Incisionless surgery gains ground
Jessica Philips, a 28-year-old retail store manager from St. Peters, Mo., suffered for 10 years with swallowing problems that grew progressively worse, until she had trouble consuming any food at all. In March 2017, Jessica was diagnosed with achalasia, a rare swallowing disorder in which the esophagus is unable to move food into the stomach.
The next month — before she could get treatment for the condition — Philips was admitted to Barnes-Jewish Hospital with dehydration. There, she underwent a per oral endoscopic myotomy (POEM), a surgical procedure for achalasia performed via endoscope through the mouth.
Philips’ surgeons, Jeffrey Blatnik, MD, and Michael Awad, MD, PhD, report that patients typically feel no pain from the POEM procedure, in which surgeons relax the muscle that connects the esophagus to the stomach.
“I can eat a regular diet and am sleeping now, the best in years,” says Philips.
POEM is a relatively new, less-invasive alternative to the long-standing conventional choice, the Heller myotomy, in which surgeons access the esophagus through abdominal incisions; originally performed as an open surgery, the laparoscopic Heller surgery has been the procedure of choice since the 1990s. Japanese surgeon Hirano Inoue, MD, performed the first POEM in 2009, and since then the popularity of the procedure has grown. It has a similar success rate as Heller myotomy, with about 95 percent of patients having a significant, long-term improvement in swallowing. Still, it is a highly technical procedure, and a limited number of U.S. centers offer it.
Awad performed Barnes-Jewish Hospital’s first POEM with an interventional endoscopist from the Division of Gastroenterology in 2013. He and Blatnik now perform the procedure together.
“Two- and three-year follow-up in U.S. case studies and longer-term Japanese studies show equivalent outcomes to laparoscopic Heller myotomy,” says Blatnik. “For certain populations, POEM is more effective because you can cut the muscle over a greater length of the esophagus.”
POEM may be just a start for incisionless surgery in the Section of Minimally Invasive Surgery. Awad is looking at a similar treatment for gastroparesis, a disorder that slows or stops the movement of food from the stomach to the small intestine.
Highlights
JEFFREY BLATNIK, MD, has been a champion for the Americas Hernia Society Quality Collaborative (AHSQC) among Washington University surgeons who perform hernia procedures. Formed in 2013, the AHSQC aims to improve the value in hernia care delivered to patients. The collaborative collects patient-centered data on ventral, incisional and inguinal hernia cases, offers ongoing performance feedback to clinicians, and promotes quality improvement. During his postgraduate years at Case Western Reserve Medical Center, Blatnik helped develop metrics for AHSQC.
SURGEONS OVERPRESCRIBE OPIOID PAINKILLERS following surgery, according to research by Section Chief L. Michael Brunt, MD, and colleagues. Patients undergoing minimally invasive surgery consume only a small portion of their dispensed opioid pills and still report decreased pain severity during the first two postoperative weeks. The results are being submitted for publication. Brunt also co-authored a commentary with Evan Kharasch, MD, PhD, in the journal Anesthesiology recommending that surgeons consider reducing the number of take-home opioid pills prescribed after surgery.
SHAINA ECKHOUSE, MD, is working with transplant selection committees to offer weight-loss surgery to obese patients awaiting kidney and liver transplants. Kidney transplant patients with a body mass index of 40 or greater must lose weight before they can undergo their operation. Weight-loss surgery helps them qualify for, and minimize the risks of, transplant surgery. Obese liver transplant patients may also qualify for bariatric surgery; patients with cirrhosis, related complications and portal hypertension undergo a liver transplant and weight-loss procedure simultaneously.
Noted accomplishment
MARY KLINGENSMITH, MD, vice chair of education and the Mary Culver Distinguished Professor of Surgery, became chair of the American Board of Surgery (ABS) board of directors in June 2017. The ABS certifies surgeons who have met defined educational, training and knowledge standards and oversees their continuous certification. As ABS chair, Klingensmith will lead efforts to revamp the certification process and will initiate a strategic planning process. Klingensmith is the third woman ever to chair the ABS since its founding in 1937, and she is the fourth Washington University School of Medicine surgeon to lead the organization.