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

Dr. Gillian discusses why people get reflux, why their weakened anatomy and hiatal hernia creates reflux, how medications work, how Nissen Fundoplication works and how LINX works.

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

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