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Multidisciplinary Collaboration Provides Novel Therapy for Swallowing Disorder

Eating, chewing, swallowing, digesting � it�s a process that most people take for granted. Yet for the thousands of Americans who suffer daily with achalasia � a disorder of the nerves and muscles of the esophagus that hinders the passage of swallowed food and liquids into stomach � the condition can be debilitating.

�Achalasia disrupts the organized contractions of the muscle in the esophagus that propels food into the stomach, preventing the muscular valve between the esophagus and the stomach � known as the lower esophageal sphincter (LES) � from relaxing. As a result, patients rely on drinking copious amounts of water and eating upright in order to facilitate the movement of food down the esophagus and into the stomach,� said Stavros Stavropoulos, MD, Director of Gastrointestinal Endoscopy and the Advanced Endoscopy Program at Winthrop. �If left untreated, achalasia can result in significant complications.�

For more than a decade, a laparoscopic surgical procedure known as Heller myotomy has been the primary treatment of achalasia in patients at low surgical risk. However, an emerging field known as natural orifice transluminal endoscopic surgery (NOTES) is changing the landscape for surgical interventions. The approach involves passing an endoscope � a thin tube with a built-in camera, light and miniscule tools � through the natural orifices of the body in order to perform surgery non-invasively, without any external wounds or scars.

8 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.
Determined to provide select achalasia patients with a non invasive version of surgical Heller myotomy, Dr. Stavropoulos joined forces with Board certified surgeon and critical care specialist Collin E. Brathwaite, MD, Chief of the Division of Minimally Invasive and Bariatric Surgery and Director of the Bariatric Surgery Center at Winthrop, to launch a clinical trial of an investigational technique known as endoscopic submucosal myotomy.

This unique approach involves passing an endoscope through the mouth into the esophagus, where a small incision is made on the lining of the esophagus, known as the mucosa. A balloon is then inserted and dilated in the submucosa � the layer between the inner lining of the esophagus and the outer wall consisting of the muscle of the esophagus. Dilation of the balloon in the submucosa creates a tunnel that allows insertion of the endoscope and access to the muscle of the LES. A long incision is then carefully made on the posterior portion of the muscular ring that forms the LES. The incision divides the muscle fibers of the LES, which weakens the muscle, allowing for the easier passage of food while preserving some valve function to prevent reflux of acid from the stomach into the esophagus.

As a result of Dr. Stavropoulos and Dr. Brathwaite�s unique multidisciplinary collaboration, the first clinical application of this novel technique in a patient in the United States took place at Winthrop. To-date, the trial has delivered promising results for three patients, with two additional patients scheduled to undergo treatment in the coming weeks.

�Our research was accepted for publication in the prestigious peerreviewed medical journal Gastrointestinal Endoscopy. It was also presented at the 2010 Digestive Disease Week � the world�s largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery,� said Dr. Stavropoulos, noting that the technique was initially developed in animal models by researchers at the Mayo Clinic, first performed in a porcine model in 2007, and first performed in a human patient in Japan in 2009.

�Winthrop is the first and only Center in the area performing this cutting-edge intervention,� noted Dr. Brathwaite. �The strong multidisciplinary collaboration among Winthrop�s GI Division and the Department of Surgery enable a patient�s care to be seamlessly coordinated throughout the entire process.�

Upon an initial consultation with Dr. Stavropoulos, where all treatment options are discussed, patients undergo a comprehensive evaluation involving a barium swallow, CT scan, endoscopy and a high resolution manometry study � a state-of-the-art functional assessment of the physiology of the esophagus. The study is conducted and interpreted by Winthrop�s Bhawna Halwan, MD, who possesses specialized training in this technique.

Patients also receive a comprehensive consultation with Dr. Brathwaite. In cases where endoscopic myotomy is chosen, the procedure is performed by Dr. Stavropoulos. If there is a need to assess the incision (or exclude a small perforation), Dr. Brathwaite uses a small laparoscopic instrument to make a very small key-hole incision in the patient�s abdominal wall. Using a small scope equipped with a camera, he checks for leakages from the esophagus while Dr. Stavropoulos fills the esophagus with a special dye that makes leaks more readily visible.

The entire procedure takes just over an hour. Patients are generally discharged within 24 hours with little or no pain. Six weeks after the procedure, patients are prompted to return to Winthrop to undergo a follow up manometry study to examine the pressure levels in the LES and esophagus.

As the Winthrop pilot study continues to gather data on the effectiveness of endoscopic submucosal myotomy in select achalasia patients, it is the hope of these Winthrop physicians that this will in turn lead to future multi-center trials of its efficacy when compared to surgical treatment.

For more information on interventional endoscopic services at Winthrop, call 1-866-WINTHROP.
Vol. 20, No. 2
Summer/Fall 2010

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