Scott Webb (Host): If you've ever eaten spicy foods or maybe pasta, you've probably experienced acid reflux. And my guest today is here to explain acid reflux and how robotic foregut surgery is helping folks to get back to eating foods they love. And joining me on the podcast today is Dr. Kirpal Singh. He's an advanced gastrointestinal and board-certified general surgeon with the Franciscan Physician Network.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, nice to speak with you today. We're going to talk about a very common ailment, reflux. I suffer from reflux. My wife suffers from it. We're also going to talk about robotic foregut surgery, so lots to get to today. But just as a foundational thing, what is acid reflux and how does it usually present?

Dr. Kirpal Singh: So, the acid reflux, as you mentioned, it's a fairly common finding. I mean, you know, people, friends, family members, I mean, everybody has it, especially if you eat too much or eat hot stuff or stuff like that. So, we all have acid in our stomach. It is there for a purpose. It helps us digest food, kill any bacteria or viruses that might be in the food. So, it serves a purpose.

And we also have a valve that is a flap that is at the lower portion of our food pipe, the esophagus. So right where the esophagus the food pipe meets the stomach, there's a valve that's supposed to prevent reflux or minimize it anyway, because we all have some episodes of reflux. But it's to prevent it. But in some people, over time, that flap may be lax or people may get hiatal hernia where the flap now sits in the chest and not in the abdomen. And the acid that's supposed to be naturally in our stomach now has a possibility to come up in the esophagus, and that is what we feel and is called acid reflux.

Host: Yeah. As you say, we need the acid, because the acid has a role, has a purpose. So when should someone seek medical treatment? Because, you know, I know that a lot of the folks use over-the-counter, OTC type of, you know, acid reducers and things, and I have a pill that I can take if I know that I'm going to be eating spicy foods or pasta or whatever it might be. But when is it time that somebody reaches out?

Dr. Kirpal Singh: People, as you mentioned, will take Tums or Pepcid AC or omeprazole, because it is all over-the-counter. And there is really not a good way to answer this question except when the acid starts to interfere with your daily activity. So now, you cannot eat your favorite food. It's happening every day or, you know, you go to sleep, you wake up in the middle of the night coughing and choking, or having a bad breath or it's interfering with your normal activity is when I would recommend you can try the over-the-counter stuff for maybe two weeks. And if it goes on beyond that, I would highly recommend you talk to your PCP.

Host: Yeah. That's such good advice, right? Like when it's affecting our quality of life, when we can't eat anything we want to eat, when we can't sleep, because we're coughing during the night, all of that. So then, we covered kind of there the over-the-counter Tums, those types of things. What are the surgical options for treating acid reflux?

Dr. Kirpal Singh: There are endoscopic options, meaning the procedure can be done through the endoscopy with a scope down the throat, so there are no cuts made on the abdomen area. And then, there are surgical options where you actually have to make cuts in the abdominal wall to get in and do the procedure.

The option to choose one or the other depends on whether you have a hiatal hernia or not. If you have a small hiatal hernia, say one or two centimeters, and that's diagnosed with endoscopy, EGD, then you are a candidate for endoscopic therapy. It's called TIF, transoral. Incisionless fundoplication. So again, if you have a small hiatal hernia or no hiatal hernia and you have reflux, you can be treated with endoscopy only without any abdominal incisions. If you have a bigger hernia, more than two centimeters, then the options are surgical. And with surgery, you will get four or five incisions. And we go in, we find the hernia. Most people that have reflux, even if they don't have a hernia during surgery, after you dissect the area, you will find a hernia almost always. You fix the hernia, and then we take portion of the stomach called the fundus, and we use that fundus to recreate the flap in the lower esophageal muscle, lower esophageal sphincter that has been weakened over time.

Host: Yeah. And we teased that we're going to talk about this robotic option, the robotic foregut surgery. So when we think about robotic or robotically versus laparoscopic, then, you know, which is right? Does it depend on the patient? Do you have a preference? Because I certainly love talking about robots if you can.

Dr. Kirpal Singh: Yes, absolutely. So in the beginning, we had the open operation and we used to do these surgeries with about six to eight-inch incisions. Patient will be the hospital for a long time, almost sometimes a week or so before they go home. And then, laparoscopy came along, and that really helped significantly in terms of being able to get back to home quicker, less pain and back to normal activity quicker.

The laparoscopy limitation has been that it's called "chopstick surgery", where you have these sticks, which are the instruments that we go in and dissect tissue, fix tissue, do suturing and stuff like that. The limitation is that it doesn't have wrist motion. So, open surgery, I have my wrist, I can twist my wrist and get a needle in the right spot, and make sure it is where it needs to be and it's accurate. And that is what is lacking in laparoscopy. So, robotics came along. And now, all of a sudden, you can suture a lot easier than you could laparoscopically and be more accurate about it.

Also, robotic surgery gives you better magnification and a 3D view. So laparoscopically, you are operating in a 3D world, but you're looking at a 2D screen. So, your brain has to adapt to that. And some people do better adapting than others because humans, you know...

Host: doctors are humans, right? Yeah.

Dr. Kirpal Singh: Yep. It's a 3D field of view, and you have instruments that you can use like your wrist. So, it gives you advantage of the open operation, except on a minimally invasive platform.

Host: Yeah, you just did such a nice job of explaining it there, because I can sort of picture it, like, okay, if you're doing it yourself, old school, open surgery, well, you have your wrists, you can use them. But if you don't have them and you can't use them in the laparoscopic option, I can see why robots would be huge benefit for you and for patients. And along the lines of patients, are there some that just benefit more from the foregut surgery?

Dr. Kirpal Singh: Correct. So, there are complications, acid reflux, I should say, the acid burns the esophagus. And patients, certain percentage of them will get what's called Barrett's esophagus. That is the lining of the esophagus is now changing from its normal form to what looks like a stomach lining. And that is a pre-cancer condition. So if we have something like that, those patients definitely would benefit from stopping the reflux completely. So when we take a medication, the H2 blocker, the Pepcid AC or the PPI, the omeprazole, it makes the stomach not make the acid, but you still have reflux. You can have content of the stomach still come up and some people can have bile that will reflux from the liver into the stomach and back up the esophagus. So, it can still irritate that lining and make it potentially become cancerous down the road. So, stopping the reflux in those patients, in my opinion, is a much better option than continuing with the medication that we know is not stopping the reflux. It's just making the reflux non-acidic.

Host: Yeah. Yeah, it definitely sounds like those patients would benefit, and it makes me wonder are there any other potential risks or complications involved?

Dr. Kirpal Singh: There are certainly complications. The biggest complication that we worry about during the procedure would be having injury to something around the area we are operating. And we have liver that sits in the front of the area. We have spleen that is attached to the stomach right next to where we are working. So, there's a complication of injuring the spleen, which means we may have to actually take the spleen out. Because spleen, when once it starts bleeding, it does not like to stop. So, it can be very difficult to control that without actually doing the splenectomy, which is a very big and morbid procedure on top of the foregut surgery.

So, that's along with the fact that you could have potentially injury to the esophagus of the stomach, and that is a known complication that certainly can happen. These are all complications you worry about during the operation. And then, after the operation, if you make the fundoplication or the wrap too tight, or if you close the hiatus too tight, people can have trouble swallowing. And then, you may have to have another endoscopy to try to stretch that area to make sure we can eat after the operation.

Host: Sure. Yeah. And along the lines, just from the patient experience, I guess, from that perspective, Doctor, what can they expect? So, let's say before, during, and after.

Dr. Kirpal Singh: So before the procedure, we recommend nothing to eat or drink after midnight. That's the usual for pretty much any procedure or operation we do. And in terms of intraoperatively, I mean, you'll come to the hospital, typically two hours before the procedure. And then, you'll be in the pre-op area where we make sure that we go through the medical history again, make sure nothing's changed, get an IV, go through your allergies, and all of the usual stuff. And once we are ready for the operation, then we wheel you to the operating room. You will go to sleep. The anesthesiologist will put you to sleep. And the procedure will take on average about hour and a half to two hours. Afterwards, you wake up and you wake up in the recovery room. You'll be in the recovery room about an hour, hour and a half majority of the time, and go to the surgical floor, and you are watched overnight to make sure that pain's okay, make sure you're not nauseated. And the next day, you will go home.

Host: Yeah. It makes me wonder too, Doctor, let's say after the surgery, provided there weren't any other complications, just the, you know, kind of run-of-the-mill, if you will. And everything's gone well, do patients need to make any dietary changes after surgery?

Dr. Kirpal Singh: Oh, yes. That's a huge, huge ordeal. So, I counsel my patients beforehand, and people hear they want to hear. So, I had to reinforce this at least two or three times before it kind of gets through. So, because before the operation, there is not any resistance because the valve is weakened, we can eat, take a big bite of a, you know, burger or a pizza or drumstick and not even chew, which most of us don't swallow and it's not a problem. After surgery, we fix the hernia and we take portion of the stomach and reinforce that valve. So, the opening now is roughly about two centimeters or so for most people. So if you take a bite bigger than that and you don't chew, it will get stuck and it will not pass.

And I have had this happen before. Some my patients will take a big bite of typically chicken, and they don't chew. And it will get stuck and we have to take them back to the endoscopy, put a scope down their throat, and fish out that chicken that's stuck, or meat that's stuck, either push it through or pull it back out.

So, the advice that I give my patients is, A, even if you drink water, you take one sip, you wait for it to go down and some people can feel it go down. And then, the next sip. So if you drink too fast, even the water may not pass through and you may get this feeling of something stuck at the back of your chest and may even wretch and vomit, which is the worst thing you can do after surgery because that can tear up the sutures that we just put in nice and fresh. The patients are on liquid diet for two weeks. So, day one, post-op day one, they get a clear liquid. So, that'll be jello, juice, stuff like that. And if they're swallowing okay, next day or next meal will be full liquids, meaning soups. And if they're okay, they go home the next day from surgery. And for two weeks, they are on a liquid diet and then we see them back in the office. And as long as they're not having any trouble swallowing and people will feel the food getting stuck or the water getting stuck, and I mean, it's a very distinct sensation, and as long as they don't have that, then they advance to regular diet. But the caveat is anything they eat has to be cut up on a plate.

So even if you're eating a burger or a pizza, you have to cut it on a plate, a piece, a small piece, chew well, swallow. And as long as you don't have any feeling of it hanging up, then you take the next bite. So, very, very strict diet for the first three months of slowing things down, which is very hard to do.

Host: Yeah, very hard to do. And as you say, you know, it's in the patient's best interest for long-term good outcomes. So, let's just finish up there, Doctor, and it's been really educational today, but what is the, you know, prognosis, if you will, like how effective is the foregut surgery for reflux?

Dr. Kirpal Singh: Right. So, there are some controversies as usual in the literature if you look at the success. The trouble we have is some of the data is old, like from '90s. And then, there's data from 2000s and more recent data. But overall, the consensus is that anti-reflux surgery is very effective, 80 to 90% effective.

There are some failures over time. So when we repair something, the tissue can weaken over time. I have had a few patients of mine that I did a fundoplication and, about eight to ten years later the symptoms are back. And when I went back to surgery you could see the sutures are there, but the tissue just enlarged over time and had to re-tighten it down a little bit for them to get better.

So overall, it is very successful, but there can be some recurrences where you may have to go back to surgery.

Host: Yeah. Well, I certainly appreciate your time today. I love when I can talk about robots and how effective they are. And I get it. It's like in the laparoscopic version of this, so you don't have your wrists involved. And it all makes to me. And patients obviously have to do their part. They have to reach out initially and then if they're a good candidate, go through the surgery, special diet for three months. But appreciate your time and your expertise today. Thanks so much.

Dr. Kirpal Singh: Absolutely. It is my pleasure.

Host: And for more information about reflux surgery, visit franciscanhealth.org and search reflux. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.