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University of Chicago Surgeon Provides Relief for Iowa Teen with Rare Swallowing Disorder

Nick Metcalf had always been an active teenager, involving himself in his high school theater program, playing baseball in a league and socializing with friends. But in March 2007, at the age of 16, while eating some spaghetti, Metcalf had the sensation that he could not swallow.

That meal was the beginning of a struggle that lasted nearly one and a half years, during which Metcalf had problems not only eating and drinking but also in obtaining an accurate diagnosis.

"The first time it happened, it hit me so suddenly," said Metcalf, who lives with his parents in Bettendorf, Iowa, 175 miles due west of Chicago. "But from that point forward, I had to eat very slowly and stick to a limited diet. I also became embarrassed to eat with my friends because I often had to run to the bathroom to regurgitate."

What was even more frustrating for Metcalf was his inability to find a physician able to diagnose the problem. After numerous visits with physicians who didn't have any answers, Metcalf finally sought care at the University of Iowa where he underwent esophageal manometry testing, during which a thin tube is passed through the nose, down the back of the throat and into the esophagus to assess the function of the esophagus.

The test showed that Metcalf had esophageal achalasia, a relatively rare disorder characterized by incomplete relaxation of the lower esophageal sphincter during swallowing and inability of the esophagus to contract. As a consequence, patients with the disorder experience dysphagia, regurgitation, chest pressure and heartburn. 

When adequate treatment is not given to patients with achalasia, they can develop complications beyond weight loss, such as esophagitis (inflammation of the esophageal lining), and aspiration pneumonia, which results from fluid being aspirated into the lungs during episodes of regurgitation. 

Once Metcalf was diagnosed, he turned to an online community of achalasia sufferers for support and advice. Patients in the group overwhelmingly recommended that he contact Marco Patti, MD, director of the Center for Esophageal Diseases.

"For patients with achalasia, the surgical approach to treatment is similar to opening the end of a funnel so food can pass through to the stomach via gravity," said Patti, one of the world's leading authorities on minimally invasive esophageal surgery and achalasia.

Metcalf sent his medical records to Patti and scheduled a phone consultation. During the call, Patti explained step by step the surgical procedure he said relieves symptoms in 85 to 90 percent of patients.

"I could tell right from that conversation that this was a physician with a big heart who truly empathized with what I had been going through," Metcalf said. "His confidence in being able to surgically solve my problem convinced me that this was the right surgeon for the job, and I scheduled the surgery for May 2008."

Metcalf and his mother, Vincie, arrived in Chicago and stayed with relatives for the night prior to the procedure. On the Friday morning he was scheduled for surgery, Metcalf arrived at the University of Chicago Medicine campus and met Patti for the first time in person.

After Metcalf received general anesthesia, Patti performed a laparoscopic myotomy and a partial fundoplication. Through five small incisions, Patti made a lengthwise cut (myotomy) three inches long through the muscle layers of the esophagus, starting above the lower esophageal sphincter and extending onto the stomach. This incision essentially opens up the muscular layer that is tightening the esophagus, allowing food to pass from the esophagus into the stomach.

To prevent stomach acid from refluxing upward after the myotomy, Patti performed a partial fundoplication as well. This part of the procedure involves wrapping part of the stomach around the esophagus and stitching it into place, preventing acid from backflowing from the stomach into the esophagus.

Because the surgery is performed through several small incisions instead of one larger incision, it offers patients a faster and more comfortable recovery, with minimal pain and scarring, as compared to open surgery.

"The surgery has provided me with truly amazing results," Metcalf said. "During recovery I had some pain from the incisions, but that was the extent of it because the esophagus has no pain receptors."

By midday Saturday, Metcalf took a sip of water at Patti's request and found that he could swallow easily. He then looked up at Patti and said, "Thank you for giving me my life back."

Today, Metcalf continues to feel well, has gained all of the lost weight back and is back to enjoying life as a normal, healthy teenager. This fall, he will attend Santa Monica College in California as a freshman and study film.

"I'm very hopeful that these amazing results will last 20 years," Metcalf said. "But if I ever have any problems with achalasia again, I know Dr. Patti will be there for me."
August 2009