DIGESTDIGESTMethodist Digestive Institute Newsletter

Volume 1, Issue 1 • Fall 2017

Redefining ResectabilityIrreversible electroporation improves prospects for pancreas resection

Surgical resection, when a viable option, remains the gold standard for treatment of pancreatic cancer combined with chemotherapy and/or radiation therapy. Only about 10 percent of pancreatic cancer patients present with local disease that is considered surgically resectable. The location of the pancreas and its neighboring anatomy make surgical intervention a challenge. Bordering the pancreas are multiple delicate structures such as the common bile and pancreatic ducts. Several vessels, including the celiac

artery, superior mesenteric artery, portal vein, and splenic vein also surround the pancreas further complicating and restricting access. Approximately 40 percent of patients present with disease that is too locally advanced to resect. Using thermal techniques to ablate tumors has proven unsuccessful. But because irreversible electroporation (IRE) does not rely on thermal energy, it is emerging as a reliable tool to ablate tissue while maintaining the scaffolding of surrounding tissues, making it a great weapon in treating locally advanced pancreatic cancer with vascular encasement. Continued on page 3

Precision with No IncisionMethodist Dallas offers peroralendoscopic myotomy (POEM) and submucosal dissection (ESD)

With the goal of achieving outcomes equivalent to their open surgical predecessors while at the same time reducing complications and morbidity, minimally invasive surgery continues to evolve. Submucosal tunnel endoscopy takes the evolution of minimally invasive therapy a step further by matching surgical results, in many cases, without even an incision.

Peroral endoscopic myotomy, affectionately known as POEM, is an example of a submucosal tunneling technique. It is an established minimally invasive therapy for

the treatment of achalasia, an uncommon swallowing disorder. The POEM procedure has been shown to be as effective as the standard laparoscopic Heller myotomy, which requires multiple small incisions. Prashant Kedia, MD, Director of Interventional Endoscopy at Methodist Dallas Medical Center performs POEM routinely in the endoscopy suite with great success.

Considered a novel technique because it was one of the first clinical endoscopic procedures to transcend the GI tract, POEM also conquered the challenge of closing a transmural hole for endoscopic access.

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Newsletter Spotlight

Current Registries 2

Nurse Navigation 3

Pancreas Symposium 4

Alejandro Mejia, MD, uses Nanoknife to resect vascularly encased tumors.

Prashant Kedia, MD, exhibits a HybridKnife used for submucosal tunnel endoscopy.

PRECISION continued from page 1

Furthermore, POEM opened the era of submucosal tunnel endoscopy with many other applications. Based on the same principles of POEM, in combination with new technological developments, such as endoscopic suturing, endoscopic submucosal dissection (ESD) has evolved for removing gastric tumors. ESD is becoming the first-line procedure for the resection of early gastric cancer (EGC) and is currently being performed at Methodist Dallas by Dr. Kedia.

Strict criteria for treating EGC with endoscopic resection have been established by the Japanese Gastric Association, but the criteria have been expanded with favorable long-term outcomes. The stomach preserving ability of ESD can greatly improve patients’ quality of life compared to surgery. One drawback with ESD is a generally higher incidence of metachronous gastric cancer. The risk, however, can be mitigated with careful endoscopic surveillance after a curative ESD.

Performing submucosal tunnel endoscopy is a technically demanding procedure requiring an experienced hand. High volume centers, such as Methodist Dallas, allow endoscopists to offer this technique, which improves safety and efficacy of such procedures. n

Dr. Kedia employs submucosal tunneling technique for POEM procedure.

Pursuing Quality Through Patient RegistriesMulti-center and internal clinical registries help doctors and researchers improve the quality and safety of the care they provide to their patients. To this end, Methodist Digestive Institute (MDI) physicians initiate and participate in clinical databases and registries that involve regional, national, and even international institutions. MDI contributes to this process by collecting and analyzing data on the progress of our patients to compare the effectiveness of different treatments for the same disease or condition, to evaluate various approaches to a procedure, or to see what factors influence patient experience. All patient information is blinded and aggregated to protect patient privacy. Some of the areas where MDI is currently involved in collecting and studying patient data include:

POEM Registry This is a prospective registry enrolling all patients at Methodist Dallas with a diagnosis of achalasia who undergo peroral endoscopic myotomy (POEM) for definitive minimally invasive treatment of this disease. The purpose of this registry is to further study the clinical efficacy, safety, and outcomes of patients undergoing the POEM procedure.

Therapeutic Endoscopic Ultrasound Registry (formerly called EUS-guided ERCP Registry)Multiple therapeutic procedures are performed with endoscopic ultrasound at Methodist Dallas including: 1) pancreatic fluid collection drainage; 2) pancreaticobiliary duct drainage; 3) gastric varices embolization; 4) gallbladder drainage. The purpose of this prospective registry is to further study these emerging techniques in terms of technical feasibility, clinical efficacy, safety, and long-term outcomes of patients undergoing therapeutic EUS procedures.

Endoscopic Suturing RegistryEndoscopic suturing is a novel technique that is being performed at Methodist Dallas for a variety of indications including: 1) securing lumenal metal stents; 2) closure of lumenal leaks/fistulas/perforations; 3) revision of gastrojejunal anastomoses in gastric bypass; 4) primary bariatric procedures. The purpose of this prospective registry is to further study these emerging techniques in terms of technical feasibility, clinical efficacy, safety, and long-term outcomes of patients undergoing endoscopic suturing

ERCP - RFA RegistryRadiofrequency ablation for treatment of malignant biliary strictures is a novel technology with the potential to improve biliary patency in addition to the usage of bile duct stents. The purpose of this prospective registry

is to enroll all patients with malignant biliary strictures who are undergoing repeated biliary stenting to assess the additional benefit of radiofrequency ablation on biliary patency.

Endoscopic Gallbladder Drainage RegistryFor patients with acute or chronic cholecystitis who are not surgical candidates, endoscopic drainage of the gallbladder via transcystic duct stenting through endoscopic retrograde cholangio-pancreatography (ERCP) is being performed at Methodist Dallas. This is a minimally invasive alternative to percutaneous drainage of the gallbladder with possible benefits of less pain, fewer procedures, and reduced adverse events. The purpose of this prospective registry is to study the technical feasibility, clinical efficacy, safety, and long-term outcomes of non-surgical patients undergoing endoscopic gallbladder drainage for cholecystitis

EUS-guided Liver Biopsy RegistryTranscutaneous liver biopsy has limitations in terms of body habitus, pain, and complications (including bleeding). Endoscopic ultrasound (EUS)-guided liver biopsy has been shown in early studies to be an effective alternative with a minimally invasive approach. The purpose of this prospective registry is to study the technical feasibility, diagnostic adequacy, and safety of patients undergoing endoscopic ultrasound-guided liver biopsy for the evaluation of hepatic disorders. Continued on page 4

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DIGESTNANOKNIFE Continued from page 1

Alejandro Mejia, MD, FACS, at Methodist Dallas Medical Center has been using IRE, also known as Nanoknife®, technology to perform pancreas ablation since February 2016. Hepatobiliary surgeons are also employing IRE in liver surgery. “The Nanoknife® offers hope to patients who have unresectable disease due to vascular involvement and can serve as an adjunct to chemotherapy and/or radiation in patients who fail down staging for borderline resectable disease,” notes Dr. Mejia.

Although pancreatic cancer accounts for only three percent of cancers, it accounts for seven percent of cancer deaths, making it the fourth leading cause of cancer death in both men and women.* Furthermore, the prevalence of pancreatic cancer is increasing by 1.3 percent each year. These grim statistics underscore the ever-increasing urgency to develop improved ways to treat locally advanced cancers. “The Nanoknife® technology increases the armamentarium of HPB surgeons to treat tumors close to vascular structures in organs such as liver and pancreas,” explains Dr. Mejia. “These technologies are best offered in high volume centers, such as Methodist Dallas, where the full milieu of treatment options is available and physicians utilize a multidisciplinary team approach to treatment planning.” n

*According to the American Cancer Society.

Often what sets a good hotel apart from a five-star hotel is a great concierge service – someone who knows your needs and matches them with the sites and amenities of the local area. Likewise, nurse navigators at Methodist Digestive Institute work with patients and caregivers to learn their needs and guide them through the complex healthcare system on both an inpatient and an outpatient basis.

Armed with knowledge and understanding of the healthcare process for treatment of digestive diseases, nurse navigators smooth the way, anticipating and clearing roadblocks to ensure easy access to care. Reducing the time between diagnosis and treatment is one of the goals of the Methodist Digestive Institute. Nurse navigators are a key tool to closing the time-to-treatment gap, as is a responsive multidisciplinary team that attends weekly tumor boards to discuss treatment plans and consult with one another frequently.

How do nurse navigator services work? An inpatient nurse navigator is assigned to patients diagnosed with pancreatitis. Navigator services for patients diagnosed with pancreatic cancer, other complex GI cancers, or patients needing pancreatic surgery may be obtained by calling the nurse navigator directly. The navigator will obtain the background on the patient, and will retrieve copies of imaging and lab results for the consulting physicians. Typically, the consultation takes place within one business day. Recommendations are communicated back to the referring physician. Should a patient receive care at Methodist Dallas Medical Center, the nurse navigator will keep the referring physician informed, and follow up with the patient to help transition care back to the referring physician in the patient’s community. To obtain pancreatic nurse navigator services, call 214-933-6601. n

Candice DeLuna, BSN, RN Oncology Nurse Navigator

Beth Lowder, BSN, RN Pancreatitis Nurse Navigator

Nurse Navigators Provide Personalized Service

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Second Annual Pancreas Symposium Set for November 18 in Dallas Speaker line-up unveiled

The only free, regional symposium dedicated solely to pancreatic disease will be held on November 18, 2017, in Dallas, Texas. Presented by the Methodist Digestive Institute, “Pancreatic Neoplasia and Pancreatitis: A Modern Multidisciplinary Approach,” is a day-long symposium that brings together a nationally renowned, multidisciplinary faculty to focus on the most up-to-date clinical practices for the management of pancreatic cancer, pancreatic surgery, and pancreatitis.

This unique symposium will include eight didactic lectures, featuring experts in the field of surgery, medical oncology, gastroenterology, and interventional radiology. Cases will be presented to illustrate treatment approaches in each field, and subsequent panel discussions will include audience participation.

To register for this valuable symposium, visit www.pancreas-symposium.com or call 214-933-6601.

Topics and Speakers Future Direction of Metastatic Pancreatic Cancer Treatment Steven R. Alberts, MDProfessor of Oncology, Mayo Clinic College of MedicineDeputy Director of Clinical Research, Mayo Clinic Cancer Center

Advancements in Treatment of Neuroendocrine Tumors Lowell B. Anthony, MD, FACP Professsor of Medicine, Chief, Division of Medical OncologyUniversity of Kentucky

Percutaneous Management of Locally Advanced Pancreatic Cancer - George Behrens, MDInterventional RadiologyVascular and Interventional Radiology Professionals Chicago, IL

Navigating the Guidelines for Evaluation and Management of Pancreatic Cysts - Robert Hawes, MD Professor of MedicineUniversity of Central Florida College of MedicineMedical Dir., Florida Hospital Institute for Minimally Invasive Therapy

Modern Treatments of Locally Advanced Pancreatic Cancer Milind Javle, MDProfessor, Department of GI Medical OncologyUniversity of Texas MD Anderson Cancer Center

Advancements in Minimally Invasive Pancreas Surgery Michael L. Kendrick, MD Assistant Professor of SurgeryMayo Clinic College of Medicine

Understanding the Alphabet Soup of Hereditary Pancreatic Disease - David Whitcomb, MD, PhD Professor of Medicine/GastroenterologyChief of the Division of Gastroenterology/Hepatology and Nutrition; Director of the Center for Genomic Studies University of Pittsburgh Department of Cell Biology

Changing Epidemiology of Acute Pancreatitis and Current Recommendations for Early Medical Management C. Mel Wilcox, MDProfessor of Medicine; Director of GastroenterologyUniversity of Alabama at Birmingham n

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REGISTRIES Continued from page 2

Radiation-Emitting SIR-Spheres in Non-resectable (RESIN) Liver Tumor (RESiN) RegistryThe RESiN registry is a national, multicenter database that will enroll patients with primary or secondary liver cancer who are scheduled for treatment with Y90 resin microspheres as part of their care plan. The purpose of this registry is to provide information on United States treatment patterns and long-term outcomes with Y90 resin microspheres and will guide future research with this therapy, especially for conditions with limited data. Click here to access the clinical trial website.

For a complete list of ongoing studies, click here. n

The physicians mentioned in this publication are independent practitioners who are members of the medical staff at Methodist Health System. Texas law prohibits hospitals from practicing medicine.The physicians on the Methodist Health System medical staff are independent practitioners who are not employees or agents of Methodist Health System or any of its affiliated hospitals.

Methodist Digestive Institute Methodist Dallas Medical Center1441 N. Beckley Ave., Dallas, TX 75203214-933-6601 (T) n 214-947-1925 (F)DigestiveHealth@mhd.comwww.MethodistHealthSystem.org/mdi4