Saving Terri: Incisionless surgery for swallowing

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ST. LOUIS, Mo. (Ivanhoe Newswire) –Imagine not being able to eat or drink without pain, nausea, or vomiting. That’s the reality for people with a condition known as achalasia. Now, there’s a new procedure to fix the problem and there is no incision required!

Today, Terri Conley savors every bite of food. Not long ago, she wasn’t able to swallow without pain.

“It’s like wow, I can’t eat. I really can’t eat,” Terri told Ivanhoe.

Terri lost 86 pounds, was malnourished, and had no energy to perform her job as a dental hygienist.

“I went to the doctor, and they said, ‘Oh, you know, take some Prilosec and get the stress out of your life,’” Teri explained.

However, another doctor and an ultrasound revealed Terri had achalasia—a condition where the base of the esophagus doesn’t relax, so food can’t pass through to the stomach. The result is pain and vomiting.

“In really severe cases, they can’t even take liquids or swallow their own saliva,” Michael M. Awad, MD, PhD, FACS, Director, Washington University Institute for Surgical Education (WISE), Washington University School of Medicine in St. Louis, told Ivanhoe.

Doctors at Washington University are performing a new procedure to fix the problem. They enter through the patient’s mouth and make a small incision on the lining of the esophagus, cut the muscle in the lower esophagus to help it relax, allowing food to pass through.

“Since there’s no pain fibers in the GI tract, people don’t feel this,” Faris M. Murad, MD, Interventional Endoscopist, Director of Endoscopic Ultrasound, Washington University School of Medicine, St. Louis Children's Hospital, told Ivanhoe.

Now, Terri can eat what she wants.

“When I finally got to eat what I wanted to eat, I wanted to make chicken enchiladas. That was the one big thing,” Terri said.

This procedure was first performed in japan. To date, there have been a little more than 400 incisionless procedures worldwide for achalasia. About one in 10 thousand people have this condition. Doctors don’t know what causes it, but some have theorized that it may be triggered by a virus.

BACKGROUND: Achalasia is a disorder that prevents people from eating and drinking. The disorder takes place in the esophagus and does not allow food to pass into the stomach. The esophagus is compromised and is no longer available to transfer food to the appropriate organs. This happens due to damage done to the nerves in the esophagus and is not curable. (Source:

CAUSES: Doctors do not know the exact cause of achalasia, but they believe that it stems from a virus. Cancer in the upper stomach, or esophagus, as well as a parasite infection can also cause achalasia. This disorder is very rare and can occur at any age. Achalasia is more common in older or middle-aged adults, and it can be inherited. (

SYMPTOMS: First, symptoms are mild, and then grow worse.Common symptoms of achalasia are:

NEW PROCEDURE: There are different ways to treat achalasia, but most of the treatments include surgery. Now, doctors can perform a minimally invasive surgery to help patients with achalasia. This is one of the first of its kind in the region performed through a natural opening in the body rather than an incision.  “When we swallow, it’s important that foods and liquids move through the esophagus into the stomach,” Dr. Faris M. Murad, was quoted as saying. “Patients with achalasia develop chest pain, and sometimes the problems are so severe that patients get liquid in their lungs, causing pneumonia. But the main difficulty is that food and liquids tend to fill the esophagus and then are regurgitated.”  Some patients get treated with drugs or with a procedure that involves inflating a balloon to stretch the opening between the stomach and the esophagus.  About half receive laparoscopic surgery, which involves many keyhole incisions in the chest and abdomen.  The new procedure was first performed in Japan and is part of a trend to make surgery increasingly less invasive. (Source:

Michael M. Awad, MD, PhD, FACS, Associate Dean, Medical Student Education, Program Director, General Surgery, Director, Washington University Institute for Surgical Education (WISE), Washington University School of Medicine, talks about a new procedure for achalasia.

Achalasia, what is it?

Dr. Awad: Achalasia is a somewhat unusual disorder. It’s a swallowing disorder that affects about one in one hundred thousand patients a year. It’s a little bit unknown as to what the cause is and it affects people of all ages, of all backgrounds. The root of the problem is Normally, the sphincter between the esophagus and the stomach is closed but opens to allow food to pass through. In patients with achalasia, the sphincter doesn’t relax properly.

It doesn’t push the food down into the stomach, is that what it is?

Dr. Awad: That’s right. When people swallow the food hits that sphincter and it stops there, and then they have chest pain, the food comes up, they have nausea and vomiting. Initially it’s to really tough foods like steak and breads however over time it progresses to even soft foods and in really severe cases they can’t even take liquids or swallow their own saliva.

Does it happen quickly?

Dr. Awad: In some patients it slowly progresses, it can increase over a years’ time frame. However, in Terri’s case really in over just a few months’ time period she went from normal to very severe achalasia.

There is no reason, no known because it just happens?

Dr. Awad: Unfortunately not. There are a lot of theories, perhaps a virus that might cause it, but the short answer is that we still don’t know what causes achalasia.

How do you treat something like that? Before you do that I would think these people once they get to you they’re just desperate.

Dr. Awad: Very much so and you’re exactly right in that you know, often times it’s something we take for granted. Eating and drinking normally is something we do automatically, and as you say it’s a very important part of our lives both you know for health reasons but social reasons as well. In patients with achalasia they don’t have that at all, they are just miserable. Miss Connelly is an example but I’ve had patients in my clinics that have come in with their spouse really in tears because their lives have been turned upside down. They can’t go out to restaurants; they can’t meet with friends because they’re always vomiting up their last meal or their food. They’re losing weight, they’re weak, and they can’t do their jobs or their normal activities and exercises. It really is a life changing disease.

When you don’t get the basic food that you need, what can happen to your body?

Dr. Awad: It depends on if it’s just a gradual progression disease or rapid. In general, the initial is weight loss and most of us have some extra stores where in the beginning it’s manageable. However, in the end stages of achalasia then the signs of malnutrition weigh in or set in. Which is loss of hair poor dentition or teeth, skin easy bruising and bleeding and other manifestations of malnutrition.

Traditionally how did you treat this?

Dr. Awad: Achalasia has been recognized as disease for over a hundred years. The real gold standard of treatment right now for achalasia is a surgical one. Fortunately, it can be done laparoscopically which means a keyhole approach can be used, the same type of surgery that’s used to take out people’s gallbladders. Through small incisions that are roughly a quarter to a half inch in size. During that surgery the abdomen is inflated with carbon dioxide, a scope and instruments are put in and that muscle that overlies that esophagus, right between the esophagus and stomach a slit is made in that muscle, and what that does is it permanently relaxes that muscle and that allows food then to pass through more easily.

Do you lose anything by doing that?

Dr. Awad: The one of the potential risks is that valve is there for a reason and that is to prevent gastroesophageal reflux disease or GERD. If you do that procedure by itself it can result in really bad reflux disease where the acid comes from the stomach and washes back up in to the esophagus. If we did the muscle-splitting procedure by itself it could result in that reflux so what we also do during that procedure is what’s called a fundoplication or a wrap. Where part of the stomach is taken and wrapped around the esophagus to create kind of a new anti-reflux valve. That’s a good question.

GERD can also be a precursor to cancer right?

Dr. Awad: In a very small number of cases it really can lead to esophageal cancer.

Now, you don’t have to do any incisions right?

Dr. Awad: That’s right, yes.

That’s a great thing. That’s a huge advancement.

Dr. Awad: Yes, in minimally invasive which is my field, and really in all types of surgery we’re always looking for the Holy Grail. Which is a procedure that a patient could walk in with really minimal preparation, they come in they go and have the surgery with minimal anesthesia, they feel no pain, and they wake up from the procedure and can go back to their regular lives the same day. Or the next day and soon thereafter go back to eating and drinking normally, going back to work and all their normal activities. That’s the Holy Grail of all types of surgery that we do. One of the things that we’re so excited about this new procedure the POEM procedure is that it brings us probably the closest we’ve ever been to that Holy Grail.
