Minimally Invasive Procedure Allows 90-Year-Old to Eat and Drink Again

March 2013

A few months after she came home from Stanford Hospital & Clinics, Marjorie McFadden went to a fish fry and loved the clam chowder there so much she went back to the kitchen and asked to buy some. She walked out with a half-gallon of it, as a gift from the cook. “I’ve been eating it all week,” she said. “It was so good!”

Marjorie McFadden
At 90, Marjorie McFadden found herself unable to swallow. At Stanford Hospital & Clinics, she found innovative care that restored her ability to enjoy food again.

A simple thing—scooping up a spoonful of soup and savoring its flavors in a swallow—but for McFadden, the basic ability to eat or drink anything slowly disappeared over a decade until, after dozens of unsuccessful visits to doctors, she was restricted to bed, losing a pound of weight a day and relying on a nasal-gastric feeding tube for survival.

She was 90, and many at that age might count themselves lucky to be alive in any state. But McFadden, the mother of four, grandmother of another four and great-grandmother of eight, had not retired from her job as food service director for a public school district until age 85. Until her ability to swallow shut down, she was a regular at the Lions Club, the Mosquito Abatement Board and regularly scheduled social gatherings that included bingo and pinochle. “When I make a commitment, I stay with it,” she said.

And she’d never been to the hospital or to see doctors except to give birth. Even when she noticed that she was having trouble keeping food down, she didn’t seek help. “I have to be really sick to go to a doctor,” she said. “I just bluffed it off. It was nothing until it got to the point where I couldn’t even swallow water.” At first, her doctors thought it was acid reflux, and gave her medications. They didn’t work. Then her condition was diagnosed as achalasia, an unusual tightening of the muscles at the lower end of the esophagus. They tried a couple of standard endoscopic procedures, which didn’t work either.

Finally, she found herself at home, in a hospital bed, with a feeding tube inserted through her nose as her only means of staying alive. Her son, Clint, was distraught. “I thought, ‘We’re losing her,’” he said. “I got mad. I said, ‘Find somebody! Do something!’ and that’s when her doctors called Dr. Rivas.”
Marjorie McFadden
Homero Rivas is a digestive surgeon, Stanfordís director of innovative surgery.

Homero Rivas is a digestive surgeon, Stanford’s director of innovative surgery. His specialty is minimally invasive surgery that has moved beyond the laparoscopic approach with multiple small incisions to procedures like the one he performed on McFadden: per oral endoscopic myotomy, or POEM, where there are no external incisions in the skin.

POEM is the latest treatment for achalasia, one inspired by a former Stanford gastroenterology department chair, perfected in the last two years by a Japanese surgeon and now performed by a small handful of surgeons around the world, including Rivas. He is the only surgeon in Northern California trained in the procedure. By coincidence, he was in Japan to train surgeons, including POEM’s pioneer, in advanced laparoscopic techniques he’s known for internationally. They got to talking about their craft and Rivas was happy to trade his teaching for learning POEM. He was eager to learn the procedure because of his belief in the value of this type of minimally invasive surgery—and because of the suffering he’d seen in patients with achalasia who’d sought a permanent form of treatment.

“The quality of life of someone who cannot eat is horrible,” Rivas said. “We take eating for granted until the time you have difficulty eating—and that’s what lots of people experience. It’s like torture because you know you feel thirsty, that you feel hungry, yet you feel scared because whenever you eat, you’re going to feel discomfort or vomiting. It can be very miserable.”

Sometimes medication can help, including Botox, which can relax muscles, but that’s typically a temporary solution that lasts only a few months. Another option is to widen the opening using a balloon that’s inserted and then inflated. But the procedure is challenging and the results often unpredictable. “As surgeons, we prefer more definitive approaches,” Rivas said.

Conventional surgery and laparoscopic surgery can improve this condition, yet they require incisions and, consequently, some pain inflicted to patients. Instead, in the POEM procedure, surgeons insert a narrow tube into the patient’s esophagus and then slip its cutting tool through the esophageal lining to reach and then cut the constricted fibers at the base of the esophagus. There is no residual pain or visible scarring. “It's such a rewarding procedure because, with something very simple, you make a huge impact on someone’s life,” Rivas said. “And for everyone, “the less physical insult you give a patient in an operation, the faster they will recover.”

As impressed as he was with Rivas’ resume, Clint McFadden was still concerned about his mother’s age and her ability to recover from surgery. Rivas had told him that his mother would be the oldest patient on whom the procedure had been done, but he was confident she would be fine, especially after he met her. The surgery took three hours in McFadden’s case because her condition was of such long standing that Rivas needed more time to release the tightened muscles.

She stayed in the hospital just two days (most people stay only overnight) and since then she’s bounced back completely, although she has followed Rivas’ instructions to add new foods to her diet one at a time, with particular attention to spicy dishes that might be irritating. “I do go out a lot again,” she said, “and a lot of it has to do with food. If anybody wants to go someplace, I’m ready!”

She also has been sharing her new knowledge about achalasia and the POEM procedure. “To think that I wasted all that time without going to a doctor. If anybody has any hesitation about any swallowing thing, it’s best to take care of it because it’s probably curable!”

 

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