Endoscopic suturing device technology has improved in recent years. In addition, it has brought improved success in the immediate repair of selected GI perforations and the potential to allow natural orifice transluminal endoscopic surgery (NOTES) to be performed in a safer and more effective way.1 Marking the first documented use of the Overstitch™ endoscopic suturing device (Apollo Endosurgery, Austin, Texas) for the repair of a duodenal perforation in conjunction with a NOTES abdominal washout, the Penn State Health Milton S. Hershey Medical Center team of Abraham Mathew, M.D., Matthew T. Moyer, M.D., M.S., and fellow, Ryan Gaffney, D.O., presented their success with this technique at the third annual American College of Gastroenterology international endoscopy video competition in October 2015, Honolulu, Hawaii.2 The video presented two cases in which surgery-sparing endoscopic repair of a duodenal perforation was successfully employed. As Dr. Gaffney explains, “In both cases, the risks of morbidity or mortality with open or laparoscopic surgery were considered very high and an endoscopic approach was regarded as a potentially safer, life-saving option.”
Category Archives: Patient Care
Endoscopic Suturing Device Allows for More Reliable Repair of Duodenal Perforations and Potentially Safer NOTES
History of Pneumonia Presents Major Risk Factor for Aspiration or Pneumonia Following Routine Ambulatory Endoscopy
As the number of ambulatory endoscopies increases, it is imperative to identify and work to prevent complications. Respiratory complications are considered the most common associated with such procedures (including coughing, fever and shortness of breath) and are documented for an estimated 5.3 percent of patients following an ambulatory endoscopy where propofol was administered.1 Abraham Mathew, M.D., and Lisa Yoo, D.O., Gastroenterology and Hepatology, found that 1.1 percent of adults who underwent a routine ambulatory endoscopy experienced pneumonia or aspiration within 30 days after the procedure. The vast majority of cases involved pneumonia, while cases of aspiration were very low (0.07 percent).
Providing Hope to Patients with Carcinomatosis: Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy
For patients with peritoneal dissemination of an abdominal malignancy (e.g., carcinomatosis), cytoreductive surgery (CRS) paired with hyperthermic intraperitoneal chemotherapy (HIPEC) can significantly increase survival time.1 According to Colette Pameijer, M.D., FACS, associate professor of surgery, “The CRS/HIPEC technique offers hope to these patients. It adds a significant amount of time to their lives, which would otherwise be counted in months, rather than years.” Metastatic cancer cells implanted within the peritoneal cavity or its surfaces are not detectable by CAT scan, and do not respond well to standard resection and systemic chemotherapy. Patients with carcinomatosis who receive palliative treatment have a median survival time of six months.1 Continue reading
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
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
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
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