Transcription:
How the TIF Procedure Can Help People with GERD

Melanie Cole (Host): Acid reflux disease affects roughly 20% of the US population and can cause extreme heartburn. While medication can temporarily deal with the symptoms and pain, there is a procedure that is a revolutionary way to deal with the root cause of the issue. My guests today are Dr. J. Pruthi, he's a gastroenterologist, and Dr. Emery Chen, he's a general surgeon, and they're both members of the medical staff at Palmdale Regional Medical Center. Gentlemen, I'd like to start with you, Dr. Pruthi. Tell us what is GERD, or acid reflux disease? What really is it?

Dr. J. Pruthi, MD (Guest): Thank you for inviting us to the show, Melanie. It's always good to talk to you and give more information about GERD. So GERD is the gastroesophageal reflux disease process where the stomach contents reflux up into the esophagus, the food pipe, then cause troublesome symptoms. The symptoms most commonly are heartburn, regurgitation and difficulty in swallowing, and sometimes the symptoms can be esophageal symptoms like patients may have bronchospasm, laryngitis, hoarseness of the voice, chronic cough, dental erosion, and chronic sinusitis, recurrent pneumonitis. So when these acid fumes stack up, they cause a lot of damage in the esophagus.

Melanie: Dr. Chen, do we know what causes it? And who is at risk for GERD?

Dr. Emery Chen, MD (Guest): Well we do know that it causes- that GERD occurs in millions of Americans yearly. There is a family propensity for it, but the biggest culprit is the diet that we eat, usually associated with fatty foods, chocolate unfortunately, caffeine, foods that contain caffeine can cause GERD to happen or to make reflux and heartburn worse. So there is a genetic predisposition as well as a dietary cause for the problem.

Dr. Pruthi: Let me add to this. So as Dr. Chen said very correctly, these are the risk factors for gastroesophageal reflux disease, the dietary intake. But the fundamental problem is there is a sphincter normally at the esophagus and stomach junction that is called the lower esophageal sphincter. Normally the sphincter relaxes to let the food go into the stomach, and then it relaxes to let the air out when we burp. If the sphincter relaxes too much, the acid content from the stomach or any other content can regurgitate and reflux it up into the esophagus and that is gastroesophageal reflux disease.

So the cause could be the sphincter is loose, and the sphincter pressure goes down with certain foods like fatty fried food, chocolate, soda, mint, tea, alcohol. So these foods would lower the pressure in the sphincter and the acid reflux will back up. So these are the main reasons that patients will have reflux symptoms and come to us.

Melanie: Dr. Chen, as we have learned about GERD before, and we understand there are medical interventions that don't always work for everybody, or people don't maybe want to go on the PPIs for a long time, we're here today to discuss the TIF procedure. Will you please explain what this procedure is, and the evolution of it?

Dr. Chen: Well the TIF procedure is the newest way to treat GERD. In a nutshell, it is an incisionless way to alter the anatomy between the esophagus and the stomach to make it more normal. As Dr. Pruthi was alluding to, the problem for patients with GERD is that their esophageal gastric sphincter is abnormal, allowing acid and stomach content to go up the esophagus. And TIF is the newest and best way to bring that anatomy back in line with what's normal.

Melanie: Dr. Pruthi, explain this procedure just a little. What is it like for a patient to undergo this procedure? And is their life different afterwards? Are there certain things they can or cannot? Tell us a little bit about what it's like for the patient.

Dr. Pruthi: Yes, so let's start with the patient's perspective first. The patients feel much better because when the sphincter is loose, the acid content, or the alkaline content, or anything in the stomach can back up, they have regurgitation, and that causes their lifestyle to suffer. After eating food they have heartburn, and when they're lying down- when they're upright, the gravity keeps the contents down, but when they're lying down at nighttime the acid and the contents back up, and they have a lot of symptoms. And then they wake up in the morning, sometimes they have chest pain, and as the acid contents back up, it erodes the lining of the esophagus which can turn into Barrett's of the esophagus which can cause cancer later on, and then ulcers can form, and all other complications can happen.

Now when we do the TIF procedure, what we do as Dr. Chen correctly said, that we bring the epiglottis and the sphincter back to its original condition- try to. Now the sphincter is loose, so we go in with the instrument that is the new instrument endoscopically through the mouth. The procedure is done under general anesthesia, so we put the instrument in the esophagus and stomach and look at the sphincter. The sphincter is loose, then we have a way to put some staples in that area so that we can wrap the fundus of the stomach around the lower esophageal sphincter to make it stronger.

So previously in other times we used to do the nissen fundoplication that was done surgically, opening the abdominal wall cavity or laparoscopically. But now it's called as transoral esophagus incisionless fundoplication. That's what TIF stands for. So when we go in, there's no incision. We make the sphincter stronger, wrap the stomach around it, and through the fundoplication in that manner, and that prevents the acid contents- the other contents from backing up in the esophagus, and the patients are back on their feet next day and doing very well, and it brings them back to their normal lifestyle. They're able to eat the stuff that they were not able to eat previously, and enjoy food.

Now some patients may have hiatal hernia with it, you know? When the stomach moves up into the chest, so that is hiatal hernia. So then Dr. Chen's comment where he goes in with the robotic assisted surgery, and brings the stomach back into the proper abdominal cavity position, and reduces the hiatal hernia, fixes the defect, and then we proceed with the fundoplication.

Melanie: Dr. Chen, is there a certain patient selection criteria? And how long does it take to notice results? Are there some people for whom this is not really an option?

Dr. Chen: Well essentially, any patient who has symptoms of GERD, who have been diagnosed either by CT scan, an esophageal manometry which is an x-ray test with contrast, or upper endoscopy by a gastroenterologist like Dr. Pruthi, are candidates for this procedure, okay?

Patients who also have a hiatal hernia along with acid reflux and GERD that medications aren't completely controlling, or the patient just doesn't want to take life-long medications anymore to control their symptoms are also candidates. Interestingly, most patients with significant esophageal reflux disease also have some degree of hiatal hernia. And so that's why it's very good to have a surgeon gastroenterology team dealing with this problem, because that can provide that minimally invasive approach and the newest approach to fixing hiatal hernia.

But I think the big advantage of doing it this way instead of the old way where a surgeon does both aspects, which is fix the hiatal hernia and doing the fundoplication is that the old way of doing it caused quite a bit of long-term problems that patients can experience. And some of these include difficulty with passing food into the stomach, having too tight of a wrap, or the wrap coming apart. There's also issues with the sensation of food not passing, there's early bloating. A lot of problems associated with the old way of doing fundoplication just because the way to do it was drastically more altering to normal anatomy, in particular normal anatomy of the stomach.

So this new way with TIF in conjunction with robotic assisted hiatal hernia repair offers the best minimally invasive way to treat this very common problem.

Melanie: Dr. Pruthi, as you wrap it up for us, do they still need to take medication afterwards? Are people still tempted to eat TUMS, or look to their proton pump inhibitors? Do they still need medication? And please give us your best advice for people that have questions about their GERD, and maybe their untreated GERD, and this TIF procedure.

Dr. Pruthi: Yes. The whole idea is to control their symptoms and get them off their medication. Once we reduce the hiatal hernia and do the TIF procedure, about 80% to 90% of patients will be off their BPI medications. The data has been accumulating over the last ten years, 25,000 patients have been done with this procedure, and the majority of them are off BPI medications.

Now we don't want to keep taking BPI medications. A lot of people who are young and healthy, and they are stuck on BPI medications because their symptoms are so disturbing and they cannot get off of BPI medications, and this is the reason. These people are good candidates for the treatment.

Now once they are off BPI, they go back to their normal lifestyle, then we prevent all the complications- the long-term complications, those- what's going to happen because of reflux disease or because of the BPI medications? Now people who are on these medications who have reflux symptoms, and they have regurgitation, nocturnal symptoms, chest pain, refractory GERD, symptoms which are not under good control with their current treatment process, they should seek attention. Normally as we do, we try over-the-counter esophageal treatment, ten, fifteen days. Just try that. If it works, then stop the medication that you're on.

Now if the symptoms continue despite trying over-the-counter medications, then please go to the doctor, tell your symptoms, and seek care because there is help available and we at Palmdale Hospital have this program where we have a team of gastroenterologists and a surgeon, and we are gaining more and more experience. We are doing these procedures and helping our patient population, and the hospital is supporting us. We are developing an esophageal program where we can take care of all kinds of esophageal disorders and serve the population to the best of our ability.

Melanie: Dr. Chen, last word to you. What would you like the listeners to take away from this segment as far as their GERD and the TIF procedure and the collaborative approach that Dr. Pruthi was discussing between general surgeons and gastroenterologists at Palmdale Regional Medical Center.

Dr. Chen: Well I'd love patients to know, first of all, I don't think I answered an earlier question from you about how fast the symptoms go away, and I just want to touch on that real briefly. They go away the very first day, okay? I have patients that wake up who've suffered for decades with reflux, severe heartburn, wake up from surgery and are just amazed that they don't have that taste in their mouth anymore.

Finally, the take home message I'd like to give is that this newest way of treating esophageal reflux disease is revolutionary. Up to this point, surgeons have been reluctant to do hiatal hernia repairs because of the significant and major potential problems that one can get with a full nissen fundoplication, which is a full wrap of the stomach around the esophagus in a way to try and recreate the normal anatomy.

With TIF, that procedure is minimized. You get an extremely effective wrap, and extremely accurate recreation of normal anatomy without the long-term potential risks. So I think that this is definitely the new way to go for treatment of GERD, and it will revolutionize the field.

Melanie: Wow, what great information. Gentlemen, thank you so much for coming on today and sharing your expertise and explaining this condition of GERD, and this revolutionary procedure. It's so fascinating, and we just love to hear how you work together to really give the Palmdale residents the best possible care. So thank you so much for joining us. Again, you're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit www.PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.