Sandy Ogawa, ACNP and anti-reflux surgery at St. Joseph’s Hospital

Talking with Sandra Ogawa, ACNP about ‘What to do when the purple pill fails?”

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 syndromesBest 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 diseaseJSLS. 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 studyBMJ. 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 consensusArq 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 diseaseWorld 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.

Minimally invasive fundoplication for GERD: the transoral esophagogastric approach

the transoral esophagastric fundoplication procedure and Dr. Darren Rohan, a thoracic surgeon performing this minimally invasive technique.

A cardiothoracic surgeon in New York, Dr. Darren Rohan has started a new minimally invasive program for reflux surgery (called fundoplication.)  With the transoral esophagogastric fundoplication  procedure, he can tighten the sphincter (valve) between the stomach and the esophagus by endoscopy (instead of laparoscopic surgery) to prevent acid from refluxing into the esophagus.  This is an important development in the treatment of gerd (gastroesophageal reflux disease) since the incidence of gerd is on the rise – due to obesity and this has led to an increase in esophageal cancer (as discussed in a previous post).

(Now, Dr. Rohan isn’t the first person to perform this procedure but I thought he’s be a great person to tell us more about it here at Cirugia de Torax, so I’ve written to him to request more information and to invite him to contribute a guest post.)

We also know that in addition to esophageal cancer (and Barrett’s esophagus) that reflux does more than destroy tooth enamel.  Work by researchers at Duke has linked reflux with problems with lung transplant recipients, and then to reactive airway disease itself.  While the degree of this relationship is not fully understood and is still debated – it is clear that there is a correlation to reflux disease and airway disease.  It has also been associated with aspiration pneumonia, particularly in patients on reflux suppressing medications.

I’ll be updating this story soon with more information.

Additional references and resources:

World J Gastrointest Endosc. 2010 Dec 16;2(12):388-96.  Gastroesophageal reflux disease: Important considerations for the older patients.  Chait MM.  (free full text).  This article talks about the range of complications and how elderly patients may present with more severe symptoms.
Saudi J Gastroenterol. 2010 Apr-Jun;16(2):84-9.  Study of respiratory disorders in endoscopically negative and positive gastroesophageal reflux disease.  Maher MM, Darwish AA.  9free full text).  An Egyptian study looking at the relationship between relux and lung disease.
This 2009 review of the literature, by Kumar and Gupta  out of India claims no association between reflux and asthma (but uses the effectiveness of acid suppressing medications in treating asthma as their proof of this theory – which is a faulty premise, in my opinion since these medications often don’t effectively treat reflux.)
More about the transoral esophagogastric fundaplication:
Surg Endosc. 2011 Jun;25(6):1975-84. Epub  2010 Dec 8.  Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease.  Bell RC, Freeman KD.  (Bell and Freeman also authored the article cited in the text above.)  Free full-text.

Only TIME will tell: Esophagectomy

There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME). It’s a timely study indeed as the rates of esophageal cancer in western countries continues to increase, due to GERD and obesity.

I really don’t like the ‘cutesy’ way research trials have been named for the last ten years or so – but in this case – I will just have to look past it.  There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME) trial based in the Netherlands.  It is a multi-center trial taking place at six hospitals in Europe.  This trial will compare both morbidity and mortality in patients undergoing traditional esophagectomy (Ivor Lewis) and patients undergoing minimally – invasive (thoracoscopy combined with laparoscopy) after both sets of patients receive adjuvant chemotherapy.  (This approach differs from the transhiatal esophagectomy developed at the University of Michigan in the 1970’s).

The researchers are planning for a five-year follow-up to compare both immediate post-operative complications / mortality with long-term effects (QoL) and cancer recurrence.

The full article is detailed on Medscape. (Also published in BMC Surgery. 2011;11 ).   This couldn’t come at a more appropriate time, with recent data showing an abrupt rise in the incidence of esophageal cancer.

In an article (Chustecka) dated from September 2010, British researchers at Cancer Research UK reported a 50% increase in diagnoses of esophageal cancer in the last 25 years, particularly in men in their 50’s. (with an incidence of 14.4 men per 100,000, to put it into perspective, up from 9.9 in 1983.)

More concerning, is the fact that the prevalence of the types of cancer are changing.  Previously, the majority of esophageal cancers were caused by squamous cell carcinoma which is linked to smoking and alcohol use.  This study, along with an American study, shows an increasing incidence of adenocarcinoma, which is more commonly attributable to gastroesophageal reflux (Barrett’s esophagus). Researchers  (Dr. Mark Orringer) estimate that the incidence of adenocarcinoma of the esophagus has increased by 350% in the last thirty years – and is directly related to huge increases in obesity.  It now accounts for over 85% of esophageal cancers in the USA.

We’ll bring you more as the trial continues, and preliminary results are reported.

(Dr. Mark Orringer, who was quoted in the original medscape article from 2007 is one of several pioneering surgeons in thoracic surgery.  He invented two of the surgical techniques in use today; the aforementioned transhiatal esophagectomy and the Collis -Nissen hiatal hernia repair.)