Additional Info
- Audio Fileuab/ua126.mp3
- DoctorsNix, Jeffrey;Rais-Bahrami, Soroush
- Featured SpeakerSoroush Rais-Bahrami, MD | Jeffrey Nix, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6021
- Guest BioDr. Soroush Rais-Bahrami is an Assistant Professor of Urology and Radiology at the University of Alabama at Birmingham as well as being a co-founder of the UAB Program for Personalized Prostate Cancer Care.
Learn more about Soroush Rais-Bahrami, MD
Jeffrey Nix, MD is a board certified urologist in Birmingham, Alabama. He is affiliated with UAB Hospital, Birmingham Veterans Affairs Medical Center.
Learn more about Jeffrey Nix, MD
Release Date: October 10, 2019
Reissue Date: October 24, 2022
Expiration Date: October 23, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Soroush Rais-Bahrami, MD
Associate Professor in Urology
Jeffrey Nix, MD
Associate Professor in Urology
Dr. Rais-Bahrami has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Genomic Health Inc.
Consulting Fee - UroViu Corp; Blue Earth Diagnostics; Lamthens
Dr. Nix has the following financial relationships with ineligible companies:
Consulting Fee - Intuitive Surgical
All relevant financial relationships have been mitigated. Drs. Rais-Bahrami and Nix does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
The University of Alabama at Birmingham, one of the nation’s leading hospitals in robotic surgery volume is enhancing its work in the field. Here to discuss the new single port robot as it relates to urology surgeries are my guests, Dr. Soroush Rais-Bahrami and Dr. Jeffrey Nix, and they are both urologists at UAB Medicine. Dr. Rais-Bahrami, I’d like to start with you. What was previously done for urologic issues? How have advancements in instrumentation given birth to the era of robotic laparoendoscopic single site techniques?
Soroush Rais-Bahrami, MD (Guest): So, there has been a clear progression from open surgical techniques to laparoscopic minimally invasive approaches and then with the advent of robotic technologies, robot assisted laparoscopic techniques and now with the newest single port robotic platform; we’ve minimized the number of incisions and the size of the overall incision burden to achieve the robotic approach to achieve a lot of the surgeries that classically would be done through larger incisions and open approaches when the patients are appropriately selected for these cases.
Host: And we’re going to discuss patient selection but before we do that, Dr. Nix, tell us about the new DaVinci SP single port surgical system. How is it going to change the landscape of urologic surgeries that you are doing at UAB and why the need for this?
Jeffrey Nix, MD (Guest): So, I think what you see with the single port system is a continued evolution of minimally invasive surgery. To piggyback onto what Dr. Rais-Bahrami has said, basic laparoscopic surgery in its inception was an incredible progress over open surgery but was very difficult to teach, very difficult to do, the instruments were unwieldy. This single degrees of freedom, very basic instruments have now progressed even in those approaches, but the technology has gotten better. Things have gotten smaller. The ability to minimize things has made trocars, our port, our incision site that might have been an inch before; now we can do them as small as five millimeters in terms of multiport incisions.
But still, if you were going to have a gallbladder removed; you might have three or four small incisions. If you were going to have your prostate removed; you might have four, five or even six small incisions. And so, you have a minimally invasive approach, but you still have multiple different wounds to heal from. So, the single port platform can take that down to one or two small incisions and again, for cancer surgeries like a lot of the procedures that Dr. Rais-Bahrami and I are doing; we are taking out tissue at the end of the case.
So, as an example, the single port platform fits through about a one inch incision. So, I can hide that incision in the belly button, and I can still get out the prostate through that one inch incision and minimize the morbidity to our patients. So, the biggest quest in terms of minimally invasive surgeons as an overarching theme, is can we do the same operation that classically would have been done through a large open incision, but can we do that through these small tiny incisions that maximize recovery for patients and minimize their morbidity.
So, we are trying to do the same operation or even do it better but doing it through less morbidity and so I think that’s what you see with this single port approach is another step in that evolution towards less and less invasivity as we improve our patient outcomes in terms of short term outcomes like time back to work.
Host: Dr. Rais-Bahrami, then tell us about patient selection and how important that is for this particular type of procedure. Who is it indicated for and who might it not be?
Dr. Rais-Bahrami: Well, currently in urologic surgery this has been used for a multitude of different surgical techniques. The single port robotic platform has been FDA approved first in urologic surgeries and has also been recently approved for transoral surgeries by our ENT colleagues nationwide as well.
In urology specifically, this new robotic platform has been used for cancer surgeries as well as noncancer surgeries done by urologic surgeons. I’d say at UAB, the majority of single port robotic cases have been done as prostate surgeries for an indication of prostate cancer or kidney surgeries with an indication of either kidney tumors being removed, kidney cancers being treated or in cases of urinary tract blockage where reconstructive surgeries have been done on the urinary tract between the kidney and the bladder along the ureters drainage tube.
Host: Dr. Rais-Bahrami so, what you were just speaking of is that what it is now, as of now FDA approved for and do you see that changing in the future?
Dr. Rais-Bahrami: As with the evolution of surgical technologies and surgical techniques that Dr. Nix nicely reviewed; as the robotic platform gets further tested and expanded, I do envision that the indications and the approvals will likely expand. Urology has been a leader among surgical specialties in terms of progressive minimally invasive surgeries and endoscopies historically and I think it is very fitting that the single port robotic platform which has a small profile entrance at the incision level but can reach into deep structures of the pelvis for example, things like prostate surgery or deep bladder or ureter surgery in the pelvis, it really provides an advantage.
That’s also seen by the second FDA approval for our ENT colleagues that do limited space surgery through a transoral approach that the single port robotic platform really allows us access to a small field that may be otherwise difficult and challenging to access. As Dr. Nix also mentioned, the conventional laparoscopy through multiple ports or even the robot assisted laparoscopy through multiple ports really requires triangulation and sometimes a different amount of space to actually access a focal point where we are operating deep either in the pelvis or our colleagues may be operating in the deep oropharynx or deep throat region.
So, this technology may really fit a niche that was otherwise very challenging even with other robotic and laparoscopic devices.
Dr. Nix: And I would like to jump in and add. There’s also the surgeon discretion to use these agents off label for indications that seem appropriate where the FDA has not yet approved specifically for an indication. We see that already in urologic surgeries. I mean when you have expert robotic surgeons using a platform that they are now very comfortable with; we see an evolution of that really quickly to using it for off label procedures like partial nephrectomies, removing a part of the kidney that has become cancerous which is not currently FDA indicated, but is an easy sort of way for us to innovate and use this in an off label indication for a tool that we have begun to master based on our use for other procedures.
Host: So, Dr. Nix, based on what Dr. Rais-Bahrami said, do you feel it hasn’t gained or has gained widespread acceptance and as he was mentioning, adequate triangulation and bedside assistant, wrist articulation. There’s all these technical considerations. What do you feel other providers are thinking of this particular type of procedure? And what about the learning curve? Is there a difficult learning curve for the use of the newer robots?
Dr. Nix: Yeah, I think you are going to see a cycle of innovation like you do with any new product. So, you are going to have early adopters that are going to come well before the remainder of the field, and I think that’s what you see at UAB. I mean, there are currently about 15 platforms in existence in the US and in our utilization here, I’m one of the highest volume users in the world. So, we are early adopters of this technology. It is a different tool and it does have a learning curve associated with it and we’ve been, Dr. Rais-Bahrami and I have been involved in testing this tool at different trips out to the corporate headquarters for well into six to eight months before the platform ever became available.
So, in lots of different ways, you are going to see interest grow in our field as this becomes more mainstream and this is what if you go back and look at the history of multiport robotic surgery; it’s what you saw in that as well. You have early adopters and then you have the rest of the field take off. What I will tell you and what Dr. Rais-Bahrami I hope would echo, is that this is a very, very good technology. And when you see tools like this as early adopters come out that are good, then you know the rest of the field will eventually adopt it. It’s just a matter of time.
An example of where that wasn’t necessarily the case is with single incision laparoscopic surgery or SILS, there were different mnemonics for this but when that came out when Dr. Rais-Bahrami and I were both in training; it was incredibly difficult, incredibly arduous to use and it died out pretty quickly. So, those early adopters who were involved in single incision laparoscopic surgery without the advent of all the technology that we have now with the robotics; you saw this die out pretty quickly because it wasn’t – it just wasn’t ready.
What we’re dealing with here and this technology is technology that has evolved significantly to allow the user to adapt it pretty quickly to their expertise and to their comfort level from the previous surgical platforms. And so I think you will see this continue to evolve as hospitals become more and more interested.
Host: Dr. Rais-Bahrami, are there still clinical questions surrounding its use and is this technology superior to another? Does it improve clinical outcome compared with standard laparoscopy? Kind of summarize it for us and what you guys are seeing as outcomes now.
Dr. Rais-Bahrami: I think those are very valuable questions and questions that Dr. Nix and I and the rest of our clinical research team in the department of urology are actually investigating as we speak. As we have developed the program for the single port robotic surgical techniques in our department; we are actively acquiring data on out clinical outcomes and comparing them not only to historic data but our own series of multiport robotic procedures as well as laparoscopic and even open procedures that have been historically understood to have a certain rate of complications or a certain rate of hospital stays postoperatively as patients recover to try to evaluate just those questions. To see if this is improving overall patient outcomes from a population standpoint.
Now, from personal anecdotal experience, and I believe Dr. Nix has seen the same thing; this has really provided a lot of patient satisfaction where patients and their families are astounded by the fact that perhaps a radical prostatectomy can be done through an inch long incision that significantly can be hidden within the patient’s umbilicus or belly button with perhaps one additional small incision for a laparoscopic trocar site for our bedside assistant.
A number of patients have mentioned after their procedures as they have come back for postoperative follow-up checks how straightforward the recoveries have been and how minimal narcotic or other pain medicine requirements they’ve had since the surgery and how quick their recovery has been. We recognize that this is all anecdotal, but we are currently investigating on sort of methodical way whether or not this proves to be the same or significantly better compared to our standard approaches that we had before we adopted this technique.
Host: Thank you for clarifying that. This is such an interesting topic and an interesting time to be in your field. So, Dr. Nix last word to you here. Tell other physicians what you would like them to know about what you are doing there at UAB, when you feel it’s important to refer and maybe where you see this field going, what you see going on in the next ten years.
Dr. Nix: Yeah, I think the overarching theme I’d like to sort of express is our continued continuous continual desire to evolve surgery. We won’t rest. We won’t stop. We want to continue to do the best thing possible for patients and part of that requires a constant desire for innovation. So, the field of robotic surgery or minimally invasive surgery will only grow more complex and there will be more players in the field with more different opportunities. And so, we need to be at the front edge of that curve, trying to figure out where the innovation exists and where wasted resources exist.
And so, that’s what we are trying to do. So, I think our desire here is to really, really move the needle forward in terms of how we respect patients and their outcomes. We want to be able to continue to provide great quality cancer outcomes in terms of the classic traditional things that we are looking for, but we really are focused on our patients here and trying to get the best we can as the technologies are available and we want to continue to be at the leading edge of that curve. And I think that’s what referring providers should notice about this or the next thing. Because this won’t be the last opportunity for innovation.
Host: Dr. Rais-Bahrami have anything to add?
Dr. Rais-Bahrami: I absolutely want to just second Dr. Nix’s opinion that we want to forge forward the field of surgery, the field of urology and ultimately keep our patients as our number one goal and try to optimize their outcomes while maintaining the standards of therapy that we’ve always achieved while again, minimizing discomfort and minimizing the duration until they convalesce to full activity, return to work and comfort after their procedures.
Host: Thank you so much gentlemen for coming on in this panel discussion today and sharing your expertise. What an exciting time to be in your field. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.
That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician. If you as a provider, found this podcast as informative, as I did, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua129.mp3
- DoctorsSimmons, Jeffrey
- Featured SpeakerJeffrey Simmons, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5894
- Guest BioJeffrey Simmons, MD is an Associate Professor of Anesthesiology.
Release Date: September 16, 2019
Reissue Date: August 25, 2022
Expiration Date: August 24, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Jeffrey Simmons, MD
Professor in Anesthesiology
Dr. Simmons has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/Medcast and complete the episode’s post-test.
Welcome. Today we’re talking about perioperative medicine, and specifically preoperative optimization. My guest is Dr. Jeffrey Simmons. He’s an associate professor of anesthesiology at UAB Medicine. Dr. Simmons, I'm so glad to have you joining us today. This is a really great and very important topic. Start by telling us what is perioperative medicine and how is it different than regular medicine?
Jeffrey Simmons MD (Guest): Well Melanie, one, thanks for having me on today. Perioperative medicine is all the care that a patient is gonna get from the time that they schedule a surgery until they're fully recovered. That’s going to include nursing, surgery, anesthesia. It may involve hospitalist medicine, intensive care units, pain medicine. So there’s a full scope of what perioperative medicine can be. What I was hoping to focus on today is this idea of preoperative optimization. That is where we look at modifiable conditions that a patient has before surgery, and then we attempt to pre-habilitate them or modify those risk factors in an attempt to improve that patient’s outcomes after surgery.
Host: So then is this similar to ERAS except for an extended version of it because it starts before, when they first schedule it, all the way ‘till they're recovery?
Dr. Simmons: Yes. Enhanced recovery is very important. It’s service line specific. So if you had colorectal surgery or if you had some kind of surgical oncology surgery or spine surgery, those are gonna be surgery line specific things that you can do to improve a patient’s outcome. Where preoperative optimization comes into play is this is gonna be universal for all patients coming through regardless of the type of surgery. So if you are malnourished or you are anemic or you have risk factors because of your advanced age, these are all different things that we can optimize prior to surgery that really is universal to all different service lines. In modifying those risk factors, we can enhance enhanced recovery because we are still improving outcomes after that surgery’s over.
Host: So then let’s talk about some of those conditions that can realistically be optimized before surgery. Tell us about some of the modifiable preoperative conditions that if a patient improves upon can increase their chances of having better outcomes.
Dr. Simmons: So the list is pretty extensive. But if you look at some of the ones that we are actively working on at UAB, malnutrition tops the list. Smoking cessation, anemia, elder care planning. We look at screening for patients that do not know they have sleep apnea. We look at hyperglycemia control. We are screening patients that are at high risk for DVTs or venous thromboembolism or blood clots people would say. We are looking at opioid reduction strategies and ways to prevent adverse outcomes after surgery. When you combine all of these things into one overall kind of guideline or risk assessment, we are doing this for our orthopedic surgery patients in total. Like we’re looking at all of these things and kind of bundling them for our orthopedic surgery patients and then specifically any of our patients who are coming through our preoperative assessment clinic. So the list is very long, but each of these conditions significantly impacts a patient’s post-operative outcome.
So, for example, if a patient is anemic. Traditionally that patient comes into the hospital anemic and they're not identified as being anemic and nothing was done to treat them. That anemia may go unrecognized or even underappreciated, which is most likely what happens. Really it’s underappreciation of the significance of the disease. If that patient then comes in and becomes hypotensive during surgery, for example, and then they get transfused with blood products, well there's risk involved with the risk of transfusion. There's hospital resources that are being used maybe when it could have been prevented. Anemia in and of itself is a pretty profound multiplier of risk to other conditions like heart failure or kidney disease.
So even if we can reduce the amount of transfusions that are done, reduce the risk of that blood transfusion to the patient, reduce the risk of anemia being a multiplier of other problems, we can improve that patient’s outcomes. We can do that very easily through identifying that patient and treating them before surgery. That sounds like something that should have been and could have been done forever. The medical community as a whole has really not delved into optimization. UAB is really on the forefront of this of what is becoming the next step in surgical care. Not so much looking at intraoperative and post-operative, but really starting to see how can we optimize the patient’s presurgical condition to improve their outcomes?
Host: I certainly agree with you. As you said, it should have been done and it would make common sense that this would have been the concept for so many years. Do you feel that other facilities are recognizing this as well? While you're speaking about that, Dr. Simmons, how is UAB equipped to manage this type of optimization? What are you doing from that time ‘till the time of recovery to really help a patient through this—all of it—and the support systems needed.
Dr. Simmons: Yeah, that’s a great question. We are part of a large community. When you look at national societies that are being designed around perioperative management of a patient, I would say that the United States, as a whole, really got on board with this—I would say—probably five to eight years ago as enhanced recovery became the biggest thing in surgery. Everybody wanted to do enhanced recovery. They were really looking at the time that the patient came into the hospital until afterwards. There are many national organizations that are completely focused on perioperative improvement.
We are equipped at UAB—and I think this is a natural progression of how we are caring for patients now as we are really focusing on quality and providing quality of care over quantity of care, right? We have to make sure that we’re providing the best quality of care for the best value. We are really now focusing on things that patients, I think, want us to focus on. We’re looking at patient satisfaction. We’re looking out comes that are very important to the patient. For example, how fast were they able to return to work? Were they discharged to a nursing home or were they discharged home? What was their cognitive performance like afterwards? So we are not just looking at the traditional hospital and clinical outcomes like length of stay or transfusion risk. We really want to be patient focused and provide quality of care over quantity of care.
UAB is incredibly equipped to do this. We have two locations at UAB. We will see over 120 patients a day, which is roughly around 78 to 80% of our entire surgical population when you look at that over the course of the year. So we’ll do right around 36,000 surgeries. We’re seeing almost 30,000 of those patients in our preoperative clinic. With those two different clinics, we also have a core faculty of anesthesiologists that are assigned to those facilities everyday who are managing and screening those patients, reviewing their records, with the addition of a very robust staff of nurse practitioners.
As a team, we are seeing those patients and not only doing the traditional anesthesia preoperative assessment, but we are screening those patients for all of the modifiable risk factors that we can pre-habilitate over time. We have gotten some really amazing traction. Our surgeons are very onboard. The surgeons are taking our suggestions and saying, “Okay. Let’s make this happen because we want the patients to do better.” Certain things like smoking cessation, for example—which is one of the things that we’re screening for and offering cessation medications for, that’s just good public health in general. So we are really trying to look at the patient as a whole. We have great surgical buy in, and we are really well equipped from the staffing standpoint to be able to see all these patients.
Host: It’s really amazing. As I said before, what an interesting topic. As we wrap up Dr. Simmons, where do you see this going? Do you think it’s going to become standard of care across the board? What would you like surgeons about finding additional information on optimization? Really what you see happening and that you’d like them to know what you're doing at UAB Medicine.
Dr. Simmons: I think the most important thing is to know that they’ve got an ally in the patient’s health. When it comes to how you go about optimizing a patient, you cannot do it alone. You cannot be one person trying to move the mountain. This only works through a large collaborative effort. As we see improvements from what we’re doing with patients and we’re seeing increased patient satisfaction and we’re getting those success stories of the patient that didn’t get transfused when they probably otherwise would have. We get the phone call back from a patient that says, “I was able to stop smoking because you guys were the very first people to give me the medications or the counselling that I needed to be able to stop smoking. I knew how important it was from what you guys told me because I didn’t want to get that surgical site infection and that really prompted me to stop.” So we’re getting the patient buy-in. As we get a larger collaborative effort from the surgeons and the anesthesia group, this is where it’s really gonna take off.
Our mission in our division is to improve surgical readiness to promote the best possible outcomes. So when we are looking at a patient in the pre-operative clinic, that patient is the most important person to us at that time. So who is in front of us that we can improve, that we can educate, that we can make sure that a condition that they have that could have been improved upon is improved upon before surgery. We communicate that to the surgery team, and then we develop a plan. An individualized plan for that patient so that they can do better afterwards. So that’s really where I'm hoping to get to on a 100% scale, not just patients that are enhanced recovery patients. We want to do this on all patients.
Host: So well put, Dr. Simmons. Great information and a great topic. Thank you for coming on and sharing your expertise in this important topic for other providers. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. That wraps up this episode of UAB Medcast. For more information on resources available at UAB Medicine, you can head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast as informative as I did, please share with other providers because that’s how we all learn from the experts at UAB Medicine together. What a great topic and something so important that you spread this around. Be sure not to miss all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua127.mp3
- DoctorsGrams, Jayleen;Corey, Britney;Parmar, Abhisek
- Featured SpeakerJayleen Grams, MD, PhD | Britney Corey, MD | Abhisek Parmar, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5929
- Guest BioDr. Jayleen Grams joined the faculty at the University of Alabama at Birmingham in 2009. A native of Minnesota, Grams received her undergraduate degree from St. Cloud State University and matriculated into the Medical Scientist Training Program at the UAB. Here, she completed her Ph.D. in biochemistry and molecular biology and her M.D. in 2003.
Learn more about Jayleen Grams, MD, PhD
Dr. Corey completed her minimally invasive and advanced GI Surgery fellowship at UAB in 2016. She has a clinical interest in pre-operative optimization and education of patients prior to surgery to improve the success of hernia repairs, as well as the use of multi-modal pain management strategies pre- and post-operatively.
Learn more about Britney Corey, MD
Dr. Parmar completed his minimally invasive and advanced gastrointestinal surgery fellowship at Oregon Health and Science University in 2017. He has authored multiple chapters on hernia disease and has several active research projects investigating ways to improve hernia care. His clinical interests include minimally invasive approaches to large abdominal wall hernias.
Learn more about Abhisek Parmar, MD
Release Date: September 10, 2019
Reissue Date: September 21, 2022
Expiration Date: September 20, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Britney Corey, MD
Associate Professor in Minimally Invasive General Surgery
Jayleen Grams, MD, PhD
Director, Minimally Invasive Surgery at Birmingham VA; Assistant Program Director, Minimally Invasive Surgery Fellowship
Abhisek Parmar, MD
Assistant Professor in General Surgery
Drs. Corey, Grams and Parmar have no financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
If your patient’s current heartburn treatment is not giving them results and you’d like to reduce or eliminate dependence on medication; there’s a minimally invasive option, the LINX procedure. We’re talking about it today in this panel discussion. My guests are Dr. Abhisek Parmar. He’s an Assistant Professor and a Minimally Invasive General Surgeon, Dr. Jayleen Grams. She’s an Associate Professor and a Minimally Invasive Foregut Surgeon and Dr. Britney Corey. She’s Fellowship trained Minimally Invasive Gastrointestinal Surgeon specializing in foregut and anti-reflux operations and they are all with UAB Medicine. Doctors, thank you so much for joining us today. Dr. Parmar, I’d like to start with you. What had been the typical treatment after first line of defense for GERD. Tell us about Nissan Fundoplication and why there was a need for newer treatments.
Abhisek Parmar, MD (Guest): Sure so, the conventional medical therapy for reflux, I think most people in America know is the proton pump inhibitor that decreases the amount of acid in the stomach. But the surgical treatment that’s the Nissan Fundoplication which is usually done minimally invasively and almost I think at UAB done exclusively minimally invasively through small incisions where the proximal part of the stomach is kind of wrapped around the distal esophagus to create kind of a valve, a one-way valve that prevents acid from going back up into the chest. The Nissan Fundoplication has been around for decades. It’s well-established. It works very well. Usually 90% of people will be off PPIs in the long term, five to ten years after surgery.
But there are certainly side effects to having Nissan Fundoplication. Patients can have a gas bloat syndrome where gas is kind of trapped in the stomach. There’s an inability to belch. And there’s inability to vomit. So, those are some side effects of the Nissan procedure. But it does work very well for refractory reflux.
Host: Dr. Grams, what is LINX? How does it work?
Jayleen Grams MD (Guest): So, LINX is the commercial name for something that generically would be called a magnetic sphincter augmentation device. And it’s a ring of little magnets, like magnetic beads that both expand and contract with a food bolus. So, unlike a Nissan which is kind of a fixed floppy wrap 360 degrees around the esophagus; this little magnet gets placed around the esophagus, the distal esophagus and when the patient swallows a food bolus; or liquids, it expands and then after the bolus passes, it contracts again. And so, this might be a more physiologic method to help reflux. And it may prevent things like the gas bloating because patients are usually able to belch and vomit.
Host: That’s a really good point. Dr. Corey, please expand on this for us. Compare and contrast Nissan and LINX for us and tell us some of the advantages of LINX over Nissan and some additional symptoms that are not so much seen with LINX.
Britney Corey, MD (Guest): When my patients come to see me in clinic the ability to vomit is something they are always very concerned about. And we think that LINX long term will give them that ability and that it will really replicate what their lower esophageal sphincter should be doing which is protecting them from reflux. But opening normally to allow their food to go down and then once their food goes down, it closes, and everything stays down.
So, I think as already mentioned, the real advantage is that patients once they recover from their operation and heal up is that they are hopefully not going to really notice that anything is different beyond the fact that their reflux is well-controlled and better controlled. So, ability to release gas off their stomach or belch more normally, to vomit and also typically there’s a little bit less dissection required during the operation with the LINX and so we don’t have to disrupt as many of the normal attachments that are there in that area and it’s possible that doing less is going to also help with the recovery and the symptoms that the patients will experience long term as far as advantages.
Another advantage in the immediate postoperative period is that we are a little bit more aggressive about feeding these patients and letting them eat more frequently and so patients may experience a little bit better of a recovery we hope. And in that after a Nissan Fundoplication typically on a pureed diet for two weeks after surgery and a lot of patients just have a rough time during those two weeks. It’s hard to take in as many calories through a pureed diet. So you don’t feel quite as perky and we would hope that patients after the LINX procedure will be able to get back to their normal activities and normal eating a little quicker.
Host: Dr. Parmar, who’s a good candidate for this procedure?
Dr. Parmar: Well I think the one thing that patients may not realize is that there’s a lot of work and preoperative evaluation that goes into determining whether or not anyone is a candidate for surgical therapy for reflux. So, one thing I tell my patients, anytime I’m going to mess with someone’s swallowing ability, I want to make absolutely sure I’m doing it for the right reasons, and I have all the information I need. So, there are a number of tests that patients have to undergo and I’m quite frank with them. The tests aren’t very comfortable, there’s a high resolution manometry test where a tube is placed down their nose into their esophagus and stomach and they are asked to swallow and there’s a pH probe and endoscopy and esophagram where they have to drink this chalky substance.
So, it is uncomfortable. Most of the patients who come to see us are kind of fed up with the lack of relief they’ve gotten with their current medical therapy of reflux. And they really want a more salient approach that’s going to last a long time. So, if someone has normal motility on the tests and they have absolutely pathologic reflux on their pH study, then those are the people who would be candidates for a LINX, just the same as those who would for a Nissan.
Host: Dr. Parmar, sticking with you for a second. Sometimes there’s more than just physiological origin such as a weakened lower esophageal sphincter or hiatal hernia that can’t be managed by medications and lifestyle changes alone. Tell us about that.
Dr. Parmar: Absolutely yeah so, I think hiatal hernias are also extremely common. In fact, probably all four of us may have some component of a hiatal hernia. So as I think Dr. Grams mentioned, there is a pathophysiologic basis for how reflux occurs and a big part of it is the failure of the lower esophageal sphincter which is made up of the diaphragmatic fibers and also the way the stomach is kind of oriented specifically in space there. So, if the stomach slides up into the chest, those patients are a lot of times at risk for developing reflux. Not always, but many times that’s the case.
So, again, that lends to the need for the preoperative workup because it will identify those kinds of things that could potentially be corrected surgically and anytime, we place a LINX, we absolutely repair a hiatal hernia at the same time. Just as we would with a Nissan.
Host: Well thank you for that answer. So, Dr. Grams, what have been your outcomes and have there been post approval studies that you know about? Tell us what you’ve seen.
Dr. Grams: Well to answer your first question what have the outcomes been, I think and all three of us have been placing these now and I think for all three of us, we found that our patients have done great. The patients that I personally have done, I’ve seen them all in follow up and they’ve been really happy with the results and they were really happy that they had the LINX procedure.
One of the patients particularly, she was afraid of having the Nissan because she had known family or friends who had previously had the procedure and had significant complications. So, for her, it was – she would have been a candidate for a LINX or a Nissan but for her, it was LINX or nothing. So, I was really glad that UAB is able to now offer this procedure to patients.
In terms of I think you asked me about postop studies. The studies with the LINX have actually been really promising. We, at UAB, we were not the first to jump on the bandwagon because we kind of wanted to see how longer term outcomes were going to be. We are still waiting for long term outcomes, ten year follow up, et cetera, but initially, the outcomes are really good. They’ve learned a lot along the way with placing the LINX. The device has been adjusted. The sizing has changed, the indications have changed and so I think we’re really in a good place right now for offering this to our patients.
Host: Dr. Corey, tell us a little bit about the procedure itself and how is it sized and give a little technical considerations for us.
Dr. Corey: So, the set up for the operation is very similar to the Nissan Fundoplication. It still requires five small incisions through the abdominal wall and into the abdomen. We do this using long instruments that go through small trocars inserted into the abdominal wall and that allows us to access the abdomen and its contents through these small incisions and really give patients a quicker recovery and of course, less chance of hernias and et cetera.
Once we get into the abdomen, we are going to go up and focus on the stomach and lower esophagus. So, as previously mentioned, if there’s a hiatal hernia, where a portion of the stomach has slid up into the chest; we will pull down the stomach and release all the attachments that it has up into the chest, and we will suture back together that hiatal opening that is allowing the stomach to slid up there. So, we will tighten that back into place as it should be. And then we’ll turn our attention to the lower esophagus where we create a window around the esophagus and there is a sizer that we use to determine the size of the esophagus and what would be the appropriate size of the magnetic sphincter augmentation device or the LINX device.
So, once that’s determined, we open the device and essentially the sizing determines the number of magnetic beads. We place the magnetic beads around the esophagus, and these are all – these are on a string and so we have to clasp them or attach them together very similar to how you would attach a necklace. So, once we clasp them, then we will pass an EGD or a camera down the throat into the esophagus and all the way down into the stomach and we will then look back on that opening, the lower esophageal sphincter or the gastroesophageal junction where the esophagus meets the stomach and we want to just make sure that the device is appropriately closing that lower esophagus around the scope.
So, that gives us an idea of if it’s in the right position and if it’s doing its job properly and as long as everything looks great; then we remove the scope and take out all of our trocars and sew up our incisions and that completes the procedure. The patients will then go to the recovery room where they will begin a soft diet in the recovery room. And we ask them to snack every two hours when they are in the hospital and really for the first couple of weeks to allow that lower esophageal sphincter, those magnetic beads, to open and close frequently as they are recovering and as the LINX device is settling in.
There is some scar tissue that can form in the immediate postoperative period and so we don’t want that scar tissue to get too tight. So, that is why we ask them to eat frequently. We also, the following morning will get a swallow study where they will go to the radiology department and drink some contrast and that gives us a view to make sure that everything is in good position and also to have a comparison for in the future if anything comes up. If there are any problems that arise.
Host: Dr. Parmar, as you do yours would you please tell us if the patients still need meds for reflux, will they be able to feel it, when can they eat normally again? Just a few of the basics for other providers that they can counsel their patients on when they are considering this procedure.
Dr. Parmar: Sure. I think the first thing I understand for me and is most striking about the LINX compared to the Nissan is really like Dr. Corey mentioned, the postoperative care. Traditionally after a Nissan, patients will be on a liquid and a pureed diet for four to six weeks after surgery. But with the LINX, they eat, and they really need to be eating normally right after surgery. And for me, that’s a little bit of a game changer when it comes to considering surgical therapy for reflux. In the old days and kind of like we’ve been talking about, most of the time, people start up with a PPI first and then consider surgery only after they absolutely have to.
With the LINX device, the fact that patients can eat pretty quickly, and they actually need to eat, I think has really changed how these patients are managed and how we think about the surgical treatment. I think one of the things to consider that makes UAB a real powerful place to visit for anti-reflux surgery, whatever it may be whether it’s a Nissan or a LINX; is that as this podcast demonstrates, it’s very collaborative atmosphere here. We are not just one surgeon operating alone. There’s at least three of us here who do this operation and we all meet twice a month to discuss cases that are complicated.
So, if you come to UAB as a patient, you are considering anti-reflux surgery or really any treatment for a hiatal hernia or paraoesophageal hernia; you are not just getting the opinion of one surgeon. You are getting the opinion of three kind of experts in their field and I think that’s a really powerful thing to be able to offer as a single institution.
Host: I agree with you completely. It’s very multidisciplinary and comprehensive approach. So. Dr. Grams what would you like other providers to know about the LINX procedure and your comprehensive approach at UAB?
Dr. Grams: In terms of the LINX procedure, I think what I would like other providers to know is that first we obviously think that this is going to benefit patients, or we would not offer it to patients. And I think the Nissan Fundoplication has been around for so long and has really been the standard of care but as has been mentioned throughout this podcast, there have been side effects of it. And so, this is a really exciting new therapy we can offer patients for reflux. And it makes physiological sense in the sense that the magnet expands and contracts whereas other things that we’ve place around the stomach or esophagus in the past for whatever reasons has really been fixed including the Nissan although it is floppy.
And so, presumably, this will be a viable good alternative treatment for reflux. On the other hand, I would like to balance that with knowing that we are still really early in our experience with LINX. The Nissan has been around for decades. This while not brand new, we’re still waiting for five, ten, year longer follow up to really be able to see what’s the durability, what are the long term outcomes of this device. And so, while we are enthusiastic about it; I would just balance that with knowing that we still need to know what the longer term outcomes are going to be.
And so, I think Dr. Parmar briefly touched on this in that it is a multidisciplinary approach and we see quite a few patients who come to us because they’re concerned about what they hear in the news or see in reports about the risks of being on long term PPI therapy. And I think having the multidisciplinary conference, having gastroenterologists engaged, the surgeons engaged really helps us discuss the pros and cons, benefits, risks, of each of these interventions with the patients but also among ourselves to really give the best picture to the patient.
Host: And Dr. Corey, last word to you. What would you like patients, other providers to know about the LINX procedure and how it can help in the long term?
Dr. Corey: I think I would like other providers to know that we are always happy to see their patients and to have a discussion in clinic face to face with the patient about options and sometimes that options is just to continue therapy and to keep surgery on the back burner and see how they are treated. But we are happy to give them our experience, give the patients our experience and always happy to discuss patients on the phone or via our secure messaging system here so that we can just make sure that we are taking a kind of 360 degree view of the patient and approach to the patient in considering all options for them beyond just medical therapy.
So, that’s what I would like other providers to know. We are always happy to pick up the phone. For patients, I would like to echo what my partners have said about the multidisciplinary approach but also just let them know that we have outstanding people that are working here with the patient in the GI lab where we do testing. Our techs are wonderful people who really do everything they can to make some uncomfortable tests as comfortable as they can be. And that everybody here is really dedicated to taking a very thoughtful approach to the treatments that we offer because we want to do what’s best for the patient.
There’s no better feeling as a provider, as a physician than having our patients come back to clinic and be excited about how for the first time in five, ten, fifteen years they have been able to sleep lying flat and not experience this intense burning in their chest and are able to really get their symptoms managed and back under control. And we all really appreciate that, and we want to do what’s best for our patients and give them relief from their heartburn.
Host: Thank you so much, all of you and thank you for coming on and sharing your expertise and explaining to other providers this procedure and the technical considerations and the advantages. Thank you again.
A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please head on over to our website at www.uabmedicine.org/physician. If as a provider, you found this podcast as informative, as I did, please share with other providers. Share it with your patients, share on social media and be sure not to miss all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua124.mp3
- DoctorsLindeman, Brenessa
- Featured SpeakerBrenessa Lindeman, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5904
- Guest BioDr. Brenessa Lindeman is a native of Kentucky, receiving her M.D. from Vanderbilt, and is a member of Alpha Omega Alpha. She did her residency in general surgery at Johns Hopkins University and completed a fellowship in endocrine surgery at the Harvard/Brigham and Women’s Hospital.
Learn more about Brenessa Lindeman, MDRelease Date: September 3, 2019
Reissue Date: August 31, 2022
Expiration Date: August 30, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Brenessa Lindeman, MD, MEHP
Associate DIO for the Clinical Learning Environment; Co-Director, Multi-Disciplinary Endocrine Tumor Clinic
Dr. Lindeman has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Welcome. Today, on the Med Cast we’re examining retroperitoneoscopic adrenalectomy. And my guest is Dr. Brenessa Lindeman. She’s an endocrine surgeon in surgical oncology at UAB Medicine. Dr. Lindeman, what an interesting topic in my research. This is really fascinating. Please explain a little bit about retroperitoneoscopic adrenalectomy, this approach. Tell us a little about it.
Brenessa Lindeman, MD (Guest): Absolutely. And thank you for having me today. I have to say that adrenalectomies are one of the most interesting operations that I do because there are a variety of different approaches but of those that I offer, that being an open approach to adrenalectomy, a laparoscopic transabdominal approach to adrenalectomy and this retroperitoneoscopic adrenalectomy. The retroperitoneal approach is by far my favorite for reasons that I will explain.
What it involves is the most direct approach to the adrenal glands possible that rather than trying to go across the abdominal cavity and move other organs out of the way to reach the adrenal gland that lives at the back of our abdominal space, just above the kidneys; we can actually approach it through the back in a more direct fashion and avoid all of the intraabdominal organs that exist.
Host: Dr. Lindeman thank you for that explanation. What is the evolution of it? Why was there a need? Tell us how those indications have evolved. As you said it’s the most direct route to the adrenal glands. How did this all come about?
Dr. Lindeman: Yes. So, when laparoscopic or a minimally invasive approach to surgery began in the early 1990s, it was recognized early on that adrenalectomy would be an operation that would greatly benefit from a minimally invasive approach. Because in order to reach the adrenal glands, way at the back of the abdomen; patients had to undergo very large incision which was associated with much morbidity and an extended recovery period.
And so, while many surgeons began investigating a transabdominal approach, interestingly, only about a year after the initial laparoscopic adrenalectomy was described; the first what was called endoscopic retroperitoneal adrenalectomy was described. Because for many patients, if they have had prior intraabdominal operations; it can be quite challenging to navigate the scar tissue that has formed or otherwise be able to access the adrenals using a transabdominal approach.
And another great indication for the retroperitoneoscopic approach is that the patient is placed in the prone position or in the face down position which allows easy access to both sides for patients that need to undergo a bilateral adrenalectomy within the same operative setting. With other approaches to adrenal surgery; the patient either has to have a very large open incision to access both adrenal glands or they would need to have one side completed and then the patient would have to be repositioned to the other side and basically an entirely separate operation begun in order to perform a bilateral adrenalectomy using a minimally invasive transabdominal approach.
Host: That is so interesting that you don’t have to transverse the peritoneal cavity or mobilize other surrounding organs including potential scar tissue. What an interesting approach. So, tell us about patient selection criteria and who is it indicated for. Can everybody have this or not so much?
Dr. Lindeman: Well there are certainly patients that are ideal candidates for this approach and others for whom it becomes quite challenging. The working space with the retroperitoneal approach is smaller when you compare it to the working space in the abdomen more generally. And so, we tend to consider patients with adrenal masses that are six centimeters or less in size. Sometimes we will approach adrenal masses that are a little larger than that in certain circumstances but that is typically the cut-off that is used.
Additionally, there are some facets of a patient’s body habitus that can make the approach more challenging. One study that I conducted with some fellow investigators examined the thickness of the patient’s back musculature and skin and subcutaneous tissue and if that distance was greater than 9 centimeters in size; then we identified that the operative time for those patients was significantly longer than when patients has less retroperitoneal subcutaneous tissue that was present.
And so, I try to use the imaging that patients have had preoperatively to very carefully select which patients would benefit most or be the ideal operative candidates for this approach.
Host: Then Doctor, what have trials comparing retroperitoneoscopic adrenalectomy with transabdominal laparoscopic adrenalectomy shown? When you are looking at the two techniques, how is the RP technique shown to be superior for the patient?
Dr. Lindeman: Yes, I’m glad you asked because there has been many studies that have compared the retroperitoneal adrenalectomy approach with the transabdominal laparoscopic approach and in all but one of these, the retroperitoneal approach was found to have superior outcomes to the transabdominal laparoscopic approach and in the most rigorous study that was conducted; a randomized single blind controlled trial; that one was published in 2014. It identified that the retroperitoneal approach to adrenalectomy was superior to the transabdominal laparoscopic approach in terms of operative time, blood loss, hospital lengths of stay, postoperative complications and it also found that patients that had the retroperitoneal adrenalectomy had a shorter time to taking food by mouth and also les postoperative pain.
Host: Doctor, as complex as this is, can it be an outpatient procedure?
Dr. Lindeman: Absolutely. And when I’m counseling my own patients, I often tell them that it’s similar to having a laparoscopic cholecystectomy. And I believe that my patients that have a retroperitoneoscopic adrenalectomy actually have even less pain than patients that have had their gallbladder removed. There are some patients that require adrenalectomy for hormonally active tumors that can cause severe alterations in their blood pressure that will necessitate a need for overnight observation.
But I will tell you that in my own practice, the majority of my patients that undergo a retroperitoneoscopic adrenalectomy go home the same day or if their underlying adrenal condition warrants that overnight observation; they all go home the following day.
Host: That’s amazing. So, speak about the learning curve and what other providers might find interesting about your surgical technique and what are some technical considerations you’d like them to know about?
Dr. Lindeman: Absolutely. One of the interesting facets of the retroperitoneal approach to adrenalectomy that has been described is that it has a little bit steeper learning curve for surgeons that intend to add this to their armamentarium than does the transabdominal laparoscopic approach. And that simply relates to the familiarity of the surgeon with the anatomy that they are seeing. When I am training residents and fellows to utilize this approach; I will often flip the CT scan upside down so that they are looking at it in the same view that they will have within the operating room.
So, it requires the surgeon to be a little bit mentally flexible in their ability to manipulate the images and the views that they are seeing in their mind as they are first learning. But it’s been shown that once the surgeon reaches somewhere over 25 to 30 operations being performed this way; that their operative times greatly decrease, and they can perform this safely independently.
So, there are a few centers that offer this approach across the United States. And I am fortunate to have trained in a very high volume retroperitoneoscopic adrenalectomy center and I feel very excited to be able to bring this approach to UAB and to the patients in Alabama and across the southeastern United States.
Host: So, where do you see it going from here Dr. Lindeman? Tell us about some promising new therapies. If you were to look forward to the next ten years in the field; what do you see happening and changing?
Dr. Lindeman: Yes. I think that we will see an even further advance in terms of the technology that we are able to use. Currently, this operation is performed with three small ports that is the only part that the patient sees in terms of what’s left over following the procedure. But I think that we will be able to really advance in two ways.
One is that some patients, a small percentage, about 5% or so, after this approach, will experience a temporary abdominal wall laxity meaning that the muscles of the abdominal flank or the side of the abdomen lose a little bit of tone after surgery for a period of a couple of months and then this goes back to normal. That is caused from irritation to one of the nerves that lives in the area in which the ports are placed. And we are finding that we will have an increasing ability to identify where that nerve is using imaging modalities in order to prevent that complication in advance.
And the second advance that I see coming forward is that as our technology in minimally invasive surgical techniques continues to be refined; we will see probably robotic surgical techniques that can utilize one slightly larger port than what is used currently today, that is able to introduce multiple arms and to be able to accomplish this operation with an even smaller incision length than what we can today.
Host: How interesting. So, as a wrap up Doctor, tell other physicians what you’d like them to know about retroperitoneoscopic adrenalectomy and when you feel it’s important that they refer to the specialists at UAB Medicine.
Dr. Lindeman: Thank you. I would tell all of the providers listening out there that all patients that have an adrenal mass that is identified greater than a centimeter in size should continue to undergo a functional hormonal workup and then I would tell them that if they identify a patient that has a functional adrenal mass or any adrenal mass that’s larger than four centimeters in size; that patient should be evaluated by a high volume adrenal surgeon. Because that individual is going to be best positioned to provide the comprehensive and multidisciplinary care that these patients benefit from and will have been shown in multiple studies to be associated with a lower rate of complications.
And so, I’m very excited to be able to offer this retroperitoneoscopic adrenalectomy technique through which, I am able to offer outpatient adrenalectomy in a large majority of cases and offer this approach wherein patients have less pain, can eat and drink sooner and experience a lower rate of complications than patients even with the very well tolerated transabdominal laparoscopic approach.
Host: Wow, what an interesting segment. Thank you so much Dr. Lindeman. You really put me to the challenge today and I appreciated it and it is I hope for other providers, as interesting as it was for me. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician. If you, as a provider, found this podcast as informative as I did, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library because there are quite a few. Until next time, this is Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua114.mp3
- DoctorsMorlandt, Anthony
- Featured SpeakerAnthony Morlandt, MD, DDS
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5783
- Guest BioAnthony Morlandt, MD, DDS was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.
Learn more about Anthony Morlandt, MD, DDS
Release Date: June 14, 2019
Reissue Date: May 23, 2022
Expiration Date: May 22, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Anthony Morlandt, MD, DDS
Associate Professor, Oral and Maxillofacial Surgery
Dr. Morlandt has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Patients with head and neck cancers face the dual challenge of surviving their cancer and facing functional changes in swallowing, speech and sometimes appearance. Today, we are talking about the transoral minimally invasive microsurgical facial reconstruction. And my guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an Associate Professor at UAB Medicine. Dr. Morlandt, let’s start by speaking about treatment for head and neck cancer and reconstructing the face and throat after cancer has been removed. Start with some of the goals of the reconstruction for the patient and protecting those vital structures’ function and form.
Anthony Morlandt, MD, DDS, FACS (Guest): Yeah, that’s a great question. So, when we talk about malignant disease; the first goal is survival and to make sure that there are wide surgical margins but many times the immediate goal is to cover a wound so that that patient can survive their treatments. Whether it’s radiation therapy or radiation combined with chemotherapy. So, for example, if we resect the tongue and floor of mouth and maybe a portion of the jaw to clear a cancer; that will create an open pathway between the mouth and the neck. And the carotid artery and jugular vein which have also been exposed because of the neck dissection procedure where all of the lymph nodes are removed; if those vessels are exposed to saliva; the amylase in the saliva can cause breakdown and damage to the blood vessels and result in what can be a life threatening bleed.
So, in the short-term, the big picture of microvascular reconstructive surgery for the head and neck is to create a safe wound that allows that patient to get through their treatment. And if it were just that easy, if it were just about plugging a hole or putting tissue in place; there wouldn’t be much to talk about. But and sometimes for other body sites; it is an opportunity for obturating a defect or covering hardware. But in the head and neck we need patients who can speak and chew and swallow appropriately. And when we look at quality of life data after head and neck surgery; believe it or not, appearance, cosmesis and even pain, those outcomes are much lower in priority compared to speech, chewing and swallowing.
And so, for that reason, we have to be able to incorporate many disciplines such as dentistry, prosthodontics, maxillofacial surgery, head and neck surgery, speech language pathology, occupational therapy, nutrition, swallowing; all of these different specialists have to work together to help the patients meet those outcomes.
In terms of the microsurgical reconstruction; that arose in the 1980s and 90s for head and neck surgery because the goal of transferring vascularized tissues needed to include bone in most cases and there are really no bones adjacent to the head and neck that can be used in a pedicled fashion where the blood supply is maintained.
One option that’s been reported in the past was to take a piece of the clavicle and bring the clavicle up with the pectoralis major muscle and try and use that for jaw reconstruction. Others have reported the use of the rib with the latissimus dorsi muscle, but that creates quite a bit of tethering, contracture of the head, limited mobility of the neck and all in all, it did not provide the best long-term results and so now we try to have thin tissue that functions inside the mouth. We don’t want it to be too bulky so that it interferes with speech and swallowing. We don’t want to have a piece of bone that’s not in alignment with the dental arch.
And so if I have a piece of leg bone that doesn’t line up properly with the teeth and the top jaw for example; that patient can’t chew, no matter what we do. So, the alignment is critically important. The thickness of the tissue is important and also making sure that we maintain a seal between the mouth and the pharynx and separate those from the great vessels of the neck.
And all of that is done with the overarching theme of airway preservation. Making sure that that patient doesn’t have a compromised airway after surgery in the acute phase or even long-term by external compression from heavy soft tissues.
Host: Doctor, as you are talking about this multidisciplinary approach to care for someone with these types of cancers and the many providers that are involved, and as reconstruction is an extremely demanding challenge for all of you surgeons; tell us about some of the benefits for the surgeon when you are using some of these minimally invasive techniques that you are describing, that could allow you to reach and access some of those hard to reach areas of the mouth and throat. What are some of the benefits? What are you doing?
Dr. Morlandt: Right so, what I described are the traditional ways of bringing up tissue and using that to reconstruct the jaw for example. What has happened in oral and maxillofacial surgery since the 1960s is external facial incisions have been traded for oral cavity incisions. And so, one example of that is jaw repositioning surgery for someone with a small jaw or a large jaw or an excessive overbite or overjet or other facial deformity; most of the incisions nowadays can be done from inside the mouth. And that means the jawbones are cut, osteotomized, they are moved into a new position, they may be fixated with plates and screws, the jaws can be wired together; all of it is done in a minimally invasive fashion transorally.
That hasn’t really caught on with head and neck surgery, both in malignant and benign disease and the main reason for that is because we need excellent visibility for malignant disease to create a wide margin. We also tend to operate through the neck to remove the lymph nodes around the great vessels. So, it has led to larger incisions, more scarring, more contracture, longer length of stay in the hospital and for the surgeon; it gives us more wound issues to deal with.
In the case of benign diseases such as ameloblastoma an ossifying fibroma; we’ve transitioned completely to transoral incisions to approach the mandible and to resect the mandible up to and including the entire jaw through the oral cavity and when the reconstruction is placed; it’s also done through the oral cavity with a very tiny 2 centimeter incision in the neck to provide access to the blood vessels.
The blood vessels are dissected out through that small neck incision which is provided in a natural skin crease for cosmesis and the microsurgical anastomosis is then done through that very small incision. So, that allows for a patient to recover from a jaw resection, who doesn’t need a tracheostomy, who can stay in the hospital three to four days and go home, who speaks and swallows earlier and importantly; doesn’t have any external scarring. And what I’m finding is more and more patients are demanding that.
They know that we can do things in medicine and particularly at a large advanced center like UAB; we can do things in a way that doesn’t produce a lot of deformity. And that’s what they expect and that’s one of the first things they ask is will I have any external scarring from this resection. And I’m happy that now in many cases we can say no, there’s not any or very little external scarring that’s left behind.
Host: Is this everything you are describing; is this now, do you see the standard of care, are you seeing it going on around the country and when do you want other physicians to refer to the specialists at UAB for these kinds of amazing procedures?
Dr. Morlandt: Yeah, I think in cases of malignant disease; we still are using fairly limited incisions to provide a neck dissection. The data for sentinel lymph node biopsy for squamous cell carcinoma of the oral cavity is very limited so, that has not taken hold as the standard of care in the United States. At least not in our center. Obviously, that’s different for diseases like melanoma and Merkel cell carcinoma. But for patients who have a need for cancer resection and microvascular free-flap reconstruction; we really would like to see these patients early.
If someone has an expansile destructive jaw tumor for example, like ameloblastoma or if they have osteonecrosis of the jaw; many times we can perform those operations completely transorally. And so these are individuals we’d like to see and discuss and that has changed in recent years. it used to be, a large jaw tumor that these patients would have almost the same operation as someone with head and neck cancer. And that’s hard for the surgeons because we are seeing patients who have a condition that will not metastasize, condition that is not by itself a terminal illness and we are treating them with almost the same surgery as we would someone with head and neck cancer.
So, we are trying to pare those treatments down. We are trying to make them more patient specific using 3-D navigation, 3-D surgical planning, the fabrication of low profile surgical cutting guides that can be used in surgery, and placement of dental implants and immediate dental provisionalization all done during the same operation through the open mouth and not having to use large deforming visible neck incisions.
Host: Wow. They way you describe it, it really paints a very clear picture for other providers of what it is that you are doing. Wrap it up for us. What would you like them to know about these types of procedures that you are doing there and where you see this field going in the future to treat these types of cancers?
Dr. Morlandt: I think the field or oral and maxillofacial surgeries set the tone for doing skeletal bone cuts, skeletal repositioning and osteotomies through the mouth. Other fields use natural orifice surgery all the time and minimally invasive single port robotic surgery. We have just developed this practice at UAB as well.
But I think what’s exciting about head and neck surgery in particular the benign aggressive head and neck operations we perform; is we can now also provide those in a minimally invasive fashion and it’s much better for patient’s recovery, for their quality of life, for their length of stay in the hospital, their complications and their long-term functions.
So, it’s a great service that we can provide our patients and I’d like the community to be aware of it.
Host: Well, they certainly will after hearing this Dr. Morlandt. Thank you so much for joining us. You are just an excellent guest with so much usable information and such a good educator. You are really a great educator. Thank you so much for joining us.
A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. This is UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. I’m Melanie Cole. Thanks so much for tuning in. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua113.mp3
- DoctorsMorlandt, Anthony
- Featured SpeakerAnthony Morlandt, MD, DDS
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5778
- Guest BioAnthony Morlandt, MD, DDS was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.
Learn more about Anthony Morlandt, MD, DDS
Release Date: June 14, 2019
Reissue Date: May 23, 2022
Expiration Date: May 22, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Anthony Morlandt, MD, DDS
Associate Professor, Oral and Maxillofacial Surgery
Dr. Morlandt has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Welcome. Today we are talking about some of the exciting technology advancements in oral oncology. My guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an Associate Professor at UAB Medicine. So, Dr. Morlandt, I’m glad to have you with us. Tell us a little bit about the history of how cancer has been treated classically and what’s changed over the years?
Anthony Morlandt, MD, DDS, FACS (Guest): Well head and neck cancer is a longstanding human condition. It’s been around for probably millennia and in recent recorded history; we have cases like President Ulysses S. Grant who would receive thousands of cigars every year, when he was in the White House and when he died in 1885, he spent the last six months of his life treating his head and neck cancer with cocaine mouth rinses and bourbon. He had no option for treatment. The tumor was unresectable at diagnosis and he ultimately died in Mt. Meader, New York, handwriting his memoirs. So, his wife had some source of income after she died. Mark Twain published the memoirs and it provided income for their family for the rest of her life.
But when we have a patient like President Grant, and we compare him to someone like Michael Douglas who had the same tumor in a similar location; their outcomes couldn’t have been more different. The way cancer has classically been treated is first with surgery. Surgery has been used for about 150 years for these tumors. Surgery involves removing the cancer itself with wide margins, 1 to 1.5 centimeters in most cases for squamous cell carcinoma, usually quite a bit larger for the more rare sarcomas that we see in the head and neck.
And then in the 1950s, 60s and 70s; the rise of radiation therapy came, and radiation therapy is typically not used for first line treatment or oral cavity tumors because of all the vital structures such as the mandible and the teeth and the oral tongue and even the lips which can be damaged by high dose radiation therapy.
And in the current era, we are seeing the rise of immunotherapy and patient specific personalized medicine that can be used where a specific mutation is identified within the tumor and then targeted therapy is administered to that patient to try and shrink specific tumors that have been refractory to surgery and radiation therapy and typical cytotoxic chemotherapy.
Host: Doctor, due to that intricate nature of these types of cancers and facial reconstruction, which we will talk about at another time; what have been some of the past challenges that you’ve noted and how do you feel that some of this technology, endoscopic instrumentation coupled with improved imaging and localization; how has that helped to improve outcomes and what have you seen?
Dr. Morlandt: Yeah so, one example of that is an upper jaw cancer. For example, Grover Cleveland had a maxillectomy for an upper jaw tumor which was – later there was question about whether that represented malignancy or not. But he had that done on a boat during his presidency in secrecy with ether anesthesia and cocaine local anesthesia injection. But when the upper jaw is removed; it used to be felt that if any tissue was placed over that defect to close off the site of this cavity or the nasal cavity; it would be very difficult to identify cancer recurrence. And so some things we use to identify recurrence in those cases are a flexible fiberoptic endoscope that can be placed into the nasal cavity in clinic after using a little bit of vasoconstrictor and local anesthesia aerosolized into the nose; and that can identify tumors that may arise in hidden locations such as the sinus or the maxillary sinus or the nasal cavity.
We also can use CT imaging. So, there are plenty of papers in the literature that show the sensitivity of CT scans especially those with contrast allow us to cover those defects with a free-flap, for example and still pick up a recurrence very early.
The literature tells us though and the NCCN guidelines suggest that patients who have a recurrence whether it’s one year or two years all the way up to five years after their cancer treatment; patients tend to identify those recurrences themselves and present because of those new findings and so that may be a new neck mass, it may be new pain, swelling in the primary site, difficulty swallowing. In the case of a maxillary or sinus cavity cancer; it may be nose bleeds, intractable nose bleeds or new sinus congestion.
So, many times the patients are identifying a change and so that’s why we have a very robust survivors clinic, surveillance clinic after their treatment where the patients can come in and be seen by a physician or an advanced practice provider for up to five years after their treatment and then once a year after that for life just to be sure that we have that relationship open with the patient and family so that if they find any change; they can come back and see us.
So, detection before diagnosis is important. Detection after treatment is important. And then we have some ways that we can identify patients who need the very best in terms of long-term function up front. We have a combined oral oncology clinic which consists of an ablative cancer surgeon, a resection surgeon, a reconstructive surgeon who has advanced training in microsurgical principles and maxillofacial prosthodontist. And this is a dentist who finishes dental school, finishes prosthodontic training for three years and then does an additional one to two years in head and neck cancer prosthetics. And that may include replacement of a missing eye, a missing ear, a missing nose, missing teeth or jaw, all using silicone or acrylic or cobalt chromium or vitalium, all of these different materials that can be used for replacement of missing hard and soft tissues.
So, the prosthodontist sees every patient before surgery and many times they can optimize using 3-D imaging, 3-D scanning and even 3-D printing. They can optimize their long-term function after surgery. So, it’s a team approach.
Host: Isn’t that fascinating and I was going to be asking you about the 3-D computer planning for presurgical resection and intraoperative navigation. Tell us when you are looking at all of these factors and technology Dr. Morlandt, what do you think is the physician learning curve? Is this something that you feel is happening around the country? Is it catching on as it were? Are there plenty of resources available for physicians to learn all of this new technology for this very specific type of cancer?
Dr. Morlandt: Oh, I think there are. I think we live in an age now where we are digitally driven. My children can pick up an iPhone and get places I could never go surprisingly and so, I’m always amazed that the technology, the interfaces are pretty easy to use. I think what’s so fascinating about an academic practice is we’re just standing on the shoulders of those who’ve gone before. So, you know 40 years ago, there was no option for reconstructing a missing jaw. In 1989 Hidalgo from Memorial Sloan Kettering out of the plastic surgery world, described the use of a fibula flap for jaw reconstruction but mentioned in that paper that it was not advised to replace missing teeth with dental implants because it was felt that that would be deleterious, or it could damage the blood supply to the flap. He also felt that using skin from that particular flap could cause long-term wound breakdown and that the flap would be unreliable.
Well a few years later, people began putting dental implants into the fibula. But that would take many, many months and sometimes over a year and that was complicated by the fact that patients needed radiation therapy and that patients many times couldn’t afford the implants. Well now at UAB, our patients who have head and neck cancer and particular jaw cancers can have the implants with the use of 3-D imaging and 3-D surgical navigation that can place the implants into the leg bone, the prosthodontist comes in and puts the teeth, the temporary prosthesis at the leg. I then divide the blood vessels and transfer the leg, the metal plate, the implants and the teeth up to the jaw, hold it in place with plates and screws, reconnect the blood supply under the microscope; and that patient truly has a total jaw reconstruction done in one day.
And that is only available because of all of the different technological advances that have been made over the past 20 years. and it’s just a matter of taking all of that information and combining it. So, I think sometimes surgeons are – we have to be innovators but more than that, we have to be assimilators of data and combine different thoughts and cross disciplines, cross dentistry, cross oral and maxillofacial surgery, otolaryngology, plastic surgery and use all of these different backgrounds to come together with a very good product for our patient. Very good outcome.
Host: That is so cool. Dr. Morlandt, what you just described is absolutely amazing. So, as we wrap up where do you see this field and the technology going? I mean wow, what you’ve described to us today sounds so advanced and of course it can get more advanced. Where do you see it going in the next five to ten years?
Dr. Morlandt: Well it would be great if we got to a time where we didn’t have to do head and neck cancer surgery. So, our utility is as ablative surgeons, could be smaller and I think that is coming in terms of the medical oncology research and some of the molecular work that’s being done in radiation oncology.
In terms of reconstruction and helping these patients function because to be honest, we don’t really help patients long-term is we have – if they survive but they can’t speak, chew or swallow. And so, we want to make sure we optimize their function. But I could envision a time where we are not – we don’t have to harvest someone’s own bone, muscle and soft tissue to reconstruct the face where we can use a scaffold and the scaffold can be populated with pluripotent stem cells and be used with the right combination of growth factors and cell signaling molecules can be used to generate some bone and soft tissue that can then transferred to that patient.
A version of that is already being done where we will prelaminate or prefabricate a flap where I may take some cartilage or some mucosa or some skin and place that just on top of the fibula bone and then when the – or under the radio forearm distribution and then when that’s transferred; you have some flap component that’s already been sort of repaired. But that still requires a second donor site surgery. So, I can envision a time where we are creating smaller wounds and we have a need for smaller reconstruction and that ultimately impacts patient’s quality of life, their length of stay in the hospital, their risk of surgical wounds and infection and all of the complications that are associated with these operations we do.
So, I think we are just getting more and more streamlined as time goes on.
Host: Absolutely fascinating. Thank you so much for joining us today and sharing your incredible expertise explaining all the technology that’s available now for these types of cancers. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for tuning in. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua112.mp3
- DoctorsMorlandt, Anthony
- Featured SpeakerAnthony Morlandt, MD, DDS
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5773
- Guest BioAnthony Morlandt, MD, DDS was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.
Learn more about Anthony Morlandt, MD, DDS
Release Date: June 14, 2019
Reissue Date: May 23, 2022
Expiration Date: May 22, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Anthony Morlandt, MD, DDS
Associate Professor, Oral and Maxillofacial Surgery
Dr. Morlandt has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome. Today we’re talking about trends and oral cancer survival in Alabama. My guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an associate professor at UAB Medicine. Dr. Morlandt, I'm so glad to have you with us today. Tell us a little bit about the current state of oral cancer. What’s the prevalence in the country and specifically in Alabama?
Anthony Morlandt, MD, DDS, FACS (Guest): Well thank you Melanie. Good morning. Alabama has long been known for being number one in things like Roll Tide football and War Eagle football. But in terms of oral and oropharyngeal cancer, we’re currently ranked as number five. We had 880 estimated cases reported in 2019, and about 180 deaths from oral cavity and oropharyngeal cancer. So a fair number. Nationwide, we see 53,000 new cases a year.
Host: Wow. That’s quite a statistic. So how are the risk factors in Alabama being examined to discover those trends and survival rates? Tell us why you think this is happening.
Dr. Morlandt: Well, it’s traditionally been thought that tobacco and alcohol act synergistically to create tumors, or at least allow for premalignant conditions such as dysplasia, which may present as a white patch or a red patch or a combination of those. That these premalignants will undergo malignant transformation due to the tobacco and alcohol influence. In 2007, the World Health Organization identified HPV, and in particular high risk subtype 16, as a causal agent responsible for the development of oropharyngeal cancer. So work out of Johns Hopkins and other important centers have demonstrated this massive upswing in new cases of oropharyngeal cancer, and actually a decrease in the non-HPV related oropharyngeal and oral cavity cases, which is probably related to smoking cessation efforts. I know here in Alabama and in most other states in the union, it’s illegal to smoke in restaurants and in bars. So we’re seeing that that has caused some improvement in those non-HPV related cases.
There are other agents that are really poorly identified and may be related to genetic polymorphism, specific alterations or mutations in the human genome. So for that reason, we’re seeing this increase in young female patients, in particular young Caucasian female patients with oral cavity cancer. The most common site for an oral cavity tumor is the tongue. So these are patients who are non-smokers, non-drinkers developing mouth cancer in their 20s and 30s. Anecdotally, that’s what I'm seeing a lot in my practice are these young patients who see a dentist regularly, who have excellent health, who don’t have vices like tobacco and alcohol, and still have HPV negative tongue cancer. So it’s a very interesting group that really warrants further investigation.
Host: Well, that is an interesting group because my next question was going to be where in the continuum of diagnostic criteria is HPV a factor in this trend? Are there higher rates of HPV in Alabama, or is this a country wide thing?
Dr. Morlandt: Well, the interesting part about an HPV infection is almost everyone is exposed to the human papilloma virus at some point. Because of that, that individual may develop antibodies and even express HPV DNA in their serum. Of all of the HPV types—the types that cause oral and genital warts, the type that cause malignancies such as oropharyngealcancer or cervical cancer—of all of those types, there’re only a few high risk subtypes that are associated with the development of cancer. So after your body clears the HPV virus, you have to have an overexpression of these particular oncoproteins, which are called E6 and E7. If those are overexpressed, these patients can then develop by way of oncogenesis and malignant transformation can then develop the actual malignancy.
There is a spot in the transition zone between the keratinized thicker tissue, protective tissue lining the oral cavity that you might see on the hard palate and around the teeth related to the gingiva. There’s a transition between that thicker, healthier tissue, more robust, and the softer lining non-keratinized mucosa of the oral pharynx. So at that junction, which you can see by looking in your mouth as the junction between the hard palate and the soft palate, you can identify by speaking and seeing where the vibration occurs. At that junction, there’s a bit of an access point for these viral cells or these viruses to invade the normal mucosal cells. So it’s hard to pin down exactly how many patients who have been exposed to HPV will actually develop cancer because there’s so many steps in the process of oncogenesis.
Host: Then let’s talk about awareness, disparities. Not only in research models because we know that’s gone on for years, but in the availability of healthcare and awareness. Are these stratified by stage of diagnosis? Do you see that there’s disparities in more of the rural communities even knowing about the risks for oral cancers? Tell us what strategies you employ to raise that awareness and what you see happening.
Dr. Morlandt: That’s a huge part of what we do at UAB. So I started the oral oncology service at UAB in collaboration with the department of otolaryngology and the great work that they’ve been doing there for 30 years to raise awareness. My particular focus has been to engage dentists and hygienists as first line defenders and identifiers of tumors. There have been a number of papers showing that patients with an oral cavity cancer, in about 75% of cases, will see a dentist or hygienist first.
Another paper from Journal of Oral and Maxillofacial Surgery in 2003 showed that patients who are seen by a dentist or hygienist have an earlier stage of diagnosis and are treated with better long term success than a patient who is initially seen by an urgent care clinic or an emergency department. The main reason for that is because asymptomatic tumors that are picked up by a dentist or hygienist are smaller, and it sort of makes sense. If I have a neck mass and I present to my neck doctor or if I have a large tongue ulcer or a tongue fungating exophytic lesion, then my stage is naturally higher, and my survival is lower.
So because of those realities and because of the significant increase in survival in catching these tumors early, UAB Oral and Facial Surgery has reached out to the dental community by way of lectures and continuing education. Also a Watch Your Mouth campaign which has launched just this month in April we’ve handed out bathroom cards for patients to do a self-examination with nine different points where they can examine their own mouth and throats. They can palpate their own neck. We’re educating dentists and hygienists to palpate the neck to find normal anatomy. We spend a lot of time in dental schools and with medical students to make sure that dentists and physicians, whether they're specialists or generalists, have at least the basic knowledge to find an oral cavity tumor.
When you talk to patients who are diagnosed, many times they’ve been through a very long course. They’ve seen six or seven different specialists. They’ve seen generalists. They’ve had antibiotics. They may have had a fine-needle aspiration of a neck mass, and all of these efforts tend to delay diagnosis and ultimately can impact survival. When Michael Douglas, the actor, spoke at our national meeting a few years ago, he said he saw six specialists prior to having a diagnosis. He had lots of resources at his disposal. So our patients in the rural parts of Alabama who don’t have access to many physicians and maybe don’t have ways to get around easily, and especially may be underfunded or underinsured, we really have to help them make sure that when they see an individual, they're getting the very best care and the earliest opportunity for intervention.
Host: Those are some great ways of outreach. Dr. Morlandt, how do you evaluate the impact of such programs on your outcomes? What have you seen as a result of all of this hard work and outreach?
Dr. Morlandt: Yeah. It’s tough because where increased availability occurs, we have increased utilization. So the more people we have looking for oral cancers and certainly premalignant disease, the more patients who are referred. So it may seem, in the short term, like our numbers are going up. I would prefer dentists and hygienists and primary care physicians to identify stage I tumors or premalignant diseases. We would rather take care of many of those patients before they end up presenting with stage IV disease. So it’s a little tough to assess that.
I would say since our efforts began, our case volume has exponentially increased. I think over time we’ll begin to see that these patients—While the numbers we’re treating here at UAB have increased, we’re seeing that many of those are earlier stage patients, earlier stage tumors, and their long-term survival is much improved.
Host: What an interesting topic and such great information. Doctor, as we summarize, what would you like listeners to take away from this about these trends in oral cancer, and where you see it going from here. What do you think is going to happen in the next five or ten years or so?
Dr. Morlandt: So one thing to remember is unlike colon cancer or breast cancer or prostate cancer, we have no widespread screening assay. You may have a blue light used to asses tissue auto-fluorescents or tissue reflectance by your dentist, but the pretest probability has to be sufficiently high to use that test in screening. What we do see is the incidence or oral cavity cancer is still fairly low, as the eighth most common malignancy in the United States. So there’s no screening assay. I can’t order a PSA. I can't do mammography. I can't do a colonoscopy. It has to be white light visualization with a trained eye, and then a scalpel biopsy for tissue diagnosis. So it means that we typically need to assess these patients early and often. They should be seen by a specialist, and we should have a limited, very low threshold for doing a biopsy. I think if we continue to do that in Alabama, we’re number five for incidents in the country. I think we can see that number drop dramatically. That would be very satisfying that UAB could be a part of that drive statewide and even regionally in the southeast.
Host: Thank you so much for coming on. As I said, what a fascinating topic and the way that those trends work. Thank you for sharing your expertise and discussing that with us today. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for tuning in. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua115.mp3
- DoctorsParmar, Abhisek
- Featured SpeakerAbhisek Parmar, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5792
- Guest BioAbhisek Parmar, MD completed his minimally invasive and advanced gastrointestinal surgery fellowship at Oregon Health and Science University in 2017. He has authored multiple chapters on hernia disease and has several active research projects investigating ways to improve hernia care. His clinical interests include minimally invasive approaches to large abdominal wall hernias.
Learn more about Abhisek Parmar, MD
Release Date: May 28, 2019
Reissue Date: May 19, 2022
Expiration Date: May 18, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Abhishek Parmar, MD, MS
Assistant Professor in Gastroenterology & General Surgery
Dr. Parmar has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome. Today we’re examining options for minimally invasive hernia surgery. My guest is Dr. Abhisek Parmar. He’s a minimally invasive general surgeon and an assistant professor at UAB Medicine. Dr. Parmar, tell us about the current state of hernia today. What’s the prevalence and what are you seeing most often?
Abhisek Parmar, MD (Guest): Sure. Well, first of all, thank you so much for having me on the show. So hernias are incredibly prevalent, I think, with a lot of people listening either have hernias or know someone who’s had hernias. Probably about a million operations are performed every year in the United States for hernia disease. They’re incredible prevalent. I think what makes hernia disease especially exciting right now is I think that we’re in the golden age of surgical treatment of hernias. I've seen a lot of new advances over the past few years that are really incredibly exciting to hernia specialists like myself.
Host: Then tell us about the main factors that lead to hernia, and then we’ll get into treatment options that are available.
Dr. Parmar: Sure. So the main factor leading to hernia, the biggest risk factor is probably a prior surgery. About 50% of people after abdominal surgery can develop a hernia at their incision site. By nature when you make an incision or a cut in someone’s abdomen, you're going to weaken the tissues in the abdominal wall then. It never really has the same strength that it has before. Along with that, there are patient factors that can weaken the tissue. So patients who are obese are at higher risk for developing primary hernias. Patients who are diabetic and smokers are incredibly high risk for developing hernias.
Host: So what is the clinical presentation that would send someone, because not all hernias hurt, correct? Not all hernias are visible through outer examination. Not all of them hurt, is that correct?
Dr. Parmar: Correct. Yeah, absolutely. Not all hernias hurt. Probably the first sign the patients notice is unusual bulging in areas where hernias commonly occur. Usually at the bellybutton or the groin. Or, like I said, at the site of prior surgery. Like you said, pain is not always present, but that’s usually what brings people to see someone like me is that they're having pain in an area where there’s also bulging.
Host: So then as we’re speaking about treatment, Dr. Parmar, is treatment emergence or even always necessary? How do you decide whether to repair or to wait?
Dr. Parmar: So it’s a complex decision. Historically, we used to think that every hernia that we come across needs to be fixed because we worry about a loop of intestine getting stuck inside the hernia or getting incarcerated or strangulated where the intestine can lose it’s blood supply. So based on that concern, patients used to always have a surgery pretty much when a hernia was diagnosed. Over the past five or six years, there’ve been a few studies that have demonstrated that’s not really the case. That episode of incarceration or strangulation is actually quite rare. So now it becomes a discussion that I always have with my patients about the risk and benefits of surgery and how surgery would look like for that particular patient and their lifestyle.
Host: Then let’s talk about some of the benefits of minimally invasive surgery, including the application to inguinal or hiatal, large abdominal wall hernias that might require complex abdominal wall reconstruction. Speak about some of the benefits. What do you even tell your patients when you are discussing these surgical options?
Dr. Parmar: Right. So minimally invasive surgery has really revolutionized how we take care of these patients. So operations that used to keep people in the hospital for a week are now being done on an outpatient basis. I do all of my ventral hernia repairs robotically. Patients either go home the same day or the next. For inguinal hernias, the MIS approach has also changed how we manage these patients. Patients who undergo an MIS inguinal hernia repair are at lower risk for getting chronic pain, which I think is an incredibly difficult problem to manage after hernia repair.
There are recent guidelines that have been published that suggest that all women should undergo a minimally invasive approach for their hernia repair if they have a groin hernia. So that’s what I counsel these patients is that it can have a lower risk for chronic pain, and for women it’s kind of the gold standard for how they should be managed.
Host: Then compare and contrast for us. Open repairs versus the laparoscopic procedure and robotic assisted surgery. Tell us a little about what goes when you're going these repairs.
Dr. Parmar: Right. So you know the contrast is really between, I think, minimally invasive surgery—which includes laparoscopic and robotic—versus open surgery. The laparoscopic and robotic surgery, they both provide the same benefits of the smaller incisions, which means less pain for patients, a faster recovery, and less risk for infections which is a huge problem for obese patients and diabetic patients compared to open. The bottom line is I tell my patients I use the robot because it makes my job easier, but there really hasn’t been any proven benefit in the robot over the laparoscope, which I also use a lot of in hiatal hernia and abdominal wall reconstruction.
Host: See it’s such an interesting procedure and decision to discuss with your patients. Dr. Parmar, what about patient selection? How does this help to optimize repair?
Dr. Parmar: That’s a great question. I think it’s so appropriate for hernia because patient selection really is critical for hernia disease. For the longest time, surgeons approached hernias as “just a hernia”. We thought it’s a simple problem. You fixed the hole. Patients go on with their life, and it’s that simple. The reality is it’s much more complex. I think that’s what really differentiates UAB from a lot of other places that offer hernia surgery. Instead of whisking patients off to surgery, we realize there’s an actual patient attached to the hernia. So we spent a lot of time optimizing patient factors that can critically impact the success after surgery. So things like patient glucose management, weight loss, smoking cessation are all things that we address in our clinic visit. We have a lot of resources here at UAB to help people really get the best result possible after hernia repair. The reality is up to about 30 or 40% of people will actually get a recurrence after hernia repair. So it’s not just a hernia.
Host: Well, it’s certainly not. That’s an incredible interesting statistic. So based on that, tell us a little bit about how mesh selection for hernia repair can be challenging for clinicians. If you’d like to, give us your expert review of biologic or synthetic or bioabsorbable types, and why you choose the ones you choose.
Dr. Parmar: Sure. So the reality is mesh is the greatest resource we have in our armamentarium for decreasing recurrence of hernias. I tell my patients if we just sew the hernia close, there’s about 80 or 90% chance that the hernia will come right back. So mesh is the best way to get that number down to less than 10%. Hopefully less than 5%. You know there are literally hundreds of meshes on the market. You see the TV ads for mesh litigation, things like that. The reality is mesh complications do exist. So I'm extremely careful with how I select mesh. I think the more important question is where we place mesh. Most surgeons, I think, place mesh into the abdominal cavity. When you place mesh that abuts vital organs and viscera, a lot of complications can happen. So I always try to place my mesh in a plane that’s away from vital organs. So either in the preperitoneal space or the retrorectus space. So, in that sense, choosing the kind of mesh becomes a little less important.
There is a promising new bioabsorbable mesh that kind of maintains the same tissue integrity and strength as conventional synthetic mesh, but dissolves after about a year. What we know about tissue remodeling is it takes about a year for this to happen. So having that mesh in place still serves to function to strengthen the abdominal wall. It’s still fairly new, but the studies that have been done by leading hernia surgeons across the country suggest that it’s at least as good as the synthetic mesh. There’s also biologic meshes that, in my opinion, are weak and are substandard for hernia repair.
Host: What a great review. Thank you so much, Dr. Parmar. Wrap it up for us. Summarize this segment for other providers. What would you like them to know about minimally invasive hernia repair and, as you said, mesh selection? And why they should refer to the experts at UAB medicine.
Dr. Parmar: Well, you know, I think it’s such an interesting phenomenon. Hernia disease is something that, like we talked about, is so prevalent. I think because it’s so prevalent, people think it’s fairly commonplace and pedestrian and fairly easy to manage. The reality is there’s been a lot of new advances in the surgical management of these patients, and a lot of ways that we could really mitigate downstream complications. Just one of those is the minimally invasive approach. Here at UAB, we do minimally invasive abdominal wall reconstruction, which is a very new approach to really complex hernias. Patients who, like I said, would be in the hospital for up to two weeks can now go home the same day or the next day. Being able to offer that kind of care, I think, is really revolutionary.
The goal that we really want to attain here at UAB is that we want to fix the hernia, but we want this to be the very last repair a patient ever gets. I think with the optimization strategies we employ and the surgical techniques we use, we can really attain that. The reality is the techniques I'm doing today are techniques that weren’t really around four or five years ago. That’s a really exciting thing to be able to tell and offer patients.
Host: That’s great information. It certainly is an exciting time for these types of repairs. Thank you, again, for joining us and sharing your expertise. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. I'm Melanie Cole. Thanks for tuning in. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua120.mp3
- DoctorsGray, Meagan
- Featured SpeakerMeagan Gray, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5741
- Guest BioMeagan Gray, MD specialties include Gastroenterology, Hepatology, Transplant Hepatology.
Learn more about Meagan Gray, MD
Release Date: May 24, 2019
Reissue Date: May 10, 2022
Expiration Date: May 9, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Meagan Gray, MD
Assistant Professor, Gastroenterology, Hepatology & Transplant Hepatology
Dr. Gray has disclosed the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - SC Liver Research Consortium, Galectin Therapeutics, Eli Lilly & Company, Intercept Pharmaceuticals, Durect Corportaion
Consulting Fee - Theratechnologies, NovoNordisk, Intercept, Takeda
All relevant financial relationships have been mitigated. Dr. Gray does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers, have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome. Today we’re talking about nutrition in non-alcoholic fatty liver disease. My guest is Dr. Meagan Gray. She’s a hepatologist and an assistant professor at UAB Medicine. Dr. Gray, I'm glad to have you joining us today. Tell us about the current state of non-alcoholic fatty liver disease. What’s the prevalence or the burden of this disease?
Meagan Gray, MD (Guest): Well, thank you so much for having me. So non-alcoholic fatty liver disease is very common, much more common than we originally knew. So it’s currently the most common cause of chronic liver disease worldwide, and it effects about 30% of the United States population. We know that it’s also become the most common cause of chronic liver disease in children. So it does vary based on ethnicity. We know that Hispanics are at the highest likelihood of having non-alcoholic fatty liver disease at about 45%, Caucasians about 33%, and African Americans at about 24%. We know that this disease is more common in patients who have diabetes, up to 40 to 70% of patients with diabetes can have this disease. It’s certainly becoming the most common indication for liver transplantation. It’s currently number two. Right behind hepatitis C, but not far behind. Then it’s the third most common cause of hepatocellular carcinoma or liver cancer in the United States.
Host: Wow. Those are some incredible statistics, Dr. Gray. Do we know the etiology? Is there a close association with the epidemic of obesity? Tell us a little bit about the cause.
Dr. Gray: Absolutely. So with the rise of non-alcoholic fatty liver disease parallel with the rise in obesity and type 2 diabetes, high blood pressure, high cholesterol, all of these features of metabolic syndrome that are becoming much more common in the western world, especially the United States. So we know that for the most part, all of these diseases are related to what we eat in our diets. Certainly, there’s a lot of fast foods and processed foods, saturated fats, sugars. All of these things that not only cause these other features of metabolic syndrome but are also now being shown to cause non-alcoholic fatty liver disease as well.
Host: What’s unique about the metabolism with a person with this disease? How do they metabolize cholesterol, for example?
Dr. Gray: So the non-alcoholic fatty liver disease really is a surplus of free fatty acids in the body. So there’s three different ways that the liver gets free fatty acids. So 60% of the free fatty acids come from the systemic circulation. So this is from the adipose tissue. Then 15% come from the portal blood, this is what patients are eating in their diet. Then about 25% are actually made from the liver itself called lipogenesis. So in patients who are overweight, they have extra adipose tissue. So this is the main source of lipids that accumulate in patients who have fatty liver disease. Adipose tissue in these patients makes up about 80% of the free fatty acids. So these patients also often have insulin resistance or diabetes. So that adipose tissue is not able to store fat properly. So that extra adipose tissue, it spills out as these free fatty acids into the circulation, and then that goes to the liver to be processed. Because the liver can only handle so much free fatty acid, it stores as much as it can into triglycerides, and that’s where we see the hepatic fat.
Host: Dr. Gray, let’s talk about diagnosis for a minute. Why do you think it’s largely undiagnosed or unaddressed until it progresses to a more advanced stage? Tell us a little bit about what clinical history findings are characteristic of fatty liver disease. How do you find it?
Dr. Gray: You know, it can be a stealth diagnosis. So that’s why I think it’s often missed. So patients often don’t have any symptoms when they have non-alcoholic fatty liver disease. We know that most patients will have abnormal liver tests, that’s often how it’s picked up on their annual exams with their primary care physician. About 10 to 20% of patients have completely normal liver tests, and so that makes it even harder to diagnose. So in those patients it may be found because potentially they were having some pain and they got an imaging test for a different reason that picked it up incidentally. Or, potentially, their provider—if they had diabetes and had high risk—potentially their doctor was screening them for it. Because patients often don’t have any symptoms, it becomes more challenging to get to the right diagnosis.
Host: Dr. Gray, one of the interesting things that when I'm researching for these shows is because we’re going to be talking about nutrition and the standard therapies that are available right now. Because that’s what’s involved, can it be used as an early marker of coronary heart disease? Is there any correlation there?
Dr. Gray: Yes. Absolutely. That’s a great question. So just like metabolic syndrome, the diabetes, the high blood pressure, the cholesterol increases the risk for cardiovascular disease. Non-alcoholic fatty liver disease is also a similar marker. Actually, in patients who do have non-alcoholic fatty liver disease, the most common cause of death in these patients is actually cardiovascular disease independent of their other metabolic co-morbidities.
Host: What an interesting way that this all goes together. So let’s talk about treatment therapies. What are the standard therapies that you would use once you determine what’s going on?
Dr. Gray: So right now we don’t have any FDA approved medications for non-alcoholic fatty liver disease. Although, there are many in clinical trials. So right now the current mainstay of therapy is weight loss. So we know that if patients can lose more than 10% of their total body weight that they can significantly improve the fat in the liver as well as any fibrosus or scarring that has started to develop. So this is what we focus on most with these patients. Even if they're able to lose about 5% of their body weight, the liver disease can stabilize, and they may even have some improvement in their fibrosus. So that’s really where we start when we’re talking about making lifestyle changes is that the goal is to get them to at least 5 to 10% weight loss.
Host: How do you do that? Tell us about the providers that would be involved because, obviously, losing weight is very difficult for some people. How is that accomplished?
Dr. Gray: Absolutely. So, you know, I think you're exactly right. As providers, we do have a few minutes to spend with patients and get a small assessment of what their diet contains, but you're right. We are limited in our time that we have to counsel them on dietary factors or things that they could improve in their diet. So it’s extremely helpful if you can have a dietician spend time with the patients as well. So at UAB, we have just opened up a new non-alcoholic fatty liver disease clinic. In this clinic, not only do these patients see me, but they also see a registered dietician who can spend a little bit more time going through their diet. And can help them learn how to use tracking programs like MyFitnessPal and also making suggestions and things that they could improve in their diet that would have significant benefit.
Host: What do you see happening in the future, Dr. Gray, with this? As you and I were speaking a little off the air, there’s no FDA approved medicational therapies yet. Correct?
Dr. Gray: That is correct. There are many medications in clinical trials. So I do think over the next several years we will have several different options. But I still think, and what I counsel my patients, is the diet is the most important part. So if they can lose the weight and they can change the way that they're eating, then they can not only get rid of their fatty liver disease, but they may also be able to have significant improvement in their diabetes, their high blood pressure, their high cholesterol, and their risk for cardiovascular disease. So that treatment option is always going to be my favorite because that takes care of the whole picture as opposed to adding on one more medication on their list of 10 to 15 that they're already taking.
Host: Then wrap it up for us. What would you like other providers to know about non-alcoholic fatty liver disease and those standard therapies of weight loss and nutrition, and how important it is that providers refer when they feel that it’s really important?
Dr. Gray: Yeah. So to wrap it up I really wanted to spend a few minutes talking about the nutritional aspects and sort of targeted nutrition advice that I give my patients when I see them in the clinic for non-alcoholic fatty liver disease. So there’s three main components that we go through. So one is fat. So saturated fat is a major cause of fat in the liver. So I specifically talk to them about foods that are high in saturated fat. So these include beef, pork, lamb, processed meats, as well as full-fat dairy products like butter, cream, full-fat milk, cheese. Then some ethnicities use ghee and lard as well.
So we know that when you eat a diet that’s high in saturated fat, it actually increases the adipose tissues lipolysis. So it’s breaking down more of that adipose tissue and releasing free fatty acids into the circulation, which then come into the liver to cause hepatic steatosis. So we know that if you can eliminate that saturated fat from the diet that a lot of that can resolve. So the types of fats that are healthier for these patients to eat are seeds, nuts, avocados, olive oil, unsaturated fats that can be found more in plant products.
Then next I talk to them about sugar. So sugar is, unfortunately, added to so many things that we eat and drink as part of processing. There was actually a recent study showing that about 17% of daily calories in U.S. children and adolescents comes from pure sugar, which is such a huge part of the diet that is unnecessary. So when you eat excess sugar in the diet, this actually increases the de novo lipogenesis, or the liver’s production of fat, and that then increases the lipid content in the liver. So I specifically talk to them about removing sweet tea, full sugar soda, candy, cakes, cookies. Then also refined carbohydrates like white rice, white bread, tortillas. These things are all processed very similarly to sugar in the body.
Then I also talk with them about protein. So we are a little bit protein obsessed in the United States and patients tend to eat much more protein than is actually what is required for their body. There was a study showing that comparing patients with non-alcoholic fatty liver disease to normal healthy controls, that the patients who had the non-alcoholic fatty liver disease actually consumed about 30% more meat than the healthy controls. There’s also been several other studies associating animal product intake with non-alcoholic fatty liver disease.
We know that diets that are high in bread and processed meat significantly increase your mortality, specifically from chronic liver disease as well as cancer and cardiovascular mortality. There’s several reasons that this happens, but some of the theories are that the heme iron that is in the red meat promotes oxidative damage as well as inflammation. Then some of the nitrates and nitrites that are found in processed food can worsen insulin resistance as well as diabetes, cardiovascular disease, and cancer. We actually know that processed meat is classified as carcinogenic by the World Health Organization, meaning that we know it causes cancer. So really it should be reduced or eliminated from the diet.
There’s also some newer studies that are looking into trimethylamine oxide, which is produced when gut bacteria digests choline, lecithin, and carnitine, which are all nutrients that are abundant in animal products, specifically red meat. A recent study out of the Cleveland clinic correlated theorem trimethylamine oxide levels to predict future heart attacks, strokes, as well as death. So we know that the animal products that are high in saturated fats as well as the processed sugars and refined carbohydrates, all of these things have a role to play when it comes to insulin resistance and hepatic steatosis.
So then I specifically talk to them about a couple of different diet options. So one is a plant based diet. So we know that the higher you can adhere to a plant based diet, the less likelihood that you're going to develop fatty liver disease. This came out of a large national health and nutrition examination survey database. So plant based diets are rich in fruits and vegetables, beans, nuts, whole grains, legumes, and are rich in antioxidants and anti-inflammatory phytochemicals, which can reduce oxidative stress and protect against different types of free radicals.
Patients who still do want to consume some animal products, a Mediterranean diet still has significant benefits. So this is very similar to a plant based diet, but also includes lean meats like chicken and fish as well as low fat dairy. So there was a recent study published in 2018 looking at a Mediterranean for non-alcoholic fatty liver disease, and patients did have significant improvement not only in their liver fat, but also in metabolic risk factors after only three months on this diet. So I usually talk with patients about both of those diet options, and then we work together to figure out what’s going to work best for them.
Host: Thank you so much for joining us, Dr. Gray. What an interesting topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, please visit uabmedicine.org/physician. This is Melanie Cole.
- HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua117.mp3
- DoctorsCallaway, James
- Featured SpeakerJames Callaway, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5710
- Guest BioDr. James Callaway is a gastroenterologist in Birmingham, Alabama and a UAB Faculty Member. He received his medical degree from Medical College of Georgia School of Medicine.
Learn more about James Callaway, MD
Release Date: May 15, 2019
Reissue Date: April 29, 2022
Expiration Date: April 28, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
James Callaway, MD
Assistant Professor in Gastroenterology
Dr. Callaway has the following financial relationships with ineligible companies:
Board Membership/Payment for Lectures, Including Service on Speakers Bureaus - Sanofi
All relevant financial relationships have been mitigated. Dr. Callaway does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Welcome. In this podcast today, we’re talking about eosinophilic esophagitis and here to tell us about that is my guest, Dr. James Callaway. He’s a gastroenterologist and an Assistant Professor at UAB Medicine. Dr. Callaway, it’s sometimes referred to as EOE. Tell us about eosinophilic esophagitis and how prevalent it is.
James Callaway, MD (Guest): Absolutely. Thank you for having me today. Eosinophilic esophagitis is becoming increasingly prevalent in the United States. Currently it is of around 25 or 26 per 100,000 people and it’s a condition that involves primarily difficulty swallowing that’s related to allergies, food allergies specifically that affects the esophagus.
Host: So, are allergists and gastroenterologists seeing more patients with EOE? What do you attribute this to? Is it on the increase or is there an increased recognition of it?
Dr. Callaway: Sure. Great question. It’s probably a little bit of a combination of both. We know that most of the prevalence is just increased awareness itself that we are finding. We are more cognizant of this condition and so because of that; we are looking for it and we are biopsying for it on our routine endoscopies or diagnostic endoscopies that we are doing. In the allergy world, they are seeing increased prevalence of all sorts of types of atypic and allergic type conditions. And this is another one that just happens to be what we think both food related and potentially aeroallergen related as well.
Host: That’s so interesting and we’re going to get into some of the etiology of it in a minute, but how is it similar to GERD and yet different? Is it difficult to diagnose because of that?
Dr. Callaway: Sure, great question as well. Both conditions actually can give eosinophils which are a particular type of inflammatory cell in the esophagus and so there can be some overlap with what these things may look like when we actually look at the biopsies. That being said, reflux disease oftentimes will present differently. Again, it presents more as chest pain and heartburn whereas eosinophilic esophagitis at least in adults, is primarily difficulty swallowing and what we refer to as dysphagia. That being said, reflux disease and eosinophilic esophagitis are not exclusive of each other. And so since the prevalence of reflux disease is almost between 25-40% of the population; oftentimes, patients with eosinophilic esophagitis will also have gastroesophageal reflux disease at the same time. And so, that’s part of our job as physicians is helping determine which of their symptoms may be related to one versus the other and how to best treat them.
Host: Thank you for clarifying that. That was really very clear the way that you did that. So, tell us about some common conditions and factors that can lead to it. Is there a genetic component? Who is at risk for this?
Dr. Callaway: Sure. Absolutely. So, first and foremost, we do think that there is a immune/antigen mediated component to this. meaning that there has to be a certain exposure. We think the primary risk factor for that are actually particular foods. And if a patient has the right predisposition again, most patients, the patients that we typical see eosinophilic esophagitis in is almost always they have a history of either asthma or allergic conditions as a child and so they are predisposed to having allergic type conditions later in adolescence and then in adulthood as well. So, that’s the primary population that we see it in. But it is an antigen-mediated response meaning that there is a clear exacerbant that causes the inflammation to occur and we think that most of these are foods.
Host: Then tell us how we know. What’s the clinical presentation? You mentioned in whether it’s routine or diagnostic endoscopy that you are looking for those eosinophils and what would send somebody to the doctor anyway? People think they have GERD or reflux as you say it’s pretty popular. What else might we notice?
Dr. Callaway: Absolutely. So, the biggest thing that we see in these patients is actually the presence of difficulty swallowing, especially in adults. It actually presents slightly differently in children. In children, they may have more food intolerances, sometimes nausea, vomiting, sometimes failure to thrive may be a presentation for that. So, pediatricians are looking for it with a variety of gastrointestinal symptoms.
In adults, it appears to be more of difficulty swallowing is the primary presentation for this. there are a few cases where we find it when we are actually looking for gastroesophageal reflux disease as well, we will on the side just find eosinophilic esophagitis but primarily, these patients present with difficulty swallowing and then the most fear complication that they present with is what’s called a food impaction where food actually gets stuck in the esophagus and they can’t get additional food or liquids down and require what we call a dis-impaction, where we have to go tin with a camera scope to relieve that obstruction.
Host: Yeah, that’s a scary circumstance. So, please review treatment strategies for us and the current guidelines from the American College of Gastroenterology on this condition. And what are your primary goals of treatment Doctor?
Dr. Callaway: Absolutely. So, since this is felt to be an allergic response to different antigens itself, we have a couple of different approaches to treatment that we have. Some are dietary, some would be consider pharmacologic and then lastly would be what’s called dilation therapy of the esophagus. When we are talking about dietary therapy specifically, we are talking about trying to figure out which types of food may be causing the allergy or inflammation to occur. And we try to avoid those. And we have a couple of different ways that we will go in to actually test to see if you are – once you eliminate a food, test and see if you actually have had a response, meaning we can see that the inflammatory cells are going down if you are avoiding one of the main foods.
Again, the main foods that have been associated with this disease are dairy, wheat, eggs, shellfish, soy, and I don’t know if I mentioned wheat, already, but there six main foods that we have that we call a six food elimination diet that we will oftentimes empirically put patients on because those are the most commonly associated foods with this condition.
If dietary therapy proves to be too difficult to do, we may talk about what’s called pharmacologic therapy. Which will be the use of topical steroids or glucocorticoids or using proton pump inhibitors like Prilosec or Nexium which have both been shown to decrease the inflammatory response as well.
Lastly, I did mention dilation therapy. So, if patients have that longstanding inflammation from the eosinophilia and from the allergy response that’s actually caused scarring to occur; you can get stricture formation in the esophagus. And stricture formation is where that scarring causes narrowing that is basically what the food ends up hanging up on later on over time. And so we can actually go in and stretch the esophagus and try to break up these strictures to allow for easier passage of solid foods.
From a guidelines standpoint, we do like to rule out other conditions that would mimic eosinophilic esophagitis including looking into the presence or absence of gastroesophageal reflux disease. Also, obviously there are a number of guidelines that are associated with this condition looking at both the diagnosis of this and also treatment. From a purely treatment standpoint, we do know that dietary therapy has shown to be effective, topical steroids have been shown to be effective, proton pump inhibitors are used frequently and then dilation therapy are the main treatment mechanisms that have all been shown to be helpful in the long run.
Host: Would that scarring Dr. Callaway then predispose them to Barrett’s?
Dr. Callaway: So, it doesn’t predispose them to Barrett’s but as I mentioned, there is an overlap between gastroesophageal reflux disease and eosinophilic esophagitis. So, if they do have concomitant reflux symptoms, we should screen them for Barret’s as well. Barret’s is typically seen as from chronic reflux disease which again, can lead to chronic inflammation and scarring but it’s a slightly different physiology just because the inflammatory cells are different. The eosinophils versus the inflammatory cells seen in reflux disease.
Host: Thank you so much for clarifying that as well. So, tell us a little bit about treatment response and what you expect when you try whether it’s the dilation therapy or steroids or the six food elimination diet. What do you expect as far as results and kind of give us your best summary of what you would like other providers to take away from this when you feel it’s important that they should refer to the specialists at UAB.
Dr. Callaway: Absolutely. Great. So, with regards to results, there are two main things that I will kind of talk to my patients about as what our overall goals with therapy for this condition. First and foremost, I would like to prevent that dreaded complication of food impactions that I described earlier. It’s very frustrating for patients coming to the hospital at wild hours in the middle of the night because food is stuck and things of that nature. So, that’s first and foremost the things we are trying to prevent. And most of the time, we can achieve that goal with adherence to one of the therapies that we talked about before.
Topical steroids appear to be very effective and can be taken long term. Proton pump inhibitors like Nexium again, are commonly used for reflux disease and do have some overlap in the treatment of EOE and so because of that; there also appears to be some at least response or long term response that we have seen. And lastly, dietary therapy. Again, have over a 70% rate of actually decreasing the amount of eosinophils to normal levels if we can identify the exact food that is causing it and if strict dietary avoidance can be adhered to.
So, again, the treatments actually work fairly well at the inflammatory component. When there are strictures that develop; that can sometimes be a little bit trickier, but dilation therapy also has some long term data at being able to prevent food impactions and improve symptoms of difficulty swallowing.
Overall, this is an increasingly prevalent condition which is clearly related to food allergens that is resulting in more and more difficulty swallowing and a population that typically presents in their 20s and 30s. So, we are seeing these patients early and I would encourage physicians and referring physicians if they are having patients that are either having difficulties swallowing, have any history of allergies as a child or asthma as a child or atypical reflux symptoms that are not responding to typical reflux therapy and then we should be thinking about eosinophilic esophagitis and we should consider referral to a gastroenterologist in that situation.
Host: Thank you so much Dr. Callaway for coming on, sharing your expertise about this condition and how it is becoming more prevalent in what you’re seeing. Thank you again. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
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