Posted on Fri, Sep. 14, 2012
Heartburn can be alleviated by lifestyle modifications
By Howard Cohen
hcohen@MiamiHerald.com
Al Diaz / Miami Herald Staff
One of the newer means of surgically treating acid reflux/hiatal hernias, is to use robotics. Less incisions
means quicker recovery. Here, Dr. Anthony Gonzalez prepares the robotic arms for surgery on a patient at
South Miami Hospital on Thursday, September 6, 2012.
Got heartburn?
Nearly everyone has felt the boiling sensation in the stomach and throat after a big meal. Most of the time
the symptoms can be traced to the overindulgence and pass without concern in an hour or so — often aided
by downing an over-the-counter antacid. Changes in diet, losing weight, avoiding alcohol and smoking, and
bypassing that post-meal nap for at least three hours could be simple home remedies to alleviate the fire.
Got GERD? That might be more serious. Gastroesophageal reflux disease (GERD) can make swallowing
difficult and lead to chronic soreness in the throat and chest. Untreated, GERD destroys the lining of the
esophagus over time and stifles the esophageal sphincter flap, which helps keep stomach acid out of the
throat area. In some cases, GERD can lead to cancer of the esophagus. Hiatal hernia, in which the stomach
pushes up into the chest area, also causes acid reflux.
Advancements in surgical techniques, like robotics and high resolution three-dimensional tests, along with
numerous medications, can treat and cure the condition before it leads to cancer. But it’s estimated that 25
percent of the U.S. population suffers from GERD and the problem is growing.
On the run
“Obesity is a significant risk and America is becoming more obese. Our lifestyles are more on the run,
eating later at night and eating more when we go out to eat. Those are risk factors for acid reflux,” says Dr.
Pamela Garjian, subsection chief of endoscopy for Baptist Health in Miami.
An aging population also accounts for GERD cases, says Dr. Jamie Barkin, chief of gastroenterology at
Mount Sinai and professor of medicine at the University of Miami.
“They are taking medications that affect the esophagus,” Barkin said, citing common arthritis pain relievers
such as ibuprofen or naproxen, and bisphosphonates like Fosomax for osteoporosis.
This condition is known as pill-induced esophagitis, Barkin said, and it impacts all age groups.
Women who are anemic during their reproductive years often take iron supplements, as do teens who seek
acne treatment. Athletes also seek relief with pain meds after a hard workout. All of these folks can
experience acid reflux because of the drugs and supplements.
“They really beat up the esophagus,” Barkin said. “The message is, if you’re having symptoms, you’ve got
to tell your physician what pills you are taking.”
Normally, when food is consumed, it slides down the esophagus and into the stomach, where acids break it
down so it can be digested. The lower esophageal sphincter muscle at the stomach entrance, a flap valve, is
supposed to act as a gate and close after the food passes through to keep stomach acid away from the tender
esophagus. When this system goes awry, acid boils up from the stomach into the throat — a classic case of
heartburn, that hot sensation centering around the breastbone and radiating toward the throat.
Screening options
Some people mistake chest pains caused by weaknesses in the muscle walls of the esophagus for heart
attack symptoms, as was the case with former University of Florida football coach Urban Meyer. He was
ultimately diagnosed as suffering from esophageal spasms, which caused the pain, and difficulty in
swallowing and regurgitation, said Dr. Baharak Moshiree, associate professor of medicine at the University
of Miami.
Screenings can detect esophageal problems.
High resolution esophageal and three-dimensional anorectal manometry uses color topography to see and
measure the areas of the esophagus as they contract, Moshiree said. “We are able to see complete muscles
from the upper esophagus into the lower part of the esophagus. We can see if the abnormalities are higher
up or in the lower part. If acid in the stomach is coming into the esophagus, Impedance pH technology,
using a probe, measures the acidity in the esophagus and how many times a patient has episodes and how
long the acidity is in the esophagus.”
With Impedance pH testing, a patient wears a catheter for 24 hours and returns to the doctor’s office the
following day for assessment.
The Bravo capsule is another increasingly popular pH monitor, especially for younger patients who might
have trouble adequately telling a parent or physician how often they are suffering pain, said Dr. Jesse
Reeves-Garcia, director of the division of gastroenterology at Miami Children’s Hospital and clinical
professor for pediatrics at the Florida International University Herbert Wertheim College of Medicine.
The Bravo sensor measures the frequency and duration of acid washing into the esophagus from the
stomach over a two-day period. The capsule, which looks like a pencil eraser, is lowered into the esophagus
through the mouth and attaches to the esophagus wall. A sensor transmits information via radio frequency
to a computer for a doctor to analyze. The capsule simply passes through the GI tract and is eliminated
within 48 hours.
Adults can swallow the capsule; children are generally anesthetized for about 10 minutes for insertion,
Reeves-Garcia said.
“Now the mother doesn’t feel she’s crazy, the mother was correct. Her kid had symptoms and we can
associate these symptoms,” he said. “Now, we can be more specific.”
Surgical options
Keith Tyler would not seem a candidate for GERD. At 68, the Homestead sales and marketing professional
has stayed in shape from 40 years of tennis play and considers himself “a pretty tough guy.”
But Tyler had to undergo surgery in May at Baptist Hospital in Miami to repair a hiatal hernia and to treat
his acid reflux. A hiatal hernia happens when the diaphragm separates from the chest allowing the stomach
to move above the diaphragm and into the chest. The resulting displacement allows stomach acids to reflux,
or erupt over the banks akin to storm water over a levee, into the esophageal area. This condition can also
lead to a rise in blood pressure because the incorrect positioning puts pressure on the internal organs — the
case for Tyler.
“I noticed my stomach had become terribly distended to the point where I was doing a good impression of a
woman in her third trimester. If I accidently bumped into something, like a sharp object, as Inspector
Clouseau used to say, I would blow up,” Tyler said, chuckling.
But it was no laughing matter.
“I didn’t know what it was. I thought it was gas but I had high blood pressure and terrible acid reflux to the
point where I could not lay down. I would be on the computer at 4 a.m. because going horizontal was not
an option.”
No matter what Tyler ate, he’d suffer the burn.
Doctors determined that surgery was required.
One means of surgery, done through laparoscopy, sews the upper part of the stomach around the lower part
of the esophagus to shore up the sphincter muscle. Gonzalez was able to perform surgery on Tyler using
one of the newer advancements — robotic 3D visualization with a 360-degree field of vision.
“That allows us to deal with larger, complex operations in a much simpler fashion in a minimally invasive
way,” Gonzalez said.
Hiatal hernia repair can be accomplished with the robot via four quarter-inch incisions, and, in some cases,
one single incision. Both options allow for fewer complications and a quicker recovery.
“The surgery was over in a day and I was out the next day,” Tyler said.
Painful lesson
Upon release, patients are instructed to consume easily digestible foods like soups and other soft items. “I
only made one mistake,” Tyler said. “You have to drink soup. I got so sick of eating soup I could write a
book. My wife had cooked herself a steak and the aroma of that steak was wafting over to my side of the
table. I cut off five small pieces. That was unbelievably painful so I learned my lesson.”
Gonzalez also points toward a transoral incisionless procedure for select patients with smaller hiatal
hernias. This surgical option uses the EsophX device, which is introduced into the body through the mouth
rather than abdominal incision and affords 270 degrees of movement, he said. “Recuperation is quick” with
an overnight stay, usually for nausea, he said.
This method manipulates tissue folds to form a stronger reflux valve.
Esophageal ablation to treat Barrett syndrome — abnormal changes in the cells of the esophagus — is
another minimally invasive, outpatient procedure that removes the damaged outer layers of the lining of the
esophagus that can put a patient at risk for developing cancer. During ablation, the tissue is heated, thus
killing the undesired cells lining the esophagus. The Halo ablation procedure uses radio frequencies to
eradicate the cells.
“Barrett is a precursor to cancer,” said Dr. Barry Migicovsky, chief of gastroenterology at Memorial
Regional in Hollywood. “Cancer has to be found relatively early so we can do endoscopy, scoop out the
tissue, and do radiofrequency ablation to remove the abnormal cells. Once we eradicate Barrett, patients
have to be put on meds indefinitely; if not, this cycle will start all over again.”
Medication options
The best medicinal treatment options are proton pump inhibitors (PPIs) such as Nexium, Dexilant and
Prilosec, said Garjian of Baptist. “The medications are generally effective and work very well.”
But long-term use of the meds can increase chances for osteoporosis by interfering with the absorption of
calcium and vitamin B12.
“We don’t know what other vitamins can be affected as well yet,” Garjian said, adding that lifestyle
changes, like proper diet and exercise, might be a person’s best bet at warding off acid reflux.
“It does go away for some people so lifestyle modification is very important.”
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