Emerging Technology in the Treatment of Extreme GERD

Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Hello and welcome to the show. I'm Deborah Howell. Today our guest is Dr. Atif Iqbal, Medical Director of the Digestive Care Center at Orange Coast Medical Center. He specializes in minimally invasive bariatric procedures and digestive disorder surgery. You're listening to Weekly Dose of Wellness. Welcome, Dr. Iqbal.

Atif Iqbal, MD: Thank you so much for having me.

Deborah Howell (Host): Our pleasure. Today we're going to be talking about emerging technologies in the treatment of extreme GERD. We hear a lot about it, but what exactly is GERD, doctor?

Atif Iqbal, MD: GERD, or gastroesophageal reflux disease, is the most common gastrointestinal disorder in the United States. It's affecting about 25 million people in this country. Typically these patients present with complaints of heartburn, pain behind the sternum, feeling of food getting stuck or coming back, acid taste in their mouth, or sometimes they complain of a cough late at night that also is related to GERD.

Deborah Howell (Host): Okay. And how does one develop GERD?

Atif Iqbal, MD: GERD typically is mainly caused by a malfunctioning of a ring-shaped muscle which is present at the bottom of the food pipe we call the esophagus. Normally the function of this muscle is to prevent all the acid which we produce in the stomach going upwards and it prevents the flow of acid upwards. When it is not functioning, all the exposure of that acid causes the symptoms I just mentioned. I also wanted to mention a little bit about some of the main contributing factors also besides this main reason. Presence of hiatal hernia, which is a slippage of stomach into the chest, along with some common things like diet, a diet rich in fried food, fatty food, spicy, citrus, caffeine, and chocolate can be one of the predisposing factors. Along with the lifestyle of some of the people eating very late at night before sleep or increased weight gain, obesity, as well as diabetes has been shown to have a significant contribution towards the development of GERD.

Deborah Howell (Host): I'm surprised you said spicy because I thought spicy foods were really quite good for you.

Atif Iqbal, MD: They do impact and contribute towards acid. However, some people in our community who are used to that don't get affected with that, but they have some contribution.

Deborah Howell (Host): I hope I'm one of them because I adore spicy foods. All right. What are some of the warning signs that you may have GERD and how is it usually diagnosed?

Atif Iqbal, MD: That's great to know because these patients usually... The symptoms I mentioned, heartburns and difficulty in swallowing, the frequency of these symptoms get more and more. So the same symptoms where they were feeling once a month are coming several times a week and now they're coming several times a day. It is definitely a warning sign to see that you need to seek a physician or some expert who deals with GERD. Also if you are seeking like two or three or four pillows to sleep at night. That's also a sign of a severe GERD. Some of these patients who go and get over-the-counter medication for acid suppression feel that they don't, they have only marginal results with that and relief with that. That's also a very major warning sign. The way it is diagnosed is actually very simple. There are two tests that's required to diagnose GERD. Both are done in 10 minutes and in both tests patient is usually having a short sleep. So one is upper endoscopy where we put a camera and visualize the upper digestive system. It helps us in knowing if there is a presence of a large hiatal hernia or how much damage is done by the acid in our digestive system. The second is also a test which is done less than five minutes is a Bravo capsule placement, which is a small wireless transmitter that we place in the bottom of the esophagus and its incredible results are shown after 48 hours that determines sometimes from mild, moderate to severe disease and how much was the acid exposure of patient during that time.

Deborah Howell (Host): And how do you get that tiny camera into the human?

Atif Iqbal, MD: So it's done with the same endoscope. Once we perform the endoscopy, we just direct and place and deploy the capsule right at the bottom of the esophagus and then the patient goes home with a small black machine that records the acid exposure.

Deborah Howell (Host): Incredible. All right, well that's kind of the bad news, you have GERD, now you're diagnosed. So what are some of the emerging surgical technologies that are available now to treat GERD and what are the main differences between these and those conventional treatment methods?

Atif Iqbal, MD: The principle of the surgical repair is to treat the cause. And the cause is a malfunctioning sphincter. So that's done by wrapping the top part of the stomach around the esophagus and reconstructing this valve. That's the principle. Now the technique has emerged significantly over the last 10 years. Initially it started as an open procedure. The procedure name is Nissen fundoplication. It was done with an open large cut and patients used to have a longer recovery, a longer hospital stay. It changed into minimal invasive, which was with small little four incisions. You do the surgery and the patient has a much faster recovery. That advanced too now with the Da Vinci robot where we do it with high precision and accuracy and a very fast recovery and very short hospital stay. Also this has continued to emerge, it continued to have an evolution of its own, to transoral, which is incisionless fundoplication through the mouth. And now the most and latest and current method that has emerged is called LINX procedure. LINX is a very interesting device. It is a bracelet of tiny beads which is made of titanium and has a magnet inside. You place the bracelet at the bottom of the esophagus and it acts like a sphincter. So it is tight enough to prevent the acid going backwards but it is loose enough to let your food go down. And I think the significant difference between LINX and any other surgical procedure I just mentioned earlier is that in LINX it's a simpler procedure to do, it requires very small little incisions and you can resume normal food a day after the surgery, which is incredible. In any other procedure you have to wait two to three weeks because you construct a valve and you have to slowly open it and you have to slowly advance your diet. But in LINX you actually immediately resume your next regular meal on the day after the surgery.

Deborah Howell (Host): So Da Vinci and LINX are really the game changers.

Atif Iqbal, MD: Yes, exactly.

Deborah Howell (Host): So how frequently do you see people with extreme cases of GERD that need surgical treatment?

Atif Iqbal, MD: More and more awareness is developing in the population and community and as I mentioned 25 million people are suffering from GERD. So about 5 to 7% of that is severe GERD. So in my practice I see a lot of patients who have been on medications for a long time and still have marginal results. So the frequency is increasing. The incidence is increasing. So we see actually quite often than what we used to see in 10 years ago.

Deborah Howell (Host): I'm sorry to hear that. Because there's so much good information out there about how to eat and how not to eat and yet it's climbing.

Atif Iqbal, MD: Exactly.

Deborah Howell (Host): What sort of complications can someone experience if GERD is not treated properly?

Atif Iqbal, MD: I think this is also a very important thing to consider. The patients who are exposed to a prolonged acid damage over the period of years, they are prone to develop significant complications. Starting with more basic, when you do an endoscopy you can see the damage in the form of redness or we call it gastritis or esophagitis, from that to bleeding, from ulcer formation, scarring and narrowing of the anatomy of the digestive system. And I think the most devastating of them is the development of Barrett's disease and early cancer. Which is a pre-cancer condition that leads to the formation of esophageal cancer. And esophageal cancer unfortunately, once it's diagnosed, it's one of the most devastating and deadly cancers in the country. It is growing in the last 10 years to about 600% because of the underdiagnosis and because of the acid exposure on these patients which are not aware of that. Availability of over-the-counter medication has actually made people not go to the doctor. They don't feel a need. They just grab it whenever it's needed. And it just ultimately leads to progressive development of unfortunately this condition that changes into cancer over time.

Deborah Howell (Host): I need to stop you there, unfortunately, Dr. Iqbal. Thank you so much for taking time out of your day to talk to us about GERD and some great new technologies and treatments. To listen to the podcast or for more information, please visit memorialcare.org/podcasts. That's memorialcare.org/podcasts. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness, brought to you by MemorialCare Health System. Have a fantastic day.