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Inside Tract - Endoscopy into the breach

Inside Tract Winter 2012

Endoscopy into the breach

Date: November 15, 2011

Hopkins begins new approach to achalasia

Kalloo and Mills
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Dr. Kalloo told me I couldn’t live this way,” says patient Connie Mills. Now she won’t have to. At the close of the historic Hopkins procedure, visiting/advising Japanese surgeon Haruhiro Inoue (far left) first to apply NOTES for achalasia to patients, stands beside Anthony Kalloo (next), the approach’s pioneer.

Patient Connie Mills, 55, was five hours’ drive from Johns Hopkins, but a world away from what’s typical in terms of having her achalasia treated.

This November, Mills became the first patient at Hopkins, and one of a handful in the United States to undergo a NOTES procedure to correct an overzealous lower esophageal sphincter.

The natural orifice transluminal endoscopic surgery, performed by a team of endoscopists with surgical backup at the ready, took place in an endoscopy suite—also a first—rather than in the OR where a traditional operation would occur.

With an oral approach and no external incisions, the inner circular muscle of Mills’ sphincter was neatly resected. Blood loss was less than an eyedropper-full.

The operation was a satisfying close to a full circle that had begun at Hopkins in the late 1990s. A bench-to-bedside story, NOTES started as a brainstorm that hit gastroenterologist Tony Kalloo as he readied a talk on the future of endoscopy. “I’d been thinking how surgery had become less invasive, from open to laparoscopic, while endoscopy had taken its own direction from diagnostic to more adventurous.”               

Endoscopists now removed colonic polyps, for example, or drained pancreatic pseudocysts—domains once strictly surgical. Maybe, Kalloo told himself, we could take out the gallbladder.

But could he challenge gastroenterologists’ sacred rule: Thou shalt not breach the gastrointestinal wall?

Kalloo soon assembled a GI team that included GI colleagues along with surgical and ob-gyn specialists from around Hopkins—a pioneer group game for long hours in animal studies.

In 2004, their first published account of NOTES described peritoneal scans and liver biopsies in pigs in which standard oral endoscopic approaches veered into the abdominal cavity via gastric puncture.

Today, over 3,000 of the hardly-invasive NOTES have taken place worldwide, including transgastric appendectomies and transvaginal gallbladder removal. For now, most are hybrid procedures that blend laparoscopic surgery and endoscopy.

At Hopkins, this November’s “pure” procedure couldn’t have come soon enough for patient Mills.

Despite her sunny disposition, her life was ruled by achalasia. She learned to carry paper cups to catch unbidden food backflow. “Cold liquids would literally shoot from my mouth,” she explains. The ability to eat meat dwindled to “paper-thin turkey in a lot of gravy.” Some weeks she lived solely on soupy peach cobbler. “My worst fear,” she says, “was to be in a car crash and have to lie flat in an ambulance. Then I’d aspirate the cobbler and that would be the end of me.”

Mouen Khashab began Mills’ NOTES quietly, feeding the endoscope tipped with a tailored needle-knife into the esophagus, then puncturing the mucosa some 5 inches above the target sphincter.

The key, he says, is easing the endoscope into the submucosal space, gently tunneling down the esophagus: “Traveling between layers lessens the risk of perforation and puts you in a good approach to the muscle below.

“And we believe there’s an advantage in taking out only that immediate circular muscle of the sphincter,” he says. “Leaving the remaining longitudinal layer offers enough closure to prevent severe reflux from the stomach.” Studies to compare the NOTES approach and laparoscopic surgery, which removes both layers, will tell for sure.  

Khashab closed the entry with “a few standard clips.” Quick testing showed that Mills’ esophageal pressure and emptying fell in a good range. A few days later, one pleased lady reported easy swallowing.

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