Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration For Diagnosis of Thoracic Adenopathy & Lung Cancer Staging

Interventional pulmonologists at the Hospital of the University of Pennsylvania are using a relatively new minimally-invasive technology, Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA), to less invasively diagnose thoracic adenopathy and stage lung cancer. EBUS-TBNA integrates ultrasonography, video-enhanced visualization and real-time echogenic needle aspiration into a single flexible bronchoscopy unit (Figure 1). Using EBUS-TBNA, Penn interventional pulmonologists can observe and differentiate all mediastinal and hilar structures with the integrated ultrasound videobronchoscope. The unit’s dedicated 22-gauge needle can be seen with standard video visualization. More importantly, the needle is visualized under real-time ultrasound during the lymph node biopsy. This dedicated aspiration needle can be extended to roughly 4 cm and is capable of obtaining large core biopsies for cytologic and histopathologic analysis. With this technology, Penn interventional pulmonologists can diagnose thoracic adenopathy and stage lung cancer with a minimally invasive approach using only conscious sedation in a same-day outpatient procedure. Clinical studies have shown that for lung cancer diagnosis and staging, the sensitivity and accuracy of EBUS-TBNA are nearly equivalent to the current gold standard, cervical mediastinoscopy. At Penn, this technology is actively being used to diagnose thoracic adenopathy and to stage cancers earlier and less invasively than previously possible.

Case Study
Mr. R., a 67-year-old man with an 80 pack-year history of tobacco abuse presented to his primary physician with cough. When his cough did not respond to antibiotics, his primary physician ordered a chest X-ray which demonstrated a right lung mass. Mr. R was referred to Penn Interventional Pulmonary Services for evaluation and diagnosis. A chest CT scan demonstrated a 4.2 x 3.4 cm right upper lobe lung mass with a 1.4 cm right hilar, a 1.1 cm right paratracheal, and 1.4 cm subcarinal lymph node (Figure 2). The Interventional Pulmonology Program then performed an EBUS-TBNA of the subcarinal and right paratracheal lymph nodes (Figure 3). On-site cytologic analysis demonstrated lymphocytes without lung cancer in the subcarinal lymph node, but did demonstrate lung cancer in his right paratracheal lymph node. With the diagnosis of advanced regional lung cancer, the patient was not deemed a surgical candidate and was begun on concurrent definitive chemoradiotherapy. The patient has had a very good response to aggressive therapy.

Our Team of Faculty
Interventional Pulmonology Services at the Hospital of the University of Pennsylvania offers a broad array of diagnostic, therapeutic and palliative airway and pleural procedures. Treatments offered include flexible and rigid bronchoscopy with laser, electrocautery, and argon plasma tumor debulking modalities, endobronchial stenting, balloon brochoplasty, early lung cancer detection via LIFE-Lung fluorescence bronchoscopy, endobronchial brachytherapy, photodynamic therapy, and indwelling tunneled catheters and pleuroscopy for pleural effusions. The program is actively involved in many clinical trials evaluating various novel immunotherapeutic treatments for patients with lung cancer, mesothelioma, and metastatic pleural disease. In addition, the program participates in several clinical trials investigating novel bronchoscopic treatments for emphysema and asthma.

Daniel Sterman, MD Associate Professor of Medicine Director, Interventional Pulmonary Services
Andrew R. Haas, MD, PhD Assistant Professor of Medicine Director, Clinical Operations Section of Interventional Pulmonology and Thoracic Oncology
Colin Gillespie, MD Instructor of Medicine Director of Education, Interventional Pulmonary Services
Anil Vachani, MD Assistant Professor of Medicine Director of Clinical Research, Interventional Pulmonary Services

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Penn Lung Center
Perelman Center for Advanced Medicine
West Pavilion, 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

To refer a patient and/or consult with a doctor: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral or PennMedicine.org/lung

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Endoscopic Resection of Sinonasal Hemangiopericytomas

Surgeons with the Department of Otorhinolaryngology-Head and Neck Surgery at Penn Medicine are performing endoscopic procedures to resect sinonasal hemangiopericytomas (HPC).

These rare, malignant, vascular neoplasms originate in the contractile cells on the external surface of capillaries and post-capillary venules in the sinonasal cavity. The tumors appear as friable, gray-white polypoid lesions. Most are slow growing, painless and localized. Advanced-stage lesions (>2.5 cm) are not uncommon at presentation.

The majority of patients with sinonasal HPCs experience epistaxis, nasal obstruction and a variety of nonspecific symptoms in the months prior to diagnosis. Untreated sinonasal HPCs will continue to expand, occluding, destroying or damaging the turbinates, nasal septum, ethmoid bone, cavernous sinuses and, in extensive disease, the optic chiasm.

Penn otorhinolaryngologists perform minimally invasive endoscopy-assisted surgery through the nose to remove sinonasal tumors. Generally, this approach offers superior visualization, enhanced preservation of normal structures, and when compared to open craniofacial surgery, better cosmesis and fewer postoperative complications. Endoscopy may also be used for diagnostic procedures and long-term follow-up surveillance of patients.

Penn surgeons are able to remove these tumors under frozen section control to improve long-term outcomes. In special situations, proton beam therapy is available at the Roberts Proton Therapy Center at Penn to provide an adjunct treatment for hemangiopericytomas and other skull base lesions.
Case Study
Mr. P, a 54-year-old man, presented to an otorhinolaryngologist in his community with progressive right-sided nasal obstruction of four months duration.

Upon observing a large, reddish-gray mass filling the right nasal cavity, an MRI scan (Figure 1) and biopsy were performed. The biopsy was positive for hemangiopericytoma. Mr. P was then referred to the Division of Otorhinolaryngology-Head and Neck Surgery at Penn Medicine for minimally invasive endoscopic tumor removal.

Here, surgeons first obtained an angiogram to delineate the vascular character of the lesion and its involvement with the skull base and brain (Figure 2). After determining the vascular nature of the tumor and defining the internal maxillary artery as a major blood source, a surgeon with the Department of Neurosurgery at Penn performed selective embolization of the artery.

The anterior and posterior ethmoid arteries were then ligated at surgery to eliminate the tumor blood supply, and the tumor dissected with endoscopic bipolar forceps and removed through the nose. The duration of surgery was four hours. Total blood loss was 250cc. On post-operative day two, Mr. P was discharged to home; his recovery from surgery was unremarkable. Endoscopic evaluation performed over the course of the next year found no evidence of recurrence.
Team of Faculty
The board-certified otorhinolaryngologists with the Department of Otorhinolaryngology-Head and Neck Surgery at Penn Medicine specialize in the evaluation, diagnosis and treatment of a full spectrum of disorders of the ears, nose and throat, including rare benign and malignant lesions, thyroid disease and skull base tumors. The management of sinonasal lesions at Penn is a multidisciplinary effort involving otorhinolaryngologists and specialists trained in neurosurgery, facial plastic and reconstructive surgery, oncology, radiation oncology and interventional neuroradiology, as well as an extensive network of support services.
Performing Hemangiopericytoma Surgery at Penn Medicine
James N. Palmer, MD
Associate Professor of Otorhinolaryngology-Head and Neck Surgery  
Otorhinolaryngology–Head and Neck Surgery
Bert W. O'Malley, Jr., MD
Gabriel Tucker Professor and Chair, Department of Otorhinolaryngology-Head and Neck Surgery

Gregory S. Weinstein, MD, FACS
Vice Chairman, Department of Otorhinolaryngology-Head and Neck Surgery Professor of Otorhinolaryngology-Head and Neck Surgery

Douglas C. Bigelow, MD
Associate Professor of Otorhinolaryngology-Head and Neck Surgery


David W. Kennedy, MD
Professor of Otorhinolaryngology-Head and Neck Surgery

Jason G. Newman, MD
Assistant Professor of Otorhinolaryngology-Head and Neck Surgery

Michael J. Ruckenstein, MD
Professor of Otorhinolaryngology-Head and Neck Surgery
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Department of Otorhinolaryngology– Head and Neck Surgery
 
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104

Pennsylvania Hospital
811 Spruce Street
Philadelphia, PA 19107

To refer a patient to Penn Medicine, please contact PhysicianLink^TM online or by calling 877-937-7366.

Clinical Trials
The Department of Otorhinolaryngology-Head and Neck Surgery is devoted to a multidisciplinary approach to the study of diseases of the head and neck. Our investigators are currently conducting basic and clinical studies to gain an increased understanding of the causes and interventions for head and neck diseases such as sinusitis, speech, hearing, taste, smell, cancer, and reconstructive surgery. The many areas of investigation in which the Department is currently performing clinical trials include:

• Allergy and Sinus disorders and diseases
• Cochlear implantation
• Thyroid Cancer
• Head and Neck Cancer
• Skull base and chronic ear surgery
• Smell and Taste Disorders
• Speech and Swallowing Disorders
• Transoral Robotic Surgery (TORS) for minimally invasive resection of benign and malignant lesions of the head and neck
• Wound healing
• TORS for Sleep Apnea

For more information about clinical trials and research studies at the Department of Otorhinolaryngology-Head and Neck Surgery at Penn, contact Randall Hardie at randall.hardie@uphs.upenn.edu.

Sorafenib for Differentiated Thyroid Cancer

Researchers at Penn Medicine recently completed a phase II trial of sorafenib (Nexavar®), a promising new agent for the treatment of metastatic, iodine-refractory thyroid carcinoma.

Led by Marcia S.Brose,MD,PhD, the research team included members of both the Abramson Cancer Center of the University of Pennsylvania and the Center for Head and Neck Cancer at Penn.

The trial population included a spectrum of thyroid cancer histologic subtypes, including differentiated, anaplastic, medullary and nonmedullary cancers. All patients had progressive disease at baseline.

Sorafenib, an oral multi-kinase inhibitor currently approved for the treatment of non-resectable hepatocellular carcinoma and advanced renal cell carcinoma, was administered at a dose of 400mg orally twice daily for a minimum of 16 weeks.

Dose adjustments were made as needed for toxicity. Study endpoints included best objective response rate and progression-free survival.

On the basis of findings from the first 30 trial participants, the Penn team concluded that sorafenib represents a significant advance over chemotherapy in both response rate and progression-free survival (PFS) for patients with metastatic, iodine-refractory thyroid carcinoma.

The overall clinical benefit rate for these patients (defined as partial response plus stable disease) was 77%. Median progression-free survival (PFS) was 79 weeks.

No patient died before disease progression and no significant differences in PFS were observed between follicular and papillary subtypes. Treatment related adverse events were predominantly of grade 1 or 2, with the most common events including palmar-plantar erythema, rash, fatigue, stomatitis/mucositis, weight loss, and musculoskeletal pain.

The trial report was published in the Journal of Clinical Oncology in October 2008.¹

CASE STUDY

Mr. K, a 37-year-old man, was referred to Penn Medicine by his internist after discovering a lump in his neck. His medical history was previously unremarkable.

At Penn, a needle aspiration biopsy determined that the lump was a follicular carcinoma. Mr. K was scheduled for a thyroidectomy and bilateral central neck lymph node dissection. Of the 32 lymph nodes removed from Mr. K’s central and right lateral neck, 14 were positive for cancer.

A subsequent total body PET scan revealed lesions in his left lung and kidney. Mr. K was diagnosed with metastatic iodine-nonavid differentiated thyroid cancer. With an anticipated survival of approximately eight months, Mr. K agreed to participate in the Phase II clinical trial of sorafenib in thyroid cancer at Penn.

Within two months of initiating therapy at 400 mg bid, the progression of Mr. K’s disease stabilized; a marked decrease in both thyroglobulin levels and CT-documented tumor burden was noted.

At six months, Mr. K experienced palmar erythema, which responded well to anti-inflammatory agents; he had no other significant adverse effects during treatment. At 27 months post-treatment, his disease remained progression-free and he was otherwise healthy.

1. Gupta-Abramson V, Traxel AB, Nellore A, Puttaswamy K, Redlinger M, Ransone K, Mandel SJ, Flaherty KT, Loevner LA, O’Dwyer PJ, Brose MS. Phase II trial of sorafenib in advanced thyroid cancer. J Clin Oncol. 2008;26:4714-4719.

Faculty Team

The treatment of cancer at Penn Medicine involves more than 300 specialists and researchers collaborating under the auspices of the Abramson Cancer Center of the University of Pennsylvania, a national leader in cancer research, patient care, training, community education, and outreach.

At Penn, cancer patients are managed by oncologists, surgeons and radiation oncologists who specialize in the diagnosis and treatment of specific cancers; aftercare is tailored to address the emotional challenges facing cancer patients and their families––and all of these elements take place in a setting devoted to basic, translational, clinical and cancer control research.

Department of Otorhinolaryngology – Head and Neck Surgery
Marcia S. Brose, MD, PhD
Assistant Professor of Otorhinolaryngology
Director, Cancer Genetics Laboratory Abramson Cancer Center

Division of Endocrinology
Susan J. Mandel, MD, MPH
Professor of Medicine

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Head and Neck Oncology
Abramson Cancer Center
Perelman Center for Advanced Medicine, West Pavilion, 2nd Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Thyroid Cancer Clinical Research at the Abramson Cancer Center
Clinical research is a fundamental mission of the Abramson Cancer Center of the University of Pennsylvania. To determine whether a patient is eligible for a following trial, please visit oncolink.org and click on “Cancer Clinical Trials Matching” in the left-hand column.

Title: An International, Randomized, Double-Blinded, Phase 3 Efficacy Study of XL184 Versus Placebo in Subjects With Unresectable, Locally Advanced, or Metastatic Medullary Thyroid Cancer Phase: III Rationale: The purpose of this research study is to evaluate the progression-free survival (PFS) with XL184 as compared with placebo (an inactive substance) in subjects with unresectable, locally advanced, or metastatic medullary thyroid cancer (MTC). Subjects will be randomized to receive XL184 or placebo in a 2:1 ratio. XL184 is an investigational drug that inhibits VEGFR2, MET and RET, kinases implicated in tumor formation, growth and migration.

Title: A Phase 1/2 Dose Finding Study of an Experimental New Drug CS7017, an Oral PPARã Agonist Taken by Mouth Twice Daily in Combination With Paclitaxel Chemotherapy Administered Every Three Weeks by Venous Infusion by Patients With Anaplastic Thyroid Cancer Phase: I/II Rationale: The Phase I/II study will be conducted as an open label, multiple center study of CS-7017, an experimental drug and paclitaxel chemotherapy in subjects with advanced anaplastic thyroid cancer. Biopsies will be obtained from patients with accessible tumor at baseline, two-weeks after the first CS-7017 dosage (prior to the start of combination therapy) and at the end of the first study cycle (week 3 of combination therapy), in order to evaluate the effects of the study drug alone and in combination with the chemotherapy agent on the tumor. Treatment will continue until disease progression or the development of intolerable toxicities.

To refer a patient and/or consult with a physician, Call 800-789-PENN (7366) or visit: PennMedicine.org/referral

Downloadf a pdf of this Clinical Briefing.

Diagnosis and Treatment of Dry Eye Syndrome

Ophthalmologists at the new Penn Dry Eye & Ocular Surface Center are applying recent advances in diagnostic technology to diagnose the primary causes of keratoconjunctivitis sicca, or dry eye syndrome (DES), in order to optimize treatment of this condition. Dry eye is a very common disorder. Symptoms include blurred vision, scratchiness, irritation, redness or tiredness of the eyes. Traditionally, DES has been thought of as a deficiency of tears at the ocular surface. In recent years, however, investigations have shown that DES is much more complex than previously thought, and that “tear film dysfunction syndrome” might more accurately describe the condition. Tear film dysfunction can be broken down into two basic etiologic classifications: insufficient tear production or increased evaporation of tears from the eye surface. The tear film is made up of lipid, aqueous and mucin components. Individuals with dry eye syndrome can be deficient in any of these basic factors.

• Lipid tear deficiency is most commonly caused by blepharitis or Meibomian gland dysfunction. This leads to abnormally increased evaporation of the tears from the surface of the eye.
• Mucin deficiency can be caused by conditions such as vitamin A deficiency, chemical injury, and Stevens-Johnson syndrome. Produced by goblet cells, mucin promotes even distribution of the aqueous tears over the surface of the eye.
• Aqueous tear deficiency is associated with insufficient tear production. Congenital causes include conditions such as Riley-Day syndrome or familial dysautonomia. There are also many acquired causes of aqueous tear deficiency, which include:
• contact lens wear, increasing age, hormonal changes, medications, Sjogren’s Syndrome and other autoimmune diseases.

Diagnosis
Because DES is often misdiagnosed, accurate assessment of the underlying causes of a patient’s ocular surface disease is critical. Misdiagnosis and the resulting delay in appropriate treatment can permit the continuation of destructive disease processes and can lead to eventual permanent scarring of the ocular surface. In addition, patients are often inadequately treated and may needlessly suffer with a decreased quality of life. The physicians at the Penn Dry Eye & Ocular Surface Center have developed a multidisciplinary approach to accurately identify the cause of a patient’s tear film dysfunction or ocular surface disease. Ophthalmologists collaborate with specialists in other departments to provide state-of-the-art care for any medical problems or conditions that may be contributing to the patient's eye problems. In the office, specially-trained ophthalmologists perform thorough evaluations of the ocular surface. This may include analysis of tear film osmolarity, Schirmer testing to measure tear production, and evaluations of the conjunctiva impression cytology, ocular ferning) and lid margin (Meibomian gland transillumination).

Treatment Options
Management of tear film dysfunction and ocular surface disease at the Penn Dry Eye & Ocular Surface Center has the objective of promoting the health of the ocular surface and is tailored to the individual patient. Lifestyle changes, artificial tears and topical eye ointments may help patients with mild DES. Patients with moderate to severe DES may benefit from medical treatment with immunomodulators, anti-inflammatory agents, autologous serum, mucolytic agents or surgical interventions such as punctal occlusion, cautery or various lid surgeries. In addition, our specialists perform the latest ocular reconstructive surgeries including amniotic membrane transplantation and artificial cornea transplants (keratoprosthesis surgery).

Team of Faculty
Tear film dysfunction and other ocular surface diseases are treated at the Penn Dry Eye & Ocular Surface Center by specially-trained ophthalmologists who have a particular interest in caring for patients with dry eye and other types of ocular surface disease. The new Center involves collaboration with specialists in cornea and external disease, oculoplastics, contact lens, rheumatology, dermatology and endocrinology.

For more information about the Dry Eye & Ocular Surface Center, its programs and services, please visit: PennMedicine.org/dryeyecenter.

Ophthalmology
Mina Massaro-Giordano, MD Associate Professor, Comprehensive Ophthalmology Co-director, Penn Dry Eye & Ocular Surface Center
Vatinee Y. Bunya, MD Assistant Professor, Cornea & External Disease Co-director, Penn Dry Eye & Ocular Surface Center
Stephen E. Orlin, MD Associate Professor, Cornea & External Disease Director, Cornea Service
Michael E. Sulewski, MD Clinical Associate of Ophthalmology Chief of Ophthalmology, VA Hospital Co-director, Cornea Service

Oculoplastics
Roberta E. Gausas, MD Associate Professor of Ophthalmology

Rheumatology
Frederick B. Vivino, MD Director, Sjogren’s Syndrome Center Chief of Rheumatology, Penn Presbyterian Medical Center
Lan Chen, MD, PhD Clinical Associate of Medicine

Dermatology
Aimee S. Payne, MD, PhD Assistant Professor of Dermatology
Catherine M. Quirk, MD Clinical Associate of Dermatology

Endocrinology
David M. Finkel, MD Physician

Contact Lens
Diane Heistand-Talecki, COT, NCLC, ABOC
Kathy McNelis, COA, NCLC, ABOC
Cynthia Silvestri, COA, NCLC

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Penn Presbyterian Medical Center
Scheie Eye Institute
51 N 39th Street
Philadelphia, PA 19104

To refer a patient and/or consult with a doctor: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral

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Total Proctocolectomy with Ileal Pouch-Anal Anastomosis for Treatment of Ulcerative Colitis and Hereditary Polyposis Syndrome

Surgeons at Penn Medicine are performing restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) to treat patients with intractable ulcerative colitis (UC) and those with familial adenomatous polyposis (FAP).



Now an established alternative to proctocolectomy with end ileostomy in the surgical management of UC and FAP, proctocolectomy with IPAA involves a near total proctocolectomy with preservation of the anal sphincter complex. A single-chambered pouch is fashioned from the distal 30 cm of the ileum and attached to the anus using a double-stapled technique.



Alternatively, a hand-sewn anastomosis may be fashioned between the pouch and the anus after stripping the distal rectal mucosa from the internal anal sphincter (mucosectomy). The procedure preserves the anal sphincters and maintains continence. Patients with medically refractory UC or those unable to tolerate medical treatment are considered candidates for surgery.



As long as there is no evidence of rectal dysplasia or malignancy, these patients should have a double-stapled anastomosis and temporary diverting loop ileostomy. For patients on high-dose steroids or anti-TNF medications (e.g., Remicade® or Humira®), the procedure may be staged; first the abdominal colon is removed, preserving the rectum, and allowing the patient to heal and wean off of steroids and other medications.



In the next stage, the rectum is removed and the pouch is created, protected by a temporary loop ileostomy. Ileostomy reversal proceeds several weeks later, after the pouch has healed, but does not require re-opening the abdomen. In patients with diffuse familial adenomatous polyposis (FAP) involving the rectal mucosa, the procedure is usually accompanied by a distal rectal mucosectomy to ensure that all premalignant colonic mucosa is removed, and the IPAA is fashioned between the ileal pouch and the dentate line of the anal canal.



Studies of long-term functional outcome for patients receiving total proctocolectomy with IPAA indicate that most are fully continent, and that when present, incontinence improves over time. At Penn Medicine, these operations are performed in a minimally invasive manner (laparoscopic or hand-assisted) whenever possible.



Case Study

Mr. L, a 20-year-old male, was referred to Penn Medicine with a four-year history of ulcerative colitis. His disease had been refractory to aggressive medical management, including trials of Remicade and Humira. Symptoms could be minimized with prednisone, but Mr. L had intermittent flares requiring hospital admission and intravenous high-dose steroid treatments.



Between flares, Mr. L was unable to completely stop steroid use without the return of significant lower GI bleeding, diarrhea and pain. As a result of his medically refractory disease and intolerance of prednisone, Mr. L was an appropriate candidate for a laparoscopic, hand-assisted total proctocolectomy with ileal pouch-anal anastomosis (TPC /IPAA).



Operative Technique

Mr. L was placed under general anesthesia and in the lithotomy position. A 2.5 inch incision was then made in the lower midline immediately above the pubic bone. A hand port was inserted, and a camera port placed just above the umbilicus.



Four 5-mm instrument ports were placed through 3mm stab incisions along either flank. Using laparoscopic instruments, the entire abdominal colon was then mobilized from its intra-abdominal attachments. The blood supply was divided intracorporeally with an energy device. The colon was extracted through the small hand- port incision and the terminal ileum divided close to the cecum with a GIA stapler.



The rectum was resected under direct vision through the hand port, taking care to identify and preserve the ureters and pelvic nerves responsible for bladder and sexual function. The rectum was stapled just above the dentate line and removed; the terminal ileum was then folded in a “J”, making sure the loop of the J was able to reach the pelvic staple line. A 15-cm pouch was created with the GIA stapler and the base of the pouch anastomosed to the rectal stump.



Finally, 25 cm upstream of the newly created J-pouch, a segment of distal ileum was brought up to the skin at a pre-marked site and a loop ileostomy created. This would divert the fecal stream while the J-pouch healed and Mr. L was weaned from steroids. The incisions were then closed. Mr. L was out of bed that evening, tolerated liquids on postoperative day one and solid food on POD two. On POD four, he was discharged to home after stoma teaching and with home care.



Ten weeks later, a gastrograffin study showed his pouch was well healed, and his ileostomy was reversed. Mr. L has now fully recovered from surgery, and has several loose bowel movements/day with good control. He undergoes pouch surveillance by flexible endoscopy every one to two years, and has returned to full-time work.



Team of Faculty



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 (Crohn’s 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.



Robert D. Fry, MD

Chairman, Department of Surgery, Pennsylvania Hospital Emilie & Roland de Hellebranth Professor of Surgery



Allen H. Bar, MD, FACS

Clinical Associate Professor of Surgery



Joshua I.S. Bleier, MD

Assistant Professor of Surgery



Matt L. Kirkland, MD, FACS

Clinical Assistant Professor of Surgery



Najjia N. Mahmoud, MD

Associate Professor of Surgery



David J. Maron, MD, MBA

Assistant Professor of Clinical Surgery



Alan L. Schuricht, MD, FACS

Clinical Associate Professor of Surgery



David S. Wernsing, MD, FACS

Clinical Assistant 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



To refer a patient and/or consult with a doctor: Call: 800-789-PENN (7366) or visit: PennMedicine.org/referral



Download a pdf of this Clinical Briefing.