One of the most challenging diagnostic problems in digestive medicine is finding the source of obscure or hidden bleeding in the gastrointestinal tract.
Patients with obscure or hidden bleeding usually have unexplained anemia (red blood cell deficiency), a low blood count, or may have blackened stools.
When traditional imaging studies fail to reveal the source of the bleeding, another high-tech imaging tool, called PillCam, can provide detailed images of the small intestine — an area that’s difficult to reach with traditional endoscopy procedures.
PillCam, or video capsule endoscopy, is a procedure that uses a tiny wireless camera to take pictures of the insides of your digestive tract. The camera is housed in a vitamin-sized capsule that you swallow. As the capsule travels through your digestive system, the camera takes thousands of pictures that are transmitted to a recorder you wear on a belt around your waist.
The images then are downloaded and carefully reviewed by the gastroenterologist. If a problem is detected and the source of the bleeding is identified, follow-up procedures and treatments can be performed.
In difficult diagnostic cases, video capsule endoscopy may be able to reveal small ulcers or other abnormalities. The procedure has been particularly helpful in diagnosis with patients who suffer from Crohn’s disease, an inflammatory disease of the small intestine.
“Gastrointestinal bleeding is a symptom rather than a disease and can occur anywhere within the digestive system,” Dr. Judge said. “The PillCam is a valuable tool for diagnosing problems, and Cooper is one of the only centers in the region with the experience and expertise to provide the technology, and to use it effectively.”
Colorectal surgery has long been associated with invasive procedures, long hospital stays, and painful recoveries. At Penn Medicine, specialists are putting a new face on colorectal surgery by offering patients the latest minimally invasive procedures, including transanal endoscopic microsurgery (TEM), single-incision laparoscopic (SIL) colectomy, sacral nerve stimulation, and robotic-assisted surgery using the da Vinci® Surgical System.
Transanal-endoscopic Microsurgery
Offered to select patients with rectal tumors, TEM allows surgeons to excise large polyps and high rectal tumors that would otherwise require major surgery.
“Previously, if a patient had an early cancer or sizable polyp in the rectum that was not accessible transanally, it would require radical surgery to remove it,” explains
Joshua Bleier, MD, FACS, FASCRS. “With transanal-endoscopic microsurgery, we can access areas that were previously too high for transanal approaches.”
TEM is a relatively painless, minimally invasive procedure that requires little to no hospital stay and offers a significantly lower rate of recurrence.
“With TEM, surgeons have a 3D perspective of the operating field, allowing us to remove the tumor in its entirety while sparing much of the rectum,” says Dr. Bleier. “This is a distinct advantage over transanal excision, which can cause the tumor to fragment and result in recurrence rates as high as 30 percent.”
Even though TEM has been in existence for several years, very few surgeons possess the training necessary to perform the procedure. Dr. Bleier is one of only a handful of surgeons on the eastern seaboard and the only surgeon at Penn performing TEM.
SIL Colectomy
Patients at Penn who require a right colectomy for the treatment of polyps or cancer may benefit from an advanced laparoscopic procedure called SIL colectomy. Offered by
Brian Kann, MD, FACS, FASCRS, assistant professor of clinical surgery, SIL colectomy affords patients the benefits of a traditional laparoscopic approach, but with smaller and fewer incisions.
“With traditional laparoscopic approaches to right colectomy, surgeons make three or four port incisions and then an additional large incision,” says Dr. Kann. “A distinct advantage of SIL colectomy is that it requires only a three- to four-centimeter incision to perform the entire resection. Additionally, because the surgeon uses only one point of entry, a high degree of technical expertise is required.”
To date, Dr. Kann has performed several SIL colectomies. Penn is only one of a few centers in the country offering this procedure.
Sacral Nerve Stimulation
For patients experiencing chronic fecal incontinence who have failed or are not candidates for conventional therapies, a minimally invasive treatment option called sacral nerve stimulation may help them regain complete bowel control.
The sacral nerves regulate the muscles of the pelvic floor. For some patients with fecal incontinence, these muscles do not function properly. Sacral nerve stimulation is a therapy that uses an implantable device to stimulate the sacral nerves with mild electrical pulses to restore normal function to the pelvic floor and help patients regain bowel control.
“Sacral nerve stimulation works in more than 75 percent of potential patients, and when it works it can be profoundly life-changing,” says Dr. Bleier.
The first step in treatment is a test phase to determine if the sacral nerve stimulation will work. The test phase does not require permanent implantation of the device. Therefore, if the test is successful the internal, pacemaker-like device can be implanted with the knowledge that the treatment will work. If the test phase is not successful, unnecessary implantation of a device can be avoided. Both procedures are very safe and cause minimal, if any, discomfort.
Robotic-Assisted Surgery
In January 2011, surgeons at Penn became among the first in the region to perform minimally invasive colorectal surgery using the da Vinci® Surgical System. Robotic surgery offers distinct benefits to both colorectal surgeons and their patients.
“The pelvis is often a difficult area to operate in due to anatomic constrictions,” explains Dr. Kann. “With the robot, we have enhanced visualization of the operative field due to high-definition, magnified, 3-dimensional views. This is instrumental in identifying and protecting critical structures such as nerves in the pelvis. Additionally, the range of motion with traditional laparoscopy is limited to moving the instruments up and down, back and forth, and in and out. A key advantage to the robot is that the ends of the instruments articulate like our wrists, adding an additional range of motion and facilitating the ease of surgery."
Used mainly for rectal surgery, a significant advantage to robotic colorectal surgery is its potential to preserve nerves that control key bodily functions such as urination or ejaculation. In addition, it allows for more complete excision for rectal cancer. Drs. Kann and Bleier both perform robotic-assisted colorectal surgery at Penn Medicine.
“The addition of these procedures demonstrates our commitment to providing patients with the most advanced treatments available for their condition,” says Robert Fry, MD, FACS, FASCRS, chief of the division of colon and rectal surgery, chairman of surgery, Pennsylvania Hospital, and the Emilie and Roland deHellebranth Professor of Surgery. “We take an enthusiastic, multidisciplinary approach to treatment. Patients are seen within a day or two of their initial call and referring physicians receive regular updates on their patient’s care.”
Penn’s commitment to training future colorectal surgeons distinguishes it from many other programs in the nation. Its colorectal residency program is one of only 50 in the United States and offers aspiring surgeons the opportunity to receive specialized training in this field.
“Our program, while comparatively young, offers participants the opportunity to train with a highly skilled, widely renowned team of colorectal specialists,” says colon and rectal surgery program director Dr. Kann. “I feel that our ability to really push the envelope in terms of treatment and research makes this a great place for surgeons to train and practice.”
For more information or to schedule an appointment, please call 800-789-PENN (7366).
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