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Caitlin Whyte: When acid reflux or GERD symptoms get bad enough, surgery can be an option for relief. So today, Dr. Adham Saad joins us to talk about our options. He is the Director of the USF Hernia Center at the University of South Florida.

Welcome to the Tampa Generally Speaking podcast, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class healthcare. So doctor, talking about reflux, when should I send a patient for evaluation for anti-reflux surgery?

Adham Saad, MD, FACS: Absolutely. And we get this question all the time from our referring doctors. It's never a bad time to send patients for evaluation. Just because you send them to us, it doesn't mean that we're automatically going to choose to operate on that patient. We're really careful with how we evaluate patients. But in general, a good guide is if you have a patient with recalcitrant reflux, so somebody that's on two plus medications, somebody that you've identified that has Barrett's esophagus or esophogitis on their endoscopy. And the other thing is we see this quite a bit in our practice, is that just because people are having heartburn, it does not mean it's reflux disease.

There's often times when we have patients that get misdiagnosed with reflux disease and they get treated with PPIs or H2 blockers unsuccessfully, and there's a lot of doctors out there that will just stack on antacid pills to it and don't really go further with that diagnosis. So we'll see people that have been diagnosed with reflux and they get treated with medications and medications fail and they get sent for surgery, when all the time they had a motility disorder that has almost the exact opposite treatment. So those are really the big things, recalcitrant GERD, they're on two plus medications, Barrett's, esophagitis, and when you're considering an alternative diagnosis.

Caitlin Whyte: Okay. Great. And does your group offer repair for paraesophageal hernias?

Adham Saad, MD, FACS: Oh, yeah, a hundred percent. That's really a large part of our practice. So, when we're talking about reflux disease, it's probably the most common in a field of surgery that's starting to be defined. And then what we define it as foregut surgeries, so it's really esophageal and stomach surgery. So a lot of times patients with reflux disease have an associated hiatal hernia. That's generally always addressed at the same time that we consider antireflux surgery. But paraesophageals are sort of along that paradigm. So paraesophageal is just a type of hiatal hernia. It's just more advanced disease in general. So there's four types and we address all of them. Again, a large part of our practice. The thing is I think referring physicians tend to underrefer this stuff.

So, I've seen a lot of patients with big, giant paraesophageal hernias and their primary care doctor didn't send them over because they didn't think it would be repairable. So there's not a paraesophageal that's too large for us. We do a huge variation in size and symptoms of these paraesophageal hernias, sometimes with multiple organs in the chest. We are willing and able to take these on. In general, none are generally too large to fix. And what we recommend with the paraesophageal referrals is just plug them into us and we will follow them. Just because they have a paraesophageal hernia, it does not necessarily mean it needs to get fixed. But if once they see us, they're kind of always our patients. So we will have that discussion with them and continue to monitor them for change in symptoms or for increase in severity or the size of the hernia.

Caitlin Whyte: Now what about previous antireflux surgeries? Would that be a contraindication to revisional surgery?

Adham Saad, MD, FACS: So, no, it's not a contraindication. On the contrary, in our practice about 50% to 60% of what we do is revisional stuff. So as a quaternary referral center, patients end up with us after they've had one, two, three antireflux surgeries and they come to us to see if there's any sort of treatment alternatives for them. So we do a ton of revisional surgery, I think more than anybody else in the state. And what we tell our referring doctors is kind of to avoid this, no case is too simple. So if you think somebody is a candidate for reflux surgery, if you have any questions, just send them to us upfront and we can talk to them about it. The only way to prevent revisions is to sort of do it right the first time.

And the thing about these surgeries is you really only get two, sometimes three chances to make it right, because at the end of the day, and then we do this as well, if patients have had two or three failures prior, and depending on the patient, sometimes the sort of end of the road operation we do is we convert them to a Roux-en-y gastric bypass. So, that's where we disconnect the stomach and bring up a roux limb to bypass the stomach. And that really is the best we have to offer as far as reflux surgery. It's drastic and it's prone to leaks and complications, so we only do that when we have to. But the long story short is we do a ton of revisional work and we enjoy it. And I think we're very good at it.

Caitlin Whyte: Well, tell us a bit more about your practice. What does it offer that's unique?

Adham Saad, MD, FACS: Yeah, I think there's really two big things. The primary one is that we practice at the USF Swallow Center and this is truly a world-class esophageal disease center. So what it's comprised of is they have an esophageal motility lab, two gastroenterologists and two surgeons. And through this swallow center, patients are able to get all their workup and oftentimes see both the gastroenterologist and the surgeon at the same visit. That way, we can diagnose them correctly. A lot of times people will come to us with their workup from outside facilities. And if we feel the quality is adequate, we don't necessarily need to repeat it.

But oftentimes, we like our technicians to do that workup at our swallow center, because we think we can ensure the quality of those studies. The other nice thing is that we actually meet once a week, all four of us, along with all our trainees that we're training how to do this and we discuss these cases. And so not only are our patients getting our expert opinion, but they're getting the expert opinion of our colleagues as well, all in one. So I think that's something very unique to the state of Florida. The other thing that we can offer is we actually are one of the first of seven foregut fellowships in the country and one of four foregut/bariatric fellowships in the country.

And that's out of about over a hundred fellowships around the country. And so what that tells you is that not only do we have the expertise, but we also have the volume to teach this to people that are interested in this specialty. So I think those are really the unique aspects of it, is not only are you getting four expert opinions, but we also have been deemed to be good enough at what we do to be able to train people how to do this.

Caitlin Whyte: Are there any risks we should know about when it comes to antireflux surgeries?

Adham Saad, MD, FACS: People tend to take this a little lightly. Oh, this is just reflux. It's not cancer or anything like that. But what people don't realize is that, you know, when we're doing antireflux surgery, we're in a very small space that's surrounded by a lot of very dangerous things. So we're working right on top of the aorta. We're working right next to the vena cava. We're sometimes working up into the chest. And so it's fraught with dangers around us. The other thing is that thing that we are most concerned about is the esophageal or gastric injury, because if we are able to recognize that interoperatively, it's not a big deal.

It's the ones that go unrecognized and patients can get very, very sick, exceedingly sick to the point where it can be life-threatening. So it's nothing to take lightly. That's why I think it's important for people to do their homework and send their patients to places that do a lot of this and are able to not only do the surgery, but handle the consequences of any of these complications. What I can tell you is that we get a lot of transfers for patients that have had antireflux surgery or hiatal hernia surgery at outside facilities. And when things go wrong, this is where they send them.

The other thing is there's a lot of art to foregut surgery. And so when we're doing antireflux procedures, we can sort of give the patient the opposite problem of reflux. In other words, instead of having reflux from the stomach up into the esophagus, they can't get anything from the esophagus down in the stomach, and we call that dysphagia. That's something that we know how to deal with and try to prevent upfront. And then the last thing is when people have these associated hiatal hernias, hiatal hernias are difficult to fix and they're prone to recurrence. If you look at published literature, depending on the case series and the location recurrence rates are anywhere from 10 to all the way up to mid-40 percentile.

So that's pretty variable. And what that tells you is that each center handles this stuff differently and then how does each study define the recurrence. But long story short, risks of it are serious. And we have a really good track record here, but it's nothing to be taken lightly.

Caitlin Whyte: And can you identify some indications for antireflux surgery?

Adham Saad, MD, FACS: Absolutely. So in general, it's a longstanding reflux disease. It's patients that have had long-term PPI use and with all the bad press PPIs have gotten recently, we get a lot of patients that do not want to be on PPIs anymore. As we talked about before, the recalcitrant GERD, that's resistant to treatment, when the reflux in the patients become lifestyle-limiting. So, patients aren't able to enjoy a glass of wine or play golf, etcetera. And then Barrett's or significant esophogitis generally grade 3 or above.

Caitlin Whyte: Tell us about the appropriate workup for these surgeries?

Adham Saad, MD, FACS: Sure. I can't stress this enough. It is important to get the appropriate workup because we see several cases a year where patients don't get the appropriate workup. And then getting the inappropriate workup, they get the inappropriate surgery. So it's absolutely crucial to get pH testing, impedance versus Bravo. We generally do Bravo at our center. This is associated with the endoscopy at the same time, just to ensure there's no other pathology that we're dealing with. We generally will do a barium swallow to identify their anatomy and ensure there's not a hiatal hernia there that went undetected on endoscopy. And then very importantly is high resolution manometry. That's an indication of how well their esophagus work, gives us an indication of their motility and whether or not they will tolerate a fundoplication or a sphincter augmentation.

Caitlin Whyte: And as we wrap up here, what are the surgical options for reflux?

Adham Saad, MD, FACS: Sure. So in general, when we go in to do an antireflux operation associated with a hiatal hernia, so the first step is to get repair of the hiatal hernia. So that's generally done with a suture repair with or without mesh. That is a biologic mesh, so we do not have to deal with esophageal erosion. And that just depends on the quality of their crural repair and the size of the hernia. And generally, if you look in literature, there's generally three options for treatment of reflux. One is endoscopic fundoplication, which we do not offer at our center because we don't not feel that it's a durable option at this point. The other two options are surgical fundoplication, which is very simply just a wrapping of the stomach around the esophagus.

This is where the art of surgery comes in. It's important that the surgeon is experienced with this because this is where we get in trouble with dysphagia and making the wrap too tight or too loose. So it's a art from knowing what's to loosen what's too tight and that just comes with experience. And then the other option, and we seem to be doing more of these, is what's called a magnetic sphincter augmentation. Or in the market the only one available now is called the Linx device. This looks like a bead of metallic magnetic pearls. And we put this around the esophagus right above the GE junction. What that does is stays closed at rest.

And when a food bolus comes through, it opens and then closes back again. The important thing about this is that workup is done appropriately because patients have to have a normal peristalsis. They need to be able to push through that magnetic sphincter. We really like this. We think the advantage of it over fundoplications is its durability. And the downside to it is a foreign body. With it comes associated foreign body reactions and there's certain things that we do to prevent any problems with that. But there are there always going to be a subset of patients that do not want a foreign body.

Caitlin Whyte: Doctor, thank you so much for your time and for this information. And thank you for listening to the Tampa Generally Speaking podcast, which is available on all major streaming services for free. Visit tgh.org/cme for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa General Hospital. This has been the Tampa Generally Speaking podcast. I'm your host, Caitlin Whyte. We hope you join us again next time.