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Monday, August 15, 2022

A Tough Act to Swallow

Posted By: Advancing Care
Jay Gala

Photo courtesy of Jay Gala

When eating suddenly became difficult, Jay Gala turned to Good Samaritan Hospital for help. Thanks to the expertise of our physicians, he’s now enjoying meals again.

By Deborah Skolnik

After graduating from college, Jay Gala was living in Boston and working as a software engineer. With a job he loved and a fun city to explore, he was enjoying all that life has to offer.

Except, suddenly, food.

The problem began overnight. “One day, I could eat normally, and swallowing was fine. Then the next day it was difficult. It was like a switch had been flipped,” he remembers.

By the time he figured out how to eat—which involved constantly drinking water with his food—Jay had lost 10 pounds. “My main concern was that I’d have to live like this forever,” he says.

A long search for answers

Jay first went to an ENT doctor who did not see issues in the back of his mouth or pharynx, and he was advised to see a gastroenterologist.  Jay’s parents, who live in Nyack, suggested that he come home and make an appointment with a local specialist. Fortunately, they knew just whom Jay should visit: Vipul Shah, MD, co-director of the Esophageal and Reflux Center at Good Samaritan Hospital, a member of the Westchester Medical Center Health Network. Jay quickly scheduled an appointment. Upon his consultation, Dr. Shah stated, “After listening to his difficulties, it seemed to me that this was more than an ear, nose, and throat (ENT) problem.”

Dr. Shah suspected two potential culprits. The first was reflux, which occurs when stomach acid frequently flows back into the esophagus, the tube that connects the stomach with the mouth. The second was a potential problem with the motility of Jay’s esophagus, meaning the way it was contracting to propel food toward the stomach.

The next step was an endoscopy, a procedure in which a flexible tube with a tiny camera on its tip was inserted down Jay’s throat and into his esophagus. The test provided a chance to examine the esophagus, stomach, and the upper part of his small intestine, called the duodenum.

Even then, there were few clues about Jay’s swallowing problem other than mild reflux. Dr. Shah prescribed reflux medication; however, Jay felt no better. To further inspect Jay’s esophagus and stomach, Dr. Shah ordered a test called an esophageal manometry, to be conducted at Good Samaritan Hospital’s Esophageal and Reflux Center.

During the manometry, a catheter was inserted into Jay’s nose and then threaded down his esophagus and into his stomach. Once it was in place, Jay drank and swallowed water while special sensors on the catheter measured the pressure in the esophagus.

After this test, Jay had an answer: The manometry showed he had a condition called achalasia, which causes the muscles of the esophagus to contract poorly. With achalasia, the lower esophageal sphincter, which is a ring of muscle that forms a valve at the lower end of the esophagus, doesn’t relax during swallowing. In addition, there is not good peristalsis, the process of wave-like contractions of the esophagus. As a result, pressure builds up at the bottom of the esophagus, and it becomes difficult for food to pass from the esophagus into the stomach.

Dr. Shah was a bit surprised: “We don’t normally see this condition in such young patients,” he notes. To double-check this diagnosis, Dr. Shah ordered a test called a barium study. During this procedure, Jay drank water containing a whitish liquid called barium, which shows up on an X-ray. “It looks at the full length of the esophagus, not just the swallowing part or pharynx,” Dr. Shah says.

Jay Gala
Photo courtesy of Jay Gala

A surgical solution

Now that it was clear what the problem was, it was time to outline a treatment plan. Dr. Shah explained several treatment options that could address the condition. “The gold standard is called the Heller myotomy,” he says. “That involves surgically cutting the sphincter to release it, so we can relieve the high pressure at the bottom of the esophagus. Then, food can easily drop down the esophagus with gravity, since Jay’s peristalsis–the constriction and relaxation of his esophageal muscles–is absent,” Dr. Shah explains.

Fortunately, Good Samaritan Hospital’s Esophageal and Reflux Center has the expertise to treat achalasia. Dr. Shah introduced Jay to Lyall Gorenstein, MD, a respected thoracic surgeon in our region. 

Dr. Gorenstein went over the treatment options a second time with Jay, including the Heller myotomy. He explained to Jay the surgery would be done laparoscopically, meaning he’d only need to make a few small incisions. After careful consideration, Jay decided to proceed with that option.

“I’d never had surgery before, so it was obviously pretty heavy on my mind,” Jay shares. “Leading up to it, I was both excited and a little nervous—excited for the issue to be resolved, but definitely nervous about surgery.”

“Dr. Gorenstein and Dr. Shah explained very clearly how the procedure would be performed and the recovery process,” he says. Dr. Gorenstein performed Jay’s Heller myotomy. Once Jay was under general anesthesia, Dr. Gorenstein made four small incisions in Jay’s abdomen, just above the navel. “We put a tiny camera into the abdomen, then use the camera images broadcast on a TV monitor to assist during the operation,” explains Dr. Gorenstein.

With the guidance of those images, Dr. Gorenstein accessed the lower esophagus, which is situated at the diaphragm. He then divided the sphincter lengthwise. After that, he performed a Dor fundoplication. “We wrap a piece of the stomach over the top of the esophagus. That’s the procedure that reduces acid reflux after the myotomy,” he explains.

The Heller myotomy was completed in less than two hours.

Jay remained at Good Samaritan overnight. The next day, he underwent a barium esophagram, a test in which his upper gastroinestinal tract was examined via X-ray to double-check that his esophagus was uninjured. Nothing was amiss, and Jay was discharged.

Jay heeded Dr. Gorenstein’s directions to get up and walk around several times a day. He also followed a special diet for several weeks, gradually building up to solid food and slowly introducing foods like pizza and bread. “Even when I was eating liquid food and taking big gulps of water, it would seamlessly go down my esophagus, which is a feeling I hadn’t had for a while,” he happily shares.

Jay has since returned to the gym and looks forward to traveling and also playing his saxophone. His advice: “If anything like this ever comes up, I highly recommend you talk to your primary care physician and a gastroenterologist,” Jay says. “Get it resolved, because being proactive about your health is extremely important.”

Jay is grateful that Good Samaritan Hospital was able to diagnose and treat his condition. “I felt very comfortable and relaxed about the whole procedure. Thanks to my doctors and care team, I was able to just focus on myself and my recovery. I highly recommend Good Samaritan Hospital,” he says.