The rare catastrophic medical event often has no playbook. A medical center able to rapidly deploy the best minds to an uncommon situation can mean the difference between life and death for a patient. No one appreciates this capability better than 19-year-old Josh Szymanek. Several days after undergoing elective surgery at Northwestern Memorial Hospital to treat his inflammatory bowel disease (IBD), he developed a highly unusual complication that almost cost him dearly. Blood clots had blocked vital blood flow involving his intestinal tract and into his liver.
“If I had gone to another hospital for my surgery, I definitely wouldn’t be here today,” says the Northern Illinois University sophomore. “Northwestern Medicine is where you go if you want to get the job done right.”
A year ago during the New Year’s holiday weekend, a multidisciplinary team of Northwestern Medicine specialists dramatically reconfirmed that the teenager had made a good choice. Faced with an extensively clotted abdominal venous system, the likes of which they had never witnessed, these experienced clinicians quickly used their skills and expertise to save Szymanek’s life.
Seeking a Cure
Szymanek had dealt with the debilitating effects of ulcerative colitis since the seventh grade. Driven by intestinal inflammation, the chronic disease causes a variety of symptoms, including abdominal pain, bleeding stool and frequent diarrhea. A patient of the Northwestern Medicine Digestive Health Center, Szymanek had tried all the drugs available to manage his IBD, but to no avail. They either stopped working or didn’t work at all.
“Medical therapy is the first line of treatment for ulcerative colitis,” says Szymanek’s gastroenterologist Stephen Hanauer, MD, the Clifford Joseph Barborka Professor of Medicine and the center’s medical co-director. “When patients don’t respond to the whole gamut of medications, we then recommend surgical removal of the colon.”
Enter renowned colorectal surgeon and the center’s surgical co-director Scott Strong, MD. Specializing in IBD, Strong has performed several hundred restorative proctocolectomies with ileal pouch-anal anastomosis procedures. The closest to a “cure” for ulcerative colitis, the multiphase operation involves removing the large intestine (colon and rectum) and creating an internal pouch to collect stool that will eventually pass through the anus. The procedure allows patients to have close-to-normal bowel movements rather than a permanent external ileostomy bag.
“The colon is usually the problem for people with colitis,” says Strong, the James R. Hines, MD, Professor of Surgery and chief of Gastrointestinal and Oncologic Surgery. “By removing the entire large intestine, our goal is to get patients off medications for good.”
Ready to start living a life free of constantly scoping out restrooms, Szymanek underwent part one of his three-part surgery on December 29, 2015. The routine laparoscopic surgery went well. By day two, Szymanek was walking the hallways and looking forward to going home to Tinley Park, Illinois. Then his vital signs crashed.
“Josh said he was losing feeling in his abdomen and legs,” recalls his mother, Jennifer, a registered nurse with 28 years’ of hospital experience. “He was bottoming out. He became extremely ill very fast.”
Imaging tests revealed blood clots in Szymanek’s superior mesenteric and splenic veins and ultimately, portal vein. These conduits all drain blood from the gastrointestinal system into the liver for detoxification. “Imagine a tree with branches,” Strong explains. “Josh had clots in the smaller branches leading into the trunk or portal vein.”
To make a bad situation even worse, Szymanek also had developed a rare clot in his superior mesenteric artery, which supplies oxygenated blood directly to the intestines. In short, his intestinal tract could not get rid of or receive any blood flow, and he was quickly going into organ failure and possible death.
Late in the evening of his fourth day in the hospital, Szymanek was transferred to the intensive care unit and started on a standard anticoagulant therapy. Several hours later, it was clear that the blood clot-busting drugs were not working. It was a dire situation that called for innovative thinking. Fibrinolytic therapy — delivering blood thinning thrombolytic drugs via catheter directly into the vein — came to Strong’s mind, even though the procedure is typically performed to break up acute pulmonary embolisms in the lung. So he called in the interventional radiology (IR) team. Recalls Strong, “We discussed using the therapy but then they said, ‘We have something better.’”
Creative Problem Solving
In his 30 years at Northwestern, interventional radiologist Robert Vogelzang, MD, ’77, ’81, ’82 GME, had never before encountered such clotting in a patient with a seemingly healthy liver. But it didn’t matter. Vogelzang, the Albert Nemcek Professor of Interventional Radiology Education and former chief of Interventional Radiology, knew how to remove clots using minimally-invasive endovascular techniques. And he worked with livers all the time, performing advanced liver interventions — albeit usually in patients with liver failure due to disease.
Vogelzang began with a catheter-based procedure routinely used to alleviate portal vein hypertension known as TIPS (transjugular intrahepatic portosystemic shunt). He gained access to the portal vein through a vein in Szymanek’s neck and inserted a stent into the liver. By creating a pathway into the venous system, the IR team manually pulled out the clots blocking blood flow to the organ.
In the meantime, Matthew Potts, MD, assistant professor of Neurological Surgery and an expert in neurointerventional methods, assisted with removing the clot in the mesenteric artery. Potts used a device normally employed for removing blockages in cases of acute ischemic stroke. By the end of the six-hour procedure, the IR team had restored blood flow in and around Szymanek’s liver.
“Josh was in the right place with the right people ready to help him,” Vogelzang says. “We combined all the things we know how to do to come up with an outside-of-the-box solution for him. It’s this type of collaboration and expertise that exists in spades at Northwestern Medicine and allows us to treat patients the best way we can.”
On December 15, 2016, Szymanek underwent the last of the three surgeries for his ulcerative colitis. A weight lifter who lives for going to the gym, he’s feeling better every day.
“Every time I got sick from my colitis, I would have to stop working out,” he says. “Now I can finally get back into it without any setbacks moving forward.”