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From: Peter on 10 Sep 2007 20:22
Howard McCollister wrote:
> In article <fb1ovv09jc(a)enews1.newsguy.com>, "Peter" <peter(a)nospam.net>
> wrote:
>
>> This is mainly for Howard. I have a basic question that I just can
>> not find the answer to. I have attached my pH waveforms and
>> frequency histograms from my last 24 hour pH from three years ago (I
>> was on prilosec therapy at the time of the test, which the second
>> opinion doctor at the univ of Maryland agreed to - after previous
>> failure of other ppi's (was on prevacid for 7 years) - and the
>> prilosec was helping at the time of the test, and I passed so to
>> speak). I wrote you about the pH test approx 3 years ago. I am
>> having problems again, after doing okay on the prilosec for the last
>> three years, and the ppi's are not working again, as many of you
>> know. I have an appointment with an MIS general surgeon at Johns
>> Hopkins tomorrow.
>>
>> I understand the rules for the 24 hour pH (episodes below the pH 4
>> line, etc), and I understand that impedance testing detects bolus
>> movement and detection of non acid reflux (which to me means reflux
>> that has a pH above
>> 7.0). I have read all of Howard's posts in the past three years and
>> saved a majority of them. I have searched and searched many web
>> sites for the two tests, and I can not find an answer to a basic
>> question that confuses me.
>>
>> Here is the question. Everybody says that 24 hour pH detects acid
>> reflux (only) and that impedance testing will detect non acid
>> reflux. I believe that the 24 hour pH will detect non acid reflux
>> also (at least to some degree), since the pH wave form graphs go all
>> the way up to a pH of 8.0 on the y-axis (ie the waves are truncated
>> at 8.0), and the frequency histograms clearly indicate pH's above 7
>> (and up to 8 and 9 in my case). You can see this on the pH
>> waveforms and frequency histograms that I have attached.
>>
>> Howard, would you please explain this quandary. You will also note
>> that the distal sensor in my stomach was detecting a pH above 7
>> after approx 4:00 am and right up until about 9:00 am (which is
>> obviously caused by bile) and that the pH of the proximal sensor in
>> my esophagus was actually measuring more acidic pH's than in the
>> stomach for that same time frame (ie 4:00 am till 9:00 am). This
>> makes no sense to me. I would think the pH of the stomach would
>> have what is referred to as nighttime breakthrough even more as time
>> proceeded, especially since the morning prilosec I took would be
>> winding down (you will notice that the "Impression" from the gastro
>> who read the test, referred to "gastric acid breakthrough late in
>> the day and at night as expected on PPI qAM". But then after 4:00
>> am the pH went basic - I would think it would have even got more
>> acid since the PPI was wearing of even more if you follow me.
>> Furthermore, I would think that the higher pH after 4:00 am would
>> stimulate the gastrin producing cells to demand more acid, since I
>> recall they only shut off when the stomach pH drops below 3 or
>> something close to that.
>>
>> I hope you can shed some light on this especially the part about the
>> pH's going above 7 on both the pH waveform graphs and the frequency
>> histograms (which to me indicates that the 24 hour pH does provide
>> some degree of non acid detection so to speak), and why was my
>> stomach more basic than my esophagus after 4:00 am.
>>
>> Thank you for your time, and I look forward to your response.
>>
>> Pete
>>
>> PS - The impedance testing (MII) is constantly referring to being
>> combined with PH testing. Do they mean that literally (ie you would
>> have both done at the same time and have two nose hoses going down
>> your esophagus). That would seem unwieldy at best - one is bad
>> enough. I got the worst bronchitis of my life immediately after
>> having the 24 hour pH catheter removed three years ago. Plus if I
>> have another 24 hour pH I will certainly have to be "OFF therapy"
>> this time, which will kill me, and I will be raw from bottom to top.
>> I know I can have the "bravo" but that won't measure the pH in the
>> stomach, which I consider relevant - do you agree. Plus the bravo
>> is 48 hours which will even be longer time off therapy (even though
>> the ppi's aren't working effectively, if I stop them completely the
>> rebound effect will eat me up). I think some doctors say to be off
>> therapy for a week to 10 days - I could not stand that. I would
>> hope three days off for PPI's and take tums and maybe Zantac until
>> the day before.
>>
>> Also, what do you know about doing the lap nissen with the "da
>> Vinci" Robot (the guy at Hopkins uses it). Is it basically the old
>> story that the more you have done the better you get, but ultimately
>> it depends on the skill of the surgeon like you always say, no
>> matter how many procedures he or she has done. But you would always
>> hope there is a learning curve on everything and the more procedures
>> a person does the better he or she may get, and learn from their
>> mistakes, etc.
>>
>
>
> Accurate evaluation of GERD goes beyond simple pH measurement.
> Conventional ambulatory pH testing will only provide an indirect
> indication of what's actually happening. The value of 24-hour
> impedance testing with pH measurement is its ability to distinguish
> what those pH measurements are actually measuring - liquid vs gas vs
> food bolus. And whether they're going down or going up the esophagus.
> The mere presence of a pH catheter lying across your LES provides a
> conduit for some degree of reflux and that's why looking at bolus
> movement is important, and why measuring intragastric pH during such
> testing is of questionable value. I'm not sure we even stock any
> intragastric/esophageal pH catheters anymore. I haven't worried about
> intragastric pH in years. I worry about what's going on in the
> esophagus, not the stomach - those measurements are too variable
> relative to GERD to be of much use to me in answering the questions I
> usually need answered. Your pH does go alkaline at times, but the
> doctor that read it is only making an educated guess at what it was
> measuring or what it means. Probably accurate, and I don't disagree
> with his interpretation, since common things present commonly.
> Physiologic variation between patients and even within the same
> patient at different times and on different days means that drawing
> direct A-equals-B conclusions is dangerous. Diagnostic medicine is
> not an exact science. The other problem with this kind of testing is
> that it only provides a snapshot of one 24 hour period out of a
> lifetime of GERD. Bravo ambulatory pH testing may be more reflective
> since it measures 48 hours, and the number of such tests I read where
> the second 24 hours is markedly different than the first 24 hours is
> significant. The answer to your question could be as simple as the
> distal sensor lying in a pool of bile, or food, or in gas. There's no
> way to know. Your doctor could only guess. *I* can only guess. I
> don't view it as likely to be relevant to your diagnosis, only
> interesting.
>
> The daVinci robot is cool technology - I've spent a lot of time
> playing with it over the last few years - but for the most part it's
> a solution looking for a problem. Its two benefits are 3D
> visualization and motion-scaling. Those two things allow it to be
> helpful in operations that require a high degree of precision in
> intracorporeal suturing, but Nissen fundoplication is not one of
> those operations, nor are the VAST majority of general surgical
> minimally invasive procedures. Heller esophagomyotomy might be one
> application, but for the most part the daVinci robot is most helpful
> for surgeons who have a tremor, or for surgeons less than optimally
> skilled in minimally invasive surgery. A case in point is the
> daVinci's sentinel operation - suprapubic prostatectomy. The majority
> of urologists have little training or experience in minimally
> invasive surgery, and the majority of the operations they do don't
> require it, so they get little ongoing skill development. Anyway,
> that's the answer you'd get from a urologist who IS skilled in
> minimally invasive surgery. That subset doesn't usually use the robot
> even for prostatectomy. For a skilled MIS surgeon, it's very hard to
> justify the extra expense and the extra hour that that technology
> imposes.
>
> HMc

Howard...Thank you so much for responding to my post. I have some more
questions and some more comments on the da vinci robot also. The MIS
surgeon I just saw at Johns Hopkins (who has GERD as one of his sub
specialties, and said he knows most of the prominent surgeons in the lap
nissen arena both nationally and internationally) does the da vinci lap
nissen (ie, his residents and fellows do it while he oversees - you know how
the teaching hospitals work :-). He and I talked about that at length after
I asked him if he would be doing the surgery if I was determined to be a
candidate, and he smiled and said he couldn't say that. He is a retired air
force colonel and is really into R&D for MIS, and a nice person.

He insisted upon the upper GI and cine esophagram as a first test (and that
it had to be done at Hopkins by his radiologists) before going any further
with 24 hour ph etc, which I know is against your philosophy - and he swears
the upper GI has value. I told him I have no dysphasia at all and never
have, but I just had the test. I agree with you regarding the value of the
upper GI in GERD diagnosis, and I also read a very interesting article from
the Mayo clinic that questions the value of the upper GI as a diagnostic
tool (http://www.mayoclinicproceedings.com/inside.asp?AID=1120&UID=).

He knows I just had my yearly EGD in June, and my esophagus was okay, and
that my PPI's stopped working shortly after the EGD and I am currently
suffering from burning from my stomach to my esophagus, chest, throat,
tongue, and nose (unfortunately a lap nissen will not stop the burning in my
stomach, only above the LES as I have discussed in here many times - and he
agreed with that). BTW, I think it is gas going up the esophagus, because I
hardly ever feel any liquid reflux, or backwash and it is does not get worse
at night at all (actually better if anything). But whatever it is, it
burns, and it could be bile, or a combination of acid and bile, which might
be even worse - sorry for the rambling.

He also said the lap nissen was "absolutely major surgery" and took 3 to 4
hours (which scares me - I saw the one hour video (movie time, not real
surgery time) for the conventional lap nissen performed by Adrian Parks from
the univ of MD - and it sure looked major to me). I don't understand why
the robot would take so much longer (other than a learning curve and
training, etc), since I thought one of the advantages of the da Vinci system
was to ultimately provide for faster surgery times. Here is another
interesting article I found from Belgium which addresses the da Vinci for
lap nissens, and the extra costs and "increased" operating times, and lesser
instrument adaptation
(http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&list_uids=16736336&cmd=Retrieve&indexed=google).
Could you explain why the robot would take so long and what is your standard
operating time for a conventional lap nissen (I thought I saw something like
60-75 minutes on searching), and I thought you mentioned even lower times
for a simple non complicated procedure in one of your posts from a couple
years back. And do you consider it major surgery.

I know he will be asking me for a 24 hour pH next when they get around to it
(he's in Baltimore and I'm in western Maryland), and today I made an appt
with a gastro in a closer town that does them (and the bravo), so I won't
lose time in scheduling, since I have been suffering for three months now
since the ppi's stopped being effective. He said I could go to another
facility for the 24 hour ph, but definitely insisted on Hopkins radiologists
for the UGI (he called them the "old gray haired men" - and what a nice
person the radiologist was). I don't like radiation and especially
fluoroscopes (which are used in the upper GI), due to my lymphocyte
deficiency, and I have had too many catscans in my life, which are bad
enough. But I got by with two minutes lamp time and about 4 rads, or less.
Do you do a post op UGI (the next day) to check on how the surgery came out.
He does it, and said he would consider waiving that for me due to my
radiation concerns.

Anyway I think I will definitely ask for the bravo if I have the ph test,
even though it will be one more day off therapy (remember my first ph test
three years ago I was on therapy and the prilosec was working), since I got
the worst bronchitis of my life after they pulled the catheter (nose hose)
out from the last one. Currently I have stopped the ppi's and am taking 300
mgs of zantac BID for the placebo effect (LOL). I will definitely have to
be off therapy this time to prove if I have acid reflux.

In regard to my frequency histogram question could you please explain why
(or how) the 24 ambulatory ph tests goes past 7, and all the way up to 8 or
9 or higher (like mine did). I assume the sensors do read ph's that high,
even though they sound like they are not of any value pertaining to non acid
reflux input like the impedance test is.

I want to thank you again for you response. It was so good hearing from
you. I am very worried and concerned and scared about the outcome of my
current dilemma, and I look forward to hearing from you again.

Pete





From: Peter on 10 Sep 2007 20:34
I told him I have
> no dysphasia at all and never have, but I just had the test.

Sorry...that was supposed to be dysphagia. I had it right, and I let the
damn spell check change it :-)


From: Howard McCollister on 15 Sep 2007 09:47
In article <fc4n5702cfk(a)enews2.newsguy.com>, "Peter" <peter(a)nospam.net>
wrote:


> Howard...Thank you so much for responding to my post. I have some more
> questions and some more comments on the da vinci robot also. The MIS
> surgeon I just saw at Johns Hopkins (who has GERD as one of his sub
> specialties, and said he knows most of the prominent surgeons in the lap
> nissen arena both nationally and internationally) does the da vinci lap
> nissen (ie, his residents and fellows do it while he oversees - you know how
> the teaching hospitals work :-). He and I talked about that at length after
> I asked him if he would be doing the surgery if I was determined to be a
> candidate, and he smiled and said he couldn't say that. He is a retired air
> force colonel and is really into R&D for MIS, and a nice person.
>
> He insisted upon the upper GI and cine esophagram as a first test (and that
> it had to be done at Hopkins by his radiologists) before going any further
> with 24 hour ph etc, which I know is against your philosophy - and he swears
> the upper GI has value. I told him I have no dysphasia at all and never
> have, but I just had the test. I agree with you regarding the value of the
> upper GI in GERD diagnosis, and I also read a very interesting article from
> the Mayo clinic that questions the value of the upper GI as a diagnostic
> tool (http://www.mayoclinicproceedings.com/inside.asp?AID=1120&UID=).
>
> He knows I just had my yearly EGD in June, and my esophagus was okay, and
> that my PPI's stopped working shortly after the EGD and I am currently
> suffering from burning from my stomach to my esophagus, chest, throat,
> tongue, and nose (unfortunately a lap nissen will not stop the burning in my
> stomach, only above the LES as I have discussed in here many times - and he
> agreed with that). BTW, I think it is gas going up the esophagus, because I
> hardly ever feel any liquid reflux, or backwash and it is does not get worse
> at night at all (actually better if anything). But whatever it is, it
> burns, and it could be bile, or a combination of acid and bile, which might
> be even worse - sorry for the rambling.
>
> He also said the lap nissen was "absolutely major surgery" and took 3 to 4
> hours (which scares me - I saw the one hour video (movie time, not real
> surgery time) for the conventional lap nissen performed by Adrian Parks from
> the univ of MD - and it sure looked major to me). I don't understand why
> the robot would take so much longer (other than a learning curve and
> training, etc), since I thought one of the advantages of the da Vinci system
> was to ultimately provide for faster surgery times. Here is another
> interesting article I found from Belgium which addresses the da Vinci for
> lap nissens, and the extra costs and "increased" operating times, and lesser
> instrument adaptation
> (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&list_uids=16736336&cmd=Ret
> rieve&indexed=google).
> Could you explain why the robot would take so long and what is your standard
> operating time for a conventional lap nissen (I thought I saw something like
> 60-75 minutes on searching), and I thought you mentioned even lower times
> for a simple non complicated procedure in one of your posts from a couple
> years back. And do you consider it major surgery.
>
> I know he will be asking me for a 24 hour pH next when they get around to it
> (he's in Baltimore and I'm in western Maryland), and today I made an appt
> with a gastro in a closer town that does them (and the bravo), so I won't
> lose time in scheduling, since I have been suffering for three months now
> since the ppi's stopped being effective. He said I could go to another
> facility for the 24 hour ph, but definitely insisted on Hopkins radiologists
> for the UGI (he called them the "old gray haired men" - and what a nice
> person the radiologist was). I don't like radiation and especially
> fluoroscopes (which are used in the upper GI), due to my lymphocyte
> deficiency, and I have had too many catscans in my life, which are bad
> enough. But I got by with two minutes lamp time and about 4 rads, or less.
> Do you do a post op UGI (the next day) to check on how the surgery came out.
> He does it, and said he would consider waiving that for me due to my
> radiation concerns.
>
> Anyway I think I will definitely ask for the bravo if I have the ph test,
> even though it will be one more day off therapy (remember my first ph test
> three years ago I was on therapy and the prilosec was working), since I got
> the worst bronchitis of my life after they pulled the catheter (nose hose)
> out from the last one. Currently I have stopped the ppi's and am taking 300
> mgs of zantac BID for the placebo effect (LOL). I will definitely have to
> be off therapy this time to prove if I have acid reflux.
>
> In regard to my frequency histogram question could you please explain why
> (or how) the 24 ambulatory ph tests goes past 7, and all the way up to 8 or
> 9 or higher (like mine did). I assume the sensors do read ph's that high,
> even though they sound like they are not of any value pertaining to non acid
> reflux input like the impedance test is.
>
> I want to thank you again for you response. It was so good hearing from
> you. I am very worried and concerned and scared about the outcome of my
> current dilemma, and I look forward to hearing from you again.
>
> Pete


Sure...lap Nissen is indeed major surgery. The potential for damage to
the stomach, esophagus, spleen, vagus nerves is very real. And its
success is very surgeon-dependant, not to mention complication rate. The
laparoscopic boom of the early '90's resulted in a lot of surgeons doing
all manner of laparoscopic operations. It fostered a significant
re-interest in reflux disease, especially coming is proximity to the
development of PPIs, and we came to understand more about GERD and how
the Nissen operation works than we ever knew before. Not all surgeons
were able to develop the necessary skills. Unfotunately, some of them
are still doing these operations. We're currently seeing an almost exact
replay of that scenario in the arena of bariatric surgery.

This guy's attitudes on the daVinci run counter to virtually everything
that's commonly known about that device in surgical circles. No it
doesn't shorten operating times, it adds about an hour because of the
required setup time. It normally takes about 45 minutes to do a Nissen
laparoscopically. It might take me longer if I'm helping our MIS Fellow
do it. I can't imagine how a competent surgeon could drag that operation
out to 3-4 hours..perhaps if he were supervising a rank
newbie...otherwise that time frame is WAY outside the norm. The robot is
a toy. A very cool toy, certainly, but its usefulness in general
laparoscopic foregut surgery is generally considered to be negligible.

Cine esophagrams are different than a standard UGI. I could envision
getting one of those in a patient where I had serious concerns or
confusion about their motility after seeing their manometry results. To
order one outside of those reasons and BEFORE manometry is done is an
unconscionable waste of money IMHO and I don't know ANY surgeon who
feels differently.

I presume your pH test registered up to 8 or 9 because there was
alkaline material in your esophagus. There's no way to know where it
came from, but obviously it was either alkaline stomach contents,
saliva, something you ate....etc.

HMc
From: Peter on 15 Sep 2007 23:55
Howard McCollister wrote:
> In article <fc4n5702cfk(a)enews2.newsguy.com>, "Peter"
> <peter(a)nospam.net> wrote:
>
>
>> Howard...Thank you so much for responding to my post. I have some
>> more questions and some more comments on the da vinci robot also.
>> The MIS surgeon I just saw at Johns Hopkins (who has GERD as one of
>> his sub specialties, and said he knows most of the prominent
>> surgeons in the lap nissen arena both nationally and
>> internationally) does the da vinci lap nissen (ie, his residents and
>> fellows do it while he oversees - you know how the teaching
>> hospitals work :-). He and I talked about that at length after I
>> asked him if he would be doing the surgery if I was determined to be
>> a candidate, and he smiled and said he couldn't say that. He is a
>> retired air force colonel and is really into R&D for MIS, and a nice
>> person.
>>
>> He insisted upon the upper GI and cine esophagram as a first test
>> (and that it had to be done at Hopkins by his radiologists) before
>> going any further with 24 hour ph etc, which I know is against your
>> philosophy - and he swears the upper GI has value. I told him I
>> have no dysphasia at all and never have, but I just had the test. I
>> agree with you regarding the value of the upper GI in GERD
>> diagnosis, and I also read a very interesting article from the Mayo
>> clinic that questions the value of the upper GI as a diagnostic tool
>> (http://www.mayoclinicproceedings.com/inside.asp?AID=1120&UID=).
>>
>> He knows I just had my yearly EGD in June, and my esophagus was
>> okay, and that my PPI's stopped working shortly after the EGD and I
>> am currently suffering from burning from my stomach to my esophagus,
>> chest, throat, tongue, and nose (unfortunately a lap nissen will not
>> stop the burning in my stomach, only above the LES as I have
>> discussed in here many times - and he agreed with that). BTW, I
>> think it is gas going up the esophagus, because I hardly ever feel
>> any liquid reflux, or backwash and it is does not get worse at night
>> at all (actually better if anything). But whatever it is, it burns,
>> and it could be bile, or a combination of acid and bile, which might
>> be even worse - sorry for the rambling.
>>
>> He also said the lap nissen was "absolutely major surgery" and took
>> 3 to 4 hours (which scares me - I saw the one hour video (movie
>> time, not real surgery time) for the conventional lap nissen
>> performed by Adrian Parks from the univ of MD - and it sure looked
>> major to me). I don't understand why the robot would take so much
>> longer (other than a learning curve and training, etc), since I
>> thought one of the advantages of the da Vinci system was to
>> ultimately provide for faster surgery times. Here is another
>> interesting article I found from Belgium which addresses the da
>> Vinci for lap nissens, and the extra costs and "increased" operating
>> times, and lesser instrument adaptation
>> (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&list_uids=16736336&cmd=Ret
>> rieve&indexed=google).
>> Could you explain why the robot would take so long and what is your
>> standard operating time for a conventional lap nissen (I thought I
>> saw something like 60-75 minutes on searching), and I thought you
>> mentioned even lower times for a simple non complicated procedure in
>> one of your posts from a couple years back. And do you consider it
>> major surgery.
>>
>> I know he will be asking me for a 24 hour pH next when they get
>> around to it (he's in Baltimore and I'm in western Maryland), and
>> today I made an appt with a gastro in a closer town that does them
>> (and the bravo), so I won't lose time in scheduling, since I have
>> been suffering for three months now since the ppi's stopped being
>> effective. He said I could go to another facility for the 24 hour
>> ph, but definitely insisted on Hopkins radiologists for the UGI (he
>> called them the "old gray haired men" - and what a nice person the
>> radiologist was). I don't like radiation and especially
>> fluoroscopes (which are used in the upper GI), due to my lymphocyte
>> deficiency, and I have had too many catscans in my life, which are
>> bad enough. But I got by with two minutes lamp time and about 4
>> rads, or less. Do you do a post op UGI (the next day) to check on
>> how the surgery came out. He does it, and said he would consider
>> waiving that for me due to my radiation concerns.
>>
>> Anyway I think I will definitely ask for the bravo if I have the ph
>> test, even though it will be one more day off therapy (remember my
>> first ph test three years ago I was on therapy and the prilosec was
>> working), since I got the worst bronchitis of my life after they
>> pulled the catheter (nose hose) out from the last one. Currently I
>> have stopped the ppi's and am taking 300 mgs of zantac BID for the
>> placebo effect (LOL). I will definitely have to be off therapy this
>> time to prove if I have acid reflux.
>>
>> In regard to my frequency histogram question could you please
>> explain why (or how) the 24 ambulatory ph tests goes past 7, and all
>> the way up to 8 or 9 or higher (like mine did). I assume the
>> sensors do read ph's that high, even though they sound like they are
>> not of any value pertaining to non acid reflux input like the
>> impedance test is.
>>
>> I want to thank you again for you response. It was so good hearing
>> from you. I am very worried and concerned and scared about the
>> outcome of my current dilemma, and I look forward to hearing from
>> you again.
>>
>> Pete
>
>
> Sure...lap Nissen is indeed major surgery. The potential for damage to
> the stomach, esophagus, spleen, vagus nerves is very real. And its
> success is very surgeon-dependant, not to mention complication rate.
> The laparoscopic boom of the early '90's resulted in a lot of
> surgeons doing all manner of laparoscopic operations. It fostered a
> significant re-interest in reflux disease, especially coming is
> proximity to the development of PPIs, and we came to understand more
> about GERD and how the Nissen operation works than we ever knew
> before. Not all surgeons were able to develop the necessary skills.
> Unfotunately, some of them are still doing these operations. We're
> currently seeing an almost exact replay of that scenario in the arena
> of bariatric surgery.
>
> This guy's attitudes on the daVinci run counter to virtually
> everything that's commonly known about that device in surgical
> circles. No it doesn't shorten operating times, it adds about an hour
> because of the required setup time. It normally takes about 45
> minutes to do a Nissen laparoscopically. It might take me longer if
> I'm helping our MIS Fellow do it. I can't imagine how a competent
> surgeon could drag that operation out to 3-4 hours..perhaps if he
> were supervising a rank newbie...otherwise that time frame is WAY
> outside the norm. The robot is a toy. A very cool toy, certainly, but
> its usefulness in general laparoscopic foregut surgery is generally
> considered to be negligible.
>
> Cine esophagrams are different than a standard UGI. I could envision
> getting one of those in a patient where I had serious concerns or
> confusion about their motility after seeing their manometry results.
> To order one outside of those reasons and BEFORE manometry is done is
> an unconscionable waste of money IMHO and I don't know ANY surgeon who
> feels differently.
>
> I presume your pH test registered up to 8 or 9 because there was
> alkaline material in your esophagus. There's no way to know where it
> came from, but obviously it was either alkaline stomach contents,
> saliva, something you ate....etc.
>
> HMc

Thanks so much again Howard...I feel like I am caught between a rock and a
hard spot, and now I am really scared, and I am constantly suffering. I do
trust your knowledge and your experience and would definitely feel
comfortable with you as the lead surgeon on a conventional lap nissen, if I
were to ever have one. I told the surgeon about you at our meeting (he
seemed to be quite knowledgeable and friendly and spent over and hour with
me, and everyone had gone home). I told him I respected your opinions and
knowledge (and believed that you were a prominent surgeon in the lap nissen
arena), and he said he does not know you, and that he does not agree with
your UGI philosophy and that he does them (the UGI and the cine together) as
the very first step (with or without a previous manometry) - obviously that
is from his training and experiences in the Air Force (retired colonel), and
his current teaching at Johns Hopkins. Like I said, I agree with you and
the Mayo Clinic article I listed in my previous post, regarding the value of
the UGI as a diagostic tool for the nissen fundo.

He has been an academic surgeon at Hopkins for three years, and he and his
student residents and fellows currently use the da vinci robot for first
time nissens. He does do repairs, but most of them are from other surgeries
from other doctors - and I believe they would be done without the robot. I
asked him how many of his lap nissen surgeries (which would include his
student residents and fellows of course - with him overseeing) had to be
redone in his lifetime and he told me just ONE. I found that quite
impressive. Naturally, most of his lap nissens were done before the robot,
in the conventional manner.

I do know about the cine esophagram and my studies of it indicate it is
mainly for people with dysphagia problems, which I do not experience. I
did have a manometry three years ago as part of my 24 ph and it did show up
a motility problem, but I do not experience any dysphagia at all like I said
(ie I do not have any difficulty swallowing). I showed him the past
manometry report at our meeting, so that would reinforce what you said about
possibly doing the cine part of the UGI (they are done together). But like
I said he does them anyway as his first step in the candidacy process
(acknowledging that I just had an EGD in June and my esophagus was okay). I
don't know if I will ever get to talk to him again - I could e-mail him.

Incidentally, I got my UGI report back immediately within two days (directly
to me in the mail), since I asked the radiologist if he would please send me
a copy, and I wrote my name and address down for his assistant and she
mailed it to me the same day (that was damn nice of him and probably far
from the norm). But I still haven't heard from the surgeon - he is a busy
person (travels to seminars etc, plus all his teaching duties at Hopkins,
and I guess he comes and goes a lot). I called his secretary and told her I
have my copy of the UGI report, and I assumed he was going to get back to me
for the next phase (via her calling me I assume), but he has not as of yet.

The result of my UGI and cine was relatively harmless except it did show up
a motility abnormality again (delayed swallowing), but like I said I do not
experience difficulty swallowing, and doubt that the motility abnormality is
causing my burning all over (which I believe is coming from my stomach and
is GERD), which is pretty much constant and does not seem to be related to
eating at all (hell all I drink is water now). But like I said when the
ppi's worked I had no burning or stinging at all after eating or drinking
anything.

Now let me ask you the 24K question. I have read that the nissen fundo is
contraindicated for people who have esophageal motility abnormalities, so
therefore I would flunk based on his UGI and cine test, and not be a
candidate. Do you agree that if a motility abnormality shows up in a
manometry or cine esophagram (or worse in both), that you are not considered
a candidate for the nissen fundo.

Thank you for your time...Pete

PS - regarding the frequency histogram ph's (for both the distal and
proximal sensors) - all I am trying to say is that apparently the sensors
will measure ph's above 7, which is alkaline. But everyone always says that
the 24 hour ph test only checks for acid. I say it also shows basic ph's,
as indicated on the wave forms and the frequency histograms I attached in my
original post in the thread. I am still confused about this.


From: Howard McCollister on 16 Sep 2007 08:35
In article <fci9g60dt0(a)enews5.newsguy.com>, "Peter" <peter(a)nospam.net>
wrote:


> He has been an academic surgeon at Hopkins for three years, and he and his
> student residents and fellows currently use the da vinci robot for first
> time nissens. He does do repairs, but most of them are from other surgeries
> from other doctors - and I believe they would be done without the robot. I
> asked him how many of his lap nissen surgeries (which would include his
> student residents and fellows of course - with him overseeing) had to be
> redone in his lifetime and he told me just ONE. I found that quite
> impressive. Naturally, most of his lap nissens were done before the robot,
> in the conventional manner.

Yes, I find it impressive too. In fact, I find it unbelievable.

Fact remains, IMHO, use of the daVinci robot for a Nissen fundoplication
is outside the norm and a pointless waste of time and money. And 3-4
hours to do that operation is ridiculous.

If this guy is the one I'm thinking of, ask him about the Friday morning
MIS teleconference this month September 7th. Several of the big
east-coast academic institutions participate in that invitation-only
monthly teleconference, including Hopkins, as do we, and I think he was
there last week. This past conference was about the use of the daVinci
robot in minimally invasive surgery, roux-en-Y bypass surgery in
particular. Laparscopic Roux-en-Y bypass is a substantially more
demanding technical operation than Nissen - one where the surgeon
actually has to sew pieces of intestine together). The consensus of the
teleconference group in a nutshell was that it's a pointless waste of
time, not worth the time or effort -- basically mirroring what I've
already said here. And one of the major proponents of that consensus at
that conference was Scott Melvin, one of the leading investigators on
the use of daVinci. As I've said, based largely on Scott's opinions at
that conference, the robot is likely to be useful in the treatment of
achalasia (Heller esophagomyotomy) and in laparoscopic pancreatic
surgery where the suturing of the ducts can require substantial
precision, and it's pretty much pointless in other operations at the
current time.

http://medicalcenter.osu.edu/research/profiles/Scott_Melvin/

>
> Now let me ask you the 24K question. I have read that the nissen fundo is
> contraindicated for people who have esophageal motility abnormalities, so
> therefore I would flunk based on his UGI and cine test, and not be a
> candidate. Do you agree that if a motility abnormality shows up in a
> manometry or cine esophagram (or worse in both), that you are not considered
> a candidate for the nissen fundo.
>

It depends on the motility abnormality. It *is* contraindicated in
achalasia and in hypertensive LES. In most other motility abnormalities,
it's not. It is true, however, too much dysmotility (poor mid-body
contraction pressures) and there might be a greater chance of dysphagia
post-operatively. However, a large percentage of that mid-body
dysmotility is due to submucosal fibrosis from chronic reflux, and that
will reverse to a certain extent once the reflux is stopped. So, it
might be a trade-off....some dysphagia (usually temporary) in exchange
for no GERD. My experience indicates that the vast majority of patients
that fall into that category find it to be a good trade-off.

So, generally speaking, no, Nissen fundoplication is not contraindicated
in the face of esophageal dysmotility. I am absolutely convinced,
however, that that determination of actual motility has to be determined
by manometry. UGI or cine-esophagography might be useful *adjuncts* in
some circumstances but NOT as a primary and sole determiner of
esophageal contraction adequacy.

HMc
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