An overview of new and more traditional surgical treatments of acid reflux/GERD

1. SurgeryNews
OCTOBER 2009
SPOTLIGHT ON ESOPHAGEAL AND GENERAL SURGERY
Minimally Invasive ANATOMICAL REPAIR
Provides Relief for Patients with PERSISTENT GERD
ELLIOT R. GOODMAN, MD other structural abnor-
Chief of Bariatric Surgery
malities, such as a hiatal
Specialties: General Surgery, Bariatric Surgery
hernia, which often com-
plicates, but does not
Gastroesophageal reflux cause, GERD.
disease, or GERD, affects Fundoplication, for
more than 50 years, was
millions. More than 15 million
first performed as an open
experience daily symptoms, operation by Dr. Rudolph
reports The American College Nissen. The procedure
tightens and repairs the
of Gastroenterology, and LES by dissecting, wrap-
approximately $8 billion is ping and stitching the car-
dia of the stomach around
spent on prescription and Fundoplication involves wrapping and stitching the cardia around the
distal intra-abdominal esophagus.
the distal intra-abdominal
over-the-counter drugs esophagus, providing
annually. Unfortunately, even when coupled with lifestyle additional pressure to recreate a function-
ing sphincter. Laparoscopic intervention
changes, these prescribed medications—including the newest
over the past two decades has produced
proton pump inhibitors (PPI)—do not always relieve symptoms. the same results as open procedures, alle-
viating heartburn in up to 90 percent of
Fortunately, surgery offers a viable alterna- cases, while replacing the six- to ten-inch
tive for many of these patients. The sur- incision with a few small incisions and
geons in the Department of Surgery at
GERD is not typically a reducing LOS from eight days to a single
overnight stay.
Beth Israel Medical Center have been life-threatening illness, but
While time-proven benefits of mini-
performing laparoscopic fundoplication,
the standard GERD surgery, since 1995.
left untreated, it can have mally invasive techniques include less pain,
medication and scarring, pursuit of further
Patients considered have persistent serious complications.
improvements continues. One recent
symptoms ranging from a burning
advance currently being explored at
sensation mid-abdomen, commonly the reflux—a weakened lower esophageal
Beth Israel is transoral incisionless fun-
referred to as heartburn, to more atypical sphincter (LES) or poorly functioning gas- doplication (TIF), an incisionless, natural
complaints including sore throat, swallow- troesophageal valve (GEV)—both of orifice approach done in the OR under
ing difficulties and dry cough. Unlike which have been found to contribute to general anesthesia. Through the mouth,
medications that relieve heartburn the reflux of gastric contents back into the endoscope carries a sterile, single-use
by reducing acid production, surgery the esophagus causing inflammation and EsophyX™ device, which deploys multiple
corrects anatomical problems causing burning. Surgery will also correct (CONTINUED ON PAGE 2)

2. BI Surgeons TREAT GERD
RARE ESOPHAGEAL DISORDER
(CONTINUED FROM PAGE 1)
polypropylene fasteners, transfixing and
BURTON G. SURICK, MD
Attending, Department of Surgery
achieving serosa-to-serosa fusion, creating
Specialties: General Surgery, Minimally Invasive Laparoscopic Surgery, Bariatric Surgery a functional gastroesophageal valve. Most
patients who opt for GERD surgery are
In direct contrast to GERD, achalasia is a rare esophageal disorder suitable candidates for traditional laparo-
scopic fundoplication. The EsophyX™
resulting from an overly tight lower esophageal sphincter (LES), procedure is appropriate for those
which keeps food from passing through. Only 2,000 people without large hiatal hernias (over 2 cm),
esophageal strictures, or significant scar-
develop this condition annually in the US, according to The
ring from prior abdominal surgery.
Society of Thoracic Surgeons, but untreated it has unpleasant All patients undergo careful
consequences. Fortunately, surgeons like Beth Israel Medical evaluation and screening. Good
motility in the esophagus, determined
Center’s Burton Surick, MD, and Richard Friedman, MD, are by manometry testing, is required, as is
performing a minimally invasive surgery with great success. eliminating a cardiac diagnosis, which
can sometimes mimic GERD symptoms.
Endoscopic evaluation and an upper GI
series is standard to view the esophagus
surface and check for abnormalities.
Additional tests performed include 24-hour
pH monitoring, done on an outpatient
basis to record acid levels while a patient
goes about normal activities.
GERD is not typically a life-threatening
illness but, left untreated, it can have
A: Failure of the valve at the lower esophageal sphincter (LES) results in food entrapment and distension of the
esophagus. B: Myotomy requires splitting the LES muscle to release the valve and allow food passage into the
serious complications, including bleeding,
stomach. C: A portion of the cardia is repositioned and reattached over the site of the incision. ulcers, strictures, and Barrett’s esophagus,
a pre-cancerous condition that can even-
tually lead to a fatal outcome. Palliative
Called a myotomy, the procedure involves Symptoms of achalasia may include medical management does not correct
splitting the LES to disrupt the muscle progressive difficulty in swallowing, eating
the problem, and lifelong treatment and
fibers, allowing food to pass more easily and drinking, the need to wash food
monitoring is necessary to prevent deteri-
into the stomach. As an open surgery, down with liquids, regurgitation of food,
oration. Anatomical repair offers cure,
myotomy has been performed for decades. heartburn, chronic cough, weight loss, and
and incisionless advances reduce OR
The laparoscopic approach, initially used in chest pain or pressure that may increase
risks, potentially prompting physicians
the 1990s, has proved highly successful— after eating, or radiate to the back, neck
and their patients to opt for surgical inter-
nearly 95 percent of patients experience and arms. Patients with these complaints,
vention earlier.
years of symptom relief afterwards. Other which can appear similar to GERD, under-
treatments include application of an endo- go complete evaluations that include
scopic balloon within the LES that expands esophageal endoscopy and manometry.
For further information or to refer a
and tears the valve muscles, and a Botox
patient for surgical GERD intervention,
injection administered under endoscopic
please contact Elliot Goodman, MD, at
guidance that paralyzes the valve. But For further information about achalasia
neither provides relief for as long, or for as or to refer a patient to Burton Surick, MD, (212) 844-8838.
many patients as does myotomy. Currently, or Richard Friedman, MD, please call
no oral medications are available either. (212) 420-4520.
2

3. Beth Israel’s GENERAL SURGERY SPECIALISTS
Provide ADVANCED CARE FROM A TO Z
MICHAEL LEITMAN, MD
Chief of General Surgery
Specialties: Oncologic Surgery, Bariatric Surgery
General surgery specialists at Beth Israel Medical Center treat thousands of patients each year.
Providing interventions for a wide range of conditions from appendicitis to obesity, these
physicians treat diseases affecting the abdomen and its organs. Individualized treatment plans,
increasingly with minimally invasive surgery (MIS), a multidisciplinary team approach, and
collaboration with referring physicians, are all hallmarks of the division.
What is general surgery? Recent laparoscopic advances
Key Administration
In spite of its name, general surgery is a Further refinements to MIS include single
surgical specialty that focuses on the incision laparoscopic surgery (SILS),
diagnosis and treatment of diseases and MARTIN KARPEH, MD involving the application of a special
disorders affecting the abdomen, digestive Chairman, Department of Surgery device at the navel that accommodates
(212) 420-4041
tract and endocrine system. The most the three necessary instruments for chole-
common conditions treated by Beth Israel MERYL GOLD cystectomy, a technique in use at Beth
surgeons include gallstones and other Administrator, Department of Surgery Israel for the past six months. Another
gall bladder disease, a variety of hernias (212) 420-4457 advance, natural orifice endoscopic
(inguinal, recurrent, bilateral, ventral, surgery, performed with an endoscope
KATHERINE ZAYAS
and incisional), obesity, pancreatitis, Administrator, Ambulatory Surgery through one of the body’s natural orifices,
appendicitis, bowel obstructions, colon (212) 844-8203 includes the EsophyX™ and StomaphX™
inflammation and cancer, and trauma. procedures, which treat gastroesophageal
The broad perspective of these spe- reflux and revise gastric bypasses, respec-
cialists enhances comprehensive and A Vast Array of Treatments tively. Over the past year, Beth Israel has
thorough diagnosis, and allows for the established itself as a leader in the metro-
most skillful surgical solutions possible. The General Surgery Division provides politan area, performing more than 70
laparoscopic as well as open treatments for StomaphX™ procedures with good results.
patients with:
Minimally invasive • Hernia
In addition to improving care through
treatment is preferred • Gallbladder disease and gallstones technical advances, the collegial environ-
Over the last 15 years, these solutions • Gastro-esophageal reflux disorder (GERD) ment of Beth Israel Medical Center, and
• Pancreatitis the Division of General Surgery in particu-
have increasingly involved minimally
• Appendicitis
invasive surgery (MIS). Well-established lar, provides superior patient care via
• Diverticulitis disease
benefits for both physician and patient • Inflammatory bowel disease collaboration between different specialties.
hone in on one central principle— • Biliary (liver) diseases Treating obesity, for example, necessitates
• Trauma partnerships among endocrinologists,
reducing surgical risk. Smaller incisions
and reduced trauma translate to fewer behavioral specialists and general surgeons.
Additionally, within the Division of
wound complications, less post-op pain, General Surgery, is the following specialized
less pain medication, shorter LOS, faster program:
• Bariatric Surgery Program
recovery and fewer scars. MIS techniques For further information on general
are now standard care for many proce- surgery services or to schedule a consulta-
dures including cholecystectomy, Nissen www.BISurgery.org tion with a general surgeon, please call
fundoplication and hernia repair. (212) 844-8203.
3

4. NONPROFIT
ORGANIZATION
US POSTAGE
PAID
PERMIT NO. 8048
NEW YORK, NY
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
In this
issue... Laparoscopic Treatments for GERD;
Treating the Rare Disorder of Achalasia;
Advanced General Surgery Care from A to Z
SurgeryNews
OCTOBER 2009
SPOTLIGHT ON ESOPHAGEAL AND GENERAL SURGERY
Is a DIGITAL Copy of Surgery News in your Future?
The Department of Surgery is planning to go digital with future issues of Surgery News. If you
would like to receive future copies electronically, please drop us an e-mail with “Electronic SN”
in the subject line. Simply provide your full name, address, medical specialty and e-mail address
to: paphilippe@chpnet.org.
Beth Israel surgeons provide first-rate, state-of-the-art quality care to all patients and collaborate with
referring physicians to create an individualized treatment plan. For more information about surgical services
at Beth Israel Medical Center, call (212) 420 - 4044 or visit our Website at www.BISurgery.org.
4