Incisionless surgery for heartburn goes for the throat
November 19, 2008 5:00 AM
Dr. Blair Jobe examines Debra Crawford, as a followup after she had incisionless heartburn surgery.
By Pohla Smith Pittsburgh Post-Gazette
Like some 14 million Americans, Debra Crawford, a 58-year-old nurse from Farmington, Fayette County, suffered for years from heartburn, or GERD, the medical acronym for gastroesophageal reflux disease.
At first, she kept it controlled by taking Nexium twice a day. Later, when Nexium started keeping her awake at night, she began taking it earlier in the day and adding Zantac at bedtime.
But then the heartburn, caused when stomach acid gets past what's supposed to be a one-way valve and heads up into the esophagus, "started to cause a breathing problem" that turned her life upside down.
It's not an unusual development.
"Patients bring different types of symptoms. They bring cough; they bring shortness of breath; they bring asthma," said surgeon and researcher Dr. Blair Jobe, director of both esophageal research and esophageal diagnostics and therapeutic endoscopy within the UPMC Heart, Lung, and Esophageal Surgery Institute.
"The quality of life issues related to reflux really can be severe. In fact, GERD can lead to the development of a need for a lung transplant, and we see that all the time. They're [breathing in stomach acids] and they're scarring and then the lungs don't work ... [and] reflux disease is a big risk factor, the main risk factor, for esophageal cancer, which is a lethal disease."
Most reflux patients, however, don't develop that cancer. Only about 1 percent or fewer appear to get esophageal cancer.
Dr. Jobe diagnosed Mrs. Crawford's complication as probable adult-onset asthma. More important, he also provided what is, if its short track record holds up, a cure for both the heartburn and the asthma.
It's a brand-new incisionless surgery he helped to pioneer in the United States called transoral incisionless endoscopic fundoplication, or EsophX. Instead of opening an 8- or 9-inch incision as in the original heartburn surgery or the five fingertip-sized incisions of laparoscopy, which is now standard for most cases, surgeons doing EsophX reach and rebuild the valve via a tube, or endoscope, inserted down the throat into the esophagus.
Then, as in laparoscopy, a new valve is fashioned out of stomach tissue and secured by sutures fashioned out of polypropylene, a plastic. The tissue then heals over top of the sutures.
Developed in the United States by a German inventor named Stefan Kraemer, EsophX was first performed about 1 1/2 to two years ago in the Netherlands, where Dr. Jobe was trained in the procedure.
Then working in Oregon, he was part of a team that did the first EsophX in the United States a little less than a year ago. He did four more there before UPMC recruited him for the Heart, Lung and Esophageal Surgery Institute. Since starting at UPMC Jan. 2, he has teamed with Drs. Manisha Shende and Matthew Schuchert to do five more. Most recent was Mrs. Crawford on Oct. 22.
The team is the only one doing the surgery in Pennsylvania, and Dr. Jobe estimated there are only about 10 sites doing it nationwide.
The advantages of EsophX over the other surgeries are in length of hospitalization and convalescence and amount of pain.
With the traditional, long incision, which is used in about 1 percent of the cases, primarily if it's a re-do or a complicated case, the patient is hospitalized about a week. "You probably have significantly more pain and your convalescence is a lot longer," Dr. Jobe said. "Your ability to return back to your activities of daily living -- going back to work, lifting things, those sorts of things -- are limited for a significant amount of time."
For laparoscopic surgery, he said, "patients are usually in the hospital one to two days, maybe three days ... and it's a very good surgery." There is some pain, which may require pain medicine, he added.
Some EsophX patients go home the same day, others after an overnight stay. Mrs. Crawford stayed over because she had complications from the anesthesia. "I always have the same problem [with anesthesia]," she said.
"I had a good bit of chest discomfort the first week ... a tightening kind of pain," Mrs. Crawford added. She also had a sore throat for the first two days after the surgery from the endoscope.
The chest discomfort, Dr. Jobe told her, probably was "referred pain from the procedure."
Mrs. Crawford returned to work Nov. 11 and said she probably could have returned earlier. She hopes to resume working out with a trainer at her gym -- something she hasn't been able to do for four years -- in January, and Dr. Jobe said he could see no reason why she couldn't. She's also looking forward to shopping again, something else her GERD-induced asthma prohibited.
"I could go to one store," she said. "I mean my husband would drop me right off. If I went to the mall and I had to park at the bottom I just went home until he could drive me up because I knew if I walked up there it was the end. I'd have to sit up there for a half-hour."
Mrs. Crawford's breathing difficulties took her to a pulmonologist because she was afraid she had COPD, or chronic obstructive pulmonary disease. When that proved negative, the specialist sent her on to a cardiologist, and she had a heart catheterization. "My heart's great," she said, laughing.
Her gastric doctor made an appointment for her to see a surgeon in Uniontown.
But then she had a change of luck. A nurse she worked with saw a preview for a TV news story about a new, incisionless surgery for heartburn being done by UPMC.
"So I made a point to watch that on Channel 4, and I called my pulmonologist," she said. "He gave me the number and that's how I got here."
Mrs. Crawford went to see Dr. Jobe "determined" to get the new surgery "because I've had other surgeries and the recovery [is faster with EsophX] and I just wanted to do this."
The lack of any long-term study of the procedure -- Dr. Jobe is the principal investigator of a new study comparing the efficacy of EsophX with drugs like Nexium and Prilosec OTC -- didn't worry her. "He made me feel very confident," she said.
Dr. Jobe felt the same about her.
"She was the perfect person to work with on this because she had an open mind to a new procedure and was willing to try it," he said. "And I think it sort of takes that spirit of adventure."
Mrs. Crawford also met the physical qualifications. "The perfect patient for this procedure would be somebody who has heartburn despite medication and would like to get off medication," Dr. Jobe said. "That's the same person who does the best with the laparoscopic approach as well." The patient also cannot have a large hiatal hernia, he said, "and then we like to document that they have acid exposure in their esophagus."
As in laparoscopy, successful surgery also depends on the patient following some behavior modification.
"Sutures just hold things in place while the healing process occurs," the surgeon said. "That's why there's no heavy lifting greater than 20 pounds for six weeks and the diet is modified cause you don't want to over-distend the stomach. If you were to drink a beer or a carbonated beverage it would over-distend the stomach and you can see how it would put tension on that and that's really the important piece." Likewise, multiple small meals should replace fewer large ones during the healing. Dr. Jobe calls them "the bird diet."