Achalasia: incision-free treatment yields poetic outcome

Sitting down to a meal should be one of life’s simple pleasures. For Dan Schmertman, it was anything but pleasurable. The 57-year-old Muscatine, Iowa, resident had lived for years with achalasia, a disorder of the esophagus (the tube that carries food from the mouth to the stomach).

But thanks to a per-oral endoscopic myotomy (POEM), a new procedure at University of Iowa Hospitals & Clinics, eating is now a whole lot easier.

With achalasia, a muscular ring at the point where the esophagus and stomach come together (called the esophageal sphincter) does not relax like it should during swallowing. This prevents food from entering the stomach. People with achalasia often experience regurgitation, heartburn, and chest pain. For some patients, unintentional weight loss also occurs.

For Dan, mealtime was literally hard to swallow.

“I couldn’t eat anything with a skin or a seed,” he says. “I had to chew everything thoroughly. Any kind of solid food would get backed up, and it’d be very painful until it worked its way through. I had to watch what I ate and how much, and I had to eat very slowly. Even then, I’d have severe pain in the pit of my chest two or three times a week after finishing a meal.”

Years earlier, Dan had undergone an outpatient balloon procedure in Muscatine to expand the esophageal sphincter, but this provided only short-term relief. Later, he tried acupuncture, chiropractic, and reflexology treatments, which eased some of his symptoms but did not solve the problem.

Then in 2013, while vacationing in North Carolina with his wife, Dan ended up in an emergency room. What felt like a heart attack was actually achalasia. “I was out of my normal routine—not eating enough soft foods, eating too much too fast,” Dan says. “But that E.R. visit really woke me up. Something needed to be done.”

Back in Iowa, after talking with his family doctor, Dan contacted UI Hospitals & Clinics. There, he met cardiothoracic surgeon Mark Iannettoni, MD, who suggested POEM as a treatment for his condition. The new procedure was a collaborative effort—UI specialists John Keech, MD, FACS, a cardiothoracic surgeon, and Henning Gerke, MD, an interventional gastroenterologist, recently had completed training to perform the POEM.

The procedure was so new, in fact, that UI Hospitals & Clinics was one of fewer than two dozen medical centers in the United States—and the first in Iowa—to offer it.

Before the POEM procedure was developed (by a physician in Japan in 2008), the standard achalasia treatment was a laparoscopic Heller myotomy, a minimally invasive surgery that is effective but requires five incisions in the abdomen to reach the treatment site.

POEM, Keech explains, uses an endoscope (a thin, flexible tube with a light and video camera) through the sedated patient’s mouth. Using a tiny blade that passes through the endoscope, doctors make a small slit in the lining of the esophagus to reach, and carefully divide, the muscle that’s restricting the passage of food. Once completed, the endoscope is pulled back and the slit is repaired.

“The objective is the same as the laparoscopic approach, which is to divide the muscle causing the problem,” Keech says. “We’re able to achieve the same result without incisions on the belly.”

Another advantage of POEM over a Heller myotomy is no restriction in the length of the muscle incision, Gerke says. A longer incision might help patients for whom abnormal contractions of the muscle of the esophagus cause symptoms.

“This is relevant for some patients with achalasia, but also for other diseases of the esophagus—conditions like ‘jackhammer’ or ‘nutcracker’ esophagus or diffuse esophageal spasm,” Gerke says.

For patients, POEM means minimal, if any, pain and a shorter recovery time than with laparoscopic surgery.

“The patient typically spends one night in the hospital, just like they would with the surgical approach, but they usually don’t need pain medications from having multiple incisions,” Keech says. “The patient does a swallowing test the next day to make sure there are no problems, and that’s it. This technique is truly the wave of the future for this type of disorder.”

On Nov. 27, 2013, Dan became the first patient at UI Hospitals & Clinics to undergo the POEM. Keech and Gerke performed the procedure in less than two hours, and all went smoothly. Other than a sore throat afterward that went away in a week or so, Dan emphasizes he could not be more pleased with the results.

“I can highly recommend it. The doctors, nurses, everybody—it was an overall positive experience,” he says.

As for meals, Dan can “eat anything and everything, as much as I want,” he says, adding with a chuckle, “I may even have put on a few pounds—but I’m not complaining.”

–Fall 2014