Hundred-year-old Surgical Mainstay on the Verge of Obsolescence Thanks to Innovative N.O.T.E.S. Procedure


There was a time when laporoscopic surgery was the most innovative and least invasive way of making internal repairs to the human body. Today, a handful of surgeons are exploring a new approach to surgery known as N.O.T.E.S. – natural orifice transluminal endoscopic surgery.

The approach involves passing an endoscope – a thin tube with a built-in camera, light and miniscule tools – through the natural orifices of the body in order to perform surgery non-invasively, leaving no external wounds or scars.

On November 15, Dr. Stavros Stavropoulos, Director of Gastrointestinal Endoscopy and Director of the Advanced Endoscopy Program at Winthrop-University Hospital in Mineola, NY, performed back-to-back highly innovative N.O.T.E.S. procedures on two patients. These procedures are aimed at curing a disease that was long overdue for improvement in treatment options.

The disease shared by these two patients is Achalasia - a disorder of the esophagus, the tube that transports swallowed food from the mouth to the stomach, that makes it difficult for swallowed food and liquids to pass into the stomach.

In Achalasia, a condition that affects approximately 24,000 Americans, due to disease of the nerves of the esophagus, there are no coordinated contractions pushing the food towards the stomach and the lower esophageal sphincter does not relax to let the food enter the stomach. This results in food and saliva accumulating in the esophagus until the accumulated food builds enough pressure to push through the contracted sphincter and enter the stomach. Patients often adapt their diet to this condition consuming more liquid foods and drinking large amounts of water to push the food through.

Until now, the gold standard for treatment of Achalasia was the Heller myotomy. Developed in 1913, the treatment traditionally involved an open surgical procedure, either through the chest or through the abdomen, after which the lower esophageal sphincter was cut to allow food to pass through. In recent years, this procedure was adapted to a laparoscopic approach which involved multiple small incisions instead of one large one.

Today, the new N.O.T.E.S. procedure has made the repair of Achalasia even less invasive, with no external incisions whatsoever. Dr. Stavropoulos’ endoscopic submucosal myotomy has also earned its own literary acronym – P.O.E.M. for peroral (through the mouth) endoscopic myotomy. Pioneered in the United States by Dr. Stavropoulos, in collaboration with Collin E. Brathwaite, MD, Chief of the Division of Minimally Invasive and Bariatric Surgery at Winthrop, the P.O.E.M. procedure is enabling patients to make a full recovery and get back to their daily lives in just a matter of days.

“This new minimally invasive procedure will absolutely displace the traditional surgical treatment that has been the standard of care for Achalasia patients since the 1920s,” said Dr. Stavropoulos. “This radical, entirely endoscopic approach uses a natural route through which we can access the lower esophageal sphincter from the inside to get the same level of success with far less risk of complications such as infection and perforation.”

This unique approach involves passing an endoscope through the mouth into the esophagus while a patient is under deep sedation and then, through special techniques, inserting it in the layer between the inner lining of the esophagus and the muscular outer wall of the esophagus and then “tunneling” with the endoscope in this space within the wall of the esophagus until the lower esophageal sphincter is reached. The sphincter is then cut with a tiny electrical knife and then the endoscope is removed from the tunnel. The entry to the tunnel is closed with small staples and the tunnel collapses and completely seals the cut that was made in the sphincter muscle. This prevents any leak of esophageal contents such as food and saliva into the chest through the cut that was made in the muscle, a serious complication known as perforation which occurs in about 6 percent of patients undergoing laparoscopic Heller myotomy and 2-4 percent of patients undergoing balloon dilation – an alternative treatment option for achalasia that produces an uncontrolled tear in the lower esophageal sphincter. Balloon dilation delivers relief to about two-thirds of the people who undergo it, and about half of those will need to undergo repeated treatments.

In addition to the reduced risk and high success rate of the new endoscopic myotomy, the success of Dr. Stavropoulos’ procedure paves the way to exploration of other innovative and minimally invasive approaches to a wide range of conditions that could be addressed by passing an endoscope through the mouth and then through the esophageal wall using the self-sealing tunnel approach. For example, this technique could be used to biopsy lymph nodes within the chest and abdomen. This is currently performed by a much more invasive surgical procedure called mediastinoscopy involving rigid instruments inserted into a chest through a cut made at the patient’s neck.

Dr. Stavropoulos’s initial experience with this procedure was published in the prestigious peer-reviewed medical journal Gastrointestinal Endoscopy and presented at the 2010 Digestive Disease Week – the world’s largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery.