Endoscopic tools to view the digestive tract become more sophisticated every year, and gastroenterologist Dr. Stephen K. Heier is a pioneer in the field. His innovations have enabled Phelps to offer the region’s most comprehensive routine and advanced endoscopy services. Dr. Heier was Professor of Medicine and the Chief of the Section of Endoscopy for New York Medical College at Westchester Medical Center for 27 years. He is now Medical Director of Endoscopy, at Phelps and the Director of Phelps’ Advanced Endoscopy and Gastroenterology. Dr. Heier and his colleagues have developed and participated in the refinement and utilization of several new therapies to prevent, detect and treat cancer, determine the cause of bleeding, better diagnose abdominal and chest pain disorders, and diagnose and treat swallowing problems. These advances include:
•?Developing a device for Endoscopic Ultrasound Fine Needle Aspiration (EUS FNA) tissue acquisition to detect cancer •?Sending EUS FNA contributions to national DNA databases •?Performing one of the first single balloon and first Spirus enteroscopies into the small intestine •?Participating as co-investigator in national Barrx trials for curing Barrett’s Esophagus •?Testing a new device and software for diagnosing sphincter of Oddi spasm (a major cause of upper abdominal pain) •?Developing a new treatment technique for Zenker’s diverticulum
Dr. Heier and fellow gastroenterologist Dr. Floyd Byfield are expert in endoscopic ultrasonography (EUS), which uses sound waves emitted from the tip of the endoscope to precisely examine tissues. The detail provided by EUS is finer than an X-ray or CT scan image. EUS reveals whether cancer has invaded tissue; and if it has not, the cancer can be safely and completely removed from the surface by endoscopy.
EUS also offers the ability to obtain tissue samples using a Fine Needle Aspirate (FNA) scope, with sound waves guiding the needle into abnormal tissue. In 2008, a new device was developed at Phelps that markedly enhances tissue acquisition from behind the stomach and intestinal walls. Specimens obtained through FNA are immediately evaluated by the Phelps Pathology Department and are also often sent to Massachusetts General Hospital for cytology, to the Mayo Clinic for tumor markers, and to RedPath Laboratories for DNA analysis. Phelps is one of the earliest and largest users of DNA analysis in the United States. All of this information helps determine the best therapy for the patient.
Bleeding and Anemia
The small intestine has been called the “final frontier” in GI, because it is difficult to reach for visualization and treatment, but enteroscopy can reveal the more than 20 feet of small intestine beyond the reach of the standard upper endoscope or colonoscope.
The enteroscope, though not much longer than a standard colonoscope, is able to reveal the small intestine by using a balloon or a spiraling device to repeatedly accordion sections of the small intestine and hold each section in place for investigation or therapy. Phelps had the first commercially available single balloon enteroscope in the United States. In addition to evaluating and treating GI bleeding, enteroscopy helps determine the cause of anemia and can be used to treat patients with familial polyp syndromes and those who have abnormal X-ray imaging of the small intestine.
Acid Reflux and Barrett’s Esophagus
If you have ever had a problem with heartburn from acid reflux, the end result may not be as benign as needing to stock up on antacids. Acid can injure the bottom of the esophagus, destroying the normal cell lining that then gets replaced by an abnormal pre-malignant cell lining called Barrett’s esophagus. This common condition can only be diagnosed by a screening endoscopy, that takes only a few minutes to perform. Barrett’s esophagus leads to cancer in up to 1% of patients each year.
A company called Barrx has developed a radiofrequency ablation (RFA) therapy to destroy Barrett’s before cancer develops. Dr. Heier is a co-investigator in national trials for the Barrx device, called Halo 360 – a balloon with a surface coating of electrodes that deliver the radiofrequency energy. Successful energy delivery takes only one or two seconds. This breakthrough eliminates the need for surgery and provides peace of mind for patients who no longer have to worry about their Barrett’s developing into cancer.
Swallowing difficulty, called dysphagia, is usually caused by problems in the way the esophagus contracts. It is typically evaluated by passing a catheter through the patient’s nose down into the esophagus. Dr. Heier is using a new high resolution manometry system that can evaluate dysphagia and provide precise color mapping of the contracting esophagus.
When cardiovascular problems have been ruled out as the cause of chest pain, Bravo, a tiny pill-sized capsule, can be endoscopically attached to the bottom of the esophagus and used to measure acid. The capsule transmits acid information to a beeper-sized receiver worn by the patient, on which he or she presses buttons when symptoms such as chest pain arise. This reveals whether the patient refluxes too much acid into the chest, and whether the reflux causes his or her pain, to determine what to do about it. There need be no more worrisome visits to the Emergency Room by many patients with chest pain, because the cause can now be determined and treated.
Endoscopic retrograde cholangiopancreatography (ERCP) looks at the bile and pancreatic ducts with X-ray fluoroscopy. ERCP with Sphincter of Oddi Manometry (SOM) tests the pressure of the muscle at the bottom of the bile and pancreatic ducts, called the sphincter of Oddi. If the sphincter is too tight, a condition called sphincter of Oddi Dysfunction (SOD) exists. Many patients with chronic pancreatitis, recurrent acute pancreatitis, intermittent upper abdominal pain, or gallbladder pain after the gallbladder has been removed actually have undiagnosed sphincter of Oddi dysfunction. Phelps helped develop new sphincter of Oddi manometry equipment and software to analyze this muscle and was the sole beta site for testing. When SOD is diagnosed, it is cured simply by a sphincterotomy that is performed in less than a minute during ERCP.
Zenker’s diverticulum is an outpouching that forms in the back of the throat just above and behind the upper esophageal sphincter. The resulting tight sphincter muscle causes problems in swallowing and breathing. Most patients present after age 60, but many have had symptoms for years.
Traditionally, Zenker’s has been treated with significant surgery. A few centers have tried endoscopic approaches, all of which are difficult, complicated, and can take hours to perform. Recently, a tube called the flexible diverticuloscope was developed in Belgium, which can isolate the ridge of tight sphincter muscle between the diverticulum and the esophagus. Phelps borrowed this tube from its Belgian inventor, and Dr. Heier then developed a procedure that combines the tube with another device he modified to cut the muscle, eliminating the Zenker’s. This new procedure is extreme ly controlled, quick and efficient, with excellent visualization and excellent results.
Creativity Promises Future Solutions
Dr. Heier takes a creative approach to developing new ways for diagnosing and treating conditions of the digestive tract, using extraordinary technology and expertise to reach into patients’ bodies without surgery. Patients’ lives are enhanced as illnesses are detected and cured with elegant non-invasive techniques. Dr. Heier has been rated as a “Top Doctor” for the New York Metropolitan Area in all 12 annual editions of the Castle Connolly Guide on Top Doctors. For further information or consultation, the Advanced Endoscopy and Gastroenterology Practice can be reached at (914) 366-1190.