 acalizes the disorder of the esophagus, which is essentially the the muscular tube that conveys the food from the mouth to the stomach. So this tube has two important functions. One is to propel the food from the mouth to the stomach. And how does it do that? It generates a wave of muscular contraction that runs from the top of the esophagus to the end of the esophagus where it meets the stomach and squeezes the food balls down until it enters the stomach. The second function is it has a barrier between the the main body of the esophagus and the stomach. This barrier is located, if you can see over here, right in the junction here between the stomach and the esophagus. You can see this fleshy muscular tube, the esophagus, which is what brings the food down. And then this sphincter, which is a circular muscle, is essentially the gatekeeper that opens to let the food through and when it functions properly, it prevents them food or acidic contents of the esophagus from squirting back into the esophagus and causing heartburn or reflex-related symptoms. So when these sphincter functions normally, it lets the food through but prevents, but then contracts and prevents stoma contents from going back into the esophagus. Essentially, there is this function of the muscle of the esophagus. And this consists of essentially two main issues. Number one, the contraction of this part of the muscle, which happens sequentially as a wave and pushes the food down, is dysfunctional. The esophagus doesn't contract in a sequential way to push the food down. So that the medical term for that is aparystalsis, which is again like a-calacia. It's from the Greek, a means not to have. So aparystalsis means you don't have peristalsis, which is the propulsion of the food. And then you also, the second feature is, which gives the disorder its name, is the lack of relaxation. This sphincter here, this circular muscle, you can see the thickening here in the muscle that is normally closed, preventing gastric contents from going backwards and letting the food through, doesn't relax properly. Normally, there are these nerves that run along the esophagus that when you put food in your, in your mouth and start trying to swallow it, they give a signal down to the sphincter that food is arriving and it's timed. There's a reflex that is properly timed. So as the food is coming down, the sphincter relaxes to get it through. So this reflex is not functional in a-calacia. So food is coming through, but the signal to relax does not operate. So the food finds a closed sphincter, which does not relax and starts accumulating in the esophagus. And the, the classic symptom from, for a-calacia that patients tell you is that they feel that the food gets stuck and they often need to consume large amounts of liquid or water, which as the, as the water accumulates in the esophagus, it increases the pressure, the hydrostatic pressure, until it reaches a pressure level similar to what pressure the, the sphincter exerts. And when that gets exceeded, the, finally the, the food gets flustered through. Let's discuss the evaluation of patients with suspected a-calacia. The first part of the evaluation involves a very simple test that has been around for decades, which is having the patient swallow a white liquid that is visible on x-ray. It's very dense. It contains the element barium. So the test is called a barium swallow and then taking x-ray pictures to sequentially to follow the movement of this barium that was followed across the esophagus and see if there are any areas where there may be partial or complete obstruction to the flow of the, of the barium. The cardinal test for diagnosis of a-calacia, which is required, is then to do a formal testing of the muscle of the esophagus in term of its contract, contractility and relaxation using a special test that it's called esophageal manometry. The way this test is done is a, is a special small catheter is introduced from the nose down the esophagus until it enters the stomach and then the catheter is positioned properly to measure the pressure with which the muscle is squeezing all along the esophagus. Right now there are a number of treatment options. The two main ones that have traditionally been used for a-calacia are balloon dilation and disruption of the sphincter by basically inflating a balloon across it and tearing it. And a surgical option which involves a surgeon going in the abdomen finding the sphincter of the esophagus and using some sort of scalpel incising the sphincter. There has been a recent study that was of high enough quality and involving a large number of patients to be published in the New England Journal of Medicine which reviewed the efficacy of balloon dilation versus surgery so that the results indicated that the two methods were equally effective. A new technique has been developed that provides advantages of surgery but with much less invasiveness. This technique is called peroral that means through the mouth endoscopic myotomy instead of surgical myotomy. So the acronym is very nice, it spells POAM. And that is the new technique that is making waves now in the field of acalasia. It was invented in Japan in 2009. We performed the first human case at Winthrop approximately 10 to 12 months after the first Japanese case in October of 2009. And we were the first center in the US to perform this technique. And we are still only one of a handful of centers in the world that perform this technique. And we're probably also the first patient, the first center to perform this technique outside of Japan. And we had the publication of the first patient on whom we performed the technique and who did tremendously well in the main endoscopic journal in the United States and probably the preeminent endoscopic journal in the world. The way that the technique works is we introduce the endoscopy in the esophagus. We use saline injection to inject saline between the wall of the esophagus composed of three main layers. The lining of the esophagus, the muscle layer which is the outermost layer. And in between the lining and the muscle layer there is this layer that is called the sub mucosa, mucosa being the lining, which contains blood vessels, nerves, it's a very loose layer. And generally it's very thin, but once a needle is inserted through the lining into this layer and saline is injected, we expand this layer to up to a centimeter or two in thickness. And that creates a space that we can operate in. So this is a very novel approach. This is the only endoscopy technique where this space is used to perform endoscopic surgery right now in any significant scale. So what happens is after this space is created, a small hole is made in the lining and dilated with a tiny balloon and that allows the endoscope to then enter into this, you can think of it as a crawl space between the lining and the muscle of the esophagus. And then the scope is advanced down the esophagus in this sub mucosal space until the sphincter is encountered. Then it's incised with a small electrical knife the way a surgeon would do it from the outside of the esophagus. And once the complete incision is achieved, the endoscope is removed from the tunnel and the small round entry to the tunnel is closed with special little endoscopic clips, you can think of them as tiny staples that we can put to the endoscope that then fall out by themselves usually in a month or two. So what this technique achieves is by creating this tunnel there is increased safety. So as the sphincter is incised even if the incision goes through and through and perforates the esophagus there is a mucosa layer that then falls when the scope was removed falls as a flap and seals this entire tunnel including the cut into the muscle. So it's a special technique that ensures a safe incision of the muscle of the esophagus. What are the potential advantages of this kind of endoscopic myotomy compared to the surgical myotomy? There is the obvious advantage of no scars which potentially means less wound infections. Another thing we have seen in our patients that we have done is essentially none to minimize pain. Most of our patients have not required any narcotics or other pain medications after this sort of endoscopic myotomy. But the initial data we have so very good data in terms of decreased reflux than one would expect compared to what happens in the surgical heller myotomy. Also it does not preclude balloon dilation after this is performed. After the procedure is performed the patient is moved to the recovery room. Currently we do perform the procedure in the operating room because we are early in our experience so in case something that occurs that requires a surgical intervention we want to be ready for this to occur within minutes. So it is performing the order. The patient is recovered in the recovery room and then is transferred to a floor. And in most patients we are able to discharge them the following day in the afternoon after a barium swallow procedure is performed in the morning to make sure that there is no perforation. Many patients are interested to know what the diet will be after the procedure. Many want to go straight to a steak that is not allowed for a short period of time. For the first two weeks our normal protocol is to maintain the patients on a liquid diet as most of them are actually before they come for the procedure because of the severity of the dysphagia that a callasia causes. So we turn them to maintain their liquid diet for another two weeks approximately because the procedure of the modem itself even though it ablates the sphincter it causes tissue swelling from the injury to the tissue caused by the surgery. And the tissue swelling itself may cause some degree of obstruction so we basically maintain that until all the swelling from the cutting of the sphincter is solved. So for two weeks we ask the patients to maintain their liquid diet and then we liberalize the diet after that to a solid diet. So usually two to three months after the procedure we repeat a score of symptoms which quantifies those symptoms. And we selectively we may perform another barium swallow examination to make sure that that bird beak of the non-relaxing sphincter has resolved and there is ample movement of barium into the stomach. And we may repeat a manometry to document the effectiveness of the procedure in eliminating the high pressure of the sphincter. From then on usually then every six months or so we perform the symptom score again to detect early any relapse that can be easily treated with Salvat's technique as balloon dilation before there is any risk of getting a dilated esophagus that may require extensive surgery to eliminate. For more information about acalasia visit winthrop.org or call 1-866-WINTHROP.