and the Latest Treatment Option:
N.O.T.E.S. (natural orifice transluminal endoscopic surgery)
Peroral (through the mouth) Endoscopic Myotomy (POEM)
Stavros Stavropoulos, MD, internationally recognized pioneer in the treatment of Achalasia and Director of Gastrointestinal Endoscopy and the Advanced Endoscopy Program at Winthrop-University Hospital in Mineola, NY
Latest Treatment for Achalasia in the News
Dr. Stavropoulos and Dr. Inoue perform the first POEMs in Greece. Complete unedited video of the two different techniques used, TT knife by Dr. Inoue and Hybrid knife by Dr. Stavropoulos:
Research study shows advantages of POEM with the HybridKnife: significantly shorter operation time, lower bleeding rate and a lower frequency of usage of coagulation forceps. See “Water-Jet Assisted PerOral Endoscopic Myotomy (POEM) in Comparison to Conventional Endoscopic Myotomy Technique for Treatment of Esophageal Achalasia” (section 719) (PDF)
Achalasia is a disorder of the esophagus (the tube that transports swallowed food from the mouth to the stomach) that makes it difficult for swallowed food and liquids to pass into the stomach. The normal esophagus is a muscular tube that contracts in order to push the food towards the stomach (a function called “esophageal peristalsis”). A muscular ring at the end of the esophagus, called the “lower esophageal sphincter,” acts as a “valve” between the esophagus and the stomach. It is normally in a contracted (closed) state to prevent acid from the stomach from refluxing back into the esophagus. However, when food is swallowed an esophageal contraction starts carrying the food towards the stomach, nerves signal ahead to the lower esophageal sphincter to relax (open) and allow passage of the food into the stomach. After food passes through, the sphincter immediately contracts again and stays closed to prevent reflux of acid and swallowed food back into the esophagus.
In achalasia, due to disease of the nerves of the esophagus, there are no coordinated contractions pushing the food towards the stomach and the lower esophageal sphincter does not relax to let the food enter the stomach. This results in food and saliva accumulating in the esophagus until the accumulated food builds enough pressure to push through the contracted sphincter and enter the stomach. Patients often adapt their diet to this condition consuming more liquid foods and drinking large amounts of water to push the food through.
A number of symptoms are present in achalasia. Difficulty swallowing is the cardinal symptom (the medical term is “dysphagia”, a feeling of the food “getting stuck”). Patients also often have chest pain or “heartburn” (the latter resulting from the retained food in the esophagus being fermented to acids, not reflux of acid from the stomach which is the cause of heartburn in patients without achalasia). Regurgitation of retained food back into the mouth can also be present. Regurgitation of food can result in aspiration of food in to the lungs causing repeated bouts of pneumonia.
Unintentional weight-loss can occur in people with achalasia as the patient’s diet becomes more and more restricted. Achalasia also increases the risk of developing squamous cancer of the esophagus.
Treatment of Achalasia
Achalasia is a progressive unremitting disease. If left untreated over a period of years, it results in eventual massive dilation of the esophagus (known as “megaesophagus”). At this advanced stage the less-invasive treatments that are effective in earlier stages of the disease are not sufficient and invasive surgery of the esophagus - even including removal of the esophagus - may be required.
A variety of treatments for achalasia have been developed. The three standard treatments that are currently most commonly used include Botox injection into the sphincter to cause relaxation, stretching and disruption of the sphincter by inflating a large balloon across the sphincter, or cutting of the sphincter via laparoscopic surgery.
Botox injection is performed through the endoscope and is non-invasive and quick, but temporary. Its effects wane over several months and regular additional and costly injections are necessary. Therefore, this treatment is generally reserved for patients that are very elderly, frail or sick, and would not be able to tolerate any risk of complications resulting from the more aggressive treatments (balloon dilation and surgery).
Balloon dilation is an effective treatment but usually requires repeated treatments at 1-2 year intervals in a significant proportion of patients.
Surgery (laparoscopic Heller myotomy with Dor fundoplication) is effective but about 15- 20% of patients will eventually revert to balloon dilation due to relapse and up to a quarter of patients will have reflux symptoms.
What’s New in Treatment for Achalasia
Stavros Stavropoulos, MD, Director of Gastrointestinal Endoscopy and the Advanced Endoscopy Program at Winthrop (left) and Collin E. Brathwaite, MD, Chief of the Division of Minimally Invasive and Bariatric Surgery and Director of the Bariatric Surgery Center at Winthrop.
Stavros Stavropoulos, MD, Director of Gastrointestinal Endoscopy and the Advanced Endoscopy Program at Winthrop, is pioneering a novel treatment for achalasia that allows cutting of the sphincter through a scarless incision performed via an endoscope introduced through the mouth in the same fashion as in standard upper endoscopy. This technique allows definitive surgical incision of the sphincter muscle without the invasiveness of laparoscopic surgery.
In collaboration with Collin E. Brathwaite, MD, Chief of the Division of Minimally Invasive and Bariatric Surgery at Winthrop, Dr. Stavropoulos has launched a clinical trial of this technique known as peroral (through the mouth) endoscopic myotomy (P.O.E.M.). The technique was invented in Japan in 2009. Winthrop was the first center outside Japan and indeed the first center in the United States to perform this technique in October of 2009.
This unique approach involves passing an endoscope through the mouth into the esophagus while a patient is under deep sedation and then, through special techniques, inserting it in the layer between the inner lining of the esophagus and the muscular outer wall of the esophagus and then “tunneling” with the endoscope in this space within the wall of the esophagus until the lower esophageal sphincter is reached. The sphincter is then cut with a tiny electrical knife and then the endoscope is removed from the tunnel. The entry to the tunnel is closed with small staples and the tunnel collapses and completely seals the cut that was made in the sphincter muscle. This prevents any leak of esophageal contents such as food and saliva into the chest through the cut that was made in the muscle (a serious complication known as “perforation” which occurs in 2-4% of patients undergoing balloon dilation and about 6% of patients undergoing laparoscopic Heller myotomy).
For more information about treatment for Achalasia at Winthrop or to request an appointment with Dr. Stavropoulos, please call 1-866-WINTHROP.