MDNews - Cleveland-Akron-Canton

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: MINIMALLY INVASIVE PROCEDURES +++ +++ fPOEMor Achalasia A CHALASIA IS A condition which causes di f f iculty swallowing. It's generally progressive and can occur at almost any age. Caused by a lack of ganglion (nerve) cells in the muscle plexis of the esophagus, achalasia leads to lack of conduction of the impulse which normally causes the lower esophagus to relax when one swallows, allowing food to pass into the stomach. Historically, achalasia has been treated in a variety of ways. Short-term, temporary treatments have included pharmacologic therapy and endoscopic therapies with either Botox injections or balloon dila- tion, which may cause residual scarring and make any subsequent surgery for achalasia more complicated. One of the very first surgeries for this chronic disorder utilized whale bone to cut the esophagus. Later, large balloons were used to stretch the esophagus. A similar procedure, pneumatic dilation, is still performed today and can be quite effective in relieving achalasia, but is a little bit uncontrolled and may not have the long-term effect provided by surgical myotomy. In the last decade or two, a procedure which is not new but has become popular is the Heller myotomy. This procedure was initially performed via open sur- gery through the chest or through the abdomen where the muscles of the lower esophagus are separated to allow the underlining mucosa to bulge out, thus purposely weakening the lower esophageal muscle in order to let the food bolus pass. By Jeffery L. Ponsky, MD, FACS, and Jeffrey M. Marks, MD, FACS Today the procedure of choice is a laparoscopic Heller myotomy performed minimally invasively. This is done through four or five small incisions through the abdomen with selective cutting of muscles. Considered to be an improve- ment from open surgery, it still carries some risks such as persistent dysphagia due to incomplete myotomy and reflux disease due to disruption of the lower esophageal sphincter and the surround- ing phrenoesophageal attachments. To minimize this consequence, surgeons routinely add an anti-reflux procedure — a Dor fundolplication — in which the stom- ach is layed on top of the Heller myotomy. Two years ago, a brand new surgical procedure called per-oral endoscopic myotomy (POEM) was conceived using refined technologies and approaches adapted from natural orifice translumenal endoscopic surgery (NOTES). The surgery involves no external incisions. Instead, surgeons enter through the mouth to make a small incision in the inner lining or mucosa of the esophagus. They then create a tunnel underneath the mucosa in the submucosal space all the way down beyond the entry point of the esophagus into the stomach. Next, the circular muscle fibers (inner layer of muscle) of the esophagus are cut endoscopically starting just below the initial mucosal incision and extending on to the stomach. When the procedure is finished, the small opening in the mucosal lining is clipped closed. This was conceived of by researchers in the United States and implemented in Japan by Dr. Haruhiro Inoue who performed the first POEM procedure in 30 | Cleveland-Akron-Canton MD NEWS n MDNEWS.COM n MARCH-APRIL 2012 humans. So far, more than 200 have been done worldwide; six, locally. The results thus far have been excellent. The majority of patients go home the next day and eat normally within one week. They have no scars from the proce- dure. In addition to the cosmetic benefit and quicker recovery, there is potential for a decreased complication of post- procedure reflux disease as the POEM procedure does not involve destruction of the normal anatomy at the hiatus nor division of the outer longitudinal muscle. This will need to be verified, however, through longer-term studies in the future. Candidates for POEM include adult patients with documented achalasia. POEM may also serve a role in select patients with other esophageal motility disorders amenable to surgical myotomy, or division of the muscles. The procedure is of particular benefit in patients where abdominal surgery would be more difficult, such as those who are morbidly obese or have had prior abdominal surgery. In any event, surgeons must con- tinue to be meticulous in their selection of patients, as well as their techniques to obtain excellent results. Dr. Jeffery Ponsky is surgeon-in-chief, University Hospitals (UH) Case Medical Center; where the POEM procedure is performed. He is the Oliver H. Payne Chairman and Professor, Department of Surgery, Case Western Reserve University School of Medicine. Dr. Jeffrey Marks is director, Surgical Endoscopy, UH Case Medical Center, and associate professor, Case Western Reserve University School of Medicine. ■

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