LAPAROSCOPIC NISSEN FUNDOPLICATION SURGERY MCLEOD HEALTH REGIONAL MEDICAL CENTER FLORENCE, SOUTH CAROLINA JUNE 7, 2006

Transcription

1 LAPAROSCOPIC NISSEN FUNDOPLICATION SURGERY MCLEOD HEALTH REGIONAL MEDICAL CENTER FLORENCE, SOUTH CAROLINA JUNE 7, :00:11 ANNOUNCER: In a few moments, a surgical team will assemble here. Led by the surgeon, these talented professionals will offer life-changing care to our patient. Every member of the team will be focused on delivering the safest possible care that results in the best possible outcome. One team, one patient, but an event that occurs hundreds of times each week. For those that provide care here, the surgical suite is a familiar place, but not so for patients. Patients come to this place with hope, hope to be relieved of pain or disability, cure for a disease, and for some, lifesaving care. Most come with fear and anxiety as well. We believe that we can help lessen these fears by inviting the public to look into our workplace to make it a less mysterious place. These broadcasts of surgery allow us to open our doors to you in a way that hasn t been possible before. In doing so, we hope to accomplish two important goals. First, we know that educated and informed patients are able to better partner with their doctor to choose the care that is best for them. Many have described navigating the healthcare system to be like entering a foreign country that has its own language and culture. We want to change that. We want to help the public learn the language so they can be better participants in their care. Second, the same technology that allows us to invite you into our world can connect our doctors with colleagues as close as those down the hall but also those across the country or even around the world. As a result of this technology, we are witnessing the globalization of healthcare. This virtual collaboration between doctors supports and drives the rapid adoption of safe and effective innovations. Doctors can share ideas in ways never before possible. We are especially grateful to Mrs. Sybill Storz and Karl Storz Endoscopy for their commitment to education and innovations, and of course, the SLP3D broadcast network. On behalf of the medical staff and more than four thousand members in the McLeod family, we invite you now to enjoy today s webcast. 00:02:50 AMY MURRELL, M.D.: Again, welcome to McLeod Health here in Florence, South Carolina. Tonight you re going to witness a Laparoscopic Nissen Fundoplication, a minimally invasive procedure to cure Gastro Esophageal Reflux Disease. I m Dr. Amy Murrell; I ll be your moderator. Before we take a look at the procedure, a reminder: at any time during the next hour, you can ask us questions. You can do so by clicking on the button at the top of your screen. Now, on to Drs. John Sonfield and Dr. Reginald Bolick. Dr. Sonfield, can you tell us a little bit about your patient you re operating on and where you are in the procedure? 00:03:22 JOHN SONFIELD, M.D.: Yeah, thanks Amy. This is a 55-year old white female that s had a long history of gastro esophageal reflux disease. She s taken many medications, and over the years her disease has been refractory to those medications. She was worked up after the medications had stopped working for her she was worked up using ph probes and manometry. ph probe showed that the reflux disease she was having was quite significant. Given these findings, the patient was worked up again with EGD that showed no evidence of

2 esophagitis, but given her positive ph probe and the findings of abnormal progressive symptoms, the patient was signed up for surgery. At this point, we have trochars placed, five in number, one being a liver retractor and four other working points. The place umbilicus is the point for the camera, and the rest will be working ports. Now we will put the patient in proper position and put the camera into the abdominal cavity and give you a tour of the abdominal anatomy. 00:04:33 AMY MURRELL, M.D.: So John, each of these incisions is really about a centimeter to 2 centimeters in length. 00:04:38 JOHN SONFIELD, M.D.: That s true. Our largest is at the umbilicus and the rest are approximately 1 centimeter in length. 00:04:45 AMY MURRELL, M.D.: Okay. John, show us what you re looking at now. 00:04:47 JOHN SONFIELD, M.D.: In the abdomen right now, we re looking at two working instruments here, as well as this structure here being the left lobe of the liver. You can see the diaphragm and the heart beating. You can also see the stomach. This is called the omentum, which is a fatty layer that hangs off of the stomach. We ll move over this way and see the other side of the liver. This is the right lobe of the liver, including the gall bladder at that location. You can see a hint of the colon here; this would be the right colon at the hepatic flecture. This is our abdominal wall. This is called the falciform; it s a ligament that attaches the interior abdominal wall to the liver. Again, here s another working port at this location. We can actually move this camera totally around and look into the patient s pelvis. These are called adhesions. This patient has had prior abdominal surgery with a hysterectomy, and these are the old adhesions from that scarring. Right now we have proceeded with our dissection, and we re about to lift the liver and show you part of what we ve already done. With the liver lifted here, we re about to place what s called a liver retractor through one of our abdominal ports to hold this left lobe of the liver up. Structures you can see coming into view at this time are going to be the esophagus and what s called the crura. These are muscle attachments from the diaphragm. This would be the right crura attachments. That would be the esophagus, which you see in the middle there. The stomach, that is what the esophagus is attached to, and then we ll look at the other side to look at the left crura. Again, we ve done this dissection in the last 45 minutes, we ve mobilized these structures. There s the left crura there, the esophagus in the middle, and the right crura on the other side. 00:06:52 AMY MURRELL, M.D.: John, does your patient have a so-called hiatal hernia? 00:06:56 JOHN SONFIELD, M.D.: This patient does have a small hiatal hernia. This was seen on preoperative workup with an esophogram and what s also known as an upper GI. The patient was found to have a small hiatal hernia and we ll show this to you. The esophagus will be retracted to the patient s left. As we pull down on the stomach, you can see this gap in that crura there; where the right and left crura meet, sort of a V-shape structure, you can see small evidence of a hiatal hernia. 00:07:25 AMY MURRELL, M.D.: And that s where the actual hernia is, in that little V-shaped crux right there? 00:07:31 JOHN SONFIELD, M.D.: That s correct. Again, you can see the esophagus there at that location between that V-shaped structure, the crura. 00:07:41

3 AMY MURRELL, M.D.: Well, John, while you all are getting a little more work done, let s hear from one of the patients that we ve operated on recently and how this reflux disease has really affected his life and how much he s suffered from it. 00:08:00 JOHN PETRUSH: As time passed, if I skipped one because I forgot or for whatever reason, I was immediately aware that I had not taken that pill that day because the symptoms came back with a vengeance. It hurt. It was more than just some mild heartburn; it was now getting to the point where it was painful. The next thing that happened as all of this escalated were very clear episodes of reflux, where as I was asleep I would be startled awake with the feeling that I had just thrown up, when in fact what had happened is a whole bunch of stomach acids surged up my esophagus into the back of my throat. And that is a sensation that I honestly can t explain in words. It s very violent, it s very uncomfortable. To be startled awake like that is an extremely unpleasant experience, and that began to happen with greater and greater frequency. I went from, Gee, that was really weird, it happened once, to This is happening almost every night. If I had my dinner at 6:30 and went to bed at my normal time, it was a 50/50 probability that something would happen. But if I was late coming home to work for whatever reason and we didn t have dinner until 8:30, it was almost a guarantee. So it got to the point where I didn t want to eat anymore, especially if I couldn t have my dinner at 6 or 6:30, I would skip it so I wouldn t have those kinds of episodes. When I explained those set of circumstances to my physician, he said, We need to get you to a specialist and get some tests done. And that s when the next level began. 00:09:58 AMY MURRELL, M.D.: John, those are really horrible, life-changing symptoms that patient of ours had, and unfortunately all too common, even in patients who are on medical therapy for their reflux disease. Does your patient have similar complaints? 00:10:12 JOHN SONFIELD, M.D.: Very similar. This patient is much like that gentleman with her complaints. Added to her complaints is she has asthma, too, which we re hoping with this procedure this may help some of the atypical presentations of gastro esophageal reflux disease. Amy, I wanted to point right now, the next part of the procedure is to close the hiatus, or the hiatal hernia here. To do this, we ll place stitches through the two crural segments there, the right crura and the left crura, being pointed out with the dissector right there. We close this to, again, fix the hiatus and fix the defect, the hiatal hernia. So that s what we ll perform as the next questions come in. 00:10:54 AMY MURRELL, M.D.: John, you all have done a wonderful job dissecting that out, and now we ll watch you repair the hiatus. 00:11:05 JOHN SONFIELD, M.D.: We ll do this with permanent suture. This is a suture called Surgilon. 00:11:12 AMY MURRELL, M.D.: John, how often do you see patients with reflux disease? It s pretty common. 00:11:15 JOHN SONFIELD, M.D.: It is common. Of the people that have reflux, which can be up to percent of the population, the people with severe reflux disease, approximately 10 percent of those individuals can come to surgery. 00:11:30 AMY MURRELL, M.D.: Okay. 00:11:32 JOHN SONFIELD, M.D.: What you ll see now is using a suturing device; this allows us to perform sutures laparoscopically. That there is the left crux of the diaphragm. Dr. Bolick at

4 this time is going to put it into the right crux of the diaphragm. Again, we re trying to reapproximate these muscles and close the hiatus to prevent any further herniation. This will help also keep our esophagus and our wrap that we re planning to perform intraabdominal. It s the intra-abdominal pressure that we look for to help increase the pressure of this lower esophageal sphincter. And this will help prevent the reflux in the future. 00:12:17 AMY MURRELL, M.D.: Well, let s go to our first question. How many people actually have GERD, or reflux disease? And I think we have a slide here to give us some hard numbers. Reflux disease is the most common intestinal disorder in western society. About half of Americans experience heartburn at least on a monthly basis and 10 percent of patients have daily symptoms and life-changing trouble with their heartburn. Over 5 billion dollars a year in the United States are spent on pharmaceuticals to try to combat this reflux disease, so John, this is really a widespread problem that many of Americans are dealing with. 00:12:57 JOHN SONFIELD, M.D.: There s no doubt about it. And what I think people need to understand is that surgery is for people with severe symptoms. It s not for everyone with run-of-the-day gastro esophageal reflux. Dr. Bolick, at this time, he s put the first suture in the crura there. You can see as it starts to reapproximate itself. He s tying these knots actually outside the patient and pushing them down to where they need to be next to the muscle. This is one way to tie the sutures. This can be done several other ways, including tying the knots inside the abdomen. 00:13:35 AMY MURRELL, M.D.: John, our next question is, What actually is reflux disease? And I think we ve got a picture of that really demonstrating what the pathology or what the problem is in reflux disease. You have the stomach, which has acidic contents that s very burning and uncomfortable once it refluxes back up into the esophagus. The stomach has a lining that protects itself from this acidic liquid, but the esophagus does not, and so when that acid refluxes back, it truly is burning the patient s esophagus, resulting in the heartburn and other symptoms. 00:14:17 JOHN SONFIELD, M.D.: So here goes the second stitch in the crura. And Amy, again, what we re trying to do here is what the medicines cannot do. The medicines are good at reducing the acid load to the esophagus, but what the medicines can t control is the physiology behind the disease. 00:14:47 AMY MURRELL, M.D.: Well, John, let s talk a little bit more about what the typical symptoms of reflux are, and actually that s our next question, is What is the difference between heartburn and GERD? And we have a slide here discussing the typical symptoms of reflux disease. The first and most common being heartburn, the so-called burning sensation in the upper abdomen or chest. And when patients feel that pain, as I said, that is actually the acid burning the esophagus lining. The second most common symptom is regurgitation, or when the acidic contents actually back up into the patient s mouth and the patient has a very sour, bitter taste in their mouth. And that frequently occurs when the patient is either lying down flat or bending at the waist. And finally, the third most common symptom is dysphasia and what that means is the patient has a difficult time swallowing, and as this reflux disease progresses, or the longer that disease is present, the worse this dysphasia, or difficulty swallowing, gets. So certainly we try to get to these patients before that occurs, John. 00:15:54 JOHN SONFIELD, M.D.: Yeah, we worry about dysphasia with the operation, too. We put two sutures in the crural segments there from the diaphragm. We don t want to make this too tight, so we re very happy with the way it looks right now. There s enough space between the remaining segments of the diaphragm and the esophagus. That looks perfect.

5 00:16:13 AMY MURRELL, M.D.: That looks great. 00:16:15 JOHN SONFIELD, M.D.: The next step of the operation is going to be to perform the actual fundoplication. This is where we ll take the fundus of the stomach and plicate it around the esophagus. [inaudible] 00:16:30 AMY MURRELL, M.D.: John, there s some atypical symptoms, too, that occur with reflux disease. Patients frequently will present to the emergency room in the middle of the night with chest pain, very concerned that they re having a heart attack, and once their heart has been worked up and found to be in good shape, they realize that their chest pain is actually from reflux disease. It s a pretty common finding. Other things that can occur are significant pulmonary symptoms, such as asthma and chronic cough, and even pneumonia. And surgery can cure these people of those symptoms also. 00:17:06 JOHN SONFIELD, M.D.: One thing we want to ensure at this stage of the operation is enough esophageal length. We use this esophageal retractor, one, to show us our esophageal length and to help us with our fundoplication. What we re doing at this point is grabbing the fundus. We want a nice, loose, floppy wrap, and to ensure that, we want to grab it at the proper position and test it several times before we perform the actual fundoplication with sutures. 00:17:40 AMY MURRELL, M.D.: John, we ve got another question. It s, Can GERD cause cancer? And I think that s an important point to make. The burning of the esophagus is continually damaging the lining of the esophagus and there are side effects that occur with this. Initially, there s a lot of inflammation and irritation that occur in the esophagus, and as this progresses, the longer it s present, you tend to get ulcers and bleeding that form in your esophagus. And as that continues, the esophagus can narrow down or actually get strictures, and that s when the dysphasia, or the difficulty swallowing, begins to occur. And finally, if this is left long enough unchecked, this can significantly increase your risk of progression to cancer of your esophagus. 00:18:32 JOHN SONFIELD, M.D.: We ve wrapped the esophagus at this point excuse me, wrapped the stomach around the posterior, or backside, of the esophagus. At this point we ve removed the esophageal retractor, and then we ll find the front side, or anterior side of the stomach to complete the fundoplication. Again, we want this loose, we want this floppy. We don t want it tight; we don t want to cause any compression of the esophagus that may lead to difficulty swallowing. Again, we want enough pressure to help enhance the valves so there s no reflux, but on the other hand, we don t want to cause any swallowing difficulty. So we ll play with this wrap for a second. We ll play with the stomach. And again, we want to make sure that this is an esophageal wrap and not a gastric wrap, so we want to get high on the esophagus at this location. Again, we want to see if this is loose. We call this the shoeshine. We see how it moves back and forth real easily. And again, this is a perfect setup for our fundoplication. 00:19:39 AMY MURRELL, M.D.: John, our next comment is from a viewer who says that she has very good relief with her medical therapy; should she consider medical surgery? And I think that s a very good point, especially in young patients who do have good relief with their surgery can still benefit from surgery. There are definitely weaknesses of medical therapy. First and foremost, they cost a lot of money. Anybody who s on any of the proton pump inhibitors knows that it can be several hundred dollars a month for their medicines, and once you have reflux disease, usually as soon as you stop taking your medication, the reflux

6 comes right back, so these patients are really committed to lifelong therapy for their reflux disease, which is quite expensive. Also, there are side effects of the medications, and some people just simply don t want to take a medicine every day for the rest of their life to keep the reflux away. And not only that, John, when you get rid of the acid, when you use this proton pump inhibitor and decrease the amount of acid in the stomach, you still have reflux occurring, so those patients are still getting damage to their esophagus. What you all are doing right now by creating this wrap is actually going to create a new valve to keep any reflux from the stomach going back into the esophagus. And that s what you all are just putting the first sutures in. 00:21:00 JOHN SONFIELD, M.D.: That s correct. This is called incorporeal knot-tying, or tying the suture inside the body. This is just a different technique to perform this. Again, we want a nice, floppy wrap. I ve grabbed stomach and esophagus in this wrap, and we ll start tightening these sutures down. Again, nice and loose wrap here. We call this the sewing machine. It s a little trick to it, but not too hard. 00:21:45 AMY MURRELL, M.D.: John, let s talk a little bit about what this patient can expect postoperatively. What kind of diet will he be on tonight? Will he eat or drink anything tonight? When will you start him on regular food? 00:21:58 JOHN SONFIELD, M.D.: We ll talk can you comment on that while we tie this here? 00:21:59 AMY MURRELL, M.D.: Okay, yeah. Typically, these patients will be started on a very small amount of clear liquids on the night of surgery, and then tomorrow the patient will be started on a full liquid diet in advance to a soft mechanical diet. So in other words, they ll avoid hard meats like steak and breads and things. Typically, their diet is pretty much back to their normal diet in about six weeks. She ll spend the night here with is in the hospital tonight, and then she ll be discharged probably tomorrow or the next day. 00:22:40 JOHN SONFIELD, M.D.: The 12-centimeter will be better. Twelve centimeter will be fine on this one. Dolphin s a sharp nose. 00:22:56 AMY MURRELL, M.D.: John and Reg are just putting the first stitch and the wrap, and they re going to put a couple more in to hold that stomach around the lower esophagus. Again, this is a great view of the valve that they re creating. 00:23:12 JOHN SONFIELD, M.D.: I need a blunt-tipped instrument. If they have it, we ll use it; if not ah, this ll be good. Just real close-up here. Again, we want this approximately 2 centimeters in length, this wrap here. You can stay on just for a sec. Again, nice and floppy here. You can come off now. You want to go up here and grab the esophagus. A little bite of the esophagus and a little bite of the stomach. Camera over. Okay. 00:24:13 AMY MURRELL, M.D.: Okay, as you can see, they re putting another stitch to hold this wrap, or hold this new valve together. And those are permanent sutures they re putting in; they ll last forever. And this wrap will be present forever. In fact, we just had a question, How often must this procedure be redone? And the answer to that is if it s done properly the first time, it should never have to be redone. This should last for a lifetime. And that s the good thing about this procedure, that it lasts forever, it s a very durable operation, and patients no longer need medication. 00:24:54 JOHN SONFIELD, M.D.: And we re putting the last few suture knots in this wrap here. Again, nice and loose. 00:25:08

7 AMY MURRELL, M.D.: Well, John, while you all are just finishing off the wrap, let s hear back from our patient and hear what kind of relief he had after his surgery. I think it s pretty remarkable. 00:25:19 JOHN PETRUSH: I ve been told that the effect would be realized very early on, that there was no need to wait for a month to realize that things were different. And, in fact, as soon as the anesthesia wore off and I could eat anything, I knew that we were in much better shape. I could have they gave me some things to drink and real soft stuff to eat, like Jell- O, in the hospital. And not only was it easy to have, but there was no heartburn after. Immediately after. And it was just a revelation to mean. It was like, Wow, this really works, this great stuff. But in the weeks after when I was eating more like normal and my activity certainly came back to normal within days, there was an absolute absence of heartburn and not even a hint of reflux reaction, nor have I felt one since. It s just gone. So the effects of that procedure were both immediate and complete. When that reflux reaction is just totally gone, it s a wonderful sensation to not have. 00:27:13 AMY MURRELL, M.D.: John, that s a great testimonial, and I think it s very common for patients to have this kind of experience post-operatively. Patients do very well with the surgery. Their reflux is gone and they get back to their normal activity very quickly. 00:27:29 JOHN SONFIELD, M.D.: It is amazing. We did that gentleman, Dr. Bolick and I, and by the next day, he felt a dramatic difference. Here s our last stitch here. Again, we re going to grab the esophagus, get a little bit of esophagus there. 00:27:45 AMY MURRELL, M.D.: John, we just had a question from a viewer asking if the stitches interfere with any activity or have any effect on the body. 00:27:47 JOHN SONFIELD, M.D.: They don t. These are sutures that we ve used for a number of years, don t have any long-term effect. 00:28:01 AMY MURRELL, M.D.: It really would be the same as having any open procedure, whether it was a bowel operation or a hysterectomy, whatever the case may be. The suture is all very similar. 00:28:11 JOHN SONFIELD, M.D.: That s correct. 00:28:12 AMY MURRELL, M.D.: So it s tried and true. 00:28:13 JOHN SONFIELD, M.D.: That is true. And there s a perfect wrap there. 00:28:38 AMY MURRELL, M.D.: John, we ve just had another question asking about having the procedure done here at McLeod Health versus at an academic-affiliated hospital. 00:28:50 JOHN SONFIELD, M.D.: You know, I think that we do it as effectively and safely as any other academic or any other institution. We have the surgeons that have the experience, we have the equipment, so I think that it s your community hospital, that it s advanced in laparoscopic surgery like we are here at McLeod, I think that we are as good as any academic environment. 00:29:15 AMY MURRELL, M.D.: I would agree with that, John. I think that McLeod Health is a wonderful place to have this procedure done with surgeons who are well experienced and ORs that are quite advanced like this. 00:29:22

8 JOHN SONFIELD, M.D.: As you can see, we ve completed the wrap here. The goal is what we wanted to do is a short, floppy wrap. We re about to demonstrate the floppiness of the wrap here. There s not tension at all on the wrap. We ve gotten small bites of the esophagus to ensure that the wrap will not slip. We ve closed our hiatal hernia to make sure the wrap won t slip up into the chest. We re pulling downward, retraction on the esophagus now and wrap. That s why you re seeing a little of the intrathoracic esophagus at that location. You can again see the repair of the diaphragm is complete, and the wrap, again, is not tight. 00:30:00 AMY MURRELL, M.D.: John, one thing our viewers may be surprised about is how little blood there is, but this surgery really when done properly has very little blood loss. 00:30:11 JOHN SONFIELD, M.D.: What we ve lost is what you ve seen, and that includes the dissection we did before we came on air. 00:30:17 AMY MURRELL, M.D.: And that probably is a tablespoon or so of blood, so 00:30:18 JOHN SONFIELD, M.D.: Or less. Yeah, I agree. It s amazing, and we ve done it through five small 1-centimeter incisions. 00:30:29 AMY MURRELL, M.D.: John, I m going to step away from the operation just a second. We ve got Dr. Deepak Chowdhary here, who s one of our gastroenterologists here in Florence. Dr. Chowdhary, you frequently see these patients in your practice and work them up for reflux disease. Can you tell us a little about how you work them up and how you get them to the surgical side of this? 00:30:47 DEEPAK CHOWDHARY, M.D.: Actually, once we start if they have symptoms of gastric reflux, we ll try them if they have no what we call concerning symptoms, we start them on medication to cut down the acid in the stomach. And if they don t respond, then we proceed with further management. Or if they have symptoms which are concerning, like they have difficulty swallowing, they have anemia, they have bleeding, they have weight loss, then we ll proceed to endoscopy. At endoscopy, we find out what exactly is going on in the esophagus. There may be esophagitis, there may be what you call Barrett s esophagus, where the lining has changed from the normal lining of the esophagus, or there may even be cancer. Once endoscopy is done, if there is no evidence of any cancer or stricture and they don t respond to medication, only then do we consider doing surgery. 00:31:59 AMY MURRELL, M.D.: Dr. Chowdhary, I think that s an important point is that there are repercussions of this reflux disease. Just because the patient is troubled and has lifestyle issues, there are significant medical complications that can occur without treating it adequately, either by medication or by surgery. 00:32:19 DEEPAK CHOWDHARY, M.D.: Yes, I agree with you, and in fact, there was a study in which they have seen people with reflux, their lifestyle was worse than people with serial cardiac disease, so I think that reflux is a disease which should be controlled because it can affect the lifestyle very adversely. 00:32:41 AMY MURRELL, M.D.: And as a gastroenterologist, a significant portion of your practice is taken up with patients with reflux disease. 00:32:46 DEEPAK CHOWDHARY, M.D.: Yes, we see a significant amount a significant number of people with gastric reflux. 00:32:53

9 AMY MURRELL, M.D.: Okay. As you can see now, Dr. Sonfield is closing the very small incisions that they ve made, five small incisions. 00:33:03 JOHN SONFIELD, M.D.: As you can see, it s five very small incisions. Once again, with the trochars removed you can see this is where we had our liver retractor, this is where we had our camera, and then the three working ports. This will be closed with sutures that dissolve, nothing to be removed. They ll be covered with Band-Aids; we ll inject them with local medicine to help with the pain postoperatively. 00:33:26 AMY MURRELL, M.D.: John, we ve just had another question. It s from a patient who had this procedure done about 3 weeks ago and is having a little bit of trouble with food getting caught up in her esophagus right now. She wants to know, Is this normal and will it go away? How often do you see this difficulty swallowing after this surgery? 00:33:43 JOHN SONFIELD, M.D.: We can see difficulty swallowing up to 30, 35 percent of the time. This, however, gets better with time. Over a course of 6 weeks or so, this should improve, and most of the patients by 12 weeks, 90 to 95 percent of the patients that have dysphasia, it s gone by 12 weeks. 00:34:04 AMY MURRELL, M.D.: And John, just like with any surgery, there s swelling postoperatively, and that s just exactly what occurs in this case. So I would tell this viewer just to bear with her symptoms right now and it almost certainly will improve. 00:34:18 JOHN SONFIELD, M.D.: I agree totally. 00:34:20 AMY MURRELL, M.D.: Well, John, let s go back to our patient and hear why he chose McLeod Health to have his procedure done and his experience in total here. 00:34:34 JOHN PETRUSH: My particular benefits program offered me choice in terms of which hospital I went to, and the early stages of the testing process, I actually started off at a different healthcare provider. And one of the things they did was give me a pro forma invoice as to what those costs would be for those tests. After I regained my composure, I decided to call McLeod and asked for exactly those same services. And was handled very nicely, I have to say. Price shopping at a hospital is not something one would think about, and I got very concise answers, very prompt, and the numbers were very different. And as a consumer of health insurance services, I could not justify that cost difference, not only the part that I had to pay out of my own pocket, which I try to watch carefully, but my employer contribution to those benefits as well. I own stock in that company. I have a vested interest, and that was part of it. The other part of it really boiled down, though, to where I felt more comfortable. I have had procedures done here at McLeod here before and I know how this hospital operates, and I like that. So, you know, and working with Dr. Bolick, I knew that he would want to come here. And I know that my previous experiences with both out well, with surgical procedures in general, that I was going to have a good experience. 00:36:38 AMY MURRELL, M.D.: John, those are some great comments. I think we all really believe in McLeod Health and the great job that goes on here on a daily basis, all the patients here we try to give the very best experience to, and all the staff here really are just caring people. We just have another question from a pediatric dentist who talks about her patients having tooth decay and other symptoms and she wants to know if we offer this procedure on children, and if so, how young. 00:37:14

10 JOHN SONFIELD, M.D.: You know, at this institution we re not set up to do it on children. I think that s an institutional choice. I think that operation is specialized in children; it s usually in very young children, children even under the age of 2 years old that have significant reflux. Most of these children have other medical problems that cause them to have reflux and should probably be under the care of pediatric surgeons who do this procedure routinely in that age group. 00:37:44 AMY MURRELL, M.D.: That s right, John. A lot of those patients just have so many other medical problems that complicate this picture, and it s definitely not straightforward reflux disease in those patients. 00:37:55 JOHN SONFIELD, M.D.: But you know, the disease is similar as far as the medical treatment, as well as the surgical treatment, it s just, as you said, much more complex in those children. 00:38:08 AMY MURRELL, M.D.: Okay. John, while you re closing up, I m going to bring Dr. Chowdhary back again and just talk a little bit about the workup that gets done for these patients with reflux disease. We briefly touched on endoscopy, but also they have what s called a ph probe done, 24-hour ph probe, and sometimes a barium swallow done. 00:38:29 DEEPAK CHOWDHARY, M.D.: Yes, apart from ph probe and barium swallow, we do the esophageal manometry [?] also to make sure after the surgery they don t have difficulty swallowing. If the muscles in the esophagus are weak, then the surgery is not recommended, and 00:38:46 AMY MURRELL, M.D.: I think that s an important point, Dr. Chowdhary, is that when these patients come with reflux disease, we have to be very careful to make certain that their symptoms are from reflux disease and not from some other problem that could be masquerading as reflux disease. We certainly don t want to operate on someone who s not going to benefit from the surgery. 00:39:03 DEEPAK CHOWDHARY, M.D.: That is exactly true because about 30 to 50 percent patients with reflux may not have acid reflux; they may have other what you call nonfunctional gastrointestinal disorder or non-ulcer dyspepsia, and they are not good candidates for surgical intervention. 00:39:33 AMY MURRELL, M.D.: John, we ve just had a question come in from a viewer asking if this procedure can be performed using a robot. 00:39:43 JOHN SONFIELD, M.D.: [laughs] I think that s an interesting question. They ve done studies with robotics in Nissen fundoplication. Of course, this operation could be done using the robot, but at what cost, both to the patients and to the institution? And operative times for the patient: the longer they re on the table, the more risk they re at. It can be done with a robot; it has been done with a robot. Several studies have shown that it can be done successfully; however, the cost does not make it a worthwhile procedure. So the answer I would say is for this procedure, if you look at this patient s abdomen at this time, they ve had five small incisions, less than two-hour operation. Can we do it better? You know, the future will see, but for right now I think the cost issues with the robot alone its cost, its maintenance, its equipment make this not a surgery for that robot. 00:40:44 AMY MURRELL, M.D.: John, we have another question from a viewer asking about your laparoscopic suture passer and asking if it can be used in different kinds of laparoscopic surgery aside from just the Nissen.

11 00:40:54 JOHN SONFIELD, M.D.: No doubt about it. We use it in all sorts of procedures where we have to tie with sutures inside the abdominal cavity. 00:41:02 AMY MURRELL, M.D.: Absolutely. We perform quite a number of laparoscopic colon resections and other things that require tying suture within the belly laparoscopically, and so we use those a good deal here at McLeod. John, your patient here, she ll go home she ll go to a room and spend the night here tonight? 00:41:25 JOHN SONFIELD, M.D.: She will. She will be on a regular patient floor. We won t give her anything to eat or drink tonight, but starting in the morning, she ll start on clear liquid diet. If she tolerates this and her pain is controlled by the afternoon, she could go home as early as tomorrow afternoon. Little bit more local? Wet and a dry. Yeah, that s plenty. Again, her diet will progress as she tolerates. There have been many different postoperative treatment plans. What we ve gone with is to go to a soft mechanical diet after the first postoperative day, if tolerated by the patient. If not tolerated by the patient, we ll back down to a full liquid diet. We can get her enough calories in by mouth through a liquid diet. And from that point on, we ll just progress it as she tolerates. 00:42:30 AMY MURRELL, M.D.: John, we sort of touched on the benefits of surgery over medical therapy, and I think that s another important point I d like to reiterate again. Many patients do have good symptom relief with their medicines, but simply don t want to be on medicines for the rest of their life, and that certainly is a good reason to proceed with this surgery. Also, some patients continue to increase their dosage of their medications with decreased results, and those patients also benefit from this surgery. If you look at patients who are five years out from their surgery, they re much happier than they were preoperatively, and almost all patients are no longer on their medication anymore. 00:43:17 JOHN SONFIELD, M.D.: It is true. Some patients after this procedure still need some medications, and that s been well documented in the literature. However, it is at decreased dosing, which decreased dosing is more cost effective. We re just getting ready to put on the final steri strips here, and then we ll place the Band-Aids and the procedure will be completed. 00:43:59 AMY MURRELL, M.D.: John, earlier today we actually had a continuing medical education meeting for primary care doctors here in the area and discussed reflux disease really all the way through what is happening to the medical therapy and also the surgical therapy, and one of the things we discussed today were emerging medical devices or so-called endoluminal therapy for treating reflux disease. 00:44:22 JOHN SONFIELD, M.D.: Yeah, I think the endoscopist will tell you as well that this has not been what they expected it to be, and a lot of it is starting to become passé and dismissed as therapy for reflux disease. 00:44:39 AMY MURRELL, M.D.: I think an important point is that this surgery for reflux disease has been around for an awful long time and it sort of tried and true, where some of those endoluminal or endoscopic therapies are new and do not have long-term results to really compare to. 00:44:55 JOHN SONFIELD, M.D.: Again, very true. And in their short-term, the results have not been good. We have ten-year follow-up of this operation as you stated has been with the laparoscopic version, which is as good as the open operation and our ten-year follow-up

12 with the laparoscopic show that in up to 90 percent of the patients, the operation is still a success. 00:45:26 AMY MURRELL, M.D.: John, a viewer has just asked if other procedures could be done at the same time as this operation, including a hiatal hernia repair, and as we did in this patient and as we do in any patient with this procedure, we do repair the hiatal hernia at the same time as we do the fundoplication or the wrap. 00:45:47 JOHN SONFIELD, M.D.: No doubt about it. If someone also had this disease and symptomatic gall stones, you could take out their gall bladder at the same time, if they had gall bladder disease, or umbilical hernia or something like that that required operation at the same time, we could fix that as well. Band-Aids? And that s the end. 00:46:34 AMY MURRELL, M.D.: John, this really looks great. Just five small Band-Aids, and you ve really changed this woman s life. 00:46:40 JOHN SONFIELD, M.D.: There s no doubt about it. She will notice a drastic difference in the next few days. There you go. Thanks, everybody. 00:46:51 AMY MURRELL, M.D.: John, when do you expect this patient of yours to return back to work? 00:46:56 JOHN SONFIELD, M.D.: She ll be sore from the positioning of the trochars. She ll be sore for about four days to seven days. I would expect into the second week, she ll feel better through the second week, and by the third week she may be able to return to work. 00:47:13 AMY MURRELL, M.D.: Well, John, that really was a great job. We ve enjoyed bringing you into our McLeod Health OR of Tomorrow. On behalf of myself, Dr. Amy Murrell, Dr. John Sonfield, and Dr. Reginald Bolick, we appreciate you joining us today. And now a final word from our patient. 00:47:32 JOHN PETRUSH: The most significant piece of advice I would offer them is don t wait. I wished I hadn t. I didn t know any better. Don t wait. See somebody. Get the series of tests performed so that you have the necessary information on which to base the next steps. Assuming that your path is similar to mine and the recommendation from your physician comes back to have that particular procedure done, then my experience says, again, don t wait. Go ahead and get it done. The interruption to the rest of your life is very nominal, and even if it wasn t, it s still worth it because the rest of it is so much better. It s a very small investment to make. The effects will be immediate and profound. 00:48:34 END