As indications for endoscopic esophageal procedures continue to expand, UCLA leads the way
For a host of esophageal procedures, the interventional endoscopy service within the UCLA Vatche and Tamar Manoukian Division of Digestive Diseases is helping to redefine what can be performed without incisions through new technologies and techniques. “Essentially we have become endoscopic surgeons, and as the tools and devices improve, we are continually expanding our capabilities,” says V. Raman Muthusamy, MD, MAS, director of UCLA Health endoscopy, who heads a group of five interventional endoscopists who are part of an integrated, multidisciplinary team that provides comprehensive care for benign and malignant esophageal conditions within the Robert G. Kardashian Center for Esophageal Health at UCLA.
One of the most exciting additions to the interventional endoscopy armamentarium at UCLA has been the implementation of per-oral endoscopic myotomy (POEM) for patients with achalasia. While endoscopy’s purview has traditionally remained within the lumen, in POEM the endoscope is tunneled within the esophageal wall to expose the spastic muscle of the lower esophageal sphincter. “POEM emulates what a laparoscopic Heller myotomy does in a less invasive way, with the advantage of a faster recovery and quicker relief of symptoms,” says Alireza Sedarat, MD, a member of the interventional endoscopy team who performs the procedure. While POEM mostly evolved with the use of existing technology, Dr. Sedarat notes, it has inspired the advent of novel technologies, such as electrosurgical units with sophisticated microprocessors that are fueling advances in other endoscopic procedures.
Patients with gastroesophageal reflux disease are benefiting greatly from the recent development of trans-oral incisionless fundoplication (TIF), which replicates the surgical fundoplication approach while minimizing postoperative side effects. TIF augments the anti-reflux barrier with a 270-degree wrap that forms a valve to prevent reflux from entering the esophagus. “TIF has the best data of any anti-reflux device we have seen,” Dr. Muthusamy says. For individuals with Zenker’s diverticulum — a condition most commonly affecting older and frailer patients who may not be candidates for surgery, in which a pouch forms just above the upper esophageal sphincter, often leading to debilitating swallowing and other symptoms — UCLA’s interventional endoscopy service now offers cricopharyngeal myotomy, creating space between the esophagus and the pouch to eliminate the obstruction. The team also continues to evolve endoscopic techniques of eradication and ablation for early cancers of the esophagus, as well as staging with endoscopic ultrasound.
Drs. Muthusamy and Sedarat note that patient outcomes for these and other sophisticated endoscopic procedures are optimized at centers such as UCLA, where there is high-volume, multidisciplinary care. At the Kardashian center, the interventional endoscopists are part of an integrated team with surgeons, pulmonologists, medical oncologists, ENTs, speech pathologists, and dietitians. “Rather than pushing any particular procedure, we work together to reach a consensus on the best approach to treating the individual patient from the full spectrum of options,” Dr. Muthusamy says.