Farid Gharagozloo, M.D, FACS, FACHE, Director of Cardiothoracic Surgery of the Global Robotic Institute of the Florida Hospital in Orlando Florida talks about a robotic aided surgery for acid reflux.
Interview conducted by Ivanhoe Broadcast News in May 2016.
I want to talk a little bit about acid reflux. How common is this and what kind of problems is it causing a lot of patients?
Dr. Gharagozloo: Acid reflux seems to be a disease of the good life. As many of us carry extra weight, and as we do less and less physical activity, it seems that we get a condition called a hiatal hernia which until recently we thought was just a curiosity. But it turns out that the hiatal hernia is what results in acid reflux. It should not be called acid reflux, but reflux gastro-esophageal reflux or GERD because the component of reflux that’s more important is actually not the acid but the non-acid component of the stomach liquids. It’s thought that it affects about eighty million people in the United States.
When it’s a severe case what are the options, what happens to a person with a severe case of this acid reflux and what are the options?
Dr. Gharagozloo: We’re going through a change in thinking about this whole problem. In the history of Medicine so many times we have thought something was going on, and then slowly our thinking changes as we get a better understanding. We started talking about acid reflux; we thought the problem was acid. Around 1978 was the first time we made a pill that suppressed acid. It turns out that since 1978 all different pills have been used but at the same time cancer of the esophagus has gone up by six hundred percent in that very short time. We do not have evidence yet for a cause and effect relationship but it is a trend that cannot be ignored. We found that no matter how well we suppressed the acid, the condition and the problems that occur, Barret’ esophagus, the esophagitis and all the complications continued. Now we’re understanding that we are being a little too simplistic, that suppressing acid is not the idea but it’s all of reflux that has to be controlled, not just the acid. There’s much more interest in looking at the pills as a way of palliating the symptoms, meaning you don’t have pain. You might as well take a pain pill as opposed to taking your purple pill because that’s all it does: it makes the patient feel better, but the condition continues. We now understand that for symptom relief we have to use the pills. However treatment of reflux which is the key, requires a mechanical solution. Hiatal Hernias and Reflux are again becoming a surgical problem. We are getting much more interested in mechanical means of stopping reflux as opposed to just controlling the symptoms.
When you’re talking about mechanical means are you talking about surgery?
Dr. Gharagozloo: Exactly. There are many different techniques that have been used over the past 70 years, some surgical, and some sort of pseudo surgical. However, the ultimate thing is to try to reestablish the anti-reflux mechanism which exists in people who don’t have reflux. It is important to put everything back to the way it used to be. as opposed to some new human thought of or human made kind of a procedure.
How do you go about doing that and what is this procedure called?
Dr. Gharagozloo: The procedure is called Gastroesophageal Valvuloplasty which means making a valve. The procedure stems from really new information over the past fifteen years where we have understood that in a normal setting, there’s a valve which is made of your esophagus getting pushed in to the stomach similar to pushing your fingers into to a piece of cloth, by about an inch. You have a little flap that forms and that flap is what keeps the contents of the stomach from going in to the esophagus. The flap valve is held in place by the structures that connect the esophagus to the hole in the diaphragm called the hiatus. When you get a hiatal hernia, meaning the hole gets bigger from pressure on it, the esophagus is pulled out of the stomach like extending a telescope, and the valve disappears. Now without a valve the stomach contents can rise into the esophagus. It’s like taking a bottle, putting it on its side and everything goes up in to your esophagus. Valvuloplasty is the most physiologic operation for this condition. Historically, surgery has been done for this condition for more than fifty years, but the operations like the Nissen Operation have based on the old concept of having a sphincter instead of a valve. These operations have not been very effective as they have been based on the wrong concept of how nature naturally controls the reflux from stomach into the esophagus. A sphincter and a valve work very differently. Those are operations which were designed fifty years ago; wrap the stomach around the esophagus trying to make a little noose around the esophagus. Well they don’t work and the patients have a lot of trouble eating and lots of complications. That is not the natural. It is natural to have a valve. Presently with sophisticate minimally invasive surgical tools such as robotics we can make a valve by pushing the esophagus into the stomach and replicating the natural antireflux mechanism. It’s almost like plastic surgery of the esophagus and the stomach. You’re moving things, you’re suturing things, and this requires a lot of dexterity. By laparoscopic techniques which predated robotics and is technologically hampered by instrument maneuverability and 2-dimensional versus 3-dimensional visualization, you can’t do that. The robotics has allowed us to have more dexterity and the ability to actually make a valve by pushing the esophagus in to the stomach and get it just right. Think of the process this like a movie going backward. We go back to the beginning before the patient started having the problems.
Talk me through the steps that the surgical team goes through. When you’re talking about robotics you’re talking about how you’re rebuilding this flap.
Dr. Gharagozloo: Robotic gastroesophageal valvuloplasty is a very quick operation, because you don’t spend any time opening someone’s abdomen. It’s done through the abdomen by the use of small holes like laparoscopic techniques but uses robotics. The advantage of the robot is it has eight millimeter hands that are controlled by the surgeon. It’s like your hands are eight millimeters inside somebody. It has three dimensional high magnification cameras that magnify whatever you’re looking at by twenty times. You can see it brings a great deal of accuracy to the surgery. The patient is under anesthesia and five holes are made in the abdomen that are two centimeters each. These days we have trocars which cause very little pain, if any at all. Then the robot is positioned and during the operation the hiatus is closed with dissolving sutures and no Mesh. . The entire procedure is mechanically precise with many measurements and is therefore highly reproducible, as opposed to previous operations which were very qualitative and depended on the surgeon’s experience. The previous operations like Nissen were previous were like cooking, a little pinch of this and a little bit of this, but now because of the robotics and the computer interface we can measure the pressures, everything is measured to perfection. The hiatus is closed to be the right size. We don’t use extrinsic material to close this hole which had been done previously. The use of Mesh in this location is very dangerous. When people hear the word mesh they imagine all kinds of bad things, and rightfully so! We’ve really become more sophisticated. The hiatus is closed primarily as it’s called, then the esophagus is pushed in to the stomach, sutures are place to hold it in place so that the flaps stays in place until the body heals the area.. Those sutures dissolve in a couple of months and then the body forms scar tissue that keeps it in place. Most importantly the valve is suspended on that reconstructed hiatus because no valve will work unless it’s suspended on a skeleton or framework. Here the flap is like a door and the hiatus is the door frame that suspends the door. That takes about sixty minutes. The patients usually go home the day or two after surgery.
What is recovery time?
Dr. Gharagozloo: The recovery is in two phases. The recovery from surgery is very quick; it is almost pain free because even the holes that are made are four millimeters. The 4 mm holes are stretched open so that the instruments go through. When you take out these little tubes the hole goes back to four millimeters. You don’t have to suture them. There is very little pain. Then for a couple weeks the patients get some swelling where the valve is made. During that time they eat softer food. Usually at about two weeks everything is in place and they’re back to the way they were born.
The smartest thing we can do as surgeons is replicate nature. The genius of nature is to have a valve which lets you eat because the valve opens without you knowing it. When the stomach fills with liquid the valve will close but when the stomach fills with gas, the gas goes around the valve so people can burp. This is a thing that happens to anyone who has a normal antireflux mechanism. The genius of the valvuloplasty is that we put everything back to the way it used to be.
How long are the valves good for?
Dr. Gharagozloo: We have been following our patients since 2002 and we have yet to do a re-operation for a recurrent hiatal Hernia. That is in hundreds of patients over 14 years. 96 % of patients report excellent relief of symptoms.
What’s the newest thing with this particular procedure, is it the robotics, what’s making this cutting edge?
Dr. Gharagozloo: Since 2002 we have used the robot. We were one of the earliest adopters of robotics. We knew that the robot was the game changer. Laparoscopic surgeons including me know the limitations of conventional laparoscopy. Laparoscopy is like doing surgery without a wrist. As a stark illustration, if I walked into a consultation room and I didn’t have a hand, the patient would never let me touch them. In laparoscopy there’s no wrist action, it’s all done with straight instruments that pivot on the abdominal wall and only have an arm action. The robot brings the wrist and the hand into the picture. Then there is the matter of visualization and cameras. Laparoscopic surgery is two dimensional. Visualization needs to be three dimensional. If I walked in the room again with a patch over one eye, the patient would think twice about letting me operate on them. The robot camera is three dimensional and it has high resolution and high magnification. It’s like putting magnifying loops on your eyes. If the surgeon sees better, and if his movements are more accurate and have greater dexterity, it results in better surgery. It is as simple as that. The other thing that’s important is understanding the natural situation and replicating it as opposed to some idea of what it should be. The reason we have not sent patients with hiatal hernias and GERD to surgery in the past has been because of the complications of the Nissen surgery. If you had a choice of a perfect operation versus medications, everyone would pick a perfect operation which replicates the normal antireflux barrier of the body. In other words, at each point in time in Medicine our practices depend on the risk vs. benefit of the particular treatment. The risk benefit ratio is changing because the surgery is becoming much more accurate and we have a greater understanding of the normal physiology. Valvuloplasty is a game changer when it comes to patients with Hiatal hernias and GERD.
Is there anything I didn’t ask you about this particular procedure that you think we should know?
Dr. Gharagozloo: The indications are changing as people are learning about this. There was a time when the only indication was failure of medical therapy or intractability. If you failed medical therapy, you had surgery. That’s really not the best thing. We are discovering that the antacid medications have many systemic side effects ranging from kidney disease, GI disease, heart disease, to bone disease and diseases of the central nervous system. In addition it turns out that they mask the symptoms and don’t really control the nonacid reflux. The indications for surgery are becoming wider. My best advice is that people with Hiatal Hernias and GERD should be evaluated by a Gastroenterologist who specializes in the esophagus, and follow the recommendations of their physician. All of those are now becoming more and more the indications for surgery. Some believe that a few years from now, reconstructive surgery may become the first line of therapy as opposed to giving you a prescription.
We’re moving more towards surgery being your first line gold standard instead because of these side effects?
Dr. Gharagozloo: Absolutely, we’re moving towards a mechanical solution to a mechanical problem. We should learn from the history of Medicine. One potential problem which parallels GERD is heart disease. In the 1970’s if you had chest pain we would give you a pill called nitro. You put it under your tongue and you feel better. People still died of heart disease, they just felt better. Then we got sophisticated to fix the problem rather than making the people feel better. It’s the same story now with reflux.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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