CAD-CAM Modeling for Craniofacial Surgery

Surgeons at Penn Medicine are using computer-aided design and manufacturing (CAD-CAM) programs to create custom-designed cutting and placement guides for preoperative planning and bone positioning during reconstructive surgery for complex craniofacial malformations.

CAD-CAM procedures use computed tomography (CT) data to generate anatomically accurate three-dimensional (3D) models of the patient’s bone structure, permitting cephalometric assessment of traumatic and pathological defects prior to surgery. These renderings can be used to fabricate guides for both the early resection process and the later precise placement of bone for fixation during surgery and/or custom prosthetic implants.

CAD-CAM templates are precise to within 1 mm, resulting in faster surgeries and optimal aesthetic results, particularly in complex correction of facial and skull deformities. Their use, and that of CAD/CAM 3D models, has been shown to improve the predictability of outcomes in complex cranio-maxillofacial surgery and to decrease total operating time, thereby reducing the duration of intraoperative general anesthesia and wound exposure time.^1,2

Case Study

Ms. C, a 23-year-old woman, was referred to Penn Plastic Surgery for correction of orbital hypertolerism, a condition defined by excessive distance between the eyes and orbits, and vertical orbital dystopia, a condition where the eyes are not level. Three-dimensional CT scans at presentation revealed anterior and inferior displacement of the orbital bones and bilateral nonalignment (Figure 1).

Surgery to correct these defects would require the orbits to be moved in three dimensions to differential degrees. Prior to surgery, Ms. C received a cranial CT scan which was then converted into CAD format. Three dimensional cephalometric measurements were then used to determine the resection and placement/fixation parameters, and this was all “pre-planned” by the surgical team. This data was then used to manufacture the respective templates for the surgical procedure.

In the operating room, the bones of the orbits were able to be cut and repositioned precisely based on CAD/CAM pre-fabricated jigs, an improvement in accuracy and efficiency. She has recovered well, and returned to work four weeks after surgery. Post-operative photographs and 3D-CT scans (Figure 2) have demonstrated a marked improvement in her appearance, and she feels that her vision has been improved with the surgery.


Reference
1. Mehra P, Miner J, D’Innocenzo R, Nadershah M. J Maxillofac Oral Surg. 2011;10:6–13.
2. Sharaf B, Levine JP, Hirsch DL, et al. J Craniofac Surg. 2010; 21:1277-1280.

Faculty Team

Penn Medicine’s Adult Craniofacial Reconstructive Surgery Program is focused on the care of patients seeking consultation about their facial function and appearance. Penn surgeons use the latest technology for both cosmetic and reconstructive surgery, including CAD-CAM technology for cranial, facial and jaw surgery and microsurgical innovations to visualize and re-attach severed blood vessels and nerves, and optimize post-surgical feeling and function.  In addition, the Center uses lasers, dermabrasion and chemical peels to treat skin conditions, and collaborates with skin care specialists to ensure that patients’ skin care needs are met.

Plastic Surgery
Jesse A. Taylor, MD
Assistant Professor of Surgery

Scott P. Bartlett, MD
Professor of Surgery

Oral and Maxillofacial Surgery
Eric J. Granquist, DMD, MD
Joli C. Chou, DMD, MD

Otorhinolaryngology-Head and Neck Surgery
Ara A. Chalian, MD
Associate Professor of Otorhinolaryngology:
Head and Neck Surgery

Neurosurgery
M. Sean Grady, MD
Charles Harrison Frazier Professor of Neurosurgery

James M. Schuster, MD, PhD
Associate Professor of Neurosurgery

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Center for Human Appearance
Perelman Center for Advanced Medicine
East Pavilion, 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104


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Proton Therapy for Stage I, IIA, IIB and Relapsed Seminoma

Researchers at Penn Radiation Oncology are now treating patients with stage I, IIA, IIB and relapsed testicular seminoma with proton therapy.

Testicular cancers are the most common solid malignancies in men aged 20 to 35 years. The majority of these tumors (60%) are pure seminoma. Of patients diagnosed with seminoma, approximately 80% have stage I disease.

Almost all patients with stage I seminoma are cured. For those patients who require adjuvant radiation following radical inguinal orchietomy, conventional photon external beam radiotherapy has been directed to the lymph nodes of the para-aortic and pelvic regions. However, photon radiotherapy exposes normal tissues to radiation with well known treatment-related adverse effects, including fatigue and nausea.

Furthermore, in patients with testicular cancers, radiation-associated second malignancies (non-germ cell malignancies after 10 to 35 years) are a major concern. Second cancers are one of the causes of death among testicular cancer survivors.

To address these concerns for patients with seminoma, reductions in radiation dosing and fields and newer therapies, including carboplatin and surveillance, have emerged. Because proton therapy spares normal tissues distal to the target lesion, it also has been proposed as an alternative to conventional radiotherapy for seminoma.

Recently, researchers at Penn Radiation Oncology performed an institutional review board-approved study1 to compare photon and proton radiotherapy for stage I seminoma and the predicted rates of excess secondary malignancies for both treatment modalities (below). A Phase II study of adjuvant proton therapy for the treatment of Stage I, IIA, IIB and relapsed seminoma is now open at Penn. This multi-center trial will evaluate the outcomes of proton therapy in a larger group of patients.

Predicted rates of secondary malignancies from proton versus photon radiation therapy for stage I seminoma

Methods and Material: Computed tomography images from 10 consecutive patients with stage I seminoma were used to quantify dosimetric differences between photon and proton therapies. Structures reported to be at increased risk for secondary malignancies and in-field critical structures were contoured. Reported models of organ-specific radiation-induced cancer incidence rates based on organ equivalent dose were used to determine the excess absolute risk of secondary malignancies. Calculated values were compared with tumor registry reports of excess secondary malignancies among testicular cancer survivors.

Results: Photon and proton plans provided comparable target volume coverage. Proton plans delivered significantly lower mean doses to all examined normal tissues, except for the kidneys. The greatest absolute reduction in mean dose was observed for the stomach (119 cGy for proton plans vs. 768 cGy for photon plans; p<0.0001). Significantly more excess secondary cancers per 10,000 patients/year were predicted for photon radiation than for proton radiation to the stomach (4.11; 95% confidence interval [CI], 3.22–5.01), large bowel (0.81; 95% CI, 0.39–1.01), and bladder (0.03; 95% CI, 0.01–0.58), while no difference was demonstrated for radiation to the pancreas (0.02; 95% CI, –0.01–0.06).

Conclusions: For patients with stage I seminoma, proton radiation therapy reduced the predicted secondary cancer risk compared with photon therapy. We predict a reduction of one additional secondary cancer for every 50 patients with a life expectancy of 40 years from the time of radiation treatment with protons instead of photons. Proton radiation therapy also allowed significant sparing of most critical structures examined (Figure 1) and warrants further study for patients with seminoma to decrease radiation-induced toxicity.

Reference
1. Simone CB 2nd, Kramer K, O’Meara WP, Bekelman JE, Belard A, McDonough J, O’Connell J. Int J Radiat Oncol Biol Phys. 2012;82:242-249. (Go to article.)

Faculty Team
Among the largest and most respected programs in the world, Penn Radiation Oncology offers a variety of innovative treatment options to patients with cancer. In addition, as a national leader in basic science, translational research and clinical trials, Penn Radiation Oncology offers patients access to the latest treatment options––including proton therapy––before they are widely available elsewhere.

Performing Clinical Trials in Proton Therapy for Testicular Cancer at Penn Medicine

Justin E. Bekelman, MD
Assistant Professor of Radiation Oncology


John Christodouleas, MD
Assistant Professor of Radiation Oncology


Curt Deville, MD
Assistant Professor of Radiation Oncology


Thomas Guzzo, MD
Assistant Professor of Urology in Surgery


Katherine L. Nathanson, MD
Associate Professor of Medicine


Neha Vapiwala, MD
Assistant Professor of Radiation Oncology


David J. Vaughn, MD
Professor of Medicine


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Concourse Level
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Clinical Research at the Roberts Proton Therapy Center

The Roberts Proton Therapy Center has the advantage of being part of a world class academic medical center, Penn Medicine, and an NCI-designated Comprehensive Cancer Center, Penn’s Abramson Cancer Center. In addition to its primary mission of improving the treatment of cancer, however, the Roberts Proton Therapy Center at Penn Medicine has the purpose of expanding, defining and clarifying the therapeutic uses for proton therapy through clinical research.

Recent clinical protocols have sought to increase and enhance the effectiveness of proton therapy and to determine which cancers should be treated with proton versus conventional radiation.
In addition to seminoma, the conditions currently being investigated at the Roberts Center include cancers of the prostate, breast, lung and abdomen.

For more information about the Roberts Proton Therapy Center, visit: http://www.pennmedicine.org/Roberts-Proton.

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Multidisciplinary Management of Adult Congenital Heart Disease

The Philadelphia Adult Congenital Heart Center, a joint program of Penn Medicine and the Children’s Hospital of Philadelphia (CHOP), is designed to serve the unique healthcare needs of adults with congenital heart disease (ACHD).

Among less than a hundred such programs in the United States, the Center is comprised of specialists in cardiovascular surgery, anesthesiology, interventional catheterization, electrophysiology, non-invasive imaging and heart failure/ transplantation, genetics and reproductive services, collaborating to provide comprehensive inpatient and outpatient care.

In addition to surgery, the programs and services offered at the Center include the evaluation of patients for heart transplantation, the care of women requiring high-risk obstetrics and genetic research to develop better approaches to congenital heart disease.

Heart Transplantation — Between 2010 and 2011, nine patients with congenital heart disease underwent heart transplantation at the Hospital of the University of Pennsylvania, five of whom were combined heart-liver transplants for failing Fontan physiology.

High-Risk Obstetrics — The Maternal-Fetal Medicine group manages women with congenital anomalies, both repaired and unrepaired, ranging from severe aortic stenosis to tetralogy of Fallot to single ventricle physiology. The Center published the first report of successful pregnancies in two women with Hypoplastic Left Heart Syndrome in 2010.

Genetics — The Center collaborates with experts in genetics and dysmorphology at CHOP who specialize in DiGeorge Syndrome (at the “22q and You Center”), as well as channelopathies such as Long QT syndrome, and works closely with world-renowned geneticists in the field of Marfan syndrome and other connective tissue disorders at the Hospital of the University of Pennsylvania

About Adult Congenital Heart Disease

As a result of advances in cardiac surgery and medical therapies, it is estimated that there are now more than a million adults with congenital heart disease living in the United States, and that for the first time, adults with congenital heart disease outnumber children with the disorder. The spectrum of congenital heart disease varies widely from simple lesions (e.g., isolated septal defects) to complex anomalies such as functional single ventricles. Adults with congenital heart disease require ongoing sub-specialty care and lifelong surveillance to ensure continued survival and quality of life.

Case Study

At age 22, Ms. M was referred to the Philadelphia Adult Congenital Heart Center for further evaluation and management of truncus arteriosus type A1 status post-complex right ventricular outflow tract (RVOT) reconstruction.

Surgical repair of common cyanotic congenital heart defects in infancy such as truncus arteriosus (and, more commonly, tetralogy of Fallot) often results in marked anatomic distortion of the pulmonary arteries and pulmonary valve insufficiency which can lead to right ventricular failure in adulthood (Figure 1).

During the previous year, Ms. M had developed increasing exercise intolerance and fatigue and dyspnea while walking between classes on campus. She was known to have an 80 mmHg gradient across the right ventricular outflow tract with free regurgitation; the right ventricular systolic pressures were approximately three-quarters systemic.

The Philadelphia Adult Congenital Heart Center is the only program in the region to offer a percutaneous option in select patients with congenital disease of the right ventricular outflow tract that would otherwise require surgery. 

Given the complex anatomy of her RVOT reconstruction, Ms. M was offered a percutaneous pulmonary valve replacement. Subsequently, she received a Melody ^® transcatheter pulmonary valve during a two-hour, minimally invasive procedure performed by interventional cardiologists at the Philadelphia Adult Congenital Heart Center. Ms. M remained in the hospital overnight and went home the next day.

Six months after the Melody valve procedure, she returned to clinic reporting increased endurance and is now able to keep up with her friends at school. She has incorporated exercise back into her routine and walks over a mile on the treadmill daily. Repeat echocardiograms demonstrate a decrease in right ventricular size and no pulmonary insufficiency.

Melody® is a registered trademark of Medtronic, Inc.,
Minneapolis, MN.

Faculty Team

The Philadelphia Adult Congenital Heart Center team includes cardiovascular surgeons, cardiac anesthesiologists, cardiac specialists in catheterization, electrophysiology, non-invasive imaging, and heart failure/transplantation as well as genetics and reproductive services working together to provide comprehensive inpatient and outpatient care.

Medical Team

Yuli Kim, MD*†

Alex Davidson, MD†

Richard Donner, MD†

Martin St. John Sutton, MBBS*

Surgical Team

Stephanie Fuller, MD*†

Alberto Pochettino, MD*

Thomas L. Spray, MD†

Nurse Practioner

David Drajpuch, CRNP†

Patient Coordinators

Joanna Acosta*
Markesha Peterkin†

*Penn Medicine
†Children’s Hospital of Philadelphia

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Penn Heart and Vascular Center
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The Children’s Hospital of Philadelphia
3400 Civic Center Boulevard
Philadelphia, PA 19104

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Diet, Genetic Factors, and the Gut Microbiome in Crohn’s Disease

From the Spring 2012 GI News

With Frederic Bushman, PhD, of the Department of Microbiology at the Perelman School of Medicine, Gary Wu, MD, and James Lewis, MD, MSCE, of Penn Gastroenterology have initiated a series of studies to investigate the relationship between alterations in the human gut microbiome and the pathogenesis of Crohn’s disease and colitis.

The large intestine is home to one of the most densely populated microbial communities on earth, with the number of bacteria exceeding host cells by more than ten-fold. The aggregate of all human gut bacteria, or microbiome, holds 100 fold more genes than those of its host.

These microbiota provide a metabolic diversity that, among other benefits, aids in the digestion of foods and the development of the immune system. Alterations in the gut microbiome are associated with numerous diseases, however, including opportunistic infections such as C. difficile colitis and inflammatory conditions such as Crohn’s disease.

Drs. Wu, Bushman and Lewis of Penn have previously examined the role of diet in modulating the gut microbiome composition.1-2 More recently, they have initiated a series of studies, as part of the NIH Human Microbiome Project, to investigate the hypothesis that dietary therapy leads to consistent changes in the human gut microbiome that are associated with clinical response in Crohn’s disease.

The investigators are using deep sequencing to characterize the composition of the gut microbiome. Described below are two completed studies, FSM and COMBO, and a third study (known as PLEASE) that is ongoing.

Fecal Storage Methods (FSM) 

This initial study was designed to systematically evaluate methods for surveying bacterial communities in human feces using 454/Roche pyrosequencing of 16S rRNA gene sequences, generating a total of 797,276 tags.

Fecal samples from 10 individuals were analyzed and comparisons made of methods for fecal storage, DNA purification and sequence acquisition compared. These data were used to optimize protocols to collect, process and sequence bacterial 16S rDNA from fecal samples in subsequent studies.

Cross-sectional Study of Diet and Stool Microbiome Composition (COMBO)

Objectives: To evaluate the association between dietary intake, as determined by dietary questionnaire, and the composition of the gut microbiome in healthy subjects in the outpatient setting.

Methods: Diet inventories and 16S rDNA sequencing were used to characterize fecal samples from 98 individuals. Specific nutrients associated with variation in the gut microbiome for the 98 subjects were extracted, along with demographic factors. A controlled-feeding study of 10 subjects sequestered in a hospital environment was performed to compare high-fat/low-fiber and low-fat/high fiber diets. For these subjects, stool samples were collected and DNA samples analyzed by 454/Roche pyrosequencing of 16S rDNA gene segments and, for selected samples, shotgun metagenomics.

Results: Fecal communities clustered into enterotypes distinguished primarily by levels of Bacteroides and Prevotella. Enterotypes were strongly associated with longterm diets, particularly protein and animal fat (Bacteroides) versus carbohydrates (Prevotella).

Results of the controlled feeding study showed that microbiome composition changed detectably within 24 hours of initiating a high-fat/low-fiber or low-fat/high-fiber diet, but that enterotype identity remained stable during the 10 days of sequestration. Thus, alternative enterotype states are associated with long-term diet.

Pediatric Longitudinal Study of Elemental Diet and Stool Microbiome Composition (PLEASE)

Currently under way, this study examines the effects of an elemental diet treatment on pediatric patients diagnosed with inflammatory bowel disease (IBD), particularly Crohn’s disease. Elemental diet therapy is often effective in treating pediatric Crohn’s disease. This study permits investigators
to examine the microbiome changes associated with successful therapy, failed therapy and relapse. Longitudinal studies allow the investigators to specify microbial changes associated with successful or failed elemental diet therapy.

References
1. Wu GD, Chen J, Hoffmann C, Bittinger K, Chen YY, Keilbaugh SA,
Bewtra M, Knights D, Walters WA, Knight R, Sinha R, Gilroy E, Gupta
K, Baldassano R, Nessel L, Li H, Bushman FD, Lewis JD. Science.
2011;334:105-108.

2. Wu, GD,* Lewis, JD,* Hoffmann C, Chen YY, Knight R, Bittinger K, Hwang
J, Chen J, Berkowsky R, Nessel L, Li H, Bushman FD.* BMC Microbiol.
2010;10:206. *Joint corresponding authors.

Defining the Toxic Etiology of Biliary Atresia

From the Spring 2012 GI News

Biliary atresia (BA) is the leading indication for liver transplantation in children. The condition is characterized by a progressive fibroinflammatory process that leads to the obliteration of all or part of the extrahepatic biliary tree, and manifests in the neonatal period.

Surgery (i.e., Kasai portoenterostomy) in infancy is required in virtually all cases to permit bile drainage. Approximately two-thirds of children with the disease ultimately require a liver transplant due to overwhelming fibrosis (deposition of scar tissue).

Biliary atresia is uncommon (~ 1/15,000 live births) and has no known cause. Most researchers suspect it occurs in genetically susceptible patients who receive an environmental exposure (potentially a virus or toxin) late in gestation; however, no specific exposure has ever been identified, and the nature of the bile duct damage that leads to biliary atresia is not known.

This may soon change as a result of the combined efforts of Rebecca Wells, MD, and Michael Pack, MD, at the Perelman School of Medicine and their collaborator John Porter at the University of the Sciences. Dr. Wells’ laboratory studies mechanisms of liver fibrosis, while Dr. Pack’s laboratory uses zebrafish models to study the development of the biliary system.

Dr. Wells’ interest in biliary atresia began in 2004 when Elizabeth Rand, MD, medical director of the liver transplant program at Children’s Hospital of Philadelphia (CHOP), urged her to investigate the mechanism of fibrosis in this disease.

Several years later, while gathering background material on the disease, Dr. Wells discovered that there had been a recent epidemic of biliary atresia in lambs in rural Australia. Similar to two previous epidemics decades before, this epidemic seemed to be associated with the ingestion of Australian pigweed (Dysphania glomulifera) by pregnant ewes grazed in unusual pastures during drought years.

It appeared that the plants contained a toxin that affected the lambs’ biliary system late in development, causing them to be born with biliary atresia. Dr. Wells contacted the Australian veterinarians who had diagnosed biliary atresia in the lambs, and arranged for them (in collaboration with botanists, rangers and veterinary pathologists) to collect samples of the plant.

If the toxin could be purified and tested in animal studies, Dr. Wells reasoned, similar compounds of relevance to humans might be identified.

Both Dr. Wells and Dr. Pack are members of the Fred and Suzanne Biesecker Pediatric Liver Center at CHOP, which is dedicated to studying biliary atresia and liver development. Dr. Pack had developed an interest in biliary atresia through his membership in the Biesecker Center and his laboratory had previously developed assays to identify biliary damage in zebrafish.

To identify the molecular structure of the plant toxin, Dr. Wells and Dr. Pack contacted John Porter, PhD, an experienced natural products biologist at the University of the Sciences in Philadelphia. Dr. Porter agreed to fractionate the plant in an attempt to isolate a toxic fraction. The team was able to import the plant samples in 2008.

For the next 16 months, Dr. Porter fractionated the plant and Dr. Pack tested the fractions to determine whether they caused biliary damage in zebrafish. Throughout this process, they received support from the Biesecker Center and the University of Pennsylvania NIDDK Center for Molecular Studies in Digestive and Liver Diseases.

In July 2009, Dr. Pack found that exposure to a highly purified fraction of the plant caused damage to the gallbladders and extrahepatic bile ducts of zebrafish, mimicking biliary atresia – a new animal model of the disease. In February 2012, Dr. Porter’s team identified the structure of one of the toxins, a compound never before described.

The laboratories of Dr. Wells and Dr. Pack are now seeking to determine the mechanism of action of the toxin, to find chemical mimetics to which humans might be exposed, and to use this information to develop potential therapies for biliary atresia. The collaborators have recently been awarded four years of funding from the NIH to further this line of research.

Transcatheter Aortic Valve Replacement for Aortic Stenosis in Inoperable Patients

Interventional cardiologists and cardiac surgeons at Penn Medicine are performing transcatheter aortic valve replacement (TAVR) surgery for patients with aortic stenosis who are not candidates for open-heart surgery.

As original investigators in the PARTNER trial¹ that led to Food and Drug Administration approval for the first transcatheter aortic heart valve for aortic stenosis, cardiac specialists at Penn are among the most experienced in the country performing transcatheter aortic valve replacement.

In adults, aortic stenosis is now primarily a condition caused by age-related calcium deposition at the valve, and degenerative calcific aortic stenosis is the primary indication for aortic valve replacement in symptomatic patients. Other, less common etiologies include congenital disease, rheumatic fever and stenosis arising from radiotherapy and other treatments.

Open-heart valve replacement surgery is the gold standard treatment for otherwise healthy patients with aortic stenosis. Because the physical demands of the procedure and other comorbidities may be prohibitive, however, many older patients are not candidates for open surgery.

A new approach called transcatheter aortic valve replacement (TAVR) utilizes a biological valve crimped onto a stent and folded inside a large bore catheter. The catheter is introduced at the groin and threaded up the aorta. Upon reaching the aortic valve, a balloon is inflated to deploy the stented valve directly over the calcified native valve, typically eliminating the need for surgical removal.

In the recently completed PARTNER trial, the transcatheter valve proved to be significantly superior to medical treatment in inoperable patients with severe symptomatic aortic stenosis.

Penn researchers are now involved in the second phase of the trial, which is investigating a new and better valve design coupled with a smaller diameter delivery system that permits
less invasive access at the groin.

Case Study

Mr. L, an 88-year-old man, was referred to Penn Interventional Cardiology by his community cardiologist after a decade of progressive heart failure (LVEF 30%) when an echocardiogram demonstrated a heavily calcified aortic valve. Mr. L had no signs of concomitant organ dysfunction and was in otherwise relatively good health. Because he was frail, however, he was felt to be inoperable.

At Penn, a physical examination revealed signs (a low-intensity carotid pulse and a pronounced heart murmur), indicative of aortic stenosis. After an angiogram demonstrated the patency of his iliac and coronary arteries and lung and kidney function were determined to be good, Mr. L was judged a good candidate for transcatheter aortic valve replacement surgery. After a consultation, he agreed to have the procedure.

The surgery proceeded without complications. Following anesthesia, the right femoral artery was dilated and a sheath introduced and advanced to the thoracic aorta. A guide wire was then threaded to the heart and the artificial valve advanced to the aortic valve. Mr. L’s heart was then paced to halt ejection, and the artificial valve was inflated over the damaged native aortic valve. Mr. L remained in the hospital for five days, after which he went home to recuperate.

At his six-month follow-up evaluation, echocardiography showed near normal left ventricular function, and Mr. L reported notably improved quality of life.

Reference

1. Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ, for the PARTNER Trial Investigators. Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients. N Engl J Med. 2011;364:2187-2198.

Faculty Team
Penn Interventional Cardiology is comprised of a team of nationally recognized interventional cardiologists working in close collaboration with cardiac surgeons and cardiologists to perform catheter-based procedures for a variety of cardiovascular disorders.

Performing TAVR Procedures at Penn Medicine

Co-Directors Transcatheter Aortic Valve Program

Joseph E. Bavaria, MD
Brooke Roberts - William Maul Measey Professor in Surgery

Howard C. Herrmann, MD
Professor of Medicine


Saif Anwaruddin, MD
Assistant Professor of Medicine

Nimesh D. Desai, MD, PhD
Assistant Professor of Surgery

Robert H. Li, MD
Clinical Associate

Wilson Y. Szeto, MD
Associate Professor of Surgery

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Penn Heart and Vascular Center
Perelman Center for Advanced Medicine
East Pavilion, 2nd Floor
3400 Civic Center Boulevard
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Penn Presbyterian Medical Center
Heart Institute Building, Suite 2A
51 N 39th Street
Philadelphia, PA 19104

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Total Hip Arthroplasty in Patients Younger than Age 50

Orthopaedic surgeons at Penn Medicine are implanting alternative bearings with improved durability to improve joint function and relieve chronic pain in patients younger than age 50 requiring total hip arthroplasty (THA).

THA surgery was originally indicated for patients older than 60 on the premise that patients in this population were less active and thus less likely to wear out their prostheses. After documentation of excellent long-term results for THA surgery, however, and given the larger numbers of more active patients with longer life expectancies, substantial work was done to develop bearing surfaces with lower wear, greater durability and better longevity.

These bearings are considered an alternative to standard polyethylene bearings, which have been associated with increased wear and a consequent risk of osteolysis, loosening of the prosthesis and revision surgery.

In addition to advances in technology, newer techniques and approaches to minimally invasive surgery for THA have substantially improved the outlook for younger patients with advanced hip disease.

At Penn, the younger THA population includes patients who have experienced debilitating trauma, osteoarthritis and other rheumatoid conditions, congenital hip dysplasia and trauma, as well as a subset of young adult survivors of cancer and sickle cell anemia whose hips have been severely compromised or destroyed by chemotherapy, radiation or steroid treatment.

The alternative bearings available at Penn include an advanced, highly wear-resistant (cross-linked) polyethylene, hardened ceramics and metal alloy products. Minimally invasive surgery is the preferred approach for THA whenever appropriate.

Orthopaedic surgeons at Penn consider the recommendation for THA in younger patients a serious decision, and make every attempt to preserve the native hip joint when possible. THA is an option in younger patients only after medical and physical therapy (and occasionally other corrective surgeries) have failed to relieve pain and restore function to the joint.

Case Study

Mr. C, a 47-year-old man, was referred to Penn Orthopaedics with disabling pain in his right hip from a complete fracture of the femoral head sustained in an automobile accident. The fracture was treated satisfactorily at the time with pin placement. However, recent X-rays of the hip showed osteodegeneration at both the acetabulum and femoral head. Mr. C reported pain of increasing severity during ambulation that did not resolve at rest.

He was otherwise healthy. His medications included cortisone and opioids for pain. Following a consultation and a thorough pre-operative medical and diagnostic evaluation to confirm the safety of hip replacement surgery, Mr. C chose to have a total hip arthroplasty of the right hip.


Before surgery, Mr. C. received a spinal anesthetic and pre-operative antibiotics. His leg was prepped and sterilely draped to minimize infection risk. Because he had hardware from his fracture surgery, his prior posterior-lateral surgical incision was used, and a posterior approach to the hip was performed. After bone preparation, a porous metal (titanium) socket was impacted, obtaining excellent fixation against the prepared socket bone.

A liner was then attached to the metal shell. The femur was prepared for placement of a porous coated metal (titanium) stem using broaches. Once excellent stability was achieved using the appropriate size broach, the equivalent porous coated metal stem was placed. A ceramic ball head of the diameter and length to restore Mr. C’s leg length and muscle tension was chosen and attached to the metal stem (Figure 1). The hip was reduced and the range of motion, leg length and stability were all assessed and determined to be excellent.

Mr. C was ambulating by post-operative day two, and went home two days later. At his six-month follow-up visit, he reported that his pain had been substantially reduced and that he was able to perform most normal daily activities.

Faculty Team

Penn orthopaedic surgeons are leaders in the introduction of alternative bearings for total hip arthroplasty and treat each joint condition with a personalized approach.

Performing Total Hip Arthroplasty in Younger Adults at Penn Medicine

Charles L. Nelson, MD
Chief of the Adult Reconstruction Service
Associate Professor of Orthopaedic Surgery

Eric L. Hume, MD
Associate Professor of Clinical Orthopaedic Surgery

Craig Israelite, MD
Assistant Professor of Clinical Orthopaedic Surgery

Gwo-Chin Lee, MD
Assistant Professor of Orthopaedic Surgery

Penn Orthopaedics Original Research

Alternative Bearings for Total Hip Arthroplasty
in Patients Younger than 21 Years at Penn

At Penn, THA is performed using alternative bearings for patients younger than 21 years with end-stage arthritis from osteonecrosis induced by chemotherapy or steroids, sickle cell disease, lupus erythematosis and chronic dislocations. Articulation bearings include ceramic/ceramic and metal/cross-linked polyethylene surfaces. Surgical management is considered only when non-operative and medical treatments have been exhausted.

A recent clinical study at Penn examined young THA patients (mean age 18 years) receiving alternative bearings.¹

Methods: Preoperative and postoperative Harris hip scores were recorded, and radiographs were reviewed. Average follow-up was 49 months (range, 25-89). Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid-induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%).

Results: Harris hip scores improved from 43.6 to 83.6 (P < .001). At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing THA in patients < 21 years.

1. Kamath AF, Sheth NP, Hosalkar HH, Babatunde OM, Lee G, Nelson CL. Modern Total Hip    Arthroplasty in Patients Younger Than 21 Years. J Arthroplasty. 2012;27:402-408.

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Berwyn, PA 19312

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409 Route 70 East

Cherry Hill, NJ 08034


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Pipeline™ Embolization Device for Wide-Necked Intracranial Aneurysms

Endovascular neurosurgeons at Penn Medicine are now offering the Pipeline^TM  embolization device (PED, eV3, Inc., Plymouth, MN) as a treatment for adults with wide-necked intracranial aneurysms, a group of endovascular lesions for which effective treatment was, until recently, an unmet need. A tubular covered endoluminal stent composed of flexible bimetallic mesh, the PED is only available at select, specialized centers in the United States at this time.

The treatment of wide-necked aneurysms is complicated by the width of the orifice at the vessel wall, an anomaly that can preclude both clipping and coil embolization. Unlike these techniques, which block or fill the aneurysm, the PED excludes the aneurysm by providing a scaffold within the parent artery that recreates the vessel’s structure.

The PED is introduced through a catheter in the femoral artery. Once inside the brain, the device is deployed within the vessel across the neck of the aneurysm, disrupting blood flow into the dilated segment. Eventually the PED is incorporated into the vessel wall by neoendothelial growth, and ultimately achieves complete occlusion of the aneurysm. The parent artery and adjacent branch vessels are preserved.

The PED uses a proprietary delivery system requiring specialized training to achieve the unique techniques for catheter positioning and stent deployment. At Penn Medicine, the procedure expands the options for patients
with aneurysmal disease, a spectrum of treatments that also includes coil embolization, open surgery (clipping) and balloon remodeling.

Case Study
  
Mr. U, a 57-year-old patient, was referred to the Department of Neurosurgery by his ophthalmologist for evaluation after a two month period of progressively worsening headaches, retro-orbital pain
and diplopia.

At Penn, an MRI discovered a large mass posterior to the left orbit (Fig 1). A subsequent neuroradiological evaluation via three-dimensional cerebral angiography further defined the lesion as a large, wide-necked aneurysm of the cavernous internal carotid artery
(Fig 2).

After a discussion of his options, Mr. U opted to have a PED procedure. He was premedicated with aspirin and Plavix^®, and was admitted on the morning of his procedure.

Immediately before surgery, he underwent general anesthesia and a femoral artery sheath was placed. Neuromonitoring was performed by a neurologist.

After performing diagnostic angiography to determine exact vessel measurements for stent selection, two PEDs were deployed in the internal carotid artery across the neck of the aneurysm.

Post-procedure angiography confirmed good stent placement and immediate stagnation of contrast in the aneurysm, indicating initiation of occlusion (Fig 3). Mr. U was extubated and transferred to the neurology critical care unit in stable condition.

On post-op day one, he was transferred to the floor and discharged home on post op day two. He reported significant relief from his retro-orbital headache. He will undergo repeat angiography in six months to ensure complete occlusion of the aneurysm.

Faculty Team
At Penn Medicine, an expert multidisciplinary team of neurosurgeons, neurologists, diagnostic and interventional neuroradiologists, neurointensivists and neuroanesthesiologists provides highly specialized care for all aspects of cerebrovascular disease.

Performing Pipeline^TM Surgery at Penn Medicine for Wide-Necked
and Giant Intracranial Aneurysms


Michelle J. Smith, MD
Assistant Professor of Neurosurgery

Robert W. Hurst, MD
Professor of Radiology

Bryan A. Pukenas, MD
Assistant Professor of Radiology


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Penn Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

For neurological emergencies, please call 877.936.7366

For neurological non-emergencies, please call 800.789.7366

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Treatment of Idiopathic and De Novo Scoliosis in Adults

Surgeons from the departments of orthopaedic surgery and neurosurgery at Penn Medicine have developed a program to provide the full spectrum of treatments for adult patients with scoliosis of the spine.

Generally defined as a curvature of the spine in excess of 30°, scoliosis has two primary classifications in adults: idiopathic disease originating in adolescence, and de novo (or degenerative) scoliosis occurring in middle age and later life. Idiopathic scoliosis affects the thoracic/lumbar spine and has an unknown etiology.

De novo scoliosis affects the lumbar spine and is usually caused by progressive intervertebral disc degeneration. In adults, both types of scoliosis are associated with pain, disfigurement and varying degrees of disability.

Treatment for scoliosis at Penn begins with conservative (non-operative) approaches, with the objective of controlling pain and maintaining function. Typically, conservative therapy involves exercise and conditioning regimens combined with physical therapy and, when warranted, nonsteroidal anti-inflammatory drugs and/or epidural steroid injections.

Surgery has the objective of minimizing pain and ameliorating spinal curvature, and is indicated when pain is unremitting or significant coronal or sagittal decompensation occurs. Chief considerations include the likelihood of successful outcome and the potential for complications given the patient’s age, history and condition.

At Penn, surgery for adult scoliosis involves thorough preoperative evaluation and planning to tailor the procedure to the needs of the individual patient; the primary goal is to minimize complications. Surgeries include posterior and/or anterior spinal fusion and segmental instrumentation; vertebral column resection; pedicle subtraction osteotomy; and spinal reconstructive surgery.

Most patients are ambulatory within 24 to 48 hours of surgery. In many instances the scoliosis surgery will involve the expertise of both the orthopaedic surgeon and neurosurgeon.

Case Study

Mrs. A, a 62-year-old female presented with incapacitating back and leg pain and ambulatory impairment. She could walk only with the aid of a walker and her posture was significantly stooped. Mrs. A’s medical history included four surgeries (among them a lumbar fusion) and failed attempts at conservative treatment, including, physiotherapy, pain medications and epidural steroid injections.

X-rays demonstrated a severe sagittal imbalance and a degree of curvature exceeding 30° (Fig 1). Following a consultation, and after thoroughly understanding what her surgery involved, Mrs. A agreed to have a pedicle subtraction osteotomy and extension of her fusion down to the pelvis. The surgery, which involved the removal of vertebral bone and the placement of pedicle screws and rods, was performed in seven hours.

A year after her surgery, Mrs. A’s pain level has dramatically decreased. Her posture is now upright (Fig. 2) and she can walk without a walker.

Faculty Team

The Spine Service at Penn Medicine involves the expertise of a multidisciplinary team that, in addition to orthopaedic surgeons and neurosurgeons, includes neurologists, rheumatologists, oncologists, physical therapists, physiatrists, radiologists and pain management specialists. This extensive and collaborative team approach to spine care ensures a thorough consideration of both surgical and non-surgical treatment of pain and neurological symptoms.

Performing Scoliosis Surgery at Penn Medicine

Vincent Arlet, MD
Chief, Orthopaedic Spine Surgery

William C. Welch, MD, FAANS, FACS, FICS
Vice Chairman (Clinical), Neurosurgery

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Penn Neurosurgery
Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

Penn Orthopaedics
Penn Presbyterian Medical Center
1 Cupp Pavilion
51 N 39th Street
Philadelphia, PA 19104

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MAGE-A3/6 and NY-ESO-1 immunotherapy administered post-ASCT in patients with advanced myeloma

Researchers in bone marrow transplantation at Penn’s Abramson Cancer Center are currently investigating the application of autologous, genetically modified T cells to the treatment of patients with advanced multiple myeloma. This approach has been likened to vaccine therapy because it involves the introduction of cells that have been altered to prompt an immune response.

Each year, more than 20,000 new cases of multiple myeloma occur in the United States. These cases appear in all facets of the population, with a higher incidence in African-Americans; mean age at diagnosis is 61.5 years. Although myeloma remains incurable, median five-year survival has roughly doubled since the 1970s as a result of the use of novel agents (thalidomide, lenalidomide, bortezomib) in combination with autologous stem cell transplantation (ASCT). ASCT is a standard of care in the United States for patients younger than age 71 with myeloma.

Once the disease relapses and becomes resistant to chemotherapeutic treatment, however, survival is very limited. New approaches are thus needed to further extend survival in myeloma patients.

Penn researchers have pioneered techniques to substantially increase the number of autologous T cells ex vivo and modify their function to have an even greater anti-tumor effect. It has been proposed that the introduction of these autologous T cells can prompt a rapid and vigorous immune response in the aftermath of ASCT.

Retrospective studies suggest that patients who have rapid lymphocyte recovery following ASCT have better clinical outcomes, perhaps because early immune reconstitution confers a protective effect against residual disease progression.

In the current study at Penn,* patients with high-risk multiple myeloma who are otherwise candidates for autologous SCT first undergo autologous T cell collection. This is followed by autologous hematopoietic stem cell collection followed by high-dose melphalan chemotherapy and ASCT. 
Patients are then infused with engineered autologous T cells.

The Penn study seeks to evaluate the safety and efficacy of a peptide vaccine comprised of fragments of the proteins melanoma associated antigen 3 (MAGE-A3) and NY-ESO-1, both of which are frequently found in the plasma cells of patients with myeloma.

MAGE-A3 is among the best characterized and most frequently expressed cancer testis antigens in tumors and is an important target for cancer vaccines; NY-ESO-1 has been shown to elicit spontaneous cellular immune responses in patients with advanced stage cancer. MAGE-A3 is identified with human leukocyte antigen haplotypes -A*0101 and -B*35; NY-ESO-1 is identified with HLA-A*0201. HLA peptide antigens provide cell surface ‘flags’ for expression of intracellular antigens.

The endpoints of the study include degree of response, time to progression and overall survival. In addition, the study will measure the survival of T cells in patients and examine the immune evidence for biological activity of these cells. The incidence of autologous GVHD in patients following infusion of TCR modified autologous T cells will also be assessed. Outcome measures include study-related adverse events and clinical response rates.

*Redirected Auto T Cells for Advanced Myeloma. ClinicalTrials.gov Identifier: NCT01352286. Contact: Edward Stadtmauer: 215-662-2812.


Faculty Team
The Bone Marrow and Stem Cell Transplant program at Penn Medicine and Abramson Cancer Center is the largest transplant center in the region. The program’s vibrant research mission is supported by many clinical trials for both autologous and allogeneic SCT.

Transplant options are available for most patients and are performed with autologous stem cells, matched sibling and unrelated donors and umbilical cord blood. Penn has active programs using both conventional allogeneic SCT and nonmyeloablative allogeneic (“mini”) transplantation. Committed to premier clinical care, Penn physicians strive to work collaboratively with patients’ referring physicians.

Hematologic Malignancies Physicians

Edward A. Stadtmauer, MD
Director, Hematologic Malignancies Program
Professor of Medicine

Selina M. Luger, MD
Director, Leukemia Program
Professor of Medicine

David L. Porter, MD
Director, Allogeneic Stem Cell Transplantation
Professor of Medicine

Stephen J. Schuster, MD
Director, Lymphoma Program
Associate Professor of Medicine

Noelle V. Frey, MD
Assistant Professor of Medicine

Elizabeth O. Hexner, MD
Assistant Professor of Medicine

Alison Loren, MD, MS
Assistant Professor of Medicine

Sunita D. Nasta, MD
Assistant Professor of Medicine

Jakub Svoboda, MD
Assistant Professor of Medicine

Donald Tsai, MD, PhD
Assistant Professor of Medicine

Dan Vogl, MD
Assistant Professor of Medicine

Brendan M. Weiss, MD
Assistant Professor of Medicine

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Abramson Cancer Center
Perelman Center for Advanced Medicine,
West Pavilion, 2nd Floor
3400 Civic Center Boulevard

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Emergent Treatment of Complex Blunt Multisystem Trauma

Surgeons with Penn’s Division of Traumatology, Surgical Critical Care and Emergency Surgery are implementing a systematic approach to the emergent treatment and management of patients with complex blunt multisytem trauma that integrates and incorporates specialists and treatments commensurate with the severity and difficulty of these injuries.

The optimal outcome of blunt multisystem injuries requires the careful orchestration of several disciplines. Blunt thoracic aortic injury is an especially life-threatening injury that rarely occurs in isolation. Associated injuries include other chest injuries (hemopneumothorax, rib fractures, pulmonary contusion), head injuries, pelvis and extremity fractures and dislocations, and abdominopelvic injuries.

Advances in the diagnosis and management of blunt thoracic aortic injury include CT angiography, intense heart rate and blood pressure control with short acting intravenous beta blockade, and thoracic endovascular stent grafting. These advances have markedly decreased the hospital morbidity and mortality of this injury.1

Patients have better outcomes when treated at designated trauma centers.2 At the Hospital of the University of Pennsylvania (HUP), a state-accredited Level I Trauma Center, a fellowship-trained attending trauma surgeon is present in-house 24 hours a day. The surgical intensive care unit is staffed with a dedicated surgical critical care service, led by a board-certified surgical intensivist. The intensivist model is associated with better outcomes.3

Regarding specialty care, HUP is a regional referral center for complex thoracic aortic surgery, including endovascular techniques. Orthopaedic injuries are managed by the region’s only dedicated trauma orthopaedics service.

Case Study

Mrs. R, a 51-year-old female, was involved in a head-on motor vehicle collision and taken initially to a community hospital emergency room. Her workup there demonstrated the following injuries: traumatic transection of the proximal descending thoracic aorta (Figure 1), fractures of bilateral ribs (seven total), comminuted intraarticular fracture of the distal left femur, fracture of left tibial plateau, and fracture of right patella (Figure 2).

Mrs. R was transferred emergently to the trauma service at HUP for further management, including consideration for thoracic endovascular stent grafting of her aortic injury.

At HUP, her hemodynamics and pain were managed by the surgical critical care service and consultations were arranged with cardiac surgery, vascular surgery and orthopaedic surgery. The aortic injury remained stable. Imaging revealed that endovascular repair would require occlusion of the origin of the left subclavian artery.

However, because her pulmonary status was tenuous, Mrs. R was not a candidate for open aortic repair. Subsequently, she had a left carotid-subclavian artery bypass to debranch the thoracic aorta, followed by a thoracic endovascular stent graft for her aortic injury. She then underwent open reduction and internal fixation of her left femur and right patellar fractures and was eventually discharged to rehabilitation.

References - 1. Demetriades D, Velmahos GC, Scalea TM, et al. J Trauma.
2008;64:1414-1419; 2. Mackenzie EJ, Rivara FP, Jurkovich GJ, et al. New
Engl J Med. 2006;354:366-378; 3. Fuchs RJ, Berenholtz SM and Dorman T.
Best Pract Res Clin Anaesthesiol. 2005;19:125-135.

Faculty Team
The Division of Traumatology, Surgical Critical Care and Emergency Surgery at Penn Medicine operates a Level 1, regional resource trauma center accredited by the Pennsylvania Trauma Systems Foundation and a 24-bed dedicated surgical intensive care unit (SICU) with in-house trauma attendings 24/7/365.

The trauma center is nationally and internationally recognized as a model program for other hospitals. The SICU provides care for injured and critically ill patients by a multidisciplinary team comprised of a dual board-certified attending surgeon/ intensivist, board-certified physician intensivists, acute care nurse practitioners, surgical critical care fellows, resident physicians, critical care registered nurses, respiratory therapists, nutritionists and critical care pharmacists. Among the most technologically advanced in the region, the SICU also includes a telemedicine ICU.

Managing Complex Multisystem Trauma at Penn Medicine

Patrick M. Reilly, MD
Chief, Division of Traumatology, Surgical Critical Care
and Emergency Surgery
Professor of Surgery

Steven R. Allen, MD
Assistant Professor of Surgery

Benjamin Braslow, MD
Associate Professor of Surgery

Forrest Fernandez, MD
Assistant Professor of Clinical Surgery

Daniel N. Holena, MD
Assistant Professor of Surgery

Patrick K. Kim, MD
Assistant Professor of Surgery
Trauma Program Medical Director

Jose L. Pascual, MD
Assistant Professor of Surgery

C. William Schwab, MD
Professor of Surgery

Carrie A. Sims, MD
Assistant Professor of Surgery

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Hospital of the University of Pennsylvania
Traumatology, Surgical Critical Care and Emergency Surgery
Dulles 2
3400 Spruce Street
Philadelphia, PA 19104

To contact a member of the Division of Traumatology, Surgical Critical Care, or Emergency Surgery for a clinical question or patient transfer, please call 877-937-7366.


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Transanal Endoscopic Microsurgery for Lesions of the Mid to Upper Rectum

Penn colon and rectal surgeons are now using transanal endoscopic microsurgery (TEM) to excise advanced polyps and selected early cancers (ultrasound T1) in the mid to upper rectum.

A minimally invasive approach, TEM permits surgeons to reach lesions up to 10-15 cm from the anal verge and to remove whole tumors while sparing the function of the rectum. The procedure employs an operating proctoscope through which instruments are introduced to perform excision and other functions under direct three-dimensional magnified visualization of the operating field.

The objectives of rectal cancer surgery include sphincter preservation, prevention of disease recurrence and long-term survival. Oncologic surgical principles require removal of the tumor-bearing organ, along with all nodal tissue. These operations may involve significant morbidity in terms of recovery from surgery, the possible need for temporary or permanent stomas and in post-operative function.

Local excision may be appropriate for advanced polyps and certain early cancers given the very low likelihood of nodal involvement (<10 percent in many early cancers) and has traditionally been employed for the purposes of polyp removal in low rectal polyps and for diagnosis in indeterminate lesions that are otherwise not amenable to colonoscopic removal.

However, most lesions of the mid to upper rectum are inaccessible to local excision using standard instruments. In patients having standard transanal excision, incomplete removal or fragmentation of excised lesions accounts for recurrence rates as high as 30 percent.

The advantages of TEM relative to standard cancer operations include rectal preservation, less blood loss, less pain, fewer complications and a faster recovery time. When compared to standard transanal excision, TEM results in superior visualization and less tissue fragmentation. This results in a significantly decreased recurrence rate for both adenomas and selected early
cancers.


Case Study

Mrs. M, a 58-year-old woman, was referred to the division of Colon and Rectal Surgery at Penn following two months of diarrhea and acute pain when a sigmoidoscopy revealed a large villous adenoma on the right wall of the mid rectum. At Penn, an ultrasound of the lesion found no evidence of invasion; a subsequent biopsy suggested that the lesion was benign.

Although all villous adenomas are considered premalignant and should be removed, the lesion was not amenable to removal by conventional colonoscopy. A transanal endoscopic microsurgery
was scheduled to remove the lesion.

The procedure was performed in approximately 90 minutes under general anesthesia with no complications. Intraoperative biopsies revealed clear surgical margins and no invasive disease. Mrs. M was mobile on the day of surgery and was discharged the next day. At her one year follow-up, no evidence of disease was present.

Faculty Team

The Division of Colon and Rectal Surgery at Penn Medicine provides the highest quality diagnostic and surgical options for patients with colon, rectal and anal cancer, inflammatory bowel disease (Crohns disease and ulcerative colitis), diverticular disease and many other diseases and disorders of the colon, rectum and anus.

The division offers (anal) sphincter-preserving colon and rectal surgery for cancer and benign disease, laparoscopic colon surgery, surgery for anal incontinence and rectal prolapse and both operative and medical therapies for anal diseases and complaints.

Performing Transanal Endoscopic Microsurgery at Penn Medicine

Joshua I.S. Bleier, MD, FACS, FASCRS
Assistant Professor of Surgery

Colon & Rectal Surgeons

Robert D. Fry, MD, FACS, FASCRS
Chairman, Department of Surgery, Pennsylvania Hospital
Chief, Division of Colon and Rectal Surgery
Emilie & Roland de Hellebranth Professor of Surgery

Cary Aarons, MD
Assistant Professor of Surgery

Brian R. Kann, MD, FACS, FASCRS
Assistant Professor of Surgery

Najjia N. Mahmoud, MD, FACS, FASCRS
Associate Professor of Surgery

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Department of Surgery
Hospital of the University of Pennsylvania
4 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Department of Surgery
Penn Presbyterian Medical Center
Wright Saunders
Suite 266
51 N 39th Street
Philadelphia, PA 19104

Department of Surgery
Pennsylvania Hospital
Garfield Duncan Building
Suite 305
700 Spruce Street
Philadelphia, PA 19106

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