LAPAROSCOPIC NISSEN FUNDOPLICATION TAMPA GENERAL HOSPITAL, TAMPA, FLORIDA Broadcast September 7, 2005

LAPAROSCOPIC NISSEN FUNDOPLICATION TAMPA GENERAL HOSPITAL, TAMPA, FLORIDA Broadcast September 7, 2005 NARRATOR 00:00:11.000 Acid reflux, also known as gastroesophageal reflux disease or GERD, is a common problem that affects millions of people in America and worldwide. Left untreated, reflux can lead to serious complications, including esophageal ulcers or bleeding. During this live webcast, surgeons at Tampa General Hospital, from the University of South Florida College of Medicine, will perform a laparoscopic Nissen fundoplication procedure to prevent backflow of acid. 00:00:40.000 The benefits of the procedure are that it is the best long-term treatment for acid reflux. It is far superior to medical treatment. Many patients that take it, most patients are off medications for acid reflux. NARRATOR 00:01:00.000 At any time throughout this program, you may email questions to the physicians by clicking the MDirectAccess button on the screen. 00:01:13.000 Welcome to Tampa General Hospital in Tampa, Florida. Today we will be performing life over the internet, a laparoscopic Nissen fundoplication for the treatment of acid reflux. My name is Dr. Michael Albrink and the surgeon today will be Dr. Alexander Rosemurgy, who will be performing the procedure. Dr. ROSEMURGY, can you introduce your team in the OR for us? (inaudible)...scrubbing nurse and as well will be assisting me, particularly in the knottying. Denise is the center of the OR. She s the circulating nurse. Dr. Navarre and Dr. Lovell are our anesthesia colleagues that are helping us. 00:02:10.000 We ve got this going with a 5-trocar technique and what I want to show here is here s the make-up of our trocars. Dr. Kogel has a grasper to the left-sided port at

the midclavicular line. This port here is ultimately going to be our camera port. That s at the subxiphoid position. I have the harmonic scalpel here that s going in on the midclavicular line, subcostal margin on the right side. Here s a trocar that s along the anterior axillary line. It s an 11 mm port. It has a fan retractor through it. Then a Babcock is through the umbilicus, where we actually started this procedure. The patient is supine, not in a jackknife or laying on his back with his legs spread, but rather is flat on his back. I have tried to get this operation to as few moving parts as possible and, with that, he is flat on his back. Nothing fancy. No moving parts. As you can see, the fan retractor was clipped to the drapes. 00:03:08.000 Now I m going to open up the gastrohepatic omentum in a stellate fashion and carry this dissection up to the right crus. I open this up pretty widely, as I mentioned, in a stellate fashion. The reason for that is so that I have very good exposure when I roll the stomach from side to side. I obviously don t need to carry it down. I don t want to divide a vagal trunk down low, so I m making sure that I m going to get very good exposure, but with as little cost as possible. I do divide the hepatic branch of the vagus and I do that with impunity. I ve done over 1,000 now, Nissen fundoplications, as well as the experience from bariatric surgery and so on. It s pretty telling that I don t think it s important. I first got that inclination from Luke Hill, who told me that he had with impunity divided a tremendous number of hepatic branch of the vagus trunks as well, so I don t worry about it. Certainly gallbladder disease has not been a compelling issue postoperatively for these patients. However, I do use some discretion when there is a notable accessory hepatic vessel. I wouldn t with impunity sacrifice that, although as you all know, you probably could. Anyway, we ve divided now along the right crus. I m taking the dissection up over the top of the esophagus and then pretty quickly I m going to be taking the dissection behind the esophagus, intent on beginning my exposure to the right crus. 00:04:40.000 I think of this operation as being done in 3 parts. The first part is exposure of the right crus. The second part of the operation is rolling the stomach over and taking the dissection up along the short gastric vessels, dividing them all, and then the third part of the operation is actually doing the reconstruction. Timewise, it doesn t work out that that s thirds, but emotionally, I guess, or at least in my mindset, it works out that way. What I m doing here is carrying this dissection along the left crus, which is right there, to the right crus, which is right here. That little window behind this in the mediastinum, I want to make sure I don t dissect up there, but rather I carry my dissection caudad to the left crus. I do this dissection until it s not easy anymore. I carry the dissection up here, parallel to the esophagus, to make sure I don t injure a posterior vagal trunk, which again Dr. Kogel has grasped and retracted up in her grasper. I do this dissection, as I said, until it s not fun anymore, until it looks a little hard. I don t want to start blindly grabbing something which could be posterior fundus. So now I m going to roll the stomach over and start taking down the short gastric vessels. It s kind of important that the assistant here doesn t actually lift up, but rather brings the tissue over, more toward the spleen, and then I ll start making a window here, being careful not to divide any branches of the upper pole, although if I took a few branches it wouldn t be an issue, obviously, unless at

some point down the road we were going to do an operation what was going to depend on the preservation of those vessels. 00:06:28.000 We don t want to start down too low, so I m making a little bit of an effort here to start higher. As you know, she s going to retract this over more than she s going to retract it up, as I said, when we begin this dissection. Now, none of this is a race, so we re going to be patient as we go along the short gastric vessels. I think it s important to take the short gastric vessels because we want to make this floppy, loose, so to speak. We don t want any tension on this that s going to cause the stomach to want to come unwrapped or, even more insidiously and equally detrimental, we don t want to have anything happen that s going to want to twist the lower esophagus. If the lower esophagus twists just a little bit, it can accentuate dysphagia postoperatively and it s very insidious because when the patients get scoped, there s no obstruction, but when they get an upper GI, they have a hard time going through, or if the patient gets a barium tablet, it has a hard time going through. Speaking of hard times, I m having a little bit of difficulty here finding the window that I want to find, but it will come, so we patiently take this all down. 00:07:33.000 You can see in the upper left corner of the screen, you ll see a pretty notable hiatal defect. Now, part of the reason it s so notable is because I made it a little bigger. Dr. Navarre, can you stand the patient up a little more and that will help some of this fat slip out of our way. I have the Babcock in my right hand and you can see that grasping up here. There we go. That s the nice little window we want. Once we actually get in this window, this dissection is going to proceed along nice and smoothly, I trust. The spleen is in the background, obviously. I m going to grasp this very thin material and we re in our window. Now take your grasper, Sarah, and extend it in there. I call this the shaft maneuver. It s probably not the world s best name for it, but it makes the point that I want the shaft of the instrument lifting up on the gastrosplenic ligament there, so as we take down the short gastric vessels, we have very nice exposure. Now, the mistake you don t want to make is getting into the splenic hilum, so as I carry this dissection, I m always conscious about where the splenic tip is. I m going to progressively carry this dissection over toward the tip of the spleen. Now, I don t want any tension on this, obviously. I don t want to cut through these too fast. Dr. Kogel is very careful not to put a lot of tension on this. If we get a little bleeding, it s just one more thing that can be a problem. So again she s going to slip her instrument in here and she s going to lift up on the gastrosplenic ligament for me. 00:10:04.000 At some point I m going to focus not so much on this part of the dissection, but on the dissection as to where we left it when we went over the top of the esophagus from the patient s right side, as we come up now on the left side, and that s going to be my goal. Now, the Babcock is not only pulling over a little bit on the stomach, but the Babcock is going to be pulling down a little bit. As I take this material, I m going to move up this area pretty quickly because it s avascular. As I do so, I m going to deliver some of the esophagus into the peritoneal cavity and, as a consequence, this dissection will be aided by that. I want to make sure I m not over there too much on the diaphragm. This isn t a dissection for the diaphragm. This is a dissection along the

crus, so you begin to see here is our esophagus here. The left crus is going to be in here, hiding, and I m going to utilize my ultrasonic dissector here, just for a second, to aid in my obtaining a little better exposure as I roll this all over and now I ll carry this dissection up. 00:11:14.000 So we re approaching now, emotionally at least, being 2/3 of the way done with this operation. I think the operation has been moving along in a timely fashion, but it s important, obviously, not to skip what I think to be important steps and some of the goals that we re going to be working on here is to have about 8 cm of intra-abdominal esophagus upon completion of this mobilization. We want to construct a valve mechanism which we want very securely in the peritoneal cavity, which is why we want to have 8 cm of intra-abdominal esophagus. 00:11:54.000 Now you can begin to see that we ve facilitated our dissection up the left crus. I m coming back here and I m kind of doing a little mop-up work in here to expose our hiatus. You see I m going to come down here and I m going to take this. Now this is really great exposure. If you wanted to take the splenic artery, it sure wouldn t be hard. As a consequence of having done so many of these, we have now adopted some of these positions and techniques for when we do splenectomies. We do a lot of minimally invasive surgery here at the Tampa General Hospital in our minimally invasive centers. It just seems like the more you do, the better you get at doing it and the better you get at doing it, the more you do. Around and around it goes. It s kind of interesting, we do Hellers here on Tuesdays and Wednesdays, Heller myotomies for achalasia, and we now have patients booked up into early November for a Heller myotomy, so the better we get at doing Heller myotomies, the better we get at doing anti-reflux surgery, and the better we get at that, the better we get at doing esophagectomies, so on and on and on the story goes. 00:13:04.000 Here s the intra-abdominal esophagus now. Here s our left crus. Here s our right crus. We re going to take a second here and excise a little bit of the gastroesophageal fat pad. This isn t voluminous in him. That s not the issue. The issue is more about making things a little sticky. I certainly don t want to incorporate any bulk in the wrap, but it s also about having this all heal together. As you know, it s tissue ischemia, microscopically at least, that induces this all to heal, so we re going to excise the gastroesophageal fat pad, as much in an attempt to make this all a little sticky, if you will, and we begin to see what we have to do. This is not a giant hiatal hernia. This is not a giant hiatal defect. Nonetheless, it s a defect and we re going to now close this. I think that when we do that, it facilitates the construction of the fundoplication. So now in her right hand she has a grasper to the left-sidedmost port. She s now going to lift up on the esophagus for me and kind of maintain the exposure that I ve been able to obtain. She is going to take her grasper here and hold that up. I pass point a little bit. I just want to make sure that this isn t tight. This is going just great and you can see that the left crus is being pulled. I m going to pull the left and right curve together. This suture is going into the left crus. I ve taken a real good purchase of this. It s very easy to get left crus. Now I m going into the right crus and you can see that I m going to tilt my instrument downward. The reason I want to do that is to get a long suture length traveled to the right crus. Now

it s going to seem that, as I put the stitch in, it s a little disparate, that I m up higher on the left side than on the right side, but when I actually tie this, it just doesn t seem to work out that way. It seems to me that the area just to the right of the right crus, up rather ventral, is quite weak and if I end up sewing up in there, things are likely to tear. So now we re tying this down. I throw the knot extracorporeally. I push it in with a knot pusher. The reason I do it this way is, as you know, one of my functions in life here at Tampa General Hospital is to train people to do this. Since I ve mentioned that I ve tried to get this operation down to as few moving parts as possible, so the issue here isn t about tying intracorporeal ties or being too advanced in our laparoscopic techniques because our goal is to train people to go off and do laparoscopic surgery safely and I have to be able to give them a technique for tying knots. Therefore, we re making the throws extracorporeally and then pushing them in. Alexis is helping me do this, so she holds one end of the sutures while I tie and our crural defect is now being repaired. We ll take one more stitch, probably augment this just a little bit more, not much more. 00:16:29.000 Now, as you displace the esophagus ventrally, that defect is a little bigger than you think, but I do not want it too tight. Now I m going to pass point here. That gives me a little bit of slack with my suture, so after I put it in, it doesn t tear. Now I m going to go up a little higher on the left side than on the right side. These are pretty close together. It looks maybe far apart because it s magnified so much, but they re pretty close together. You could argue that I don t need to do this, I guess. I m going to tie this knot in such a way that I m going to come down on this in a ventral dorsal direction, like this. If I don t do this, the knots go right on top of each other and I don t get any benefit from the second suture, so I m going to work a little bit to make sure they stay separate and they don t lie on top of each other. I want to make this just a little more snug and that s just exactly what I wanted. 00:17:27.000 Now, after this is over, we re going to bring the posterior fundus around behind the esophagus and I would say we re about 4 minutes from wanting to pass the bougie. Ordinarily, for a man, I ll use a 56-60 French bougie. He s a thin man, so I m going to use a 56 French bougie in him. I know some people don t use them and we certainly could discuss that, but I find it to be helpful. Certainly if someone does have postoperative dysphagia, that s a very disabling event. I want to make sure that we ve done what we can to avoid that, so I place the bougie and people are very comfortable and we do it quite safely. Again, passing the bougie is an example of an event that s not a race, so we take our time, we do it safely, and we re going to help guide this in a little bit or at least recognize it s coming down as the bougie gets closer. 00:18:23.000 Now, here s the posterior fundus behind the esophagus. I m going to grasp the posterior fundus. I m going to bring this around and then you re going to see that there s really no tension on this. In part, the reason for that is that we ve done such an aggressive dissection...well, an appropriate dissection is probably more accurate, in taking down the short gastric vessels. So here is the posterior fundus. Dr. Kogel is going to let go of the esophagus and there we go. Pretty quickly we ll be sewing this in like such and it will be kind of like a hot dog in a bun. One of the things we want to avoid here is we don t want to sew body of stomach. I think it s a mistake if you grab over here

because if you let this all down, you let the fundus go around, you can see you re sewing body of stomach here, so we re actually going to make a pretty concerted effort to use right where the junction of the esophagus and stomach is. 00:19:24.000 There you go. The bougie is coming down the esophagus. You just sew it slip on by and it s going to come on down a little bit more. There it is, sneaking down, down, down, and I m going to get it in here. It s kind of like parking at the drive-in because now I want to pull back just a little bit. Perfect. That takes any potential bowing out of the esophagus. I don t want it to bow up at me. Now Dr. Kogel is going to take the fundus in her right hand, taking the Babcock clamp. Ultimately what she s going to do here, after she pulls my sutures in, as you ll see, she s going to grasp the stomach here and she s going to bring the stomach over for me. She s going to show me a little collar and it s that collar that I want that tells me that I m suturing fundus of stomach and not body of stomach, so that s how I m going to know that. After I put that stitch in, then she s going to grasp up a little bit higher, obviously being careful not to tear anything, and roll it for me here. Then I m going to put this stitch up into the anterior ventral but left part of the esophagus because it s easier for this to go here than it is for this to go here. Then I m going to have a suture in the posterior fundus and the posterior fundus will go just about anywhere. So that s why we re going to do this. 00:20:44.000 With her right hand, she has the grasper in the left-most trocar and she s going to take my suture now and she s going to advance my suture in. This isn t just simply a laparoscopic skill issue. The reason I do this is because I utilize a braided polyester suture and as I m pulling the suture through, I don t want anything to saw. If you put the suture in the esophagus and it cuts down to the esophageal fibers and tears the longitudinal fibers or whatever and you end up with a defect there, it ruins your whole day, if you know what I mean, so we re going to be very careful about this and we recognize the potential issues with utilizing the braided polyester suture. Now Dr. Kogel is going to grasp near the GE junction with her grasper. Grasp this now and bring it over to me and then I m going to utilize this to get this collar right here, which, as you can tell, is not body of stomach. Now she s going to grab up just a little bit higher. She s going to let go and that s perfect. We re going to tease down just a little bit. I didn t tease down much esophagus. There isn t much to come. I certainly don t want to tear anything, but you can clearly see that that s well above the GE junction. 00:22:06.000 Okay. Now she s going to let go of that and I m going to put a suture into the fundus of the stomach and that s where that s going to go. I take the Babcock now, release it, and I bring it up just a little closer to where I put the stitch in. Sarah s going to hold this over for me like this. This is really important. A lot of first assistants, when they do this, they let this slip down and it makes it prone to tearing. As I m pulling this back, you re going to see the slack disappear over here and I watch that to make sure nothing gets tangled and then she s going to, with great dexterity, she s going to take this and she s going to pull this over just a little bit for me, very gingerly, so that as I tie this knot together, I don t have any tension. Now, here s where the assistant is important because if they re not paying attention, her left hand, the part that s holding the posterior fundus, will slip and it will actually want to go below the esophagus and it will make it

impossible to bring this together tightly. If it does happen that the suture doesn t go in as snug as I want, then I will put another stitch in. I won t cut it out. Not only is she bringing them together, she s pushing cephalad with her hands to make sure that I m not going to be tearing the esophagus in an attempt to make this tight. 00:23:34.000 Now, as you can imagine, over the years a few of these first sutures have been a little bit loose. That being the case, it s no big deal. We just put a suture above it. I don t cut it out, per se. I don t think that really helps anything. Point in fact, I suppose, is if the first one s a little loose, it actually helps placement of the second one a little bit more cephalad, so all is well that ends well. 00:23:57.000 You can see I lost my suture as I was introducing it in and now I m coming back to pick it up. I m making it look easy, folks. Okay, there we go. I try to put in 5 knots on these. When I m closing the crural defect, I sometimes put in 6 if it looks a little bit snug. I do put mineral oil on the sutures, just to facilitate the tying and I suppose, to be honest with you, that also would facilitate the untying, so I put in the knots as I ve mentioned. I try to throw them down square and I think that s 4, isn t it? Or is it 5? Five. Then we cut these all with the harmonic scalpel. We don t open any scissors or anything because waste not, want not. 00:24:49.000 It s interesting about this, with doing all these fundoplications that we ve been doing, a significant part of what we do is doing revisional surgery for reflux and we ve done now well over 100 operations for failed fundoplications. With more and more patients in America getting more and more fundoplications, it s pretty apparent that, even though the failure rate is very low, we re going to see more patients that have failed. As a consequence, we see a fair amount of patients that require revisional surgery. One of the reasons I m bringing this up is I think the best thing you can do for a patient in a revisional operation is avoid it. The success rates of revisional surgery are very good, but they re not quite as good as operations for patients coming around the first time. As a consequence, we try very hard to avoid patients failing. So this is the second knot. On this one you ll notice that she didn t have to pull the suture in. The reason for that is that there s not very much sawing that occurs with this, so we re now putting the second suture in. with her left hand, she s bringing the posterior fundus up and she s working to approximate it and with this assistance, she s making this look easy. I might add that she will be finishing this fellowship this coming June and she s going to be looking for a super job, so if someone s looking for this and has got the kind of thing that Dr. Kogel is looking for, you d be lucky to have her. If the job s good enough, you might be lucky to have me, or I d be lucky to have you, however it works out. If my boss is listening, I m just kidding. That s a joke. Unless the offer s really good. 00:26:59.000 Dr. Rosemurgy, you have had a couple of questions from our audience. Why is it important to have that long length of intra-abdominal esophagus?

Because you want the valve mechanism to be in a high pressure zone. The issue about whether or not a hiatal hernia is really pathology or not has been debated for a long time. As you know, hiatal hernias are an anatomic normalcy, not an abnormalcy, and as a consequence, it s hard to implicate it in reflux. However, having said that, manometric studies about the gastroesophageal junction and the lower esophageal sphincter mechanism denote that it is a much more functional valve if it s placed in a high pressure zone, so just above that you ll have functional esophagus which is peristaltic and can push things through the valve mechanism as the valve mechanism lies in a high pressure zone and as distal esophagus lies in the high pressure zone. Bottom line is the lower esophageal sphincter mechanism is much more functional when it lies in a high pressure zone. I just put a stitch in here that brings the anterior and posterior fundus together. I didn t utilize any esophagus in doing this. This is probably right at the GE junction and the bougie can come out. Are there more questions, Mike? 00:28:22.000 Yes. Why do you think people recur after this? 00:28:24.000 The biggest incidence of recurrence that we see are twofold. One is hiatal reconstructions that failed. That s probably #1. #2, there s an abnormality of the wrap. It s either slipped, it s come unwrapped, something like that. Now, point in fact is the most common cause of failure is both of those. It s a combined hiatal disruption and a failure of the wrap. The reason that hiatal reconstruction fails, to me, is threefold. #1, patients that are a little older and a little chubby, and the best example I could give for that would be Aunt Bea. People that look like Aunt Bea just seem to be prone to having the sutures pull through the hiatus and, as a consequence, I am not eager to operate on patients that are heavy. In fact, I won t do it. Now, of course, how heavy is heavy? If you talk about specifically, I don t think obesity is an indication for anti-reflux surgery, but I think that when patients get to be heavier than that, BMI somewhere over 33-34, then I think that you have to really seriously question it and I put the people on a diet. If they re motivated, they ll lose weight. 00:29:35.000 Now, here s our completed fundoplication. Here s intra-abdominal esophagus. You see that you ve got a little bit of room in there for a piece of meat to come through and now what I m going to do is put in a suture that is going to help us keep this wrap suture line midline so that we don t have any tension wanting to either make this unwrap or causing the distal esophagus to twist. 00:30:01.000 The second group of people after the Aunt Beas are young men who are power lifters. Now, obviously there aren t that many of them, but the point is that failures aren t that common, but young men that go and lift a lot of weights, bench pressing 400-500 pounds, doing squats and those kinds of things, they re at high risk to push that reconstruction back up into their chest, up to the hiatus.

00:30:34.000 Then the last group, strangely enough, are people that have gotten into motor vehicle accidents. I think that the reason for that is that they get a sudden blow to the chest and it can generate a very high intra-abdominal pressure. 00:30:46.000 I m going posterior fundus, small piece of esophagus here, and then into the crus. How necessary is this? How emotional is this stitch? I don t know that I have a good answer for that, but what I am trying to do is make sure that this wrap is secure. It s well above the GE junction and that we, as much as possible, are augmenting the angle of His, so I put this suture in up here. This is one of those things that over the years I have evolved into doing. I didn t always do this. The operation, to me, has changed a little bit with experience and this is one of the things that I do now. 00:31:31.000 So, Aunt Bea, young power lifters, and people that have been involved in motor vehicle accidents. I think that by just talking about those, you begin to see that hiatal failure is a pretty common problem and a real problem. Most of the wrap failures I ve seen have been from elsewhere and most of the problems that I have had from patients that I have operated on initially have been failures of the hiatal reconstruction, so I treat the hiatal reconstruction seriously. I don t put in mesh when I do these, unless there s really an issue. An older person, again, not very good tissue, a big defect, I ll utilize a piece of non-plastic tying material, like a piece of Surgisis, and I place it up there with a tacker. I think I learned that from you, actually. 00:32:20.000 Do you think the suture choice matters? 00:32:23.000 No, I don t. Whether someone uses silk or braided polyester or whatever, the braided polyester is just really strong stuff and now we re ready to close, so just to go over this again, we ve opened up the gastrohepatic omentum widely. I carried the dissection up the right crus, back down the right crus, made the window behind the esophagus, rolled this over, took down the short gastric vessels, carried the dissection up the left crus, sewed this thing in with the bougie in place, tacked that up, and we re ready to close. I want you to know that there are no bands of tension here. This isn t tight, so there s no blood loss to speak off. I suppose we lost about 5 cc of blood. Notice now, with everything just laying there, I m not grasping it now, it lays nice and midline. You see that s esophagus. It s well above the GE junction. Personally, I think this is perfect, just perfect, and I m pleased to have done it. 00:33:19.000 So we re going to now bring the camera into the umbilical port and you ll get an idea as to the difference of exposure. Now, I don t like using 30 o scopes. I lose a little bit of light when I do that. So now what I m going to be doing is putting the camera in the umbilical port and I think you get an idea that the exposure s just not quite as good as when I use the port that s up near the xiphoid process. Now I m taking the clamps off

the drapes and I m going to be sliding out the retractor on the liver and now we ll start closing up the wound and I think it would be a great time for some questions or a few comments from you, Mike. 00:33:56.000 We have several questions here. If anybody in the audience wishes to send questions, you can click the MDirectAccess button on your screen. One question that s written here is from a patient about themself. They have Barrett s esophagus and they wonder if they should have an operation or if they have alternative methods of treating this. What are your thoughts about that, Dr. Rosemurgy? 00:34:20.000 There are lots of alternative therapies for Barrett s, but patients with Barrett s esophagus are a little bit in a tough way. They re in a tough way because patients with Barrett s esophagus tend to be hypersecreters of acid and, as a consequence, in a sense, they need the operation more than anybody else. The data s pretty clear that if you can eliminate the reflux, the Barrett s has a high likelihood of regressing. Since it seems to be that Barrett s leads to dysplasia leads to cancer, I think that treating Barrett s esophagus should be a high priority for us. As you know, Barrett s has a strict definition. The term is oftentimes loosely applied and even somewhat bastardized, but when somebody truly has Barrett s esophagus, I think that therapy really needs to be applied...aggressively, I can t say, but applied. The problem with proton pump therapy is that it s not, as you know, 24 hours a day and it s anti-acid therapy, not to be confused with anti-reflux therapy. 00:35:32.000 One of the questions that came in was whether these are permanent sutures? Do they ever dissolve? These are, in fact, permanent sutures. They re meant to stay there. 00:35:40.000 They re polyester. They won t go away any faster than that leisure suit in your closet. 00:35:47.000 In what cases might the surgeon not want to use the bougie? I can t really think of any.

00:35:52.000 Well, you know, somebody might say, for example, that I don t want to use it in a patient who has got a stricture, but point in fact is you ve really got to make sure that that stricture is well dilated before you do the procedure. If somebody has a preoperative stricture, I would tell them that no matter what, they re going to get dilated by me post-op or by my GI colleagues. By that I mean that we re going to plan on scoping them and dilating them, say, 3 weeks to a month post-op and then we re going to do it maybe every month for a while, then every 2 months for a while, then every 3 months. Once somebody gets a stricture, the ball game really changes for them and, as a consequence, I think it s really, really important that people don t have strictures while on medical therapy. I think it s really a condemnation of the physician and the therapy if someone develops a stricture while on medical management. Boy oh boy, it really changes the deal because the motility is different. Patients oftentimes end up with an entirely different set of outcomes, given that they develop a stricture. 00:37:01.000 I agree with you that avoiding a stricture is a goal of medical treatment and I think that s absolutely important to prevent. 00:37:08.000 And it can t be that, for example, someone says, well, we ll start the patient on medical management and if they fail the medical management, what we ll do is we ll just start over. It can t be that way. It s got to be taken really seriously to avoid a stricture. Patients with Barrett s esophagus really need to talk to someone, get a realistic idea as to what s out there, and then they need to make a decision which is right for them, but all things being equal, I think that patients with Barrett s esophagus should be a strong consideration for application of anti-reflux surgery. 00:37:47.000 Don t you think that the effects of reflux are cumulative and don t really regress, particularly? 00:37:56.000 Some of them certainly won t regress. I mean, there may be permanent changes to the larynx or to the vocal cords or things like that. Patients may end up with some serious respiratory disorders that they might not otherwise have had. Folks, doing a Nissen fundoplication is easy. Grabbing the suture with the trocar, this is hard. 00:38:21.000 What do you think the long-term effects of this procedure are? What are patients, in general, going to be like 20 years from now? Do you think they ll be refluxfree?

00:38:29.000 Certainly, for starters, he ll be 20 years older. The issue with that is obviously things change, bodies change as people get older, but my point is that I think he will not be having problems with gastroesophageal reflux. I think problems with reflux will be eliminated with this operation and the probability of having a lifelong solution to reflux is minimal. Let me restate that, as I m focusing on closing the defect. I think the probability of having long-term consequences of reflux once the fundoplication is constructed is minimized. Patients with Barrett s, patients with strictures, patients with complications of reflux are going to do much, much better with an anti-reflux operation and I am a strong proponent of the operation. I have a couple of thoughts about that, you know, like we ve already talked about, that the best operation is the first operation. Don t wait until people get strictures. Don t wait until you ve developed complications. Don t get an operation that s going to fail. Get it done and get it done right the first time, so on and so forth. 00:39:42.000 What side effects might a patient expect from this? What will they be like this week and maybe a week after? 00:39:51.000 He s going to have 8 things. I have to start all over here. This is the only part of the operation that s hard while I m talking. I think there s 8 things, Mike, that everybody s going to have after one of these operations and I tell every patient that they re all going to get it: 1. They re going to have problems with food catching at this new valve mechanism for the next 3-4 weeks or so. 2. They re going to have bloating. People that have bad reflux, they swallow a lot of air. They have profound aerophagia and as a consequence, people that have this operation are going to have some bloating. They all will. It s because of the air they swallow. 3. They re going to pass more gas. They ll be flatulent. 4. They re going to have, with that, a little bit of increased GI activity and they re going to have increased defecatory frequency. 5. They re going to have some early satiety because when they take that first bite, they re going to have a significant amount of air in their stomach and their gastric reservoir is smaller as a consequence of having this fundoplication constructed. We use some of their stomach, so to speak. 6. They re going to have a little bit of nausea, for reasons that I can t well explain.

7. They re going to have some pain at their trocar sites, particularly the rightsided-most trocar site because that s where I put that retractor for the liver and I pull up on that, as you know, a little bit to retract the liver. 8. They re going to have some shoulder pain that s going to last for 4-5 days. 00:41:32.000 I ve got the last suture in now, Mike, so we re going to tie these up and then we ll put one Vicryl stitch in each incision and then we ll put some steri-strips on. 00:41:43.000 What will this patient be like today and tomorrow? What will they eat? 00:41:48.000 Shoulder pain will be a big concern. The trocar sites will be a little bit of a problem. We put some local in at each of the trocar sites, just to help with the pain. I think that helps a little bit. They re going to have some nausea, probably, from a little bit of an anesthesia hangover. They re going to turn the corner at about day 4 or 5 and start feeling increasingly comfortable. Then the other issues become more of a concern, a little bit of dysphagia, some bloating, flatulence, and some defecatory frequency. A little bit of nausea. By 3 weeks, they re going to be turning the corner. I progress their diet as they feel comfortable. They can go home on full liquids, maybe even soft foods, like applesauce, yogurt, so on and so forth, but they absolutely, positively shouldn t have expectations of being able to eat meat or expectations of eating pineapple, shrimp, things like that. 00:42:40.000 What will this patient s return to activity be like? 00:42:47.000 Pretty much as quick as the patient feels comfortable doing. I would encourage him not to go home and lift any cinder blocks, but he certainly can go home and, you know, putter around the house a bit until the issues we talked about, like the hangover from anesthetic and the shoulder pain, gets better. Then I encourage them...today s Wednesday...by Monday to be back to work or doing what it is that they do, but not full-time. I encourage them just to go in in the afternoons. I know from when I ve tried to work half a day that if I go in in the morning, people always find stuff for me to do and I never get home until 6:00 or 7:00 at night. That s on a half day. So what I tell them to do is to go in at noon. The reason to go in at noon is because the end of the day comes and most of the people go home, the phones stop ringing, so on and so forth, so people have much more control at the end of the day than they do in the beginning of the day, so they should probably start going in at noontime or 1:00 when they start working half-days.

00:43:50.000 One of the questions over the internet obviously is from a physician and they re commenting on how little blood loss there was in the procedure. 00:43:58.000 Average blood loss should be essentially not measurable. I don t know, I m sure I lost a little bit, probably most when I made the trocar incisions, but I would estimate the total blood loss maybe 10-15 cc, something like that, so I didn t even use suction irrigation because there s nothing to suck. There s frankly nothing really here. 00:44:27.000 Do you think that something such as this could cause dumping? That s one of the questions from a patient. 00:44:32.000 No, I don t. I do think that people get gas bloat and I think everybody gets it. If you talk to your patients, they all get it. Now, some physicians have said they don t see that. I don t believe it. I don t think they re asking. But dumping I don t think is an issue. Physiologically, it shouldn t be an issue, although notably, an anti-reflux procedure does improve gastric emptying. The reason it does is that people who have bad reflux, when their stomach contracts and they generate a high intragastric pressure, they re likely, if they have bad reflux and a dysfunctional lower esophageal sphincter mechanism, to cause the contents of their stomach to go back up in the esophagus, as opposed to down the duodenum. So if you do a gastric emptying scan on a patient that has delayed gastric emptying preoperatively, if you do a Nissen on them, given they have adequate gastric function, then they re going to have vastly improved gastric emptying. That data is very clear. The other thing that you have to recognize is that when gastric emptying scans are undertaken preoperatively, oftentimes the report is gastroparesis if there s delayed emptying, but it s not a gastroparesis issue at all. What it is is an issue with bad reflux. So a lot of people out there that have been diagnosed as being gastroparetics are, in fact, bad refluxers. 00:45:52.000 Dr. Rosemurgy, we have a question from another one of your patients here. It s would a patient post-whipple surgery be a candidate for this operation? 00:46:01.000 As long as the stomach is intact, it certainly is an option. After a pancreatic duodenectomy, if the pylorus is preserved, the whole stomach is there, so the fundus, esophagus, and so on is there. If that s what they need, that s what they get. Of course,

you know, if the patient s got pancreatic cancer, the concern always is how long is this going to be an issue for, unfortunately, god bless patients with pancreatic cancer, but it s a bad cancer, as you know, and as a consequence, given risk:benefit ratios, it might be better off to have the patient treated medically. However, if the operation is done for benign disease and the patient is doing well and is cleared of their cancer, I don t see a reason why they should be denied a curative approach to their reflux. I m always reminded of the story of a patient that I saw one time who had a bad enterovesicle fistula with Crohn s disease and they had been treated medically for a long time. I was struck by the thought that the only physician who could treat somebody medically for an enterovesicle fistula is a physician who has never had a urinary tract infection. I think a lot of the same deal here is that people who have never had these kinds of problems are much more prone to treating them medically, but I just don t think that in this time and place anymore there s an approach that goes like this, which is, you know, we ll treat the patient with anti-reflux therapy and medical management and if we fail, then we ll just start over. I just don t think that holds water anymore. Now, there are other issues here. What s the role of Enterex? What s the role of the Stretta procedure? Those kinds of things. That continues to evolve and we, as surgeons, need to embrace these concepts and thoughts because today, tomorrow, whenever, it s going to continually be lead, follow, or get out of the way, which is one of the reasons here at Tampa General Hospital that we ve adopted a multidisciplinary approach to care of patients that have reflux and we have these options available for the patients as they need them. 00:48:08.000 How long will a patient such as this, or a patient in general, be in the hospital? How long will they be NPO? Will they need an NG tube? 00:48:17.000 There s no NG tubes. They ll be taking liquids tonight. If the patient wants, they can go home today, but if you ask me, that s cruel and unusual punishment for the spouse, particularly when the patients are males, because as we all know, men make bad patients and probably no one would be worse than me. God help my wife if I ever get sick. Having said that, almost all of the patients stay overnight and our median length of stay is clearly 1 day. However, occasionally someone will have some dysphagia. We operate on patients that are pretty sick, like they are on home oxygen, they have serious medical problems, like bad pulmonary disorders. Somebody might say, well, that increases your length of stay, it does this, it does that, I don t know that that s a good idea to operate on those patients. Well, point in fact is I think those patients need it more than anybody. People that, for example, have bad pulmonary disease or a limited pulmonary reserve and they have problems with reflux, particularly with aspiration, they re making it even harder on themselves and I think they re particularly well suited to have an operation.

00:49:25.000 One question here that I think I can probably answer too is one of the viewers has asked why would there be bloating if the valve has been reconstructed? Wouldn t one expect to swallow less air, rather than more? The air swallowing that is learned behavior from GERD is a habit that takes a long time to break. In my experience, it takes 6 months or so for people to unlearn that behavior, so they remain aerophagic for a period of time afterwards. 00:49:54.000 I agree, Mike. There s 2 things happening here. One is that they unlearn behavior, which takes time, just like you said. The other one is that the GI motility picks up and that s why they re flatulent, so it s a combination of increasing flatulence with unlearning behavior that makes that problem go away. 00:50:13.000 Here s a question. One patient s asking about, I believe, the natural history of Barrett s esophagus. The question is once the normal squamous epithelium has been changed with columnar epithelium, what happens? 00:50:28.000 Well, as you know, the issue is one of a premalignant condition. People have to be very careful that the strict definition of Barrett s esophagus is adhered to. It s not just a matter of finding the columnar epithelium in the course of diagnosing complications of Barrett s esophagus. It s also an issue about how the biopsies are obtained, the accuracy of the biopsies. For example, if someone biopsies stomach and labels it esophagus, it s going to come back as columnar epithelium. Having said that...i forgot what the question was. 00:51:04.000 Natural history of Barrett s. 00:51:05.000 I think the natural history of Barrett s is somewhat the same as if you had enough monkeys typing, one would type Shakespeare. In this case, if you have enough people with Barrett s esophagus and enough time, ultimately they re going to have cancer. I think it s a pretty well documented sequence of events that they go from a normal lower esophagus to columnar epithelium with metaplasia, with dysplasia, with high grade dysplasia, with cancer. So, given the untreated Barrett s esophagus, and by untreated I mean no anti-acid medication, patients are going to ultimately get cancer, given enough time. Obviously it s multifactorial, so I can t say 100% of the people will get cancer, but certainly the data is very clear that, given enough time and the risk factors, the progression of Barrett s esophagus is toward cancer. People shouldn t be out there

with Barrett s esophagus going untreated. They shouldn t be out there with Barrett s esophagus going untreated. 20 years ago, we didn t see many adenocarcinomas of the GE junction. Now it s an epidemic and I mean that sincerely. It s an epidemic in the United States. You wonder what role antisecretory medications have had in that, what s going on in American diets, our lifestyle, etc., etc., that has caused people to have this epidemic of adenocarcinomas at the gastroesophageal junction, but it s a real thing in Barrett s esophagus and undoubtedly plays a role in it. 00:52:32.000 I think it s an interesting problem and it certainly is increasing. Here s a question. Is GERD genetic? We certainly know that in children, in babies, all babies have GERD. They spit up and have wet burps all the time. The physiology of swallowing is not well developed as a neurologic process until children reach about one year of age. Their throat, their tongue, their mouth, they can t speak and phonate words normally, so to develop neurologic maturity takes a year or two just for the swallowing mechanism to get intact, so all babies have GERD. Having said that, do you think adults develop a tendency toward GERD or a physiologic inheritance toward GERD? 00:53:14.000 Everybody in America refluxes some. I do, you do, we all do some, but only in a small percentage of us is it a problem. Everybody refluxes some. A smaller number obviously reflux once a month, a smaller number every 2 weeks, a smaller number once a week, and so on. In only a small number of Americans would we actually say that gastroesophageal reflux is a disease or a disorder, so lots of people may have GER, but only a small number of patients have GERD. It s a matter of separating those 2 groups. If people have symptoms, if people have Barrett s esophagus, as we just talked about, those people clearly have GERD. They have gastroesophageal reflux disease and need to be treated. The issue here is sorting out people that have pathologic reflux from people that don t. Really the hallmark of that, the cornerstone of that, is ambulatory ph study. What s made this so much more palatable, if that s a fair pun, is that it s palatable because the chips can be placed now on the inside of the esophagus, about 5 cm from the gastroesophageal junction, and people can go about their daily activities. They don t have to have a tube hanging out of their nose like in the day gone by. As a consequence, we can diagnose this disorder more safely, more conveniently, with less morbidity, and that is the cornerstone of who should be treated. Patients that have abnormal reflux, either by percentage of time with a ph less than 4 or a composite of a whole host of factors, like number of reflux episodes per day, length of longest acid reflux number more than 5 minutes, percentage of time less than ph of 4. Those patients that end up with a composite score, called a DeMeester score after Tom DeMeester, they are candidates for strong consideration for reflux, particularly when you add in things like symptoms or complications of reflux which might be anything from laryngeal disorders to erosions to bleeding to, god I hope not, but stricture formation, you end up with a group of patients that clearly are candidates for anti-reflux surgery.