Ask the Expert: GERD (Filling the Gaps in Gerd Management. What’s Keeping you up at Night?)

Transcript

00:07

okay

00:08

and sometimes we have people who are

00:09

here because they got a spouse who’s got

00:11

them and they’re trying to

00:12

uh get things fixed so they can both

00:14

sleep a little better

00:16

it probably seems a little bit

00:18

strange

00:19

to you that there’s a surgeon up here

00:20

talking to you

00:22

and and I get that a lot I get a lot

00:24

of people who are confused about

00:27

what I even do you know are you a gi are

00:29

you my gi doctor are you a surgeon what

00:31

do you do

00:32

are you a chest surgeon a little bit

00:34

about me

00:36

i’m a general surgeon but I did a

00:37

fellowship in minimally invasive

00:40

laparoscopic surgery back in 1998

00:44

back when I did it I was literally

00:48

in a situation where my my residency

00:51

director tried to talk me out of it

00:53

because he said there was no future in

00:54

that

00:55

okay so I was there at the very

00:59

beginning of this training process where

01:02

we’re trying to learn how to do these

01:03

things and

01:04

you know 90 of surgeons were against the

01:07

even the idea of it or the concept of it

01:10

things have changed quite a bit

01:13

and so i’ve been at this sort of stuff

01:15

and and dealing with reflux and

01:17

anti-reflux surgeries

01:18

since 1998 uh i’ve taught people

01:22

coast to coast and this kind of stuff

01:23

i’ve taught in asia i’ve taught in in in

01:26

europe so i’ve been pretty busy

01:30

I do everything this isn’t the only

01:33

thing I do

01:34

you know people ask me what do you know

01:35

what do you do I tell them i’m a general

01:38

surgeon

01:38

i just there’s certain things that I do

01:41

a little better a little easier

01:43

a little faster a little safer than

01:44

other people so we I tend to focus on

01:46

that

01:48

over the years i’ve taught courses in

01:50

laparoscopic colon surgery

01:52

splenectomys adrenalectomies teach

01:54

people how to take out gallbladders

01:55

safer

01:57

i I focus now primarily on anti-reflux

02:00

surgery

02:01

and complicated hernia repairs and

02:03

inguinal hernia repairs and things like

02:04

that

02:07

how did I get into this stuff this

02:08

reflux stuff most most of you have a

02:10

surgeon or general surgeon they don’t do

02:12

this

02:13

the skill set for doing minimally

02:16

invasive surgery laparoscopic surgery

02:18

really lends itself to

02:19

taking care of this problem but taking

02:21

care of the problem has

02:23

also has a lot to do with not just

02:24

having a diagnosis and doing a procedure

02:27

it’s a

02:28

it’s a constellation of care it’s making

02:29

sure the diagnosis is correct

02:31

making sure that the different

02:32

procedures we do are the appropriate

02:34

procedure for the patient

02:37

and that’s what we’re going to talk

02:38

about you know tonight

02:41

i think you know I see a lot of patients

02:43

i do hundreds of these operations per

02:45

year i’ve done thousands in my career

02:48

universally what I find with patients

02:51

who come to my office

02:53

is a misunderstanding of what’s going on

02:58

or why they feel bad they have been

03:01

walking the walk

03:02

taking the medications doing what

03:03

everybody tells them they still feel bad

03:05

they’re uncomfortable and they want to

03:07

get better

03:09

and we’re going it’s a

03:12

it’s a miscommunication or maybe a lack

03:14

of education that happens to people

03:17

and they they often think of themselves

03:19

as it’s a battle between them and the

03:21

acid

03:22

i mean how many people here think acid

03:23

is the problem now you probably tell

03:25

from what I just said it’s not but

03:26

i mean coming in here you probably

03:27

thought acid was the problem you

03:29

probably thought

03:30

if I just eat the right food that

03:32

doesn’t cause my acid reflux i’ll get

03:34

better

03:35

that’s not true a little bit of a shock

03:37

probably shock to some of your gi

03:39

doctors too

03:40

in terms of the medications well how

03:42

come this hasn’t fixed my

03:44

my reflux i’ve been taking it for five

03:45

years where how wise I still have reflux

03:47

when I stop

03:48

these are all things you’re going to

03:49

understand when we’re done

03:51

reflux is not an acid problem

03:55

acid is not our enemy we are supposed to

03:58

have acid in our stomach we need it to

04:00

help us digest

04:00

food to help protect us from infections

04:03

to help us absorb calci

04:05

a lot of things we need the acid for we

04:07

strip it out

04:09

things don’t digest very well we get

04:11

upset stomachs we get irritable bowel

04:13

syndrome we get things we think we have

04:14

celiac disease all these crazy things

04:16

they’re related to the fact that we

04:17

strip the acid out you know

04:20

i use the analogy in my office that

04:23

you know when you go to the car wash the

04:24

first thing they do is throw some soap

04:26

on the car add some water and run it

04:28

through

04:29

if you don’t add the soap and you run it

04:31

through your car is still going to be

04:33

cleaner

04:35

but not as good as if you had the soap

04:37

so your gi tract doesn’t really

04:39

like it when you don’t have acid it’ll

04:41

do okay

04:43

but you’re really supposed to have the

04:44

acid in there and and we were never

04:46

supposed to be taking these medications

04:49

uh for acid relief long term

04:52

when I was a resident we were forbidden

04:55

from rewriting these prescriptions after

04:57

six weeks

04:58

they would come to our clinic and like

04:59

doc I got to have them like now i’m

05:00

gonna get in trouble I can’t write this

05:02

so they go down the hallway and go to

05:04

the internal medicine clinic and say

05:05

i’ve never had this medicine can you

05:07

rewrite it okay

05:08

so that that’s where this started

05:12

so i’ve got slides and we’re going to

05:15

talk about i’m going to show you slides

05:17

because

05:17

you know it’s helpful uh i’m going to

05:20

break out

05:21

away from the slides as much as possible

05:24

uh

05:24

i want you to interrupt me often

05:28

okay and ask questions because i’m

05:32

this isn’t one of those i’m going to do

05:33

a talk i’m going to read my slides kind

05:35

of talk

05:36

i’ve got thousands of slides i’ve been

05:38

given presentations for 20 years

05:40

i don’t need to do that I know how to do

05:42

that you don’t need to listen to that I

05:44

want you guys to

05:45

understand what’s going on understand

05:47

why you feel bad and and have a little

05:49

bit more of a

05:50

dialogue okay

05:58

no there is heartburn can you repeat the

06:01

question yeah so the question was is

06:02

there a difference between heartburn and

06:04

gerd

06:05

okay no

06:08

these are just the words we’ve been

06:09

taught to use to describe how we feel

06:12

when someone comes to my office and says

06:13

i’ve got heartburn and the next

06:15

person says i’ve got gerd I don’t treat

06:18

them differently I don’t even I don’t I

06:20

do nothing differently

06:21

it just has to do with the idea here is

06:25

you’ve got a pl bing problem you got a

06:28

leak

06:29

stuff that’s supposed to stay in your

06:30

stomach isn’t staying there

06:33

now first of all uh as

06:36

h ans we all burp we all belch we all

06:39

can throw up

06:40

right so if we can do all those things

06:44

normally then that valve

06:48

that mysterious sphincter valve this

06:51

between the esophagus and stomach

06:52

it ain’t that good if we can burp belch

06:55

and throw up it’s already

06:56

weak we shouldn’t be able to do those

06:59

things if it was

07:00

vigorous i’m not saying those are bad

07:02

things it’s just it’s not that strong

07:04

so it doesn’t take much to go from a

07:07

good valve

07:08

to a bad valve and there are a lot of

07:10

different things

07:11

that push you into that territory and

07:14

it’s different for everybody

07:16

when we talk about needing surgery or

07:19

thinking about surgery or

07:21

why people fail medical management it’s

07:23

a different story for everybody

07:25

and sometimes you know when you’re it

07:27

may take 20 years and some gray hair to

07:29

figure that out

07:30

but everybody’s got a different story

07:31

and there’s different solutions for that

07:33

so let me kind of show you the idea here

07:36

was you know what’s keeping you up at

07:37

night because I see a lot of people who

07:38

you know can’t sleep at night they wake

07:40

up or their spouse can’t sleep because

07:42

this one’s got heartburn or reflux

07:44

or gerd you know so so we’re going to

07:45

talk about all those

07:47

different things provided that

07:50

technology doesn’t fail let’s see let me

07:52

turn this back on

07:55

hey all right so this is crazy how much

07:59

how many of these drugs we take right

08:03

in the united states these are basically

08:05

united states data right

08:06

a quarter of people in the united states

08:08

have reflux

08:10

okay 81 million people so it’s not it’s

08:13

almost I don’t say normal

08:14

but it’s not that abnormal to have some

08:17

reflux okay

08:18

in terms of how much medication we use

08:20

you know 19 million people

08:22

uh are using it daily i’m sure a lot of

08:24

you who are in this room use it daily

08:26

sometimes twice a day

08:31

in terms of being directed towards

08:34

a therapy for uh cert

08:37

or surgery or something a little more

08:39

definitive to control it right

08:42

not very many people ever get that

08:43

advice and the reason being

08:46

very few people know how to do these

08:47

operations

08:49

historically it’s tough it takes a

08:52

pretty good

08:52

learning curve and it’s a whole lot

08:54

easier to write a prescription

08:55

right you know someone comes in I got

08:57

some heartburn you go see your primary

08:58

care doctor now

09:00

it’s the primary care doctor it’s the

09:01

it’s the pa it’s the nurse practitioner

09:03

is your pulmonologist it’s your ent

09:05

everybody you walk in you go uh you know

09:08

oh

09:08

you need some of this there you go any

09:10

explanation given

09:11

no you know so very few people actually

09:15

get a chance to have the conversation

09:16

about well what else

09:18

is there what else can we do social

09:21

medias help with that a lot

09:23

this is what I you know see people are

09:24

like I got you know I got you know tom’s

09:26

in my car t s in my purse t s under

09:28

the bed roll aids over here

09:29

right all flavors and then i’ve tried

09:31

zantac on my own i’ve tried

09:33

you know knitting I can’t take zantac

09:35

right now it’s bad now I don’t know

09:37

maybe next week it won’t be bad but now

09:39

it’s bad

09:40

and then now you got proton p p

09:42

inhibitors that work great

09:44

but insurance company don’t want to pay

09:45

for them right and so

09:47

uh this is escalation of dosing and what

09:50

i see on this spectr is I often see

09:52

people

09:52

they’re here and then now they’ve gone

09:54

to twice a day

09:56

i see people taking twice a day ppis

09:58

they’re supposed to be 24-hour drugs

10:01

they’re taking it twice a day then

10:02

they’re doubling it up now not everyone

10:04

here can see but they’re a lot of heads

10:05

going like this

10:07

okay so I see that all the time I don’t

10:10

see

10:10

anyone who starts over here with once a

10:13

day zantac

10:14

then they add a little nexi now they

10:16

got nexi and zantac nexi twice a day

10:18

and zantac

10:19

who suddenly gets better okay so once

10:22

you’re on this let’s take it twice a day

10:25

regiment you’re not getting better

10:27

because they’re not

10:28

fixing anything you’re still reflexing

10:32

that just no one tells you that

10:35

the other side effect you guys hear

10:37

about bad things with ppis

10:39

right now you know all these side

10:40

effects I see people coming in

10:43

just like people come in my office

10:44

asking is mesh safe they come in asking

10:46

about

10:46

my ppi is safe okay I do not

10:50

try to scare people into stopping ppis

10:52

if I have somebody who is

10:54

you know 65 years old they feel just

10:56

fine they take

10:57

one ppi a day and they have no symptoms

10:59

and their esophagus looks

11:01

pristine on endoscopy there’s no reason

11:04

to take them and say

11:05

this is terrible let’s run over here and

11:06

do surgery okay

11:08

now some people are anxious they don’t

11:10

want to do that I don’t think someone

11:11

who’s

11:12

25 years old or a lady who’s had a

11:14

couple of children who has reflux and

11:16

she’s 35 years old

11:17

who’s already on twice a day medication

11:19

should continue that pathway

11:21

that’s probably bad I think a lot of

11:24

this

11:24

all these things are true all these

11:26

things are true that causes polyps in

11:27

your stomach it

11:28

decreases the way you can absorb calci

11:31

like I said we’re supposed to have acid

11:32

in our stomach

11:33

you strip it out things downstream

11:36

aren’t happy we don’t absorb food we

11:38

don’t

11:39

absorb nutrients we don’t fight

11:40

infections as well doesn’t mean it

11:42

happens to everybody

11:44

i can tell you right now there’s no one

11:45

in the hospital over here who got

11:47

admitted through the er because they

11:48

took ppis

11:50

okay it doesn’t happen very often but

11:52

over time

11:54

things build up and when you have

11:55

options you should consider it

11:58

when you’re taking too many drugs more

12:00

than you need you need to make sure the

12:01

diagnosis is correct

12:03

before you just sort of voluntarily take

12:05

things you don’t need

12:08

this is what we try to do right these

12:11

drugs are not

12:12

we’re not meant to be lifetime they’ve

12:14

turned into lifetime drugs

12:16

i had several people today I talked to

12:18

who were in their 40s who’ve already

12:20

been on the medication for 15 years

12:22

okay and because of social media they’re

12:24

starting to get concerned

12:26

and the problem is it might be okay

12:30

if it actually

12:31

fixed something okay when you’ve got

12:35

diabetes okay and you take your

12:39

sudden your sugar levels drop

12:40

it’s actually working to help you and

12:42

protect you from problems

12:44

okay when you take a ppi

12:47

you’re still reflexing it just doesn’t

12:49

burn as bad

12:50

it’s still coming up no one in this room

12:53

selectively reflexes

12:55

acid you reflex whatever is in your

12:58

stomach

12:59

bile starbucks tomato sauce

13:04

whatever it is okay that’s what comes

13:06

back up

13:07

and in a lot of studies bile may

13:09

actually be the worst

13:10

component that may be actually what the

13:12

word what’s causing the danger

13:14

fda you know went crazy a few years

13:17

ago with all these black box warnings

13:18

that scared people to death

13:21

my business went way up no but you know

13:23

what happens is

13:25

i don’t think it’s fair to just scare

13:27

the crap out of people you got to

13:28

educate people and if I think

13:30

i have no problems writing people for

13:33

a once a day proton p p inhibitor if

13:35

they understand

13:37

why we’re doing it and and but I do find

13:40

a problem with again double dosing

13:42

triple dosing adding band-aid after

13:45

band-aid after band-aid when we can fix

13:47

the problem

13:48

okay again people on ppis

13:52

most people are kind of happy but

13:54

there’s probably about 30 40

13:56

who are not happy okay they continue to

13:59

have breakthrough symptoms even though

14:00

they’re on the pills they have

14:02

breakthrough symptoms because they

14:03

you know they stray just a little bit

14:05

off of their diet you know they’re

14:07

you know it’s the torture people put

14:10

themselves through and then they’re very

14:11

disappointed the time to come see me

14:12

they’re very disappointed

14:14

because they’re trying they’re

14:16

frustrated they’re googling this they’re

14:18

googling that they’re

14:19

drinking you know vinegar solutions and

14:23

alkaline water and this may be familiar

14:25

to some of you people in here

14:26

you know they’ve been online they’ve

14:28

seen their chiropractor he’s

14:29

manipulating things to try to make their

14:30

reflux go away

14:32

it’s crazy and and so they’re very upset

14:36

why why is this happening

14:39

it’s anatomy like I said it’s a pl bing

14:42

problem we have a weakness in terms of

14:44

the anatomy

14:46

you know if somebody has a broken foot

14:49

or broken toe

14:51

let’s say a broken arm makes visually

14:52

makes more sense right

14:54

i can give you enough drugs that you

14:56

don’t care about your broken arm

14:58

but I didn’t fix your broken arm okay

15:01

we might be able to give you enough

15:02

drugs to mask the symptoms

15:04

but we didn’t fix the thing that’s

15:05

causing the symptoms now in this case

15:08

you’re still reflexing you’re reflexing

15:10

bile and digestive

15:12

enzymes and all these things so what

15:14

happens is there’s there is kind of a

15:17

a can be can be a natural progression

15:20

you know

15:20

and I drew down here my you know we’ll

15:23

sign these and auction these off later

15:24

for nova charities I guess

15:26

but so what happens is this is normal

15:28

anatomy we swallow

15:30

we chew we swallow food goes down our

15:32

esophagus we don’t think about

15:34

pushing it down but it gets moved down

15:36

towards our stomach

15:38

normally as it passes the esophagus

15:40

passes from our chest

15:42

down to our abdomen to our stomach where

15:44

all the acids made

15:46

it passes through a layer thin layer

15:49

muscle called the diaphragm

15:50

okay so we all have a diaphragm

15:54

there is a little gap that lets your

15:57

your esophagus go through called the

15:59

hiatus

16:01

people heard the term hiatal hernia yeah

16:03

we all have

16:04

a hiatus okay that little gap is called

16:07

the hiatus but it’s not supposed to be a

16:09

big gap

16:10

it’s under normal circ stances

16:13

our esophagus is closed it’s not like

16:16

this pvc

16:17

pipe that’s open it’s supposed to be

16:20

closed it only

16:21

kind of opens when food gets pushed

16:23

through it and it opens up and then

16:25

closes after the food goes through

16:27

all right so that’s naturally what

16:30

happens

16:31

naturally these muscles are kind of

16:33

tight against the esophagus

16:36

okay naturally there’s a little bit of

16:38

esophagus below the diaphragm

16:40

pressure in our chest is negative

16:44

suction vacu okay ever heard the

16:47

phrase sucking chest wounds right

16:49

that means because you puncture those

16:51

the lungs the ribs

16:53

your lung collapses because it’s

16:54

negative pressure but that’s why we can

16:55

breathe

16:56

think about it as suction sucking on a

16:58

straw there’s a negative pressure inside

17:00

our chest

17:01

there’s a positive pressure inside our

17:03

abdomen so you have positive pressure

17:06

squeeze squeezing the esophagus below

17:10

the diaphragm to keep it closed

17:12

there’s muscles pinching it to keep it

17:14

closed

17:15

okay there’s your valve

17:19

that’s it I didn’t draw a whole lot of

17:22

muscle fibers and things that

17:24

really that’s about it a few other minor

17:26

things but that’s the

17:27

that’s the main that’s the majority of

17:28

what’s going on okay

17:30

so it’s not some you know you you slice

17:32

through here looking under a microscope

17:34

nobody can point at and say there’s the

17:35

sphincter

17:37

so there’s some subtle things that come

17:38

together to protect us from reflux

17:41

now let’s add some genetics

17:45

wear and tear having babies gaining

17:48

weight

17:49

doing what I like to call d b guy stuff

17:51

okay we’re lifting heavy things and

17:52

increasing the pressure in our abdomen

17:54

okay and also just bad luck okay just

17:57

bad luck

17:58

this gap can start to stretch the hiatus

18:01

starts to pull apart

18:03

okay we don’t have any empty spots

18:06

in our abdomen or our chest everything

18:09

trust me i’ve been there

18:10

everything is full of something so if

18:12

you spread these muscles

18:14

it doesn’t just stay there something

18:16

happens things start moving

18:18

stomach starts to slide up into the

18:20

chest it herniates through the hiatus

18:23

so you get a hiatal hernia now what’s

18:26

protecting you from reflux when you have

18:27

a hiatal hernia

18:31

nothing okay maybe eating smaller meals

18:35

so your stomach’s not so distended

18:37

that you you burp and belch and leak but

18:39

that’s it

18:40

it door’s wide open front door is wide

18:42

open you swallow

18:43

food goes down once this kind of fills

18:46

up

18:48

and the stomach starts to contract it’s

18:49

going to the food and the fluid the acid

18:51

the bile

18:52

your nexi tablet are all going to go

18:54

whichever direction

18:56

is easier okay it’ll come up it’ll come

19:00

up and they’ll go back down it’ll come

19:01

up it’ll go back down eventually it’ll

19:02

kind of work its way through

19:04

okay that’s what happens to most people

19:07

there are some

19:08

more technical things but that’s the

19:09

majority of what happens to people that

19:11

i see

19:13

okay so if you look at the anatomically

19:16

a lot a lot of you probably had

19:18

endoscopies if you’re here you probably

19:19

seen a gi doctor and they put a camera

19:21

in there

19:22

what you’re supposed to see uh is

19:25

actually

19:26

if this is normal anatomy your esophagus

19:28

that sort of junction I talked about is

19:30

supposed to be kind of tight

19:32

and they put the camera this is their

19:34

camera coming through the stomach and

19:35

it’s

19:36

look it’s bent like a candy cane it’s

19:37

looking back at itself okay

19:39

so if you can imagine

19:43

let’s find a color you can see if that’s

19:45

the camera coming through

19:47

it’s going down and it’s looking back at

19:50

itself

19:51

okay so we’re looking at this junction

19:53

it’s tight

19:54

right it’s squeezing that that camera

19:57

you don’t see a gap

19:58

you look at the other picture you see a

20:00

gap

20:01

okay it’s it’s loose it’s open okay

20:05

that’s why we reflex there’s a gap

20:07

that’s a little gap

20:09

that’s a baby gap okay but it’s a real

20:11

gap now

20:12

i’m going to show you what on my side

20:14

where I live okay this is the liver

20:17

here is there to oh it’s okay you’ll be

20:20

able to see even with the lights like

20:21

that

20:22

so this is the liver this is stomach

20:24

there’s a lot of air that p ped into

20:25

someone’s stomach so I can see what i’m

20:27

doing and work

20:28

let’s see here

20:33

i think I click it there we go okay so

20:36

everybody heard of a sliding hiatal

20:38

hernia or hurt behind a hernia

20:40

here’s your stomach here’s the hiatus

20:43

see me pull it down

20:45

do you see that little hole that just

20:46

this is all the stomach that just slid

20:48

out some of the stomach just slid out

20:49

and if I let go of it there it goes see

20:51

that nice hole

20:53

can anyone explain how that’s going to

20:54

keep you from reflexing it isn’t

20:57

okay I let go boing bungee cord that’s

21:00

your sliding hiatal hernia

21:02

okay so stomach is moving

21:05

it’s going up and down because the

21:06

hiatus the muscles are too far apart

21:09

structurally everything’s loosened up

21:10

okay so we got to fix that no matter how

21:13

many pills you take

21:14

that is broken pills never fix

21:17

that okay it can get huge you know

21:20

this is a big gap with the stomach going

21:23

up into the chest

21:24

okay this is same big gap after we

21:27

pulled the stomach out and that’s the

21:29

esophagus

21:32

to get you fixed we’ve got to get back

21:35

to normal anatomy

21:36

i gotta get everything back to where

21:37

it’s supposed to be stomach out of the

21:40

chest

21:41

diaphragm the height is closed increase

21:43

the pressure in this area

21:45

somehow to protect you structurally from

21:48

reflux okay

21:50

to do that involves not just guessing

21:54

it involves some testing and confirming

21:57

some things we do all of these things

21:59

here

22:00

okay i’m the director of the heartburn

22:02

center we do all of these things here we

22:04

do all the manometry the ph testing

22:06

radiology endoscopy been doing this for

22:10

i got a lady who works with me susan who

22:12

normally had been here tonight she had

22:13

some family issues but she’s been with

22:15

me since 1998

22:17

okay she and I together in that center

22:21

do more studies than

22:23

georgetown gw johns hopkins

22:27

and hospital center combined okay

22:31

so we’ve been pretty busy we we

22:34

understand this

22:35

inside and out and they’re not just my

22:38

patients they come to us from all over

22:40

the place they come from other states

22:41

they come from other

22:42

they come from other surgeons okay i’ve

22:44

got other surgeons who do these kind of

22:45

surgeries who send

22:46

me the patients to do the work up and

22:48

then we send them back

22:49

so we live in we do a ton of this

22:53

what are the surgical options well

22:55

there’s this nissan

22:56

almost this is like word salad you

22:58

probably heard some of these words

22:59

there’s a nissan fundablication that’s

23:00

just named after an old dead german

23:02

surgeon

23:02

from many years ago the procedure is

23:04

more than 70 years old

23:06

we used to do it through a big open

23:07

incision okay big incision

23:10

i used to talk about it’s like you know

23:12

open up a can of biscuits to make these

23:14

incisions it was big

23:15

to get this there’s a reason why the

23:16

pill got popular compared to that

23:19

right very painful laparoscopic

23:22

missing is what we do now we go in with

23:24

small incisions

23:25

very precise work an overnight stay in

23:28

the hospital do the same operation with

23:29

the robot

23:30

okay I was pretty much the first general

23:33

surgeon in the east coast trained to use

23:35

the robot back in 2009 now everybody

23:37

acts like it’s

23:38

it’s brand new no i’ve been doing it

23:41

since 2009.

23:42

it doesn’t it doesn’t make it’s not

23:44

magic it’s still surgery

23:46

i don’t hit a button go get some coffee

23:48

come back doesn’t work that way

23:50

okay so it’s still the same operation

23:54

same recovery you know it’s it’s all has

23:56

to do with the work up and

23:57

and experience there’s a transoral

24:00

incisionless funduplication or called a

24:02

tiff procedure my piano I used to do

24:04

that

24:05

we did hundreds of them we stopped doing

24:08

that back in 2014

24:10

so i’m not going to talk about that if

24:11

anyone wants to talk about it later i’m

24:13

happy to talk to you about it

24:15

links have you guys heard about this

24:16

links procedure online

24:18

a little bit so lynx is something that

24:20

we do

24:22

uh we’ve been involved with that since

24:24

it basically came

24:25

was released by the fda in 2012 that we

24:28

could start

24:29

doing this on people not prior research

24:31

protocols we’ve been doing it since

24:33

uh late 2013 early 2014.

24:37

i’m we’re an epi center for lynx which

24:39

means we’re a training center

24:41

uh surgeons come from all over the

24:42

country to learn how to do it from

24:44

us we’re we’re we’re basically the

24:47

east coast center for this we’re

24:49

we’ve always been basically in the top

24:51

10 in the country for vol e

24:52

cases and teaching so

24:56

translation is we know how to do this

24:58

stuff okay and we know which we can help

25:00

you figure out which one’s best if

25:02

you’re if you’re interested

25:03

just briefly because we’re not here

25:05

to teach you how to do surgery but I

25:07

want you to kind of understand a little

25:08

bit

25:08

when we’re doing a nissan we’re put

25:11

we’re bringing things back down

25:12

we’re making sure the stomach is below

25:14

the diaphragm we’re sewing that hole

25:16

closed

25:17

we’re taking the stomach and we’re

25:19

wrapping it

25:20

you can do that I can wrap it around the

25:23

esophagus

25:24

okay i’ve got this old beat up

25:28

bag of purple bag that I stole from

25:31

barney

25:32

okay so if this is the esophagus okay

25:34

and the stomach

25:37

if you’ve got your stomach up in your

25:39

chest okay first move is to pull it

25:42

down okay second move close the hole

25:46

third move tighten this up so we tighten

25:48

it up

25:50

by wrapping the stomach around the lower

25:53

part of the esophagus to create some

25:54

pressure

25:55

it’s called a nissan it creates a

25:57

one-way valve

25:58

okay so it’s harder to burp harder to

26:00

belch harder to throw up

26:02

but reflux is gone and this isn’t

26:05

something where we kind of see how it

26:06

goes

26:07

you wake up in the recovery room flat on

26:08

your back with no reflux

26:10

you go home off your meds so it’s not

26:13

one of those let’s do it and see what

26:14

happens

26:16

always works okay now

26:19

when we look at anatomically okay

26:23

this is just the drawing and just kind

26:25

of show you again esophagus esophagus

26:29

stomach stomach is kind of off the

26:31

screen and then this is the gap

26:33

the little v right here in the diaphragm

26:36

another picture esophagus see that

26:39

little v

26:40

kind of correlates maybe with my drawing

26:42

here a little bit

26:44

okay and so we end up sewing that hole

26:46

closed

26:47

all right when it’s closed

26:50

and tight and everything’s in the right

26:52

position

26:55

pretty good most reflux will be

26:57

controlled not perfect

26:59

but pretty good we have to add you know

27:01

a little more compression by wrapping

27:03

the stomach

27:04

around the esophagus and holding it in

27:06

place

27:07

okay you can get big holes okay

27:10

whole stomach’s in the chest you can

27:11

barely i’m sorry it’s a little bright in

27:13

here but you can see this this is the

27:14

stomach over here

27:15

okay there we go sorry

27:19

so that’s the stomach up here in the

27:20

chest I do cases where the whole

27:23

stomach’s in the chest

27:24

the spleen went up there and part of the

27:26

stomach those the colon

27:28

okay that’s a hiatal hernia

27:31

there’s babies and there’s big ones when

27:32

they’re bigger we call them para

27:34

esophageal defects

27:36

guess what that patient went home the

27:38

next day

27:40

okay they go home this next day there’s

27:42

it’s almost

27:43

you can’t tell the difference between

27:44

someone with a little defect and a big

27:46

one when we after we’re done operating

27:48

but it ends up with a big hole here’s

27:50

the esophagus here’s a big hole

27:52

and then we close the hole and then I

27:55

often now

27:56

will reinforce those repairs with

27:59

a we call it a biologic mesh what does

28:02

that mean it means it doesn’t stay

28:03

forever it’s not made out of plastic

28:05

it’s it basically helps the body create

28:07

some scar tissue so this doesn’t happen

28:09

again

28:10

okay yes sir

28:14

the big procedure open chest procedure

28:16

you’re talking

28:17

this is all laparoscopic so he’s asking

28:20

is this the big procedure

28:21

no I i if I if I had to do that every

28:24

day

28:25

no i’d find something else to do I mean

28:27

that is a morbid operation

28:30

and what we’re doing is we’re going in

28:32

with five small incisions

28:34

across the upper abdomen

28:38

the operation typically takes me about

28:39

an hour and 15 minutes

28:42

okay we keep you overnight we send

28:45

you home the next day

28:47

regardless of whether it’s a small

28:50

defect or a big defect

28:52

the bigger the big open incisions are

28:55

rarely done

28:55

they are still done some places you know

28:58

you go

28:58

you know you land at a hospital where

29:00

there’s an old uh thoracic surgeon who

29:02

never learned laparoscopic surgery or

29:04

didn’t believe in it

29:06

that’s what you’re gonna get

29:08

particularly for the bigger defects

29:09

sometimes they just kind of panic and

29:11

say oh it’s too big I can’t do it that

29:12

way

29:13

you know i’ve after about 3000 of them

29:15

i’ve gotten the hang of it

29:17

okay so we’re pretty good at it

29:20

and this is often what happens we end up

29:23

reinforcing these big defects with one

29:25

of these biologic meshes

29:26

uh and wrapping the stomach in fact my

29:29

pee and I just

29:31

finished an article that’s getting

29:32

published in one of the scientific

29:34

journals next month

29:35

on these types of meshes that we did our

29:37

series of patients so

29:39

so even though i’m in private practice I

29:41

stay in the teaching academic side too

29:44

robotics ooh robotics okay

29:48

it’s the same operation plus two million

29:49

dollars

29:51

okay I do it been doing it for many many

29:54

years

29:55

uh no difference in the results this is

29:57

just one of our cases where

29:59

the difference here is the camera is

30:02

held by the robot instead of a person

30:04

so it’s a lot more still you don’t you

30:06

don’t see anything shaking here

30:07

i don’t think shaking really is just the

30:08

heart beats causing the things to move a

30:10

little bit

30:11

but so precision can go up uh but the

30:14

operation doesn’t change the steps

30:16

are the same okay and people ask me you

30:20

know well

30:20

how do you decide if you do a robot or a

30:23

laparoscopic version I just tell them if

30:25

it’s wednesday

30:26

the third wednesday of the month it’s a

30:27

robot doesn’t matter to me that’s just

30:30

when i’m scheduled to do robots and i’ll

30:31

do robots on those days just to stay in

30:33

practice

30:34

but the outcomes don’t change they

30:36

shouldn’t change if the surgeon knows

30:37

what they’re doing

30:42

it’s not i’m just joking i’m joking the

30:43

robot costs two million dollars

30:45

so whether i’m doing it with the

30:47

laparoscope

30:48

or I walk down to the fancy room with

30:50

the robot that cost two million dollars

30:53

you get the same operation and so

30:56

in this kind of cost conscious days

30:59

you got to look at the value of what

31:01

whether you should do it or not

31:02

now some people now there are certainly

31:04

surgeons that i’ve trained around the

31:05

country for different procedures

31:08

who inspired their training they were

31:09

more comfortable doing it this way

31:11

than laparoscopically laparoscopic just

31:14

means

31:14

small incisions a camera little little

31:18

incisions and putting gas in your belly

31:20

okay

31:21

robotic is laparoscopic it’s just that

31:23

instead of holding the instr ents with

31:25

my hands

31:26

the robot’s holding them and i’m sitting

31:28

in the corner with the console

31:29

in a chair little I got a 3d

31:33

monitor in front of me so I see better

31:35

it’s a little more intense

31:36

you know and so but there are

31:39

certainly surgeons who

31:41

trained at programs where they learn how

31:44

to do it this way

31:45

and if the robot was broken that day

31:47

they probably couldn’t do your surgery

31:49

whereas i’m the other way like if

31:51

someone really needed the robot I could

31:52

care less they can have it

31:54

i’ll go back over here so same operation

31:58

nothing magic just same operation yes

32:00

sir this one uh do you have issues with

32:03

uh vomiting or belching dust stops or

32:07

after the nissan it’s we’re creating a

32:10

one-way valve

32:12

and so because of that it’s harder to

32:15

belch it’s harder to vomit

32:17

if someone gets the flu for instance

32:20

nothing comes up they just kind of dry

32:22

heave okay

32:23

we give people medication to help them

32:25

if they get nauseous and want to take it

32:28

it’s always sort of a concern but the

32:30

reality is

32:31

you know and I do hundreds of these a

32:33

year I may have

32:35

one person every two years that I have

32:37

to send to the er

32:38

years later after a nissan because

32:40

they’re having some vomiting issues so

32:42

it’s very rare

32:44

people who have a lot of reflux and

32:46

heartburn and

32:48

when everything’s coming up they kind of

32:49

think that’s normal they think they’re

32:51

supposed to be belching and burping and

32:52

throwing up and relieving themselves and

32:55

that’s not normal and so when we get you

32:57

back to not reflexing it doesn’t really

32:59

become that big of a deal

33:01

but there’s another procedure where it’s

33:03

possible we’re going to talk about that

33:05

one too that’s the links

33:06

okay so

33:11

very few people actually get antireflex

33:13

surgery millions and millions of people

33:15

have the problem about one percent ever

33:19

get offered anti-reflux surgery

33:22

okay and it’s just and it’s because

33:24

again the market’s flooded with all

33:26

these medications people writing

33:27

prescriptions people writing

33:28

prescriptions without doing any kind of

33:29

workups

33:31

and it’s unfortunate it also has to do

33:33

with experience and

33:34

and training is these aren’t

33:38

operations that everybody

33:39

everyone’s trained to do training is

33:41

very important

33:42

you know if a certain isn’t doing if

33:45

someone’s doing one you know three or

33:46

four times a year

33:48

no you know there are a lot of things

33:50

that i’ve done three or four times in my

33:51

surgical career that I think i’m not bad

33:53

at

33:54

but I wouldn’t want to be my surgeon for

33:56

that you know and so

33:59

it needs to be people who do it all the

34:01

time

34:02

if they seem really excited because they

34:04

haven’t done one in a while bad idea

34:06

they should be bored you know we have we

34:09

schedule three and four of these a day

34:11

when we’re here another interesting

34:14

fact

34:15

yes sir is there any

34:18

problems uh occur by overtaking uh

34:21

the the medicine uh approach can you

34:24

overdo it

34:25

well in terms of overdoing it

34:29

i’m not seeing you know no one comes to

34:30

the er with

34:32

you know uh nexi toxicity I mean

34:35

maybe I guess you could i’ve never

34:36

really seen that happen the problem is

34:40

these medications do have

34:43

c ulative effects okay in terms of

34:47

not absorbing calci not if you don’t

34:50

have acid in your stomach you’re more

34:51

prone to getting infections there are

34:52

some

34:54

studies that will show some uh

34:56

difficulties with

34:57

your your kidney function uh if you use

35:00

these too long there’s some have shown

35:01

some

35:02

heart rhythm problems if you take them

35:04

too long

35:05

so it can what it tends to do is it can

35:07

and has been shown in some studies to

35:09

exacerbate chronic problems that people

35:11

already have

35:12

and so if you don’t if you’re taking it

35:15

and it’s not working

35:18

doubling it doesn’t make it better I

35:20

think that’s probably

35:21

the best take home maybe doubling it for

35:24

a couple weeks

35:25

but not forever yes sir

35:36

if you’re healthy enough for general

35:37

anesthesia I mean my

35:39

that’s the one thing about I mean let’s

35:41

look in this room okay that I mean

35:43

i I mean I i’ve operated on people as

35:45

young as 13

35:47

all the way up into their 90s depends so

35:50

it’s not a

35:51

it’s not a you know a fat guy thing a

35:54

skinny lady thing

35:55

a pregnant mom thing a guy who lifts to

35:57

me weights

35:58

it’s a it’s an equal opportunity problem

36:02

yeah the previous slide

36:05

said had a line there said either

36:07

perceived side effects or side effects

36:09

of the surgery

36:12

or side effects of the procedure can you

36:15

go into those or or will you be going

36:17

into those later

36:19

well in terms of what we mean by this

36:22

is that this had to do with why you

36:24

don’t see as many opera people doing

36:26

surgery and it’s because

36:28

okay there was a perception and i’ve had

36:31

gi guys tell me this that they thought

36:33

for years they literally felt like

36:37

proton p p inhibitors you know the

36:38

nexi s the the

36:40

ameprasols this kind of stuff dexalent

36:44

uh protonics these kind of things they

36:47

thought they were so

36:47

safe I literally had them say we should

36:49

probably just put it in the water like

36:51

fluoride

36:52

okay in other words they themselves

36:54

thought they were that safe let’s just

36:56

give it out what’s the problem no one

36:58

gets hurt by this stuff

37:00

people have surgery bad things can

37:01

happen no one’s gonna get hurt by these

37:03

pills

37:04

that’s what that means and now I got

37:07

people flooding my gate because well dr

37:09

bob took me off on mine he’s had me on

37:10

next him for 20 years now he stopped it

37:12

and

37:12

i’m dying you know and so

37:16

you know there you go every time

37:17

something comes on you know

37:19

cnn my office fills back up with people

37:21

that you know

37:22

so this is another thing yes ma’am

37:26

37:34

i mean esophagitis yeah okay

37:37

so the question is you know what’s

37:39

esophage esophagitis basically right

37:41

and this is the other thing

37:44

people throw words at patients

37:46

particularly

37:48

you know dr bob the gastroenterologist

37:49

does your endoscopy

37:51

you wake up you barely know where you

37:52

are the anesthesia has not worn off

37:54

you’re still woo you know and they come

37:56

and they go blah blah blah blah blah

37:58

esophagis blah blah blah you’ll be fine

38:00

and all you hear is sofa goes something

38:04

do I have cancer what does that mean

38:05

right then you get on google

38:07

it scares the crap out of you right

38:10

uh so I mean esophagitis

38:14

jidas just means inflammation irritation

38:17

okay

38:18

so esophagitis means that something’s

38:21

irritating your esophagus it can be

38:23

a margarita you had last night when they

38:25

scoped you it looks awfully red

38:26

it can be taken too many aspirin it can

38:30

be you just drink some hot tea

38:32

or it could be that stuff coming up from

38:33

your stomach it looks sunburned when

38:35

they do the endoscopy it looks sunburned

38:37

and they do biopsies

38:39

there’s there’s acute which means I was

38:41

fine a week ago but i’m having a bad

38:42

week

38:43

you know I did a little too much

38:45

partying I drank too much at the at the

38:47

tailgate I ate too much whatever or

38:51

it’s chronic and and they can tell the

38:53

difference visually they can tell the

38:54

difference when they do biopsies

38:56

and the progression

38:59

it doesn’t mean you start here and you

39:01

end up there but the progression

39:03

is you start with some irritation and it

39:06

gets a little worse

39:06

it gets a little worse the cells look

39:08

different cells aren’t supposed to look

39:10

different cells start to look different

39:12

they act different they start becoming

39:13

other things

39:14

we become this this entity called

39:16

barrett’s which is

39:18

an entity that a lot of people have and

39:20

scares them to death and I understand

39:21

that

39:22

it doesn’t mean your got barrett’s i’m

39:24

going to get cancer it means you’ve been

39:25

exposed to this stuff a long time it’s

39:27

kind of like

39:28

you know you go out in the sun when

39:29

you’re a kid and then you’re turned 40

39:31

you’re like how come I got all these

39:32

wrinkles in these funny spots

39:34

okay it’s a c ulative thing are you

39:37

gonna get a skin cancer maybe

39:39

most people don’t you might most people

39:42

with barrett’s don’t get cancers either

39:44

but you might

39:45

and so you want to try to bend that

39:46

curve and do what you can to control it

39:54

is it yeah like it’s so bad

39:58

i can’t breathe like I literally am like

40:00

freaking out

40:02

because I cannot breathe and i’m trying

40:03

to like lift my arms up and i’m

40:05

pacing and i’m sweating because I can’t

40:06

breathe when does that happen

40:08

so her question is why is it why is my

40:10

symptoms so bad sometimes I can’t

40:11

breathe when does it happen night

40:13

okay when you lay down well no sometimes

40:15

i’m not even laying down i’m sitting

40:16

down watching tv

40:17

okay and then I start freaking up

40:19

freaking out and pacing and walking

40:20

around putting my arms up because I

40:21

can’t breathe and i’m worried like

40:22

should I go to the hospital

40:24

well first of all two things there’s a

40:27

difference between your swallowing tube

40:28

and your breathing tube

40:29

right a lot of people get panicky like I

40:31

can’t breathe it’s like you’re talking

40:32

you’re breathing

40:33

you feel bad now some people will

40:36

actually bring

40:36

fluid up high enough that it’ll get into

40:39

their lungs

40:40

and they’re usually coughing and gagging

40:42

and you know

40:43

that’s the wheezing this kind of thing

40:46

when you feel like you can’t breathe

40:48

something they ever tell you had a

40:49

hiatal hernia

40:50

an endoscopy okay

40:53

okay so a lot of people when they have a

40:55

hiatal hernia it slides up it’s moving

40:57

remember that little picture I showed

40:59

you

40:59

and it can be like this and then you

41:02

bend over or you do something and it

41:03

just slides up and you’re like oh my g

41:06

and it sets off panic attacks people go

41:07

the er I see a lot of people who’ve

41:09

you know they’ve already been the er

41:10

three times to work up their chest pain

41:12

that they thought was a heart attack

41:14

and so there is testing that I do to

41:17

help figure

41:17

that out to make sure that to figure out

41:20

what that is

41:21

okay but otherwise other than just it

41:24

sounds like it’s

41:24

from a familiar story and there aren’t

41:27

too many other things that do that

41:28

sometimes it’s esophageal spasm

41:30

it’ll do that you get a little burst of

41:31

reflux and your esophagus just

41:34

doesn’t like it you think you’re going

41:36

to die you know and panic attacks and

41:38

so that happens it’s real it’s real

41:42

it’s just part of the workout so

41:46

and along this zone we’re talking about

41:49

this is awful okay you guys are probably

41:51

looking at this thinking oh god

41:53

this one was cancer talks this is not

41:54

meant to be a cancer talk but I want to

41:56

explain something

42:00

about the only cancer that rate has gone

42:02

up

42:03

in the last 20 to 30 years is

42:05

adenocarcinoma

42:07

of the esophagus and it has gone up

42:09

about

42:10

700 percent 700 percent

42:14

guess what else has happened during that

42:16

time frame we started taking a lot of

42:18

proton p p inhibitors and h2 blockers

42:20

and started masking

42:21

our symptoms okay and now

42:24

we can go to costco and get a bucket of

42:26

it okay

42:27

so what’s happening and what we think is

42:31

happening

42:33

remember what I said do we just reflex

42:35

acid no

42:36

we reflex anything that’s in our stomach

42:38

and so there is a thought process that

42:40

the bile that’s in your stomach that

42:42

comes from the liver that’s kind of

42:43

backwashed into your stomach

42:45

backwashing into your esophagus affects

42:48

the lining of the lower esophagus

42:50

which is where the adenocarcinomas come

42:52

from

42:54

okay so even though we may feel a little

42:56

better or masking symptoms with these

42:58

drugs

42:59

we may be paying the price for it okay

43:03

so

43:06

it’s a failure you know and it’s not

43:08

it’s not artifact it’s not that oh we’re

43:10

just doing more biopsies

43:12

or we’re just screening more people all

43:14

that stuff’s been accounted for

43:15

so it’s just happening more okay so

43:18

we’re kind of losing the battle

43:20

people are now worried about ppis

43:22

problems are getting up we aren’t using

43:24

people a little afraid in this sense

43:25

because they don’t they won’t be able to

43:26

throw up

43:27

okay they want they want to get the flu

43:29

and throw up okay that’s fine

43:32

all right so we got to do something a

43:33

little bit different

43:35

so there is something that’s

43:38

different okay

43:40

trying to get control you know

43:41

laparoscopic nissan and taking the

43:43

stomach and folding it and doing all

43:45

this stuff

43:46

a lot of variability in how people do it

43:47

how well they do it and how well they

43:49

suture

43:50

okay how well they tie their knots and

43:54

you know is the robot smart today or

43:55

d b today okay all these variables that

43:58

go into creating a nissan and I can tell

44:01

you as a guy who’s trained people all

44:02

across the country and preceptor people

44:05

i’m impressed and not usually in a good

44:07

way about all the different ways people

44:09

do this operation that I thought was

44:10

standard

44:12

and i’m like wow well that’s one way to

44:13

do it I wouldn’t do it that way

44:15

but okay so the combination of

44:19

of trying to get acid out of the acid

44:23

and the refluxed fluid out of the

44:25

stomach

44:26

and restoring anatomy is what our goal

44:30

needs to be so enter the links

44:33

okay right here here’s this stomach

44:35

esophagus

44:37

lynx

44:41

titani it looks like those little

44:42

bracelets kids used to eat with the

44:44

little candy bracelets right

44:45

okay and what it is is it’s titani

44:49

little titani bracelet little magnets

44:51

inside all these beads move back and

44:53

forth

44:54

people oh that’s like a lap i’ve heard

44:55

that’s like a lap band it is not like a

44:57

lap bail that band’s supposed to make

44:58

you lose weight because it squeezes your

44:59

stomach so hard nothing goes down

45:01

okay this just basically fits very

45:04

loosely around the esophagus and it

45:06

resists

45:07

opening it resists over stretching okay

45:11

you know if you’ve got a ring on you

45:13

don’t feel it it’s the right size

45:15

if you feel it it’s too tight the idea

45:17

is to put this on in a way that you

45:19

don’t feel it it just

45:20

protects you from reflux because it

45:22

doesn’t allow things to over stretch

45:23

we still have to fix the hiatal hernia

45:25

if there is one

45:27

but instead of wrapping the stomach we

45:29

can put the lynx device on

45:31

so it opens and closes it is not one can

45:33

people like I don’t want that in there

45:34

all those beads are going to fall off

45:36

and they’re going to go everywhere

45:38

no they don’t okay there’s a there’s a

45:41

wire between

45:42

each bead I can cut it in the middle of

45:44

the operation the beads don’t go

45:45

anywhere

45:47

okay so it doesn’t do that this is a

45:50

little video i’ve spent

45:52

all day making so I want you guys to

45:53

watch it real closely uh just to show

45:55

you kind of graphically what happens all

45:57

right

45:58

and hopefully the sound won’t come out

45:59

try to turn the sound off so

46:01

esophagus stomach bad stuff green is

46:04

always the bad stuff right

46:05

so acid floating here the idea is that

46:08

the lynx

46:09

is augmenting or making the valve

46:13

work better that valve I told you that

46:14

doesn’t really exist and so as food goes

46:17

through

46:18

there’s just enough pressure to make the

46:20

beads open up

46:22

but then it comes back to closed but

46:24

here’s the thing

46:25

there’s also if you need to burp or

46:27

belch it generates enough pressure to

46:30

pop the beads open so that you can do

46:31

that

46:33

as opposed to you can’t do that and that

46:36

may be

46:37

helpful because one of the issues over

46:40

time with the nissan has been durability

46:42

like remember I said it always works it

46:44

does always work how long does it last

46:46

it almost

46:47

lasts always okay

46:51

but everybody’s not the same some people

46:55

have great tissues some people have

46:57

terrible

46:58

tissues some people are 100 pounds

47:01

overweight some people have diabetes

47:02

some people cough and they smoke or they

47:04

have a job where they lift heavy things

47:08

so we can’t control what happens to

47:09

people over time and we’re basically

47:11

fixing

47:12

you when we’re doing this in with the

47:14

same parts that broke

47:16

right i’m rebuilding you with your

47:17

broken parts

47:20

if you have a bad knee and you go get a

47:22

joint replacement

47:24

grandma gets a new knee they throw the

47:26

old one away

47:28

they cut it out throw the bone away put

47:29

in a titani job right a new knee

47:32

so they don’t rebuild her old knee they

47:34

get rid of it I can’t get rid of your

47:36

esophagus in your stomach

47:38

okay a lot of paperwork involved if I

47:40

did that we don’t do that

47:41

all right so the idea here is

47:46

do the repair do it in a way that’s

47:48

that’s that

47:49

keeps the problem coming back is as much

47:52

as you can

47:53

if if let’s say I did your nissan now

47:56

now keep in mind I love doing this

47:58

i’ve done thousands of them I scheduled

48:00

several today i’m doing

48:01

three tomorrow okay great operation not

48:04

everybody wants it they they’re

48:05

they want to throw up when they get the

48:06

flu okay so

48:09

but let’s say I do urnison and you go

48:11

home and you didn’t follow my directions

48:13

now I know all of you would follow all

48:15

my directions but occasionally

48:16

people don’t listen and they didn’t hear

48:19

it they didn’t look at the paperwork the

48:20

nurse didn’t give it to me whatever so

48:22

they go home

48:23

the day after this and they said oh i’m

48:25

gonna go eat a sub sandwich because it’s

48:26

on sale because it really looks good

48:27

even though they’re supposed to be on

48:28

liquids

48:29

okay and they jam their sub sandwich in

48:32

there and they throw up

48:35

and they cough and they retch and they

48:36

throw up pop pop pop

48:39

stitches break okay you’re not going to

48:42

break my titani

48:45

links you might break some other things

48:48

but you’re not gonna break

48:49

the links okay and so

48:53

it’s that’s what I like about it it

48:57

gives us a little more flexibility

48:58

okay okay you can’t hardly see

49:02

there’s any turn lights down just

49:03

just a scotch is okay

49:06

i can i’ll restart it and let you guys

49:07

see it again but

49:10

i’ll try to huh

49:14

yes yeah yeah and so people talk and I

49:17

don’t want to

49:19

this stuff works I don’t want to bore

49:21

you with you know slide after slide of

49:22

you know how many people did this and

49:24

that and

49:24

it works you know as I tell people you

49:27

know they ask me

49:29

which one would you want which one would

49:30

you which one would you doug dr gillian

49:32

if I had to do the operation on you

49:34

and I tell them it doesn’t matter what I

49:36

want you know

49:38

what i’ve done is I only provide

49:40

procedures that work

49:42

i don’t care which one you do or which

49:44

one we do for you okay

49:47

what I find is that people tend to

49:49

gravitate towards one

49:51

once we start the conversation they

49:53

either look at the links and say

49:56

that is the coolest thing since the

49:57

iphone I think it’s great

50:00

you know and and they love the idea

50:02

of technology

50:04

and they they come in and they’ve done

50:05

all the research and they tell me i’m an

50:07

engineer and that this makes sense

50:09

okay and then other people walk in and

50:11

say well I just don’t like that

50:12

something foreign in my body

50:14

and then I have other people who say

50:16

well i’ve already got you know two hips

50:18

and a knee and

50:18

and and you know i’m fine you know just

50:21

what what’s another piece of

50:23

metal you know so I don’t know uh the

50:26

job my job is to do it right and do it

50:28

safe

50:29

and in terms of what we decide upon

50:31

between two of us it doesn’t really

50:32

matter

50:34

recovery is a little different for well

50:36

recovery

50:38

is really more related to how much work

50:39

i do on the inside most of the recovery

50:41

for everybody in terms of

50:43

most recovery is related to diet and

50:45

getting back to a normal diet

50:47

when we do the lynx procedure and you’re

50:49

gonna see i’m gonna let you guys play

50:50

with this

50:51

again it’s a magnet have you noticed

50:53

something about my instr ents what are

50:54

they made out of

50:56

metal okay it’s like getting something

50:58

on your finger you can’t get off you’re

50:59

trying to i’m trying to manipulate this

51:01

thing that’s why I have the strings to

51:02

help me

51:03

put the clasp together it’s like a

51:04

little jewelry clasp that we’re trying

51:05

to

51:06

put together and so

51:10

in terms of recovery

51:14

small incisions overnight stay home the

51:17

next day

51:18

off your meds with links most people are

51:21

tolerating a regular

51:22

diet the first day with nissin

51:25

because of all that wrapping and moving

51:27

and the stomach and stuff

51:29

more swelling so I gotta wait till the

51:31

swelling goes down before I can let you

51:33

eat and have your sub sandwich okay so

51:36

certainly when you go online and see

51:39

stuff about links

51:40

i think some things are a little bit

51:41

exaggerated again you know

51:44

my pa and I we’ve done we’re in the top

51:46

10 in the country and have been for

51:48

many years from a practical standpoint

51:52

we know not everybody is the same the

51:54

length is not a magic

51:55

device it’s still surgery some people

51:59

nothing some people have a little more

52:01

trouble swallowing than others

52:02

some people have a little more swelling

52:04

and we have to put them on some steroids

52:05

for a couple days to get the swelling

52:07

down

52:07

okay not everybody has the surgery rolls

52:10

out the door

52:11

and heads down and has hot wings and sub

52:13

sandwiches and drinks of beer and

52:15

they’re happy

52:15

some do you know certainly no one in the

52:19

nissan group does that

52:21

but when they all come back to the

52:22

office

52:24

they kind of look the same you know the

52:26

the nissan people had to be on liquids

52:28

for a little bit longer

52:30

but at the end of the month I can’t tell

52:33

the difference

52:34

i can’t tell the difference where they

52:35

had a robot a laparoscopic and lynx or

52:37

innocent

52:38

okay relief is the same yeah

52:43

the revision rates need to intervene or

52:45

to take things out

52:46

etcetera with the length is actually it

52:48

used to be about four percent now it’s

52:50

down to about one percent

52:51

that’s because people have gotten more

52:53

comfortable with the technique

52:55

uh that mirrors our experience as well

52:59

if for some reason we need to take it

53:00

out we can always take it out replace it

53:02

take it out revise it to a nissan revise

53:04

it to something else if we needed to

53:06

the need to

53:10

re-intervene or manage or do something

53:12

after a nissan is

53:14

all over the place on a national basis

53:17

for us it’s probably around five percent

53:18

whether someone needs you know

53:20

they may break some stitches they may

53:24

you know just everything may just loosen

53:26

up and look beautiful when we’re done

53:28

pictures look great things start to

53:29

stretch open again for whatever reason

53:31

like I said it’s it’s a

53:33

i mean they got the problem in the

53:36

hiatal hernia because there’s probably

53:37

either something genetic going on

53:40

or there’s something in just sort of how

53:42

they’re made or their habits

53:44

right that don’t really change after i’m

53:46

done

53:47

so those things continue and so

53:52

and I can’t control all of that so what

53:54

happens is the wear and tear

53:55

just kind of we reset the clock for most

53:57

people

53:58

they never need anything done for a

53:59

small n ber we may have to re-intervene

54:03

no you know and i’m I i’ve got guys

54:05

going in now the white house that don’t

54:07

set it off either

54:09

the I should say that but yeah so the

54:12

it should I don’t know why it doesn’t

54:14

i’m kind of alarmed that it doesn’t but

54:16

you get a little card

54:17

uh that will will in case someone asks

54:20

you

54:21

you say yeah this is what’s going on

54:23

this is just a little x-ray just to kind

54:25

of show you

54:26

what happens if you put we put a little

54:27

balloon in to stretch it this is

54:28

actually a dog not a person but

54:30

uh dogs have reflux so uh so that’s what

54:34

that was from and then

54:35

uh this is just whoops let me go back

54:39

i think this one might run if it doesn’t

54:42

i apologize but

54:44

yeah yeah yeah you say that you do

54:47

the two separately or you do the links

54:51

and in addition you do the nissan no

54:55

what you do the first step for both

54:59

is get the stomach back below the

55:02

diaphragm and close the hole if there is

55:04

one the high it’ll hernia hole

55:05

first step everybody gets that

55:08

how much work is involved how big the

55:11

hole is how much stomachs in the chest

55:13

different for everybody we know that

55:15

going into the procedure

55:17

second part is make it better

55:21

either by doing the nissan the wrap

55:24

or doing the links which we’ve and it’s

55:27

not

55:28

dr gillian is going to decide based on

55:29

his mood no we we’ve already decided

55:31

that going in

55:33

to that procedure which one we’re going

55:34

to do okay

55:37

i can adjust the nissan

55:40

based on testing we do in our lab

55:43

which is right across the hall

55:46

if your motility your esophagus is a

55:50

muscle it’s just a tube

55:51

a tube of muscle if it’s not very strong

55:53

it doesn’t squeeze very hard

55:55

and I do the world’s best tightest

55:58

nissan wrap at the bottom your reflux is

56:01

gone

56:02

but you can’t swallow food’s getting

56:03

stuck and i’m getting phone calls

56:06

we’re both unhappy so we have to mirror

56:09

and match

56:11

the intensity of the repair to your

56:13

ability to push stuff through

56:15

okay and that’s testing that we do in

56:17

our lab a lot of the referrals that I

56:19

see

56:20

or have seen over the years related to

56:22

boo-boos

56:23

done elsewhere are because the surgeon

56:25

just said ah we don’t need that test

56:27

and they just did the uh their standard

56:30

repair

56:31

and the consequence was

56:34

people can’t swallow they’re choking on

56:36

food

56:37

and then we have to go in and revise it

56:41

so who is the link space yes sir

56:45

that people maybe aren’t severe enough

56:48

to necessitate the the surgery are

56:50

there what natural or dietary things

56:53

will you get to that

56:54

well here’s okay that’s a great question

56:56

so someone’s not severe enough for

56:58

surgery then what right now

57:01

most of those don’t end up in my office

57:03

so I have sort of a different

57:05

i I don’t have the i’m so happy

57:07

everything’s great

57:08

reflex patience I got the oh god doc

57:11

that’s been going on for 20 years

57:12

or I just got this diagnosis and i’ve

57:15

been reading all this stuff and I

57:16

am not taking these medicines even

57:18

though I felt better when I did

57:19

so that’s kind of who I see most of the

57:22

time what I do see

57:24

okay is

57:27

people who have been misdiagnosed

57:30

they came in through their doc you know

57:32

oh I eat food I throw up and I reflect

57:34

oh

57:35

take these pills

57:38

they don’t have reflux they’ve got

57:40

horrible motility their esophagus isn’t

57:42

even working

57:43

i’ll i’ll do a test and there’s no

57:45

peristalsis it’s not pushing anything

57:47

down

57:47

so they’re not reflexing from their

57:48

stomach foods going down and not kind of

57:51

making it all the way to the

57:53

the end zone and it’s coming back up

57:55

it’s called achalasia

57:57

or there’s a motility disorder so we

58:00

don’t operate on everybody walks in the

58:02

door sometimes we

58:03

with the testing I can I divert them

58:05

into the therapy they really need it

58:08

or I can tell them and say if i’m

58:11

testing you for 24 hours

58:12

maybe you’re taking your nexi in the

58:14

morning

58:15

okay and I do your testing and that’s

58:18

like well

58:19

we test you off your medicine and maybe

58:21

i test you and I find out you know what

58:22

your acid exposures

58:24

you barely have any during the day but

58:26

boy at night it’s terrible

58:28

well you move your next him to before

58:30

you go to bed

58:31

okay so we want to match the

58:35

therapy to and the intensity of the

58:38

therapy

58:39

to what’s really going on what happens

58:42

is people will get managed by others

58:46

my colleagues you know primary care and

58:48

ent and pulmonary

58:50

and stuff and they’ll say well you go

58:53

and you say

58:54

i think this sounds like reflux and you

58:55

come back three weeks later say doc this

58:59

this expensive prescription really

59:00

didn’t help much oh

59:02

let’s double it let’s take twice as much

59:06

of the stuff that didn’t work

59:08

okay and then and by time you get back

59:11

into them and get off from work and

59:12

you know it’s a year and a half later

59:14

and you’ve been double dosing something

59:15

you may not have even needed

59:17

okay because no one even tested I mean

59:21

certainly it’s it’s expeditious to say

59:24

it sounds like reflux let’s try this see

59:27

what happens come back

59:29

no fault there but you can’t base

59:32

5-10 years of therapy on a hunch

59:36

at some point you need to do an

59:37

endoscopy and take a look or do an x-ray

59:39

and take a look

59:40

okay yes ma’am i’m just curious if

59:45

because it’s not acid one of the things

59:49

my doctor is concerned about

59:51

is taking ppis

59:54

means that I have a lower absorption of

59:56

my medicine

59:58

so does often when people

60:02

get the surgery do you find that they

60:03

have to adjust their other medications

60:06

because it’s now being absorbed

60:07

correctly

60:09

that’s okay that’s an interesting

60:11

question yeah so

60:13

the idea here is

60:16

taking anti-acids affects your ability

60:19

to absorb I mean

60:20

when a drug is made it’s done with the

60:23

absorption that you’re a normal h an

60:25

with acid in your stomach right and now

60:27

you’re not a normal

60:28

h an you’re a h an with no acid in

60:30

your stomach and now you’re taking these

60:31

other medications and they don’t work

60:32

quite right they don’t get absorbed

60:34

quite right

60:35

uh the way they were intended by the fan

60:38

the smart pharmacologists right

60:40

so what she’s saying is well if you fix

60:41

it do all your other

60:43

medications go haywire because now

60:44

you’re absorbing stuff that you couldn’t

60:46

absorb

60:46

before that is a great question I have

60:49

never

60:51

dealt with that and i’ve been because

60:53

what happens is

60:55

i talk to people about you know it’s

60:57

catch and release in my office you know

60:59

you come in with this problem I fix it I

61:00

don’t take over all of the other ones

61:03

i do find that people need a

61:07

want you know suddenly they don’t need

61:08

their ibs drugs anymore

61:10

okay suddenly they don’t need all their

61:12

stuff for their abdominal cramping

61:14

anymore suddenly they don’t need all

61:16

their uh

61:17

their supplements where they’ve been

61:19

taking piles of stuff for this and that

61:21

and constipation and diarrhea

61:23

and and probiotics and all this stuff

61:26

all this voodoo i’m a surgeon i’m

61:29

blunt okay so that’s and so they get rid

61:32

of it

61:33

people come into my office with bags of

61:34

stuff

61:36

they’re spending so much money every

61:39

every month

61:40

is just you might as well flush it down

61:42

the toilet it’s not doing that much

61:44

i mean not all your drugs not all things

61:46

have been prescribed but a lot of this

61:47

stuff

61:47

they’re desperate and I understand that

61:49

they’re trying to find something that

61:50

worked

61:51

and they’re desperate and they’re trying

61:52

stuff

61:54

it’s a great point i’ll start thinking

61:56

more about that but I i don’t you know

61:58

what happens is we

61:59

turn them back over once we know you’re

62:01

swallowing you’re eating the heartburn’s

62:02

gone

62:03

wounds are healed we tell you what to

62:06

look for in the future and

62:08

so I don’t I don’t follow all your drug

62:11

levels and things like that over time

62:13

but it’s a great point you know they may

62:15

be they need to

62:16

you know to drop them a little bit could

62:18

blood

62:19

yeah yeah because i’m just wondering if

62:22

within a certain amount of time you need

62:24

to go back to your rate your other

62:25

doctors and

62:26

have your medicine checked oh yeah I

62:28

mean that’s normal

62:29

and the thing is I mean we communicate

62:31

with and we say hey you know

62:33

miss smith did great da da da she

62:35

stopped her meds

62:36

this is what we’re looking forward to if

62:38

you need anything let me know

62:40

but I don’t have them managing your

62:42

reflux after I don’t have them managing

62:43

you as a surgical patient

62:45

they need to go back to managing you the

62:46

way they normally would

62:49

yes yes sir yeah you haven’t mentioned

62:52

stretcher is there a reason

62:53

or because that company’s gone out of

62:55

business three times

62:57

for a reason so it’s gone out of

62:59

business three times for a reason

63:00

it’s like the phoenix of stuff that

63:02

doesn’t work it gets like

63:04

strata he’s asking about strata which is

63:06

a procedure where you basically put a

63:08

catheter

63:10

into this area right here and you burn

63:13

the lining of the esophagus to create a

63:15

little bit of scarring to

63:17

remodel and stop reflux it’s never been

63:19

shown to really work in any efficacious

63:22

way

63:23

there are a few very tiny

63:27

studies you know among a few people that

63:30

i know

63:32

and no is it out there yes does it work

63:36

no does insurance pay for it no

63:40

uh does it have any long-term durable

63:42

effects

63:43

never really been demonstrated nothing

63:45

more than placebo

63:49

you know and I to the point that i’ve

63:50

even when it first started coming out I

63:54

was very i’ve i’ve operated on people

63:57

who have had strata because their strata

63:59

failed to get them under control and it

64:02

makes operation a lot more difficult

64:04

because there’s a lot of scarring

64:06

that happens in that zone but you’re

64:07

basically cooking the inner lining of

64:09

the esophagus

64:10

hoping to come up and if you ask the

64:12

reps they can’t even tell you what it’s

64:13

doing

64:14

they tell you how to do it they can’t

64:16

tell you how it’s supposed to work

64:20

so yeah strata is not again if it worked

64:23

we’d do it it’s just a matter of me

64:25

picking up a phone and

64:27

trust me they’ve been knocking my door

64:28

down for 20 something years I don’t do

64:30

it because it doesn’t work

64:32

yes

64:36

with mri you can get mri it’s a great

64:39

question the question is can you get an

64:40

mri with the links right is that what

64:42

you’re asking yes

64:44

but what happened and i’ll show you I

64:46

have a little device i’ll hand it around

64:48

actually i’ll do it now so you guys can

64:49

play with it

64:50

the

64:53

the this is the second iteration or

64:55

second version of this

64:57

device and

65:00

i guess i’ll start here so okay i’ll go

65:02

up here and then back down

65:05

the first generation mris have a

65:08

horsepower that’s measured in something

65:10

called tesla

65:11

okay 0.7 was the original

65:15

tesla then it became 1.5 this was

65:18

designed for 1.5

65:20

so anything 1.5 or less is fine

65:23

guess what now we got 3.0 uh

65:26

there most of them are not 3.0 some of

65:29

them are

65:30

you’re not supposed to get in 3.0 have

65:33

people done that

65:34

yes there’s always someone in europe

65:36

that does that and

65:38

and we’ve looked at it and nothing bad

65:39

happened uh but the magnet itself is not

65:42

supposed to be in that field it’s not

65:44

approved for that

65:45

it’s not gonna come flying out of your

65:46

chest like an

65:48

aliens movie okay but you’ve got a small

65:51

magnet inside of a really strong

65:52

magnetic field it may warp it it may

65:54

affect how it functions

65:56

uh and a couple have been taken out

65:58

around the world because of their

66:00

exposure to the magnet

66:02

and warping what kind of magnet is what

66:06

this they’re rare earth uh

66:09

stuff uh no actually it’s n idi I

66:12

think something like that

66:13

yeah so and then the shell is titani

66:16

so it’s basically everything that looks

66:18

metal on there is titani

66:20

the wire is titani uh magnets inside

66:25

yes how about

66:28

i got two questions the first one is

66:30

kind of half serious

66:32

the uh metal going through air

66:35

airport airport security yeah it’s not a

66:38

it doesn’t it doesn’t set anything off

66:40

it really doesn’t I wish I don’t know

66:41

why I had I had a really really really

66:43

skinny young lady

66:45

22 that we did many years ago she set

66:49

off the alarm

66:50

in target but not in the airport

66:54

so target has better security than the

66:55

airport

66:57

and then everything that you’re talking

66:59

about is minimally invasive

67:01

correct yeah small incisions for the

67:03

lynx it’s all five millimeter incisions

67:06

uh for the nissan uh the three of them

67:08

are five

67:09

two of them are ten just right right

67:12

under your ribs

67:13

just to arch right across there

67:17

excuse me yeah this man yeah how

67:20

often do you

67:21

monitor the links I mean monitor it

67:25

yeah there’s we see you in the office

67:27

like any other post-op patient about a

67:29

week after surgery

67:30

we see you again about three weeks later

67:33

most people by that point

67:34

are even wondering why they’re there

67:36

some of them we just even do the

67:38

follow-up by phone because there’s

67:39

nothing to look at out here

67:41

it’s all you know they’re little tiny

67:42

incisions they’re healed they’re gone

67:44

uh so most of the visits are really just

67:46

talking and a lot of times we do that by

67:48

phone and then we you know we we

67:49

communicate with them over time if they

67:51

need anything we tell them what to look

67:52

for

67:52

but there’s no more there’s no testing

67:55

in other words I don’t bring you back

67:56

every six months

67:57

every year take an x-ray put a tube in

67:59

your nose do an endoscopy

68:02

we fix it you’re an adult we tell you

68:05

what to look out for

68:06

we tell you to give us a call if you

68:07

need us and then we let you go

68:13

because does the little donahue’s got

68:15

the mic I gotta do what he

68:17

does the links also take five incisions

68:19

yes okay

68:20

and what is what percentage of people

68:24

have

68:24

a uh bad reaction I mean or some

68:28

side effect that that something needs to

68:30

be done and what percent have to have it

68:32

ultimately taken out do you know

68:34

well yeah I do I mean that’s what I said

68:35

in terms of taking it out

68:37

historically when this first started

68:39

this is this has been a

68:40

it’s a newer procedure so it’s

68:42

combination of

68:43

surgeons learning how to do it and then

68:46

surgeons learning not to freak out when

68:47

something’s a little bit weird right

68:49

after surgery because what happens is

68:51

it’s never the surge’s fault just so you

68:53

guys know

68:55

it’s the device it’s somebody else never

68:57

our fault so what happens is

68:59

when you’re first training somebody and

69:01

their their second or third patient

69:03

calls them in the middle of night oh my

69:04

god doctor I got my

69:06

subway sandwich stuck I can’t take it

69:08

anymore

69:09

they’re nervous the patient’s nervous

69:12

their their confidence is a little bit

69:14

low they’re like you know what let’s

69:15

just take that thing out

69:17

you know let’s just take it out let’s do

69:18

what I know how to do so what happens is

69:19

when people are early in their

69:21

experience they take out more

69:24

when they’ve done 20 50 they start

69:26

taking out less because they realize

69:28

that they can handle all these problems

69:29

they know how to handle it

69:31

in terms of horrible serious bad things

69:33

no we’ve never seen anything like that

69:35

with the lynx procedure

69:36

when you just raised another question

69:38

here when you said they know how to

69:39

handle it what

69:40

would they do I mean well they know that

69:42

the

69:43

part of the healing process in some

69:45

people is a little bit of spasm they

69:46

know

69:47

we’ve learned that the best way to treat

69:48

that is explaining it

69:51

not letting people get scared for both

69:54

the surgeon and the

69:55

the you know that’s why I train

69:57

people that’s why I proctor and go

69:59

around the country and

70:00

give these talks and we’ve learned

70:02

that we can give people some steroids to

70:03

get the swelling down and they feel

70:05

much better we very rarely have to we

70:07

used to dilate them a lot stretch the

70:09

area we’ve learned there’s really no

70:10

reason to do that most of the time

70:12

and we’ve and we’ve changed how we size

70:14

them as well in terms of we’ve adjusted

70:16

how we measure

70:17

on the inside and last two

70:21

we did not say anything about the cost

70:24

and whether or not they will be covered

70:27

by medicare

70:28

okay so the cost uh nissan

70:31

covered nissan with mesh covered pair

70:34

esophageal covered

70:35

all the work up covered by medicare uh

70:38

lynx not covered by medicare

70:42

which is interesting is when it was

70:43

considered experimental

70:45

medicare was only one people that was

70:47

covering it now that it’s no longer

70:49

experimental medicare is reevaluating

70:51

and they haven’t decided to cover it yet

70:53

probably because they’re afraid that

70:54

everybody’s going to want it

70:55

like most things with medicare now we do

70:58

have

70:59

a scenario where people can get it even

71:02

if they have medicare

71:04

okay everybody turn off your phones no

71:06

recording okay

71:09

if you have a hiatal hernia

71:12

and most people i’m operating on are

71:14

going to do

71:17

what happens is we schedule you for a

71:19

hiatal hernia repair

71:21

and we do that we’re going to do that

71:23

anyway that’s part of the repair right

71:24

so that’s what I said

71:26

but the hospital makes enough money off

71:29

of the hiatal hernia repair

71:31

that this hospital has agreed

71:34

to give the lynx device

71:37

to my patients in that setting because

71:40

they still get paid enough

71:42

that at the end they still made a profit

71:44

okay

71:45

because you know there’s a business side

71:46

to this for the hospital

71:49

and so people who have a hiatal hernia

71:53

who have medicare who want to links can

71:55

get it

71:56

i don’t like playing those games but I

71:59

also don’t like my patients not getting

72:00

what they deserve

72:01

so that’s how we built we just build

72:04

it as a highlander repair which is what

72:05

we’re doing i’m not not doing that and

72:07

then the hospital’s just agreeing not to

72:09

bill

72:10

for the links it’s their decision

72:15

okay did everybody get to play with the

72:17

links did you guys see it

72:19

what do you think

72:23

a little bling for your esophagus you

72:25

know a little titani uh and those

72:27

things are not cheap they are about five

72:28

that little device is five grand so I

72:30

want it back

72:32

whoever’s got it they’re not party

72:33

favors there you go

72:36

they leave from my office that’s why I

72:38

have to you know

72:40

so that means it costs five grams that’s

72:43

what they built for it but you know it’s

72:44

millions of dollars of research so they

72:45

have to

72:46

do that does private insurance work the

72:49

same way as medicare no

72:50

private insurance what happens

72:53

is again like a lot of insurance things

72:57

a lot

72:57

just like bariatrics years ago bariatric

73:00

surgery works

73:02

suddenly laparoscopic surgery more

73:03

people wanted bariatric surgery

73:04

insurance companies said

73:05

no so people paying out of pocket paying

73:08

lots of money to get that operation

73:10

eventually all insurance companies

73:13

started agreeing to cover it

73:15

okay in selected markets uh

73:18

some insurance companies cover the links

73:20

right away

73:22

in this market almost all of them say no

73:25

initially and then we put it through

73:28

there’s an outside reviewer

73:30

called priya that you don’t pay for that

73:33

collects the data it goes to an outside

73:35

review a legal issue basically

73:38

and I get about 75 80 percent of them

73:40

approved through priya so that they get

73:42

paid for

73:42

we don’t we don’t take anyone to the

73:44

operating room hoping that it will get

73:46

paid for

73:48

we’re not going to do that to anybody

73:50

because we have the other option within

73:51

this and if we if we want to so we

73:53

usually do if someone wants to do it

73:55

again that whole idea of hiatal hernia

74:00

for that not the links that’s also

74:02

available for people

74:03

so most people private insurance don’t

74:05

have any trouble getting it

74:08

care first covers it really pretty

74:10

quickly a lot of people have federal and

74:12

they have care

74:13

first through here so yep

74:17

yeah so uh but but like tricare and

74:20

medicare basically track each other they

74:21

do the same kind of thing so we had to

74:23

play that little game

74:24

uh but we you know i’ve been at this

74:27

long we don’t have any trouble getting

74:28

people covered

74:29

the key is the work up and the data

74:32

there’s nothing shady it’s just

74:34

it’s how they’re forcing us to play this

74:35

game

74:38

and our goal is you know we won’t get

74:39

you better I don’t want to have a bill

74:41

you shouldn’t have

74:43

okay was that yes ma’am so

74:46

you said that there are a bunch of tests

74:48

that have to be done

74:54

there are a bunch of tests that need to

74:55

be done to determine the necessity and

74:58

type and severity and all of that stuff

75:00

so

75:00

what would be like a timeline from

75:02

first visit until

75:04

a decision would be made to have it done

75:06

great great questions

75:07

the work up and the timing and how fast

75:09

right

75:14

the most well most people show up in my

75:16

office with who have already had a

75:18

variety of things done

75:20

okay what do I need I i want a recent

75:23

endoscopy egd where they you know

75:26

look in the stomach take some biopsies

75:29

uh usually within two or three years

75:31

okay if it hasn’t been done in that time

75:34

frame

75:36

and I think it needs to be repeated I

75:37

will request it if I think there’s

75:40

something I need to know

75:41

anatomically I might just order a

75:42

radiology test of a bari swallow upper

75:44

gi

75:45

okay then we do the motility testing in

75:49

my lab

75:50

okay which is basically a 15-20

75:54

minute procedure where we put a little

75:55

tube down the esophagus and you swallow

75:57

some jello

75:58

to figure out how strong your esophagus

76:00

is at squeezing

76:01

and then if there’s some question

76:05

about

76:06

is this really reflux you know are we

76:09

sure that it’s reflex we don’t know if

76:10

it’s reflux

76:12

how bad is the reflux we do

76:15

we call it 24-hour ph testing where we

76:18

there’s two ways to do that we do it

76:21

with a little thin

76:22

wire that sits in yourself I guess it

76:24

basically measures your entire

76:26

acid exposure in your esophagus for 24

76:28

hours even while you’re sleeping

76:30

people eat people drink people run i’ve

76:32

had some i’ve had a fellow win a bowling

76:34

tournament with it in place so it’s not

76:36

a big deal it’s just weird

76:38

i mean I know it’s a weird test but but

76:40

it tells me what’s going on it tells me

76:42

how much acid it tells me how much

76:43

bile it tells me what’s really happening

76:46

if you’re someone who has you know

76:50

clear-cut esophageal ulcers and that

76:52

kind of stuff

76:53

we don’t usually have to do that but if

76:55

we’re not the key is I want to

76:57

cure the right problem I don’t I can do

76:59

a nissan or links on

77:00

every one of you okay doesn’t mean

77:03

everyone is going to be happy because

77:04

some of you don’t have the right

77:05

diagnosis so I need to make sure that

77:06

the diagnosis is correct

77:08

before I do the surgery and that’s all

77:10

depends that’s all kind of a

77:11

you know depends on the person if

77:14

someone rolls in my door and hadn’t had

77:15

a darn thing done

77:17

and we got to start from scratch or they

77:19

had their endoscopy

77:20

ten years ago they got they didn’t think

77:22

they had a hiatal hernia and they’re not

77:23

really sure and I haven’t seen about

77:25

and we gotta kind of go through step

77:26

wise it usually takes me about three

77:29

weeks to get the testing done

77:31

uh which isn’t you know terrible uh and

77:34

usually

77:34

based on people’s story we will go ahead

77:37

and schedule

77:38

them for an operation to reserve a spot

77:41

which motivates them get the work up

77:43

done and then you come back to see us

77:45

before your surgery if it all makes

77:46

sense we proceed if it doesn’t make

77:48

sense we stop

77:49

and back up so we’re trying to be

77:52

efficient

77:52

you know this is time is precious around

77:55

here

77:56

and so we try not to waste anybody’s

77:57

time

78:00

yes sir this might sound like a tried

78:02

question you said that if you have this

78:04

uh

78:05

procedure you can’t burp or throw up

78:08

it’s harder

78:09

it’s not zero let’s say you have food

78:11

poisoning you’ve got to throw up right

78:13

i mean hopefully you can throw up some

78:16

people can’t they just kind of dry heave

78:17

uh because it won’t you know it’s it’s

78:19

it’s meant to be a one-way valve

78:21

now you can some people can generate

78:24

enough pressure to overcome that

78:26

some people don’t most people just kind

78:29

of dry heave a little bit and then it

78:30

stops

78:31

and if it’s bad enough they know to call

78:33

us and we we then

78:35

if you really needed we needed to

78:36

evacuate your stomach for whatever

78:37

reason right

78:38

we can just put a little nasogastric

78:40

tube in you know the stomach p p kind

78:41

of thing for

78:42

15 minutes suction your stomach and

78:43

you’re done so it’s not a

78:46

not a catastrophe it’s an inconvenience

78:48

if it happens

78:52

no it’s just that’s just what you do but

78:54

that’s not curing anything

78:56

right getting rid of the poison no not

78:58

no not really but the thing is

79:00

it’s more of an what reason you throw up

79:02

is really kind of an illest and it’s if

79:03

it’s actually

79:04

bacteria and infection what’s in your

79:06

stomach

79:07

isn’t the issue it’s it’s what’s

79:09

downstream

79:10

that’s that’s creating a vagal nerve

79:14

it’s it’s a complicated thing but it’s

79:15

not really fixing anything it makes you

79:16

feel better makes you a little bit

79:18

nauseous if your stomach’s all distended

79:20

not really fixing anything

79:22

but it can be accomplished by

79:25

putting two but again you know done

79:28

more than three thousand of these how

79:29

many times does this really come up

79:31

a handful it really isn’t a big issue

79:36

okay well hopefully that was helpful

79:39

i’m not running away so if you guys have

79:41

questions or

79:42

were too shy to answer i’m happy to sit

79:45

here and hang out and answer