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Diagnosing Your Condition

Most patients that have gastroesophageal disorders from reflux to achalasia to stomach cancer will require specific tests that will be discussed with you during the initial appointment. Some tests maybe set up for you even prior to your initial visit if appropriate. If you have had outside tests performed we may ask your permission to obtain results for a more comprehensive discussion of management at the initial visit.

Typically to minimize your inconvenience we will arrange to perform some testing during your visit if feasible and if further testing is required attempt to arrange based on your schedule.

Typical, testing includes:

X-ray (barium swallow) detects a hiatal hernia or a narrowing of the esophagus.
Endoscopy enables the physician to see inside the throat and into the stomach. In a diagnostic endoscopy, a thin, flexible tube equipped with a tiny camera and light is inserted through the mouth and down the throat.
Esophageal manometry shows how well the muscles of the esophagus are functioning. In our state-of-the art esophageal motility lab, we can obtain information about the functioning of the muscular valve located between the esophagus and the stomach (lower esophageal sphincter), and the ability of the esophageal muscles to squeeze (esophageal peristalsis).
Ambulatory pH monitoring measures the frequency and amount of gastric contents (acid and non-acid) that reflux from the stomach to the esophagus, usually over a 24-48 hour period. This test either involves threading a very thin tube (catheter) through the nose and down the esophagus or placing a chip (Bravo device) to the esophagus. "Ambulatory" means that you can walk around and perform your normal activities while wearing this monitor.

Learn more about these diagnostic tests and the treatments we offer.

pH Studies (Bravo/Impedance)

Overview

pH Studies are very important for the correct diagnosis of reflux. Given that antacids are one of the most common over the counter medications and also one of the most commonly prescribed medications it is vital that you get the proper workup prior to long term treatment for reflux either with medications or surgery. You may say that these medications are harmless but more data has come out indicating the many potential hazards of these medications including: cardiovascular, mental function, bone loss, and even early death.

It is unclear what the root cause of these hazards is but some scientists believe it may be due to the alteration of your gut flora since your stomach is not designed to be non-acidic.

As such it is important to have appropriate testing prior to long term therapy. Our group previously published on the over-utilization of antacids and found with appropriate testing nearly one-third of patients on these medications did not meet criteria for these medications.

Therefore, we strongly suggest testing prior to long-term therapy and have two diagnostic tests to help determine if you have reflux.

BRAVO Chip

The BRAVO chip is a device that detects acid reflux. Most patients are recommended to be off different types of medications for up to 2 weeks prior to placement. This chip is placed Endoscopically under light sedations and records your acid reflux for a 2-day period. For the days of the testing you perform all normal activities without restrictions and use the diary and the device to record symptoms and activities. After the study period, we analyze the data and determine if and how significant your reflux is. We can also determine if there are specifics events that can trigger symptoms.

This technique is our preferred method for the diagnosis of reflux as it does not impact your daily activities and is in most cases very comfortable. Less than 1% of patients have difficulty with chest pain from the device.

Impedance Probe

The impedance probe is use to detect both acid and weak or non-acid reflux. This is a 24 hour test and involved placing a thin probe in your nose that is attached to a recording device. For the 24-hour of the test you resume all normal activities. The probe can be removed 24 hours after placement. It is more noticeable than the BRAVO probe and is therefore used as second line diagnostic test for reflux. The data can augment the BRAVO data.

High Resolution Manometry and Endoflip

High Resolution Manometry

This technique is important in determining the cause of specific gastroesophageal disorders by helping identify issues with esophageal motor function. The device has multiple sensors that go along the entire esophagus therefore, issues with any section can be identified.

Several diseases can effect esophageal function including reflux, achalasia, and esophageal motor disorders.

The test involves placing a 4.3mm probe in the esophagus and having you swallow several times while being monitored. Most times given the experience of our staff testing can be done in less that 10 minutes. In some cases, and especially in the pediatric population this test is performed in the Endoscopy Suite after giving the patient medications to provide some relaxation.

Endoflip

Sometimes the data from your manometry study may not provide enough information for determination of an esophageal disorder. In these scenarios, the Endoflip device maybe useful to help provide more information of your esophageal motor disorder. This test is used to complement conventional testing including manometry and barium swallow.

In comparison to the manometry catheter which is very thin the Endoflip device more mimics solid food as it travels down the esophagus.

EndoFLIP uses a balloon mounted on a thin catheter placed transorally at the time of a sedated endoscopy. In comparison to the traditional diagnostic tests, EndoFLIP offers the additional capability of measuring the cross-sectional area and intraluminal pressure of the esophagus while under distension (as if a solid bolus was present).

The information we collect from this will be used by our team to determine what treatments will most fix your needs.

Robotic Anti-Reflux Surgery

Operating room set up for surgery

Anti-reflux surgery is commonly performed to repair the lower esophageal valve and close the hernia defect if one is present. This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis entails wrapping a small amount of your own stomach around the esophagus to reinforce the valve and prevent reflux. This does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. As such some patients have noted some weight loss up to 25lbs after surgery which will usually return unless you attempt to keep it off.

The surgical procedure typically takes 1 1/2 to 2 hours to complete and the majority of patients go home on a liquid diet the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.

The majority of patients after surgery have no return of symptoms even while they are off their reflux medications and no longer need to follow the reflux diet. Therefore, you can indulge a little. We continue to encourage however a healthy lifestyle and diet plan.

Most patients who have this procedure continue to not require medications for reflux at 10 years.

Most patients with heartburn, chest-pain, and regurgitation of food will no longer have these issues on a routine basis after the procedure. However, like any regular person that overeats you can have occasional heartburn. This is normal but should not be routine.

Atypical symptoms of reflux are harder to predict outcomes after surgery. These include throat clearing, hoarseness, asthma, sinusitis among others. We are more than happy to discuss the response of these to surgery and sometimes the testing methods may guide us in optimizing the recommendations. The reason patients may get a partial response is related to the symptom and potentially irreversible damage versus multifactorial nature of the problem.

NISSEN FUNDOPLICATION:

Illustration depicting the Nissen Fundoplication

This is the standard procedure that has been typically advocated for most patients. This involved a 360 degree wrap to avoid reflux. This is a loose wrap.

Of course, there are pros and cons to every procedure. For this procedure:

The "Pros" include:

Mechanical fix
No further medications
Unrestricted diet
Improved quality of life

The "Cons" include:

Surgery
Flatulance (15%)
Bloating (10%)
Difficulty swallowing (2%)

Therefore, if you are concerned about these symptoms we will perform other procedures to avoid these issues. Especially if you have bloating already.

View our brochure to learn more about this procedure.

TOUPET FUNDOPLICATION:

This is a partial wrap (270 degree) and as such is aimed at reducing these complications. The wrap is tolerated well and has similar outcomes to the full wrap.

Medical illustration depicting the Toupet Fundoplication

HILL FUNDOPLICATION:

This procedure does not require a true wrap but enhancing the muscle fibers of the stomach to support the Sphincter to prevent reflux similar to how it was supposed to be designed.

25 year data on this has recently shown similar outcomes (over 85% of patients continue not to take medications) and has a lower risk of side effects.

This barely anatomically changes the structure of your stomach and esophagus.

Medical illustration depicting the Hill Fundoplication

Robotic LINX

Medical illustration demonstrating the Robotic LINX procedure

The LINX procedure is similar to the more conventional Anti-reflux surgery. Similar to the conventional approach this is performed robotically and we still need to fix a hiatal hernia if present. However, instead of using a small part of your stomach to strengthen your valve we would use a magnetic ring.

This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis.

This does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. But because we need you to "exercise" the magnetic valve we do start you on regular food soon after surgery. This may feel uncomfortable at first but typically improves with time. Some patients have noted some weight loss up to 15lbs after surgery which will usually return unless you attempt to keep it off.

The surgical procedure typically takes 1 to 1 1/2 hours to complete and the majority of patients go home on the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.

There is no significant long-term data on this device but compared to the conventional anti-reflux procedure there is less bloating based on most current studies. There is however more difficulty with swallowing early on that does typically resolve.

This procedure is our recommended procedure in the setting of prior sleeve gastrectomy for weight loss.

Endoscopic Reflux Procedures

Endoscopic Anti-reflux procedures are designed for specific patients and are part of the discussion of best approach. The TIF procedure (Transoral Incisionless Fundoplication) has the best outcome of all endoscopic anti-reflux procedures. This is performed through the mouth without incisions and we use a special device to reconstruct the valve between the esophagus and the stomach.

This procedure is ideal for patients who have reflux and no longer want to take medications or perform lifestyle modifications.

There are certain situations that this procedure will not work. Data on all anti-reflux procedures in the setting of hiatal hernia fail to show improvement if the hernia is NOT REPAIRED. The drawback of the TIF procedure or any other endoscopic procedure is the failure to fix hiatal hernias and in this group of patients the failure rate is very high. Even without a hiatal hernia the failure rate can be up to 70% at one year with patients requiring medications again to manage symptoms. However, symptom management should be improved.

As such our typical algorithm is to recommend the robotic anti-reflux procedure as to most effective with over 10 year data with 85% cure rates, followed by the LINX and lastly the TIF procedure for patients who are not candidates for the more effective options.

c-TIF Robotic and Endoscopic Reflux Procedures

Extensive focus on reflux and hiatal and paraesophageal hernia surgery has shown the diaphragm closure contributes 80% to the repair and the wrap only 20%. To improve the effectiveness of endoscopic procedures in collaboration with our advanced interventional gastroenterologists the surgeons work to create a combined procedure involving repair of the hiatal or paraesophageal hernia robotically and the gastroenterologist endoscopically perform a wrap.

The goal is to create a robust reflux barrier and reduce the side effects including bloating and difficulty swallowing.

Medications for Reflux

There are a variety of medications for the management of reflux. These range from over the counter medications to prescription medications. These medications should be taken under careful monitoring of a trained specialist as there maybe side effects to long term use of these medications and correct diagnostic workup should be performed to ensure you are on the right medications and are on it for the right reasons.

The 4 main types of medications which are all antacids work by different mechanisms to block the acid excretion of your stomach or neutralize it.

Tums/Rolaids: These medications work by neutralizing the acid by using an ingredient that work quickly on the acid secreted into the stomach. These medications have minimal side effects and are good for occasional symptoms usually with heavy meals. Typically, most patients take these medications knowing they will have symptoms or soon after having symptoms.
Zantac and H2 blockers: These medications block the release of acid into your stomach and take slightly longer to work but last longer. Therefore, they are ideal for patients with some underlying daily symptoms that are mild. They do block acid production and side effect profiles are slightly worse than Tums and Rolaids.
Proton Pump Inhibitors (PPI's): This is the major drug group used to treat symptomatic reflux. Drugs in this group include Omeprazole, Nexium, Dexilant, Prilosec among others. These drugs have been associated with bone loss, cardiovascular issues, and potentially mental acuity changes.
Carafate, Gaviscon: These drugs work by coating the stomach and esophagus and are given prior to meals for onset of action. They do require and acidic environment for activation. Although Gaviscon is over the counter Carafate requires a prescription and due to having Aluminum can only be used for a brief period.

Robotic Achalasia Surgery

Robotic Heller Myotomy with some type of fundoplication has been shown to have the BEST LONG-TERM RESULTS. This technique typically involves making 5 tiny incisions (8mm) and performing the procedure typically in 1 to 1 1/2 hours. This procedure is performed as an outpatient procedure in most cases with patients either going home the same day or the next day. Patients usually are sent home without any reflux medications and advised to advance their diet.

The technique has been modified over the last 20 years and the length of the incision as well as the type of wrap play an important role in the outcome of the procedure.

What has been learnt has been that adequate myotomies are important for successful outcomes as far as relieving symptoms. However, failure of performing an anti-reflux procedure leaves patients prone to reflux in 60-80% of cases. With appropriate wrap placement, this rate drops to 5%. Otherwise, you are replacing one disease with another and will require long term medications to treat the reflux.

The more recent advance has been the use of robotics to perform the procedure that leads to a significant reduction in perforation and longer hospital stays.

Overall, most patients do very well. We do follow you closely for issues as this is a chronic disease and may require more interventions.

Our goal is to get you back to being yourself and improving your quality of life.

View our brochure to learn more about the procedure.

Per Oral Myotomy (Endoscopic)

This procedure involves general anesthesia and you are intubated for the procedure similar to the robotic Heller and the procedure takes approximately 1 1/2 hours. You are typically in the hospital for 2 days and are sent home on a 3-month course of anti-reflux medications after which time we will assess if you have any evidence of reflux.

The recovery pattern is similar to the Heller myotomy and the diet is advanced as you can tolerate. The resolution of your difficulty swallowing which is the most common symptom with achalasia will usually resolve. Although long term data is still lacking.

Reflux is however a common issue with data ranging from 40-80%. This requires typically lifelong anti-reflux medications or further intervention surgically for resolution.

Although we believe this is an important tool in the management of achalasia and given the identical procedure risks patients will be candidates for both procedures but the outcomes and reflux rates of the robotic approach will typically surpass that of the endoscopic procedure due to the anti-reflux component of the operation.

We believe this is an excellent procedure to avoid reoperative Heller and will be used in our algorithm as third line therapy in complex cases.

Complications rates including perforation will typically be around 6%.

Endoscopic Balloon Dilation

This procedure involves general anesthesia and you are intubated for the procedure similar to the robotic Heller and the POEM. However, this procedure is typically fast taking usually 30-45min. You typically go home the same day and are sent home on a 3-month course of anti-reflux medications after which time we will assess if you have any evidence of reflux.

The recovery pattern faster than the 2 other procedures and the diet is advanced as you see fit. The resolution of your difficulty swallowing which is the most common symptom with achalasia will usually resolve but typically this requires 3 rounds of dilation with increasing size balloons. Data comparing outcomes compared to Heller showed similar outcomes for improvement in difficulty swallowing.

Reflux is however a common issue with data ranging from 40-80%. This requires typically lifelong anti-reflux medications or further intervention surgically for resolution.

Although we believe this is an important tool in the management of achalasia given that it requires typically at least THREE Dilations for improvement over several months with repeat exposure to anesthesia and higher reflux rates when compared to the robotic approach we typically perform this procedure as second line therapy after patients have issues with the initial surgery.

We believe this is an excellent procedure to avoid reoperative Heller and will be used in our algorithm as second line therapy in cases when patients have return of symptoms.

Complications rates including perforation will typically be around 3-4%.

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