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NYP Neuro Template N E W Y O R K – P R E S B Y T E R I A N DIGESTIVE DISEASES DIGESTIVE DISEASES Affiliated with COLUMBIA UNIVERSITY CAOfLfLiEliGaEt eOdF PwHiYthSICOIALNUSM ABNIAD USNUIRVGEEROSNITSY aCOnLdLEWGEE IOLLF CPOHRYNSIECLILA MNSE DAINCADL S CUORLGLEOGNE S Spring 2007 ACS Recognizes New Technology for Pancreatic Advances in Cancer Shines in Early Trials Obesity Therapy . D M ith few signs in its earliest stages , s n he American College of Surgeons and later symptoms that mimic e v e t S (ACS) recently accredited the those of many other illnesses, . D W NewYork-Presbyterian Hospital pancreatic cancer is notoriously difficult to r e t T e P Center for Obesity Surgery as a Center pinpoint. However, a new fiber-optic device f o y of Excellence, inducting the program being tested at NewYork-Presbyterian s e t r into its Bariatric Surgery Center Hospital/Columbia University Medical Center u o c o t Network. may ultimately enable physicians to diagnose o h In recognition of the Center’s high the disease with visually directed biopsy. P level of care and superior facilities, the The new instrument, a choledochoscope A SpyGlass endoscopic image of the pancreatic ACS designated it a top-rated 1A facili- known as the SpyGlass System, will soon be duct shows neoplastic mucosa appearing like a ty, the first such honor given in New launched by Boston Scientific Corporation. A crescent moon (lower left) in a patient with intraductal papillary mucinous neoplasms. York State. The accreditation applies to choledochoscope is an extremely small scope the programs at both Centers of designed to examine the interior of the common bile duct and is used in concert with NewYork-Presbyterian: the Weill endoscopic retrograde cholangiopancreatography (ERCP). Endoscopists at NewYork- Cornell Weight Loss Surgery Center and Presbyterian/Columbia perform nearly 1,000 ERCP procedures per year. the Columbia Center for Weight Loss “It’s a tool to visualize in real color and real time what’s going on in the [gastroin- Surgery. As leaders in their field, the testinal] tract,” said Peter D. Stevens, MD. “It builds on technologic advances in bariatric surgeons of NewYork- fiberoptics, which have gotten much easier to make and less expensive.” Presbyterian are also called on to help The system consists of a 6,000-pixel choledochoscope that can be reused approxi- the ACS evaluate other institutions. mately 20 times, a disposable delivery catheter that enables the delicate fiber to travel “There has been a huge growth in the further into the body, accessories for taking tissue samples or removing stones, and number of places doing bariatric surgery capital equipment such as a monitor, cart, and light source. over the past 5 years, but not all are SpyGlass offers several advantages over previous choledochoscopes, which first achieving a high level of excellence,” see SpyGlass, page 8 said Marc Bessler, MD. “Patients can greatly benefit from this surgery, but Case Study: Crohn’s Disease Pediatric Capsule Endoscopy Archived Web Cast elective operations that are high-risk The application of new options should be done in centers such as ours 2 available for the treatment of IBD. Advances in Colorectal Cancer Therapies that have been recognized for their Web Cast Jill Roberts IBD Center June 20, 2007 expertise.” New center fosters collaboration, “Pure” laparoscopic versus “hand-assisted” laparoscopic The prestige of the accreditation E innovation in the treatment of IBD. surgery; new approaches to minimally invasive surgery. D 4 holds another important benefit for I Update in Gastroenterology 2007 CME S patients: better insurance coverage. Crohn’s Disease June 22-23, 2007 N “There’s a direct relationship between I Fabrizio Michelassi, MD, pioneered a Simultaneous broadcasts in New York and Moscow. accreditation as a Center of Excellence 5 surgical technique more than a decade ago; today, it continues to improve News flash: Columbia doctors perform revolutionary and [reimbursement] by the Centers for patient outcomes. procedure to remove a patient’s gall bladder. Medicare & Medicaid Services (CMS). For more information, please visit ES www.nypdigestive.org AT see Obesity, page 6 PD U N E W Y O R K – P R E S B Y T E R I A N The case was discussed with Peter D. Green, MD, and an overlap with celiac DIGESTIVE DISEASES disease was excluded by serologic evalua- tion including antigliadin, antiendomysial, and antireticulin antibodies. A small Case Study: Considering New bowel series was performed at the Jill Roberts Center to further rule out celiac Options in the Treatment of IBD disease and to define the extent of ileal Crohn’s disease. The X-ray images showed The Case possible abscess in the right lower quad- 3 strictures in the distal 2 feet of the A 20-year-old woman diagnosed with rant. She was treated aggressively with ileum, with what appeared to be some Crohn’s ileocolitis presented to the Jill I.V. antibiotics. A second CT scan showed obstructive component with mild dilation Roberts Center for Inflammatory Bowel a resolution of the abscess, but no of the loops proximal to the strictures. Diseases (IBD) at NewYork-Presbyterian improvement in the other findings. There was a long segment of relative nar- Hospital/Weill Cornell Medical Center for Colonoscopy indicted an ulcerated ter- rowing 9 to 10 cm in the distal ileum and a second opinion regarding her severe minal ileum and a segmental colitis 10 cm from the ileocecal valve. There was weight loss and loss of response to inflix- involving the cecum, the right and trans- no evidence of fistula or abscess. imab therapy. verse colons, and the rectosigmoid. The . D The woman’s medical history had been rectum was relatively spared, with only M , l r one of progressive decline. She had been in patchy hyperemia and no fistula noted. e h c S perfect health until summer 2005, when The patient was started on infliximab . J n she suddenly developed new-onset diar- 5 mg/kg, with a 3-dose induction, at zero, e l l E rhea, which failed to subside. She subse- 2, 6, followed by every 8 weeks. Her aza- f o y quently detected traces of blood in her thioprine dose was increased to 100 mg. s e t r stool. Presenting to an outlying hospital She remained on prednisone 50 to 60 mg. u o c o emergency room, she was found to have a By summer, she had 7 infusions of inflix- t o h hemoglobin level of 5 g/dL. imab and was able to come off the P Upon admission, the woman under- steroids. Initially, she regained much of went a computed tomography (CT) scan, the lost weight. which showed extensive segmental colitis. In December 2006, she presented to She was started on intravenous (I.V.) the Jill Roberts Center with a 40-lb Small bowel series showing 3 strictures in the antibiotics, ciprofloxacin and metronida- weight loss and more than 10 watery, distal 2 feet of the ileum with mild dilation. zole, and I.V. steroids. semiformed bowel movements per day. After 2 weeks, she was discharged She was no longer responding to inflix- D M , home on oral antibiotics, prednisone, and imab and was considered refractory to l r e h mesalamine (Pentasa). Within 1 week, she mesalamine, azathioprine, and steroids. c S . J developed new-onset tachycardia, and in a The clinical question became: What was n e l second hospitalization was diagnosed to causing her attenuated response to inflix- l E f o have Wolff-Parkinson-White syndrome. imab? What are her surgical options? y s e After undergoing ablation, she developed t r u o c a thrombosis secondary to ablation that Discussion o t o required anticoagulation therapy. Because According to Ellen J. Scherl, MD, the h she was still on steroids, she was started patient’s failure to respond is typical of P on low-dose azathioprine. many cases seen at the Jill Roberts Center. Over the next 4 months, the patient’s One explanation in this case, Dr. Scherl Crohn’s symptoms gradually improved said, was that the patient had become Severe left-sided colitis with deep ulcerations. with steroids and low-dose azathioprine, resistant to infliximab. Other possibilities but she never went into remission. She were that she needed a higher dose or had A colonoscopy indicated severe left- was having 3 to 4 semiformed bowel developed strictures that were not improv- sided inflammation from the anal verge movements per day, and her weight was ing on the medication. An option was to to the splenic flexure with narrowing at down from 138 to 115 lb. In January shorten the interval between infliximab 5 to 10 cm and then 20 to 30 cm. Above 2006, she began to have 10 to 15 bowel infusions and increase the dose while eval- the splenic flexure the colon appeared movements per day, and by February she uating whether the patient had developed normal, and there was a narrowing of the weighed 85 lb. antibodies to infliximab or was a true terminal ileum. Biopsies showed focally During a subsequent hospitalization, a nonresponder (with therapeutic levels of active colitis. No granulomas were seen CT scan showed extensive thickening of infliximab in her blood but no antibodies and upper endoscopy showed no gastro- the entire colon and distal ileum, and a to infliximab). duodenal Crohn’s disease. 2 www.nypdigestive.org “We could increase the patient’s med- NewYork-Presbyterian Digestive Diseases ication or discuss a clinical trial,” Dr. is a publication of the Digestive Diseases Centers of NewYork-Presbyterian Hospital. The Digestive Diseases Centers are Scherl said, “but we need to consider at the forefront of research and practice in the areas of gastroenterology; GI surgery; and liver, bile duct, and pancreat- surgery for her obstructive symptoms.
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