Phoenix, Arizona
During my visit with Dr. Bremner at St. Joseph’s Hospital, I had the pleasure of meeting several members of the thoracic surgery team, including Sandy Ogawa.
Ms. Ogawa is an acute care nurse practitioner specializing in Thoracic Surgery. She initially began working with Dr. Bremner at USC as a nurse coordinator, and has been working with Dr. Bremner since he was a thoracic surgery fellow. After returning to school for her master’s degree – Ms. Ogawa became a nurse practitioner in thoracic surgery.
Since then she has taken on a wide range of duties and responsibilities caring for thoracic surgery patients, with a keen interest in anti-reflux procedures such as the Nissen fundaplication and the Toupet procedure.
One of the things we talked about was her upcoming presentation on proper patient selection and patient referral, or as Ms. Ogawa states, “What to do when the purple pill fails?”
Who should consider surgery for reflux?
The best patients for surgical treatment of reflux are patients who have failed first-line medical treatments such as Nexium (or other proton pump inhibitors.) Patients should explore these options as well as standard medical recommendations such as weight loss, and dietary modification prior to seeking the advice of a surgeon.
Symptoms & Complications of Reflux
Symptoms of GERD are varied and can range from simple heartburn to dysphagia (difficulty swallowing), chest pain, respiratory infections and dental erosion. Uncontrolled gastric reflux has been shown to negatively impact the patient’s quality of life; through interrupted sleep, impaired eating and other activities of daily living.
Uncontrolled or untreated GERD can lead to serious complications including esophageal ulceration, development of esophageal strictures, pneumonias and scarring of lung tissue (from aspiration of acid contents) and increase the risk of developing esophageal cancer.
At St. Joseph’s, Dr Bremner and his colleagues specialize in both of these procedures (Nissen fundaplication and Toupet procedure) as well as re-do procedures for patients with re-current symptoms or re-current hernias after surgery.
Pre-surgical Evaluation: Diagnosis & Testing
Having ‘heartburn’ alone isn’t the only factor to consider prior to undergoing an anti-reflux procedure. The are multiple physiological factors that also help surgeons determine whether surgery is an appropriate treatment, and which surgical procedure is the best surgical option.
As part of their anti-reflux program, all pre-operative evaluation procedures (endoscopy with four quadrant biopsies, barium esophagrams, and manometry are performed in-house. In fact, the department has their own manometry lab, where they read all of their studies (versus sending patients to multiple departments). These tests help determine whether reflux is related to different conditions such as the presence of a hiatal hernia, or a malfunctioning esophageal sphincter. It is also important to rule out other causes of symptoms such as dysphagia such as an esophageal stricture since this condition is treated differently. If there is acid damaged tissue (tissue changes in the esophagus and stomach due to acid erosion), biopsies of the tissue will be taken to rule out Barrett’s esophagus or esophageal cancer.
Guess we’ll have to wait for the rest of Ms. Ogawa’s presentation to hear more.
Additional Resources: Anti-reflux procedures, GERD and treatment strategies
Overview of GERD, and treatment options from New York Times – health section.
Bansal A, Kahrilas PJ. (2010). Treatment of GERD complications (Barrett’s, peptic stricture) and extra-oesophageal syndromes. Best Pract Res Clin Gastroenterol. 2010 Dec;24(6):961-8. Review. Does surgery prevent long-term complications from reflux disease? A review of the literature reveals inconsistant results: bad data, or bad research design?
Davis CS, Baldea A, Johns JR, Joehl RJ, Fisichella PM. (2010). The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease. JSLS. 2010 Jul-Sep;14(3):332-41. Review. Comparison of surgical techniques.
Epstein D, Bojke L, Sculpher MJ; REFLUX trial group. (2009). Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study. BMJ. 2009 Jul 14;339:b2576. Surgery emerges as the cheaper option.
Ip S, Chung M, Moorthy D, Yu WW, Lee J, Chan JA, Bonis PA, Lau J. (2011). Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Sep. Report showing similar efficacy in therapies.
Kripke C. (2010). Medical management vs. surgery for gastroesophageal reflux disease. Am Fam Physician. 2010 Aug 1;82(3):244. Kind of a skimpy statement, which doesn’t really answer the clinical question.
Lippmann QK, Crockett SD, Dellon ES, Shaheen NJ (2009). Quality of life in GERD and Barrett’s esophagus is related to gender and manifestation of disease. Am J Gastroenterol. 2009 Nov;104(11):2695-703. Epub 2009 Sep 15
Moraes-Filho JP, Navarro-Rodriguez T, Barbuti R, Eisig J, Chinzon D, Bernardo W; Brazilian Gerd Consensus Group. (2010). Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus. Arq Gastroenterol. 2010 Jan-Mar;47(1):99-115
Shan CX, Zhang W, Zheng XM, Jiang DZ, Liu S, Qiu M. (2010). Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease. World J Gastroenterol. 2010 Jun 28;16(24):3063-71. Review of literature comparing surgical techniques.
Tessier DJ. (2009). Medical, surgical, and endoscopic management of gastroesophageal reflux disease. Perm J. 2009 Winter;13(1):30-6. Review article aimed at Primary care physicians. Excellent overview article of GERD and treatment options.
Thoracic Surgery 
Kristin, You are so amazing and brilliant. The medical community and patients are so lucky to have you advocate and do the research that is greatly needed.
Sherry Schultz RN,BSN,CCM, Cardiovascular Care Coordinator