Transcription:
Do You Suffer from GERD? We Are There to Help

Bill Claproth (Host):  If you have chronic heartburn or the feeling of food backing up in your esophagus, you may be suffering from gastroesophageal reflux disease or GERD. My guest today is Dr. Robert Fanelli. He is the chief of minimally invasive surgery and surgical endoscopy at Guthrie. Dr. Fanelli, thanks so much for being on with us today. So let’s just jump in. What is GERD?  

Dr. Robert Fanelli (Guest):  Bill, thanks so much. It’s my pleasure to be here. GERD is a constellation of symptoms that come from reflux disease, and the bottom line this is the abnormal relocation of acid from the stomach up into the esophagus. Everybody has that to a certain extent, but when someone has GERD, they’re having that continuously, sometimes during the day, sometimes during the night, and when it’s at its worst, day and night. 

Bill:  Okay. So acid reflux occasionally now and then is okay. It’s not GERD. But when it becomes chronic, that’s when it’s potentially GERD.  

Dr. Robert:  Right. Everybody gets heartburn once in a while, they overeat or eat something that’s particularly spicy or something like that. But a person who has GERD, it’s more than heartburn, it’s that they’ve got a real situation where there’s mechanical failure of some of the anatomical components, the valve between the stomach and the esophagus, for example, where that acid is just jumping up in the esophagus all the time and bathing the esophagus. And it’s really a miserable thing. In fact, if you look at quality of life studies, people who have reflux disease have the same quality of life impact as those who have kidney failure, congestive heart failure, certain advanced infections or cancers, and it really can make someone feel quite miserable. 

Bill:  So, this is more than just an annoyance for people that have GERD. This is a serious problem that can affect quality of life.

Dr. Robert:  It does affect quality of life, and it can range and run the gamut from just that to also causing other diseases. Some people who have reflux disease then end up converting some of their cells into something called Barrett’s esophagus, which is a precancerous change that happens in the esophagus that makes the risk of getting esophageal cancer even greater. And some people get manifestations that are not even involved with the esophagus—for example, chest pain really coming from the esophagus but they think they’re having a heart attack and they’re in the emergency department all the time, or hoarseness or changes in their voice related to what we call LPR, laryngopharyngeal reflux. 

Bill:  And how often does that happen, Barrett’s esophagus? Does this happen quite often, or is this more a rarer form? 

Dr. Robert:  Barrett’s esophagus is actually seen fairly often. It depends on what population you look at. If you look at the general population, the occurrence is quite low. But if you look at the population of people who already have reflux and we know they have reflux, it could be somewhere between 10 and 15 or 18 percent depending again on how you select folks out for evaluation. 

Bill:  And let’s break this down then. So, what symptoms might a person feel on a regular basis, and how often would they feel this that would send up a red flag and they would come to see you? 

Dr. Robert:  So, reflux disease is something that usually bothers people persistently and not something that happens just occasionally. So in other words, if someone gets heartburn and they have it for two days in a row and then six months go by and they might get heartburn for another one or two or three days, that’s probably not reflux or very serious reflux. But the kind of reflux patients that I’m seeing are those who are having these symptoms at least three days out of five, and sometimes they’re having them every single day. The first approach is usually that they’ll try an over-the-counter medication. It might even just be antacids in tablet form or liquid form, and they’ll get some relief from that, but it’s short-lived. It’s not long-lasting. 

Bill:  And what food or lifestyle decisions exacerbate this acid reflux where it turns into GERD? 

Dr. Robert:  Well, Bill, the first thing that I’m going to tell you, it’s cigarette smoking. Tobacco use really in any form but particularly inhaled forms of tobacco with its direct negative effects of nicotine and the other inhaled components in cigarette smoke, really damaging to the esophagus, to the airways, to all of the structures in the upper digestive tract. So, smoking has to go. Overeating or eating too close to bedtime, that’s another no-no. Because what happens is the stomach is over full, and then when we lie down, the whole stomach esophagus assembly is then flat. And if that valve is compromised, even to a minor degree with a stomach that’s very full, it’s just going to overflow back up into the esophagus. Carbonated beverages are another food choice that really should be eliminated when somebody’s having reflux or even garden-variety heartburn, because what’s happening there is those drinks are acidic by nature, and they also are volume expanders. When you drink soda for example, those bubbles will expand in the stomach. And so they increase the volume of liquid in another material that’s in the stomach and encourage reflux to happen more commonly. 

Bill:  So if you cut these things out of your diet and you quit smoking, you should be able to control this a little bit. If you do cut those out and you’re still suffering from it, then what are the treatment options? 

Dr. Robert:  So if you looked at a hundred people who had reflux, you would expect that these type one maneuvers, or behavioral modifications, as we call them, that is eliminating caffeine, tobacco, carbonated beverages, and eating a lower fat diet than normal in a lower volume and not eating for four hours before you’re going to lie down. About 10 to 12 percent of people should expect to have significant improvement of their symptoms based on that, so 10 or 12 out of that group of 100 people with reflux. The next line of therapy is going to be a trial of medication. And so, for young people, for people in their 20s and 30s and maybe their early 40s, particularly if they don’t have any risk factors or family history of cancers of the esophagus, of the stomach, then it’s safe to try a type of medication called a proton pump inhibitor or a PPI. Those are common things that we’ve all heard of, like Prilosec and Nexium and Protonix and Prevacid and those kinds of things. And so, they may see their doctor and get a prescription for a trial period of those. And they do a great job. About 65 percent of people who have reflux will respond to both the dietary modification and the medication together. When people have persistent symptoms, those that are partially relieved by the medication or they get great relief in the medication initially but then it seems like they get used to it almost after a few months and their symptoms start to happen more commonly, those are folks that we like to see in a specialty practice like mine because it’s going to take more than medication. It’s going to take some further evaluation, and then it’s going to take choosing the right therapy, which could be surgery or could be an endoscopic therapy. 

Bill:  And what is endoscopic therapy? What does that entail? 

Dr. Robert:  So for years, those of us in the field of gastrointestinal surgery have sought less and less invasive ways of treating things. And so, endoscopic therapies are those things that are delivered through a natural body opening, so either through the mouth, or for this problem, certainly anything dealing with the esophagus will be introduced through the mouth. And there are certain therapies that might be introduced for other problems down through the rectum. Regarding upper GI techniques, there have been a slew of devices and procedures over the years that have been developed trying to be the remedy for reflux disease, and many of them haven’t really passed muster. They haven’t done a good job relieving the symptoms, or they never got to a point where people felt that they work better than their medication. But there are really two endoluminal options right now, and both are promising. One is called the Stretta procedure, and that’s the procedure that we offer here at Guthrie. And that other is called TIF or transoral incisionless fundoplication. That’s a little bit more involved than for a very selected patient population. That’s one that we don’t think fits in very well with our multidisciplinary program here, so we’ve chosen not to offer that right now.  

Bill:  Very interesting. It sounds like you’re advancing in trying to come up with potential relief and/or cure. Is there such a thing as a cure for this? 

Dr. Robert:  Yeah, the gold standard in treating reflux is what’s called a laparoscopic Nissen fundoplication, which is an operation that’s done laparoscopically. So through four one-quarter inch incisions on the abdominal wall and then a smaller fifth incision for a retraction device that’s placed during surgery, we’re able to surgically correct a hiatal hernia by reuniting the muscles that has become separated in the diaphragm and create what’s called a fundoplication or a wrap. Easiest way to think of it is we use a sloppy part of the upper portion of the stomach to wrap around the esophagus. It’s an awful lot like if you put a turtleneck on and you have that doubled over layer of fabric around your neck. This fundoplication is a double-layered piece of tissue wrapped around the lower esophagus. And the way it works is that wrap communicates with the stomach. And so, as someone begins to eat when the stomach is empty, it’s wide open. But as the stomach gets more and more full, that wrap collects fluid and gasses and things like that and starts to pinch in on the esophagus a little bit. So it’s a progressive valve that keeps things from flowing backward from the stomach back up into the esophagus. It worked very well. 

Bill:  Yes, so it closes it off as you eat, then? 

Dr. Robert:  That’s exactly right. Yeah and this is an operation first was done in 1956, several changes over the years, leading up to 1991, when it began being done laparoscopically. And I’ve been doing it laparoscopically since 1992 when I came out of my fellowship. 

Bill:  So if behavioral modifications and the Prilosecs don’t work, is this the last resort then? 

Dr. Robert:  It’s a last resort in the sense that we try all of those more conservative things first because we want to offer patients the least invasive treatment that’s available. It’s not a last resort option in the sense that if someone had reflux for 40 years and neglected it or, really, they needed to move on from medication much earlier, it is possible that after a lot of acid exposure, the esophagus just doesn’t work properly anymore, in which case they might no longer be a candidate for the operation because things may have gotten too far along. 

Bill:  Sounds good. Dr. Fanelli, thank you so much for being on with us today. So why should someone choose Guthrie for their GERD needs? 

Dr. Robert:  Well, I think it’s for all the reasons that we’ve talked about. I’ve talked about the topic in general, but I have a lot of colleagues here who share my interest and passion for reflux disease and trying to relieve people from that misery and across all departments—gastroenterology; ear, nose, and throat surgery; general surgery; radiology. And we all work together to take care of these patients. And I can tell you that a multidisciplinary approach is always the best approach to most disease processes, the old two heads are better than one kind of approach. And in this situation, we have an opportunity to really discuss the specifics of every individual patient and come up with a treatment plan that’s tailored for them. 

Bill:  Sounds good, Dr. Fanelli. Thank you again for your time. We really appreciate it. For more information, please visit guthrie.org. That’s guthrie.org. I’m Bill Claproth, and this is Guthrie Radio. Thanks for listening.