Imagine if you felt like you were going to choke every time you ate food or drank liquid? That's what people with a condition called achalasia have to deal with daily. Now there's a simple procedure that could offer relief, it's surgery without an incision!
Don Ellison has been a welder for more than 30 years and he's loved every minute of his job.
Ellison told Ivanhoe, "To me, it's like money for nothing. I mean, I enjoy this!"
But a few years ago, work became harder when Don started having trouble swallowing.
"I was working here one day, and I had a corndog, and it felt like it was stuck in my throat" Ellison explained.
That happened every time he ate or drank! Don went from 170 pounds to 129 pounds!
Ellison told Ivanhoe, "I would choke on water!"
Don had a condition called achalasia, it happens when the esophagus doesn't contract.
Brian Louie, M.D., FRCSC, FACS, Thoracic Surgeon at Swedish Medical Center and Cancer Institute in Seattle, Washington told Ivanhoe, "They can't swallow regular food. They have trouble swallowing liquids, and they get a sensation that stuff just sits in their esophagus."
One way to relieve symptoms is surgery to cut the reflux muscle in the esophagus. Dr. Louie is now doing that without making any incisions on the outside of the patient's body.
"It's truly what people consider natural orifice surgery" Dr. Louie said.
With the POEM procedure, surgeons put a scope down the patient's throat. Then they weave small instruments down the esophagus and cut the muscle, helping it relax. Patients go home the next day and are back at work within a week.
Don had the procedure and didn't miss a beat at work. Now he can eat and drink without choking.
Ellison exclaimed, "I feel like I'm back in the game!"
Achalasia is rare, and doctors don't know exactly what causes it. It can occur at any age, but is most common from the mid-20s to the 60s. Other treatments may include Botox or a procedure where doctors stretch the esophagus called dilation.
Contributors to this news report include: Cyndy McGrath, Supervising Producer; Marsha Hitchcock, Field Producer; Cortni Spearman, Assistant Producer; Rusty Reed, Videographer and Jamison Koczan, Editor.
BACKGROUND: Achalasia is a disease where the function of the esophagus stops working overtime. The disease is a disorder of the esophagus that occurs to due to the degeneration of the nerve network within the walls of the esophagus. The disease leaves patients with little propulsive power to push food toward and into the stomach as well as causing the valve at the top of the stomach to remain closed. Because of this it is very hard for patients to eat or drink anything. Some may need to drink a lot of fluids in order to get food into the stomach and others may feel pain and/or discomfort after eating. Some patients suffering from achalasia may have undigested food come up many hours after eating or when lying down.
(Source: Brian E. Louie, MD, Director of Thoracic Research and Education)
SYMPTOMS: Symptoms of achalasia may include:
· Regurgitation of food
· Chest pain or pain felt in the back, neck and arms
· Cough
· Difficulty swallowing liquids and solids
· Heartburn
· Unintentional weight loss
Many patients who suffer from achalasia cannot swallow regular food, they have trouble swallowing liquids and they get a sensation that food sits in their esophagus.
(Source: http://www.nlm.nih.gov/medlineplus/ency/article/000267.htm)
NEW TECHNOLOGY: Prior to the POEM procedure, many patients would opt for a laparoscopic surgery which entails cutting the muscle of the valve with five small incisions. POEM or Per Oral Endoscopic Myotomy now offers patients an incision-free option where that muscle is cut by introducing an endoscope through the mouth and into the esophagus. POEM is the first natural orifice surgical procedure. Brian E. Louie, MD, FRCSC, FACS, Thoracic Surgeon at Swedish Medical Center and Cancer Institute performed the first POEM procedure in Seattle, Washington on July 18th 2014.
(Source: Brian E. Louie, MD)
FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:
Clay Holtzman
Media Relations Manager
206-386-2748
If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com
Brian Louie, M.D., Thoracic Surgeon at Swedish Medical Center and Cancer Institute explains what achalasia of the esophagus is and the procedure that is fixing it.
Interview conducted by Ivanhoe Broadcast News in November 2014.
What is achalasia?
Dr. Louie: Achalasia is a disease where the function of the esophagus stops working over time. It's thought to be neural degeneration of the nerve fibers in the body of the esophagus. The esophagus stops pushing food downwards. As a result of the deterioration of the nerve function, the lower esophageal sphincter, or the barrier which keeps things in the stomach and prevents you from having stuff come up, stays tonically closed and only opens to a certain level of pressure. People begin to experience trouble swallowing. They can't swallow regular food, they have trouble swallowing liquids and they get a sensation that stuff just sits in their esophagus.
Is that what happens, does stuff just sit there?
Dr. Louie: Stuff just sits there until you build up enough of a column of pressure and when you reach that pressure point, the valve will open. It will only open in that fashion because there's no nerve conduction that tells the valve to open up in response to having a swallow.
Is it like GERD where over time it can cause cancer?
Dr. Louie: No. This not the same as GERD causing cancer. But, if you have untreated achalasia over 20 or more years, then, there is the possibility you can develop cancer. But, it's not the same as having a reflux related esophageal cancer.
Is achalasia something that can just happen?
Dr. Louie: With some people, there will be a switch where they go from one day swallowing fine and then over a very short period of time discover that they can't swallow a variety of things. They will lose weight and develop symptoms from achalasia. For other people, it takes them several years to develop the symptoms of achalasia. They first notice that maybe bread doesn't go down very well, and then they notice that meat doesn't go down very well, and they slowly get to the point where both liquids and solids don't go down very well. It may take them several years for them to get there. So, there's a wide variety of presentations of achalasia.
For Don, it was like he had something stuck in his throat or he felt like it just didn't go down and worried that he'd choke. Is this true?
Dr. Louie: Well, choking and getting something stuck in your esophagus are two different things. Choking is getting food in your airway and blocking the windpipe. You do the Heimlich to relieve that pressure in the airway or that blockage in air so you can breathe. With people who have achalasia, the food goes down properly into their esophagus but it stays there and then you can just feel it. People develop pressure, they develop chest discomfort, and they might salivate heavily until they can get the food to either go down into the stomach or they throw it up the other way.
Is achalasia often misdiagnosed?
Dr. Louie: I think it depends on whether you've had any experience with the disease. I do think people, because the symptoms are vague, often think its reflux. They can't swallow, so they go through a variety of sort of scenarios and evaluations by different physicians before somebody says, you need to go see an esophageal physician or a gastroenterologists or a surgeon who knows something about esophageal disease. For me, when I listen to the story, it's very clear that he has achalasia. But, if you don't see it all the time you're not necessarily going to pick up on that because trouble swallowing is very common. Lots of people have some sort of trouble swallowing. It can be very minor or can be very dramatic.
What would be the conventional treatment before POEM?
Dr. Louie: The are two conventional treatments for achalasia before POEM came along. First, is called dilation. People place a large balloon down the endoscopy and against the sphincter. The balloon is inflated to stretch the sphincter by tearing the muscle to allow it to stay open. Second, is surgical cutting of the muscle or a myotomy. This has been a laparoscopic operation where we put five small incisions and a camera into the patient's abdominal cavity. We cut the sphincter muscle from the outside to allow passage of food. When you cut the muscle, by definition, you will give that patient gastric esophageal reflux disease because you basically cut the reflux muscle. That generally relieves the trouble swallowing and people can eat a whole lot better after that.
What muscle do you cut?
Dr. Louie: The lower esophageal sphincter is what's cut. Three or four years ago some innovative endoscopists decided that maybe we can cut the muscle internally. The POEM procedure, or peroral endoscopic myotomy, takes advantage of the fact that there are different layers in the esophagus. You can be in between those layers of the esophagus and cut that muscle still endoscopically with just passing a camera and a scope down your mouth and having no incisions on your abdomen. The advantage is truly what people consider natural orifice surgery and the fact that you go in through the mouth. You make a small cut in the wall of the esophagus and go between the layers and then cut that exact same muscle that you would normally laparoscopically do. Then, you come out; close the hole in the esophagus and do it all with an endoscope as opposed to laparoscopic operation.
Is there any more risk with it this way?
Dr. Louie: In the studies that have been done, the risk of the POEM procedure is about the same as the risk of the laparoscopic surgery. You don't want to subject patients to anymore risk if you are developing a new procedure or you're starting a new procedure.
Could it hurt any other muscles or damage anything else?
Dr. Louie: Generally not because you are in a very confined space. The reported complication rate after a POEM procedure is very, very small, about less than one-percent. The same goes for laparoscopic procedure. There's a less than one-percent complication to which is very small.
What's the healing time for the laparoscopic surgery?
Dr. Louie: For patients who have a laparoscopic myotomy for achalasia, they usually stay overnight in the hospital. They are typically back up and running at work within a couple of weeks. For the POEM procedure, right now we keep everybody overnight as well, but they have no incisions to recover from. They have very little postoperative discomfort because they don't have any incisions on their abdominal wall and generally they're back at work within less than a week.
Can they eat immediately?
Dr. Louie: We keep them on a liquid diet immediately after surgery and keep them on a liquid diet for a couple of weeks. That's no different whether we do it laparoscopically or with the POEM. We manage the patients the same way.
Do you see this as a cure?
Dr. Louie: The procedures are not designed to cure achalasia because there's no known cure. The procedures are designed to improve the ability to swallow food and liquids. That's all they are designed to do.
So what causes achalasia?
Dr. Louie: Nobody knows what causes achalasia. There are lots of theories. Some of them are autoimmune, some of them are virally mediated, but nobody knows the cause of achalasia at the current time.
Does cutting the muscle make it normal again?
Dr. Louie: The muscles are much improved. Some people do get back to normal, but the esophagus is still abnormal because we haven't changed it. So they can have some residual symptoms with either procedure.
What would continue?
Dr. Louie: Some people still need to drink a little bit of water to get the food to go down because the propulsive power of the esophagus is gone. All you now have is a tube and all you're relieving at the bottom end of the tube is the valve. You want to make it easier for food to go through that valve.
The outcome for Don has been dramatic?
Dr. Louie: Yes. For Don, the outcome has been dramatic because he has changed the way he lives. He wouldn't eat at work; he wouldn't go to restaurants and has done so for over a decade because he was fearful of what might happen. We've given him his confidence back and some of his quality of life back to go out to a restaurant to eat, to eat at work with his colleagues, which he's ecstatic about.
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.