Medical innovation is assumed to travel downhill, from wealthy institutions toward everyone else. Dr. Michel Kahaleh’s career has run in the opposite direction often enough to make the assumption difficult to hold. He first encountered per-oral endoscopic myotomy at a conference in Latin America in 2011, watching a Japanese physician perform it, and he went to Japan to learn the technique from that physician directly.
The procedure treats achalasia by creating a tunnel between the epithelium and the muscular layer, then opening the muscle blocking food from passing into the stomach. “I fell in love with the procedure, and I decided to learn it,” he says. The incident bears none of the hallmarks of knowledge radiating from a leading center. Instead, Kahaleh argues that it reveals the way innovation actually spreads—through iterative practice, shared experience, and collective refinement.
Travel Changes How a Physician Thinks
Techniques are the visible product of international exchange. Kahaleh describes something less obvious as the more valuable return. “Every time you travel, you learn new ways, new techniques, new concepts,” he says, and combining those concepts is what makes the most minimally invasive option available to a patient.
He points to complex altered anatomy as an example. Patients with a Roux-en-Y gastric bypass present a problem that resists the obvious approaches, and Kahaleh learned that the answer lies in working from the inside, creating a connection between the original pouch and the excluded stomach. The insight came from accumulated exposure rather than a single lesson. Travel, according to Kahaleh, forms a physician’s way of thinking rather than simply adding to their catalog of procedures.
Constraint Produces Capability
The comparison Kahaleh draws between endoscopy units is direct and unflattering to the wealthier system. American units, he says, suffer from extremely long turnover and are not designed to be cost-effective or particularly performant. Units in Latin America operate differently, running faster and using resources with more discipline. No device is ordered simply to fill stock, and every order carries a purpose. Kahaleh is careful to reject the reading that this reflects a lesser standard.
“That doesn’t make them worse,” he says. On the contrary, they are extremely powerful because of the cost constraint and the time constraint.” The abundance that removes those constraints also removes the pressure that produced the efficiency, which is why he treats these units as places to learn from rather than places to help. He offers Venezuela as the case that most surprised him. In 2010 it was, in his assessment, the most competitive country in Latin America, equipped with lasers and cholangioscopy, and considerably more advanced than he had expected.
What Does Not Transfer
Robotic and AI-assisted endoscopy are scaling quickly. These tools assist, and the physician performs the procedure and carries legal responsibility for it, which settles the question of what a trainee must still learn. “In the absence of AI or robotics, you still need to be able to master fundamental endoscopy,” he says.
The techniques moving between countries are meanwhile moving between departments. Gastroenteric bypass, once performed open and later laparoscopically, can now be completed from the inside using an echoendoscope to connect the bowel to the stomach, and surgeons are referring those patients directly. Heller myotomy has followed the same path through Peroral Endoscopic Myotomy (POEM).
Procedures continue shifting from laparoscopy toward endoluminal approaches, and Kahaleh’s own path suggests where the next one is likely to be found. Someone will see it performed in a country that was not supposed to be ahead. To learn more about therapeutic endoscopy, connect with Dr. Michel Kahaleh on LinkedIn.
