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.

Dr. Ross Bremner, and the state of thoracic surgery in Arizona

Talking with Dr. Ross Bremner, Chief of Thoracic Surgery and Chair of Thoracic Disease & Transplant at St. Joseph’s Hospital in Phoenix, Arizona.

Dr. Ross Bremner

St. Joseph’s Hospital

After talking to Dr. Bremner of the phone, I felt compelled to come down to Phoenix and meet him in person.  I am glad I did.  While St. Joseph’s is a large 607 bed hospital – it’s just one of many large healthcare facilities in the Phoenix area.  The same can not be said of their robust thoracic surgery program.  They have a surprising range of thoracic surgery subspecialties, and sub-specialty programs including transplant, anti-reflux surgery, minimally invasive surgery, esophageal surgery program and robotic surgery.  As you can imagine, I felt a bit like a kid in a candy store – so overwhelmed by the array of services, that my mind was just bursting with questions.  (I rounded with the group and got to see the full spectrum of patients – including four recent post-transplant patients.)  They also have a pediatric thoracic surgery program and plan to start a pediatric transplant program soon.

Dr. Ross Bremner & Dr. Mike Smith, Heart & Lung Institute

The head of the program, Dr. Ross Bremner is one of five thoracic surgeons at the Heart & Lung Institute of St. Joseph’s Hospital in Phoenix, Arizona which is currently the state’s largest thoracic surgery program.  A native of Johannesburg, Dr. Bremner maintains international ties to his home country by staying active in the South African Cardiothoracic Surgery Society.  He began his thoracic surgery career at University of Southern California (USC) where he met and recruited both Dr. Michael Smith, MD and Sandra Ogawa, ACNP.

As Arizona has grown, so has thoracic surgery.  Despite the relatively small population of Arizona overall, both the esophageal surgery program and the lung transplant program maintain volumes that are competitive with the big-name east coast institutions.

With over 45 lung transplants last year – and the University of Arizona currently out of the running, Dr. Bremner* and his team are set to boost those numbers this year.  They have already done ten transplants here in the first quarter of 2012, and anticipate doing fifty to sixty this year.  (If you remember from our previous posts about lung transplantation – even very large institutions are not doing huge numbers of transplants.  In fact, you can check the numbers at the Organ Procurement and Transplant Network if you’re interested*.)

St. Joseph’s also has an esophageal surgery program which maintains the high volumes of esophagectomies needed for optimal outcomes.  Dr. Bremner reports that they perform on average 50 – 60 esophagectomies for esophageal cancer ever year in addition to their benign esophageal surgery program.  (As we discussed with Dr. Molena, ‘benign’ is a bit of a misnomer for esophageal conditions since achalasia, esophageal strictures and other non-cancerous conditions of the esophagus may have a huge negative impact on the individual’s quality of life.)

The Heart & Lung Institute also offers training courses for surgeons and residents in minimally invasive surgery – in fact, they are teaching a course the weekend of my visit.

As a practicing surgeon in Phoenix, Arizona, Dr. Bremner also sees numerous cases of Coccidoidomycosis** (or Valley Fever) which is endemic to this area of the country.  In fact, Maricopa county, which encompasses the city of Phoenix sees more cases annually than the California valley the disease was originally named for.

* At the site, you can create data reports by organ, region, outcome, waiting period, etc..  For example – using this data table – we can see that there were a total 1,516 isolated lung transplants in the United States in 2011 which is actually a decrease from 2010 and 2009.

** Readers can anticipate a future article on this topic

More about Dr. Ross Bremner, MD, PhD

Dr. Bremner is a genial gentleman and a ready conversationalist.  Our interview was relaxed, but informative.  He welcomed my questions on a variety of topics and was generous with his time.  In fact, I had ready access to multiple members of his team, and spent the entire afternoon with the department of thoracic surgery.  It was an engaging afternoon, and highlighted one of the reasons I pursue interviews and opportunities to speak to my colleagues within thoracics; it was an opportunity to learn more about the specialty, and the care of thoracic surgery patients.

Dr. Bremner is a board-certified thoracic surgeon.  After obtaining his baccalaureate degree and medical school training at Witwatersrand University in South Africa, he continued his education in the United States.

He completed his general surgery residency, PhD research and thoracic surgery residency at the University of Southern California. He was the Director of the Hastings Thoracic Oncology Research Laboratory on the USC campus.  At this lab, surgeons along with researchers from multiple disciplines conduct research on the diagnosis and treatment of lung cancer including research in gene therapies prior to coming to Arizona.

He has several YouTube videos talking about his current research projects at St. Joseph’s.

He also has an informational series for patients about Lung Transplant over at EmpowHer.com

Dr. Ross M. Bremner, MD, PhD

Chief of Thoracic Surgery

Chair of the Center for Thoracic Disease & Transplantation

Heart & Lung Institute – St. Joseph’s Hospital and Medical Center

500 W. Thomas Road, Suite 500

Phoenix, Arizona 85013

Tele: (602) 406 4000

Fax: (602) 406 3090

Selected publications (not a full listing)

Jacobs JV, Hodges TN, Bremner RM, Walia R, Huang J, Smith MA. (2011). Hardware preservation after sternal wound infection in a lung transplant recipient. Ann Thorac Surg. 2011 Aug;92(2):718-20. [no free text available].

Felton VM, Inge LJ, Willis BC, Bremner RM, Smith MA. (2011). Immunosuppression-induced bronchial epithelial-mesenchymal transition: a potential contributor to obliterative bronchiolitis.  J Thorac Cardiovasc Surg. 2011 Feb;141(2):523-30.  [no free text available].

Gotway MB, Conomos PJ, Bremner RM. (2011)  Pleural metastatic disease from glioblastoma multiforme.  J Thorac Imaging. 2011 May;26(2):W54-8. [no free text available].

Coon KD, Inge LJ, Swetel K, Felton V, Stafford P, Bremner RM.  (2010).  Genomic characterization of the inflammatory response initiated by surgical intervention and the effect of perioperative cyclooxygenase 2 blockade.  J Thorac Cardiovasc Surg. 2010 May;139(5):1253-60, 1260.e1-2.  [no free text available].

Wu C, Hao H, Li L, Zhou X, Guo Z, Zhang L, Zhang X, Zhong W, Guo H, Bremner RM, Lin P. (2009).  Preliminary investigation of the clinical significance of detecting circulating tumor cells enriched from lung cancer patients.  J Thorac Oncol. 2009 Jan;4(1):30-6. [no free full-text available].

Backhus LM, Bremner RM. (2006).  Images in clinical medicine. Intrathoracic splenosis after remote trauma.  N Engl J Med. 2006 Oct 26;355(17):1811.

Backhus LM, Sievers E, Lin GY, Castanos R, Bart RD, Starnes VA, Bremner RM.  (2006).  Perioperative cyclooxygenase 2 inhibition to reduce tumor cell adhesion and metastatic potential of circulating tumor cells in non-small cell lung cancer.  J Thorac Cardiovasc Surg. 2006 Aug;132(2):297-303. [no free full-text available].

Backhus LM, Sievers EM, Schenkel FA, Barr ML, Cohen RG, Smith MA, Starnes VA, Bremner RM.  (2005).  Pleural space problems after living lobar transplantation.  J Heart Lung Transplant. 2005 Dec;24(12):2086-90.  [no free text available].

Backhus LM, Petasis NA, Uddin J, Schönthal AH, Bart RD, Lin Y, Starnes VA, Bremner RM. (2005).  Dimethyl celecoxib as a novel non-cyclooxygenase 2 therapy in the treatment of non-small cell lung cancer.  J Thorac Cardiovasc Surg. 2005 Nov;130(5):1406-12.  [no free full-text available].

Sievers EM, Bart RD, Backhus LM, Lin Y, Starnes M, Castanos R, Starnes VA, Bremner RM.  (2005).  Evaluation of cyclooxygenase-2 inhibition in an orthotopic murine model of lung cancer for dose-dependent effect.  J Thorac Cardiovasc Surg. 2005 Jun;129(6):1242-9.  [no free full-text available].

Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA.  (2004).  A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies.  Am J Transplant. 2004 Aug;4(8):1283-8.  [no free full-text available].

Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML.  (2004).  A decade of living lobar lung transplantation: recipient outcomes.  J Thorac Cardiovasc Surg. 2004 Jan;127(1):114-22.   [no free full-text available].

Haddy SM, Bremner RM, Moore-Jefferies EW, Thangathurai D, Schenkel FA, Barr ML, Starnes VA.  (2002).  Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation.  Anesthesiology. 2002 Nov;97(5):1315-7.

DiPerna CA, Bowdish ME, Weaver FA, Bremner RM, Jabbour N, Skinner D, Menendez LR, Hood DB, Rowe VL, Katz S, Kohl R.  (2002).  Concomitant vascular procedures for malignancies with vascular invasion.  Arch Surg. 2002 Aug;137(8):901-6; discussion 906-7.

Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. (1993).  Pharyngeal swallowing. The major factor in clearance of esophageal reflux episodesAnn Surg. 1993 Sep;218(3):364-9; discussion 369-70.