sign in sign up
<<
Home , Esophageal achalasia, Heller myotomy

PENN DIVISION OF SPRING 2015 VOLUME 6 ISSUE 2

SELECTED ENROLLING CLINICAL TRIALS AT PENN GASTROENTEROLOGY POEM FOR ACHALASIA CHIEF’S CORNER (continued from page 4) Expanding the Clinical Applications of Functional “I am delighted to update you on the following exciting developments Luminal Imaging (EndoFLIP) in Esophageal Stenoses ABOUT ACHALASIA at the Division of Gastroenterology at Penn Medicine.” GASTROENTEROLOGY

The purpose of this study is to investigate the use of a Achalasia is a rare idiopathic Newsletter functional luminal imaging probe to characterize benign motility disorder that manifests On behalf of our entire GI division, especially our faculty/fellows/staff esophageal luminal strictures before and after dilation and our colleagues in transplantation, I am most pleased to announce that Dr. K. and identify predictors of response to therapy. Patients as incomplete relaxation of the RAJENDER REDDY has been appointed the Ruimy Family President’s Distinguished will be evaluated during using functional lower esophageal (LES) Professor of Medicine (GI). luminal imaging (EndoFLIP; Crospon Medical Devices, and aperistalsis of the esophageal ANIL K. RUSTGI, MD Galway, Ireland) to characterize the geometry of benign body as a result of impairment of DAVID L. JAFFE, MD has been selected as the ASGE (American Society of GI Endoscopy) luminal esophageal narrowing before and after dilation. the fibers, leading T. Grier Miller distinguished educator award, which will be given at Digestive Diseases Week (DDW) Professor of Medicine and , in May 2015 in Washington, DC. MICHAEL KOCHMAN, MD, recently received the to failure of bolus transit through Achalasia manifests as Chief, Division of Gastroenterology ASGE Master Endoscopist Award. the . Symptoms include incomplete relaxation of the lower esophageal CONTACT MAUREEN DEMARSHALL, BSN,RN, , regurgitation, heartburn sphincter (above) and JOHN P. LYNCH, MD, PhD, has won a large pilot grant from the Institute of Regenerative [email protected] LOCATIONS and chronic , with the esophageal aperistalsis. Medicine (with F. Bradley Johnson, MD, PhD, of the Department of Pathology). consequent potential for , Ruth and Raymond Perelman PRELIMINARY EVALUATION OF SEPTIN9 IN PATIENTS malnutrition and pulmonary sequelae. JAMES LEWIS, MD, has received the Lindback Award for Distinguished Teaching, the Center for Advanced Medicine WITH HEREDITARY COLON SYNDROMES highest teaching award at the University of Pennsylvania. PERORAL ENDOSCOPIC 3400 Civic Center Boulevard This is an observational, case-control study evaluating Following diagnosis of by esophageal manometry Philadelphia, PA 19104 the quantitative level of Septin9 in plasma pre- and and barium swallow esophagram, the standard surgical treatment CHRISTINA A. TWYMAN-ST. VICTOR, MD, has won the prestigious AGA Research (POEM) FOR Award, a 3 year career development grant. 215.349.8222 post- among patients with hereditary colorectal for achalasia is the . First performed in 1914, Heller cancer (CRC) syndrome, familial adenomatous Penn Presbyterian myotomy involves cutting the muscles of the LES to open the valve ESOPHAGEAL ACHALASIA polyposis (FAP), Lynch syndrome (also known as HNPCC), Medical Center and multiple adenomatous polyposis (MAP–also and permit food and liquids to pass into the . Laparoscopic Gregory G. Ginsberg, MD, Director, Endoscopic Services, Professor of For information about research developments at Penn Gastroenterology, visit: www.med.upenn.edu/gastro/news.shtml 38th and Market Streets known as MYK/MYH), with genetically related FAP– multi-port Heller myotomies are now the preferred approach. Post- 218 Wright-Saunders Building Medicine, Professor of family members as controls and references. operative complications may include , bleeding and rarely, Philadelphia, PA 19104 esophageal or gastric perforation. The Heller procedure is often 215.662.8900 combined with fundoplication to prevent gastroesophageal reflux. Pennsylvania Hospital CONTACT JULIE STARR AT 215.349.8527, Gastroenterological endoscopists at Penn Medicine are now performing incisionless Peroral [email protected]. Alternatives to surgery for the treatment of achalasia include 230 W. Washington Square Endoscopic Myotomy (POEM) to treat esophageal achalasia. POEM was developed in 4th Floor balloon dilation to expand the constricted sphincter and injections Japan by Haruhiro Inoue, MD, PhD, who guided the introduction of the procedure at Penn of botulinum directly into the esophagus to relax spastic muscle Philadelphia, PA 19106 FAMILIAL BARRETT’S ESOPHAGUS (FBE) 215.829.35613 Medicine. POEM involves the use of endoscopic tools to perform an intramural myotomy contractions. Both treatments are effective in the short term, but may This is a multi-center study whose aim is to define Penn Medicine at Radnor (as opposed to the extramural Heller procedure). the epidemiology and genetics of Barrett’s esophagus require repeated administration to improve the symptoms of achalasia. and adenocarcinoma. The researchers have studied 250 King of Prussia Road In Dr. Inoue’s original series of 70 cases at Showa University Hospital, Yokohama, Japan,

families affected with Barrett’s esophagus and Module B POEM resulted in significant reductions in LES pressure (elevated in most patients with Radnor, PA 19087 esophageal adenocarcinoma, a specific type of cancer RESOURCES achalasia) and subjective symptom score, and marked improvement was noted in endoscopic of the esophagus. They have found that Barrett’s 610.902.1500 and occur at a younger age in Penn GI Division patient website www.pennmedicine.org/GI appearance and esophageal emptying on barium swallow. Symptomatic post-POEM these families suggesting that familial Barrett’s Penn GI Division academic website www.med.upenn.edu/gastro gastroesophageal reflux disease (GERD) was observed in 11.4% of patients, but all were

esophagus is a genetically inherited disease. 19104 PA Phila., IN THIS ISSUE successfully treated with standard proton pump inhibitors. [1] Philadelphia, PA 19104 PA Philadelphia, Abramson Cancer Center website www.penncancer.org 2563 No. Permit

210 Suite • Street Market 3600

Penn GI Hepatology Research site www.med.upenn.edu/molecular PAID (Continued on page 3) U.S. Postage U.S. 1 POEM

Penn Cancer Information www.oncolink.org CONTACT MAUREEN DEMARSHALL, RN Org. Non-Profit

2 Fibroscan 1. Minami H, Inoue H, Haji A, et al. Per-oral endoscopic myotomy: Emerging indications and evolving [email protected]. Penn Viral Grand Rounds www.viraled.com techniques. Digestive Endoscopy 2015; 27: 175–181.

4 Clinical Trials

Newsletter

ISSUE 2 ISSUE 6 VOLUME 2014 FALL

5 New Faculty GASTROENTEROLOGY

5 SPRING 2015 VOLUME 6 ISSUE 2 PENN DIVISION OF GASTROENTEROLOGY SPRING 2015 VOLUME 7 ISSUE 2

FIBROSCAN® TRANSIENT ELASTOGRAPHY FOR PERORAL ENDOSCOPIC MYOTOMY (POEM) NONINVASIVE ASSESSMENT OF LIVER FOR ESOPHAGEAL ACHALASIA GASTROENTEROLOGY AND DISEASE (Continued from page 1) Gregory G. Ginsberg, MD, Director, Endoscopic Services, Professor of Medicine, Professor of Surgery DIVISION NEW FACULTY K. Rajender Reddy, MD, Director of Hepatology, Medical Director ;

Christine Hsu, MD, is a graduate of Jefferson Medical College (now the Sidney Kimmel Hepatologists at Penn Gastroenterology have introduced Fibroscan* Transient elastography was introduced in Europe more than a decade Medical College) and completed her internship and residency in internal medicine at transient elastography, an effective, noninvasive addition to the ago, and several systems are available. Fibroscan uses vibration- Boston Medical Center. She subsequently completed fellowships in gastroenterology POEM is initiated by creating a 2 cm entry site into the mid- diagnostic armamentarium for the assessment and staging of chronic controlled transient elastography, one of the world’s most used and and transplant hepatology at New York-Presbyterian/Columbia University Medical esophageal wall and then a tunnel in the submucosal space liver disease. Fibroscan uses low-frequency ultrasound to assess validated methods, and was FDA approved for use in the United Center. Dr. Hsu’s clinical interests include hepatic and transplant hepatology. extending immediately beyond the esophagogastric junction hepatic transient elasticity (stiffness) and fibrosis as a complement States in 2013. Fibroscan measurements are obtained by placing an She is board certified in internal medicine and gastroenterology. to percutaneous and laparoscopic liver for the staging of liver ultrasonic transducer into an intercostal space over the right lobe of to the lesser curve of the gastric cardia (Fig. 1). Next, an inner injury. Studies of Fibroscan have established an equivalence between the liver. A low frequency vibration is then transmitted to the liver circular muscle myotomy is performed by grasping and dividing increased liver stiffness and fibrosis stage. tissue to initiate an elastic shear wave. As it propagates through the the fibers. Following the myotomy, the endoscope is withdrawn liver tissue, the velocity of the shear wave is measured, and yields a from the submucosal tunnel and reinserted into the lumen to and fibrosis staging have been described as inexact gauge of liver stiffness that can be used in fibrosis staging. inspect the mucosa and ensure mucosal integrity. Easy passage Jan-Michael A. Klapproth, MD, received his medical degree at Albert-Ludwigs sciences. Percutaneous liver biopsy is the current gold standard of the endoscope through the LES then confirms an adequate University, Freiburg, Germany, and completed his internal medicine residency and for fibrosis assessment, but is tarnished by a variety of limitations Staging of fibrosis is critical to the appropriate treatment of patients myotomy (Fig. 2), and the mucosal entry site is closed with gastroenterology subspecialty training at the University of Maryland Medical Center. (sampling of only a 50,000th of the liver, inter-observer variability) with liver disease. Staging is used to predict the extent of a patient’s endoscopic clips. Dr. Klapproth’s research interests include bacterial modification of the enteric and complications, particularly when administered by inexperienced response to interferon-based therapy, for example, and can offer an immune system and outcome investigations of medical education. Dr. Klapproth operators, including bleeding, pain and inadvertent sampling of other approximate time to development. In patients who have At Penn, patients are observed overnight in the Second-Stage the Fellowship Director at Penn Medicine. He is board certified in internal organs. Laparoscopic liver biopsy is more invasive and has similar had liver transplantation for , staging can be used to Recovery Unit following the procedure and receive medicine and gastroenterology. complications. assess fibrosis progression. Beyond staging, the incentives for liver IV-hydration until post-operative day 1, when a barium screening include the surveillance of patients at risk for hepatocellular esophagram is obtained. If no loss of mucosal integrity or carcinoma consequent to hepatitis C or cirrhosis, and monitoring for leakage is noted, patients are then started on a liquid diet Immanuel K. Ho, MD, is a graduate of the University of Rochester School of Medicine patients receiving hepatotoxic chemotherapy. and discharged home. Two days later, they begin a solid diet. and Dentistry. Dr. Ho completed his internship and residency training at Montefiore The majority of patients experience a complete resolution of Medical Center in the Bronx, New York. He then pursued a fellowship in gastroenterology Penn Gastroenterology uses a semiquantitative classification system symptoms within 6 months. at Mount Sinai Medical Center. Dr. Ho specializes in upper endoscopy, , similar to that used in a recent multicenter US trial to confirm (Continued on page 5) interventional endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic the accuracy of Fibroscan liver fibrosis assessment. The system ultrasound. He is board certified in internal medicine and gastroenterology. incorporates that incorporates a five-stage fibrosis score (where F0=no fibrosis and F4=cirrhosis). Fibroscan is not used typically to provide exact staging, but to distinguish patients with mild (F0-F1) from Figure 2: Endoscopic those with more advanced (>F2) fibrosis. observation following the POEM procedure reveals a Manoj A. Shirodkar, MD, has joined the Division of Gastroenterology at Pennsylvania Indications for Fibroscan at Penn Gastroenterology include successful myotomy with sufficient dilation of the lower Hospital. Dr. Shirodkar received his medical degree from the University of Maryland nonalcoholic , liver fibrosis and liver cirrhosis. Fig. 1: POEM: A 2 cm entry site is established in the mid-esophageal esophageal sphincter and School of Medicine and completed his internship and residency in internal medicine wall; a tunnel is then made in the submucosal space extending no loss of mucosal integrity at Thomas Jefferson University Hospital. He was a Gastroenterology/Hepatology immediately beyond the esophagogastric junction to the lesser curve following closure of the of the gastric cardia. mucosal entry site. Fellow at Robert Wood Johnson University Hospital. Dr. Shirodkar’s clinical research * Fibroscan(R) is a trademark of Echosens S.A., Paris, FR. interests include Barrett’s esophagus and Crohn’s disease. He is board certified

K. Rajender Reddy, MD, reports no financial or commercial relationship with in gastroenterology. Echosens S.A. or its affiliated companies.

2 4