent of precancerous lesions are missed. Part of the challenge is the difficulty in visualizing pre-cancerous lesions in IBD patients because they can be multiple and flat with subtle irregularities rather than polypoid.” Chromoendoscopy, a technique that uses dye to highlight dysplastic tissue in existence since the 1970s, was introduced to IBD surveillance in 2003, and has since proven to markedly increase dysplastic lesion detection. While simple and inexpensive to do, Williams notes, “The technique requires training and practice, and additional time needed for obtaining dye-targeted biopsies and thus is typically only offered in tertiary care settings.”

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January 13, 2012 · 6:33 pm

Minimally Invasive and Maximally Effective Approaches to Pancreatic Fluid Collections and Pancreatic Necrosis

Severe necrotizing pancreatitis represents an enormous clinical problem due to its prevalence, economic costs and high levels of morbidity and mortality. After an initial period characterized by systemic inflammatory response, the leading cause of mortality stems from infection of the pancreatic necrosis which develops in 40-70 percent of patients. 1 Without intervention, the mortality rate of this group is exceedingly high, but can be significantly reduced using various methods of surgical pancreatic necrosectomy. However, with perioperative mortality rates of 10-40 percent and complication rates in excess of 70 percent, conventional pancreatic necrosectomy presents its own problems and is typically approached with trepidation. Additionally, repeated trips to the operating room are often required. 2,3    Continue reading →

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