MEDICAL BREAKTHROUGHS
RESEARCH SUMMARY
TOPIC:
REPORT:
POEM: HELP FOR SWALLOWING DISORDER
MB #3911
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
Clay.holtzman@swedish.org
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.
END OF INTERVIEW
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.
If you would like more information, please contact:
Brian E. Louie, MD
Director of Thoracic Research and Education
Swedish Medical Center and Cancer Institute
Brian.louie@swedish.org
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