Siva Raja, Md, PhD, MD
Staff Thoracic Surgeon, Department of Thoracic and Cardiovascular Surgery in the Sydell and Arnold Miller Family Heart & Vascular Institute
David Mason, MD
Staff Surgeon, Cleveland Clinic Department of Thoracic and Cardiovascular Surgery
Wednesday, April 10, 2013 - Noon
As one of the largest, most experienced thoracic surgery groups in the world, our surgeons offer virtually every type of thoracic surgery, including surgery for GERD, Esophageal Cancer and Achalasia Reflux. We specialize in very complex cases as well as groundbreaking surgeries procedures, such as minimally invasive procedures. Dr. Siva Raja and Dr. David Mason, thoracic surgeons from Cleveland Clinic answer your questions about swallowing and esophageal disorders.
Gastroesophageal reflux disease (GERD, Reflux)
Steve 1976: I have GERD and have had 2 operations--they cannot fix it--what else can I do--is there a manmade object that can replace the valve at the connection to my stomach.
David_Mason,_MD_: Surgical management of GERD becomes increasingly difficult with each subsequent operation however, this does not mean there is not the opportunity to improve your symptoms either medically or surgically. Given the description of your problem, a combined evaluation with experts in swallowing and in reflux from both medical and surgical side would be suggested.
We have a Swallowing Center that addresses these complex issues. If you can identify a mechanical problem - surgery can treat the mechanical problem - Finding the root cause can determine the right treatment. Surgeons with expertise in re-do anti-reflux surgery are critical to good outcomes and are only available in select centers across the country.
jdavidof: I have GERD and a medium-sized hiatus hernia was present without erosions or bleeding.? I had Biliopancreatic Diversion five years ago. My stomach has enlarged and my doctor is recommending Roux-en-Y gastric bypass. Is this the only solution to my problems? I am a coumadin patient and choose the Biliopancreatic Diversion to keep the absorption of my medications. My BMI is 39. Three times this past year I have had to take Nexium twice a day to calm down my GERD. Could surgery just be done on the hiatus hernia?
David_Mason,_MD_: The problem you are describing with reflux is complex. It is not possible to answer without gaining much further information and evaluation in a surgeon’s office.
Siva_Raja,_MD,_PhD: That being said, there are other solutions to repair the hiatus hernia such as surgery approaching it from the chest instead of the abdomen. More importantly if you have only had to take meds for your GERD a couple times a year, is the problem you are having, bothering you enough to make you undergo a major operation. That is what it boils down to - and if the answer is yes - there are options.
hartland: I had surgery in 02 and since then my heartburn and acid reflux have been unbearable, I have pain in my chest, my back, I have shooting up into my gums. when this happens it shuts me down, will I always be messed up like this? Also I have a piece of my ribs in the back that is not right, like an indention where my rib should be and I have pain under my left arm. Its fine unless someone touches it... helps me.
Siva_Raja,_MD,_PhD: From hearing your story it seems as though you have typical and atypical symptoms of reflux. The typical symptoms are heart burn, and possibly regurgitation. These things are more clearly associated with reflux. Other symptoms such as pain are not as clearly assoc with reflux and as such any surgical approach to treating reflux disease is not a reliable way to fix it. You need to come in for additional studies such as esophagram, pressure measurements of the esophagus, and possible endoscopy (esophageal exam with a flexible camera) would further shed evidence to the level of reflux and without knowing the exact surgery you have had it is difficult to place the indentation of the rib as part of this problem. In summary, there are potential opportunities to help you.
Grannyscott: I have a diagnosed large hiatal hernia (had an endoscopy 3 years go); have taken omneprezole for several years for acid reflux, but after having some violent scary coughing spells, especially at night, a couple of years ago, the dose was increased to two per day - that has helped, but I have read that there is a danger in long-term use of proton pump inhibitors? I am 84 years old, and would be very apprehensive about surgery for this - or any - problem!
Siva_Raja,_MD,_PhD: The down sides of long term PPI use are probably minimal. At your age surgery carries increased risk but is not prohibitive. Obviously a risk benefit analysis would need to be made by you after a visit with a surgeon and gastroenterologist.
MargotU: I had bariatric surgery and now I have GERD. Taking a lot of medication for this. Is there a surgery or procedure that can be done to treat the GERD after B Surgery?
David_Mason,_MD_: GERD after bariatric surgery is not uncommon. Certainly there are surgical options for repair and improvement of your symptoms. This would be dependent upon the specific operation that you already had. I recommend asking your bariatric surgeon his or her recommendations first and then be seen at a Swallowing Center if you have further questions or concerns.
GloriaOH22: I have had GERD for a long time and have now been diagnosed with Barrett's esophagus. Are you familiar with the use of ablation therapy for this or any other treatments that would be successful?
Siva_Raja,_MD,_PhD: Ablation therapy with RFA is a commonly performed procedure for the eradication of Barrett's esophagus. There are other treatments such as cryotherapy, photodynamic therapy and endomucosal resection that work to varying degrees. The most important thing in pursuing this avenue of treatment is complete eradication and continued follow-up. Some patients can have Barrett's Esophagus that are refractory to this therapy and can progress to cancer. Early diagnosis and treatment is the best way to insure long term survival in esophageal cancer.
luvinit22much: I have had GERD since I was in high school. I have been taking Nexium, and then the generic for Nexium when it came out, for around 12 years. Should I be concerned about being on this medication for so long? I recently stopped cold turkey for about a month and a half but the reflux was so painful it was waking me up in the middle of the night. I had to go back on it. My doctor told me I need to slowly wean myself off the medication. Do you have any additional suggestions? Do I need to do anything to remedy the fact that I have been on this medication for so long?
Siva_Raja,_MD,_PhD: If you have significant reflux, weaning yourself off the medication is going to almost certainly cause recurrence of your symptoms. Your options are usually continuing meds or having an anti-reflux procedure. In the intermediate term PPI use is probably associated with minimal complications and risk.
We do not have data over 20 - 40 yrs to know what the affect it would have. So an indication for having an anti-reflux procedure, is someone with significant symptoms whose unable to wean off the medication or is acquiring escalating doses. Prior to embarking on any operation it is important to have a thorough workup to insure that your symptoms are truly related to acid reflux. This is the best way to insure the optimal outcome.
sinaihospital: I have severe gerd. I am on medicine for it. I have edg tests I fell medicines for this. Can surgery help my gerd problem yes or no. I was diagnosed with gerd and other gig problems.
David_Mason,_MD_: Clearly surgery has a role in improving severe GERD in the appropriate patient. However, medical therapy is also quite effective and a physician with expertise in the management in GERD can help you choose the appropriate therapy in the context of your other GI problems.
Theo: How long should someone stay on prevacid medication for reflux if it seems to return when medication is stopped?
David_Mason,_MD_: Chronic use of antacids for reflux is somewhat common. Considering surgery may also be an option. Long term reflux should always be evaluated by a gastroenterologist for complications of reflux such as stricture and Barrett’s esophagus (a pre-cancerous condition), as well as to determine if your symptoms are truly reflux related.
SoCal: What are the indications for the LINX procedure to treat GERD? What are the pros and cons? Thank you.
David_Mason,_MD_: The LINX is a device that has been recently developed to treat GERD. However, data is limited to short-term outcomes and therefore it is difficult to recommend this procedure at this time. Its pros are that it might be a less invasive form of anti-reflux surgery and its cons are that it may not be effective in the long term and potentially subject to complications.
SLH: I have scleroderma and have terrible reflux, both acidic and non-acidic. I take Nexium twice a day and have tried Omeprozole as well. What is the anti-reflux procedure? Has it been successful in patients with scleroderma? I am only 40 years old and don't want to have to depend on the purple pill forever!
David_Mason,_MD_: An anti-reflux procedure is a surgical operation that utilizes a portion of your stomach to create a valve that allows for food to pass into your stomach, but not backwash into you esophagus. This backwash is reflux. For patients with scleroderma, anti-reflux surgery can be quite challenging and in general, is infrequently undertaken. Often, surgery can worsen your present symptoms. I recommend evaluation by a Swallowing Center with expertise in the treatment of scleroderma. There may be some other medical options.
AnnieTWD: I have Barretts, no symptoms, take the purple pill. How often do I need an esophageal exam?
Siva_Raja,_MD,_PhD: The question of how often one should be followed - is answered previously.
Theo: Does taking prevacid 30mg dissolvable tablets (am and pm) for a 12 year old female pose long term problems? She has GERD and it is also affecting her teeth the dentist says. Lots of pitting. She also has celiac disease and down syndrome. Has had ICP - was on meds, but no longer. Sometimes says the back of her neck hurts and her throat and head hurts too. Neurologist says not symptomatic of ICP return.
David_Mason,_MD_: The patient you are describing is quite complex. Clearly prevacid has a side effect profile, but surgery for GERD is likely not an option given your description. Any other treatment options would have to be individualized for her.
jdavidof: I am in the middle of monitoring my pH for my reflux today. Yesterday I had the 1/2 hour test done at the clinic that showed acid reflux. The Doctor told me that this testing would help to determine what type of surgery I might need. I am on long term Nexium being a coumadin patient so I do not develop any ulcers. When prevacid went to over the counter my prescription insurance changed me to the generic. My reflux increased and it was determined through testing that I needed brand name only. Should I be worried about Barrett's cancer? or if we keep the acid reflux under control this could be avoided?
Siva_Raja,_MD,_PhD: It is not uncommon to have an increasing dose requirement of anti-reflux medication over time. While there is an association of GERD with BE and esophageal cancer, we do not yet understand the specific link. There are millions of people with GERD and only a small subset of patients develop Barretts Esophagus and an even smaller group progresses to cancer. Since we do not know which person will progress to BE, long term reflux may benefit from evaluation by a gastroenterologist for appropriateness for endoscopy.
Moderator: There have been several questions on anti reflux surgery, can you provide some final comments?
Siva_Raja,_MD,_PhD: My parting thoughts on the subject are these. Anti-reflux surgery can be effective in palliating GERD and its complications in severe cases. Medical therapy is still the first line of therapy for GERD and seems to be associated with minimal morbidity. However, when surgery is performed for the wrong indication or if there are complications of anti-reflux surgery, the re-operation to restore anatomy and function is never ideal. As such, a thorough work up prior to embarking on surgery for GERD, by experienced physicians in high volume centers, is likely to lead to the best outcomes. This is especially true for re-operative esophageal surgery.
KRT: I had a Heller Myotomy for treatment of Achalasia at CCF 16 years ago. I still experience no cardiac chest pain frequently. Is there any new treatment for this? It is unpredictable and the only means of relief is eating bread and drinking water. Is there a preventative treatment?
Siva_Raja,_MD,_PhD: Achalasia is a chronic disease where the heller myotomy is a symptomatic treatment but not a cure. Non cardiac chest pain may not be unusual finding in the setting of achalasia. In the setting of a prior heller myotomy and persistent symptoms, continued screening for complications of achalasia and progression of esophageal dysfunction may be beneficial in decreasing long term complications.
Lauren: My mom had the balloon procedure for achalasia and it did not work. What are her next options? What can she eat that would make her life more tolerable.
Siva_Raja,_MD,_PhD: Achalasia is a chronic problem where the gastroesophageal junction does not relax. The medical treatments such as botox injections and balloon dilations can be effective in the short term. However, the only long term solution is often a surgical procedure called Heller myotomy where the abnormal muscle is divided. Seeking such an operation depends on the age of the individual, fitness for surgery and the time point in the spectrum of the disease. There are newer minimally invasive procedures such as POEM that are being attempted but do not have long term data.
Swallowing Problems (Dysphagia)
Tracy Z.: I have had a Chiari Malformation 1 Decompression Surgery, MVD for Geniculate Neuralgia and rebuilt C Spine. I now have dysphagia. I get choked several times a week mostly at night during dinner. I saw a gastroenterologist and he scared me saying when I became a senior citizen I would probably have to be on a feeding tube & I was 37 years old at the time. I am now afraid to go back to the Gastro. Earlier I did have some polyps removed could they be causing the choking? I was told they might come back & after my surgeries all my swallowing tests were fine. It would be much easier to get an Endoscopy & less stressful.
Siva_Raja,_MD,_PhD: The first step would be to seen by a Swallowing Center specialist for evaluation of your complex problems. If you had a polyp before a recurrence is certainly not unusual. Our Swallowing Center at the Cleveland Clinic sees extremely complex issues such as yours and can likely be helpful.
Theo: Good Morning. My father had throat cancer from smoking 30 years ago. Part of his jaw was removed and he has always had trouble swallowing and tasting food. This January, he had a feeding tube put in because a swallowing test showed every time he ate or drank something, it would go directly to his lungs. He got pneumonia in December and could not stop coughing. He can no longer take anything by mouth - food or drink. He has terrible dry mouth to deal with as well. Has mild COPD, but does not require oxygen. He is 77 years old and has always worked out and still does. Is there any type of operation that he can have to reverse this so he can eat and drink by mouth again? Thanks.
Siva_Raja,_MD,_PhD: The effect of prior surgery and radiation for head and neck cancer can often be permanent. It sounds as though you are describing aspiration in your father. Feeding with a tube may be his safest option. I would still consider a work-up to see if there is a mechanical problem that would be amenable to treatment.
SLH: Do you have another drug suggestion besides Reglan to help with swallowing?
Siva_Raja,_MD,_PhD: Reglan can help improve the contractions of the stomach - long term use of reglan can have neurological side effects that may or may not be reversible with cessation of the drug. I would recommend getting an evaluation by a Swallowing Center to determine the specific problem with your swallowing to determine if there are other therapies. There are other medications that are not available in the United States that can be used in this setting.
jscmorse: Please explain the procedure and reasons for EGD. I am a speech pathologist working with patients with dysphagia and often have to explain this. What risks are involved and is it often repeated?
David_Mason,_MD_: Indications for EGD (telescopic evaluation of the esophagus) are for diagnosis and treatment of underlying pathology. Given that your patients are being referred to EGD, given the symptoms of dysphagia, this is likely being done to rule out anatomic blockage such as stricture or cancer.
SLH: I recently had manometry and failed all of my swallows. What would this indicate?
Siva_Raja,_MD,_PhD: Swallowing problems are complex - there are a wide spectrum of swallowing disorders that can all result in failed swallows. It is difficult to interpret that specific piece of information with the remainder of the manometry results. The differential diagnosis can include but are not limited to achalasia and scleroderma.
SaraFR23: My husband was diagnosed with Barrett’s esophagus after an endoscopy and they said that can become throat cancer. How often does that occur? What is the normal follow up for endoscopies he should have? What is the normal treatment?
Siva_Raja,_MD,_PhD: Barrett's esophagus (BE) in and of itself can be benign in the long term. It increases the likelihood of developing esophageal cancer 50 - 200 fold. Never the less, it is not a guarantee that it will progress to cancer. When BE progresses to dysplasia, low grade and then high grade, its potential to become invasive cancer increases. There are clear guidelines on the frequency on which BE should be followed up - it depends on the degree of Barretts under the microscope. When there is more dysplasia, more frequent surveillance is needed or ablative therapy is entertained. Surgery is reserved only for people who fail these treatments.
Cynthia1986: How does Barrett's esophagus turn in to cancer?
Siva_Raja,_MD,_PhD: BE is considered a pre-cancerous condition. At present we do not definitively know why BE turns to cancer in some and in others it does not. There is a lot of medical literature dedicated to genetic changes within Barrett’s esophagus that predisposes it to becoming cancer. The only thing we do know is that the higher grade of dysplasia within BE makes it more likely to become cancer.
Sam2135: Can you talk about the stages of esophageal cancer and what they mean for treatment?
David_Mason,_MD_: I will give you a general overview of the stages of esophageal cancer. Like all cancers, stages are categorized from Stage 1, the earliest stage, to Stage 4, the most advanced. In synopsis, Stage 1 cancers of the esophagus are limited to the inner lining. Stage 2 cancers, are slightly deeper into the wall of the esophagus. Stage 3 cancers, are larger cancers that involve the drainage basins of the esophagus (lymph nodes) and Stage 4 cancers are cancers that have spread throughout the body. Treatment of the esophageal cancer is clearly stage dependent. Early stage cancers are typically treated with surgery while more advanced cancers treated with chemotherapy.
ChasFLA: My dad was diagnosed with esophageal cancer. He had a pet scan done and it is also in a spot near his esophagus in the upper chest. The doctor wants to do chemotherapy and radiation. It is not in lymph nodes. We are thinking of getting another opinion. Is this something a surgeon would look at too to see if there is surgery option?
David_Mason,_MD_: Treatment of esophageal cancer is determined by stage, location of the tumor, and a patient's fitness for surgery. I am not certain as to your dad's tumor location, stage and fitness. Nonetheless, I do think, that a surgical opinion would be warranted.
jdavidof: My boss has Stage 4 stomach cancer. She is at Anderson in a clinical study. The cancer has advanced so surgery is out. How long should we expect her to live? The information on the internet is depressing and states under a year.
Siva_Raja,_MD,_PhD: Stage 4 stomach cancer is unfortunately a bad disease. It often spreads rapidly - that being said - the biology of every tumor is different. Occasionally there are long term survivors with stage 4 cancer with medical therapy such as chemotherapy and radiation. Sadly they are very rare.
Theo: My 69 year old Aunt has varices in her esophagus and stomach. She recently had them banded for the 2nd time. She has had low grade fevers on and off for 7 weeks now. She has had MRI, CT, bloodwork, ultrasound, etc... and they can't find the reason for the fevers and fatigue she is experiencing. She also gets pain in her stomach which is extremely bloated!!! They drained fluid from her stomach. She has cirrhosis of the liver from chemo treatments from colon cancer 5 years ago. She has been to infectious disease twice - no answers from anyone. Any thoughts? Could it be the varices causing the bloating, fever and fatigue?
Siva_Raja,_MD,_PhD: People with fluid in their belly (ascites) in the setting of cirrhosis can have slowing of their bowels as well as be prone to infections of that fluid (spontaneous bacterial peritonitis). It is important to see a gastroenterologist or abdominal surgeon to sample the fluid to make sure it is not an infection. The varices themselves may not be related to the fevers but rather a consequence of the cirrhosis unless the banding was recent.
Theo: Banding was recent, but belly was bloated prior to.
Siva_Raja,_MD,_PhD: It is possible - you should seek an opinion by a gastroenterologist.