New Procedure Is Easy to Swallow

    David Cournoyeris actually happy he is gaining weight.

    The 57-year-old North Attleboro, Mass., resident sees it as a benchmark of success after undergoing a per-oral endoscopic myotomy (POEM), a new surgical treatment for achalasia. The rare disorder occurs when the muscle at the bottom of the esophagus that normally functions as a valve fails to relax, preventing food from entering the stomach. Patients with achalasia feel like they can’t swallow.

    “People assume that when they eat, food just falls into the stomach like water pouring out of a pitcher,” says David Rattner, MD, chief of the MGH Division of General and Gastrointestinal Surgery at the Digestive Healthcare Center. “In reality, the ring of muscle called the lower esophageal sphincter opens and closes with each swallow to control transport of food and to keep it in the stomach once it gets there. If it stops working, you have a big problem: it can cause choking or difficulty swallowing that is severe enough to cause extreme weight loss.”

    The symptoms are quite familiar to Cournoyer, who struggled with achalasia for almost three years. “Before the surgery, I felt like I wanted to throw up all the time,” he says. “It was terrible, a horror show. I lost over 40 pounds. It was a really uncomfortable, scary way to live.”

    On April 12, Cournoyer became the first patient at the MGH and in Boston to undergo the POEM procedure. Rattner performed the procedure alongside surgeon Ozanan Meireles, MD, in under two-and-a-half hours.

    Rattner says a standard way to treat achalasia is with a laparoscopic Heller myotomy, a surgery that is effective and minimally invasive, but requires four or five small cuts in the abdomen to reach the area that needs attention. Those incisions cause pain and require a certain amount of time to heal. “With the POEM procedure, we go in through the patient’s mouth and, using a small knife that passes through an endoscope, make a slit in the inner lining of the esophagus to tunnel down to the sphincter muscle,” explains Rattner. “We then cut this muscle so that it no longer blocks the passage of food. Once we confirm that we have relieved the blockage caused by the malfunctioning sphincter muscle, we pull the endoscope back and repair the slit.”

    Because there are no pain fibers in the esophagus, the patient experiences little to no pain. “Less pain usually means a faster recovery period,” Rattner says.

    And for Cournoyer it also means a healthy weight gain of about 15 pounds and a strong sense of gratitude. “When I woke up from surgery, I felt great. I ate some Jell-O that night and when I put it in my mouth and swallowed – it was such a weird feeling. The food went down and I didn’t have any problems. I was just so relieved,” he says. “I am blown away by how effective the procedure was. Dr. Rattner and this surgery changed my life.”

    The POEM procedure was developed by a physician in Japan, but stemmed from Rattner’s Center for Integration of Medicine and Innovative Technology-sponsored Natural Orifice Translumenal Endoscopic Surgery (NOTES) research. Since 2006, the NOTES program has worked to develop minimally invasive surgical procedures using the body’s natural orifices as entrance points for surgery. In doing so, the hope is to reduce pain and scarring, and to speed recovery time.

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