Drs. Sharona B. Ross & Alexander Rosemurgy

1. The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery Drs. Sharona B. Ross & Alexander Rosemurgy

2. Trusting Your Tummy Have you ever: • Had butterflies or a knot in your stomach? • Followed a gut instinct? • Felt you couldn’t stomach a situation? • Experienced a gut-wrenching sensation?

3. Tummy Talk • Gas, burping, bloating, heartburn, diarrhea, constipation • We often suffer in silence and hope it passes • Could be something we ate, nerves or a poor diet • Could be more serious, a symptom of a greater underlying problem

4. Digestive Disorders • As embarrassing as intestinal symptoms can be, don’t let embarrassment keep you from seeking help – in most cases, treatment is available.

5. What You Will Learn Today • The most common digestive disorders: • symptoms, • causes and • risk factors • Ways to prevent and treat digestive disorders • How to maintain a healthy digestive system

6. Your Digestive System • Digestion allows our bodies to get the energy and nutrients they need from the foods we eat

7. Why is a healthy Digestive System so important? • A healthy digestive system prevents disruption to our daily lives • Problems of the digestive system can • Make everyday living very difficult, sometimes impossible • cause pain, discomfort, “accidents”, lead to very serious health complications

8. Common Types • Gastro-Esophageal Reflux Disease (GERD) • Esophageal Cancer • Gallbladder Disease • Pancreatitis • Chronic Constipation • Diverticular Disease • Colorectal Cancer • Second leading cause of cancer-related deaths

9. Gastro-Esophageal Reflux Disease (GERD) • Chronic digestive disease • Persistent reflux • stomach acid flowing up (refluxing) into the esophagus • Most common symptom is heartburn • Cause of GERD unknown • Treatment: • Relief of symptoms: lifestyle changes & medicine • Prolong use of PPI medications may result in esophageal cancer • Cure: Surgery

10. Gallbladder Disease • Symptoms: • nausea & vomiting, bloating, constant right upper abdominal pain lasting for several hours after consumption of fatty foods • Diagnosis: • History, physical exam, RUQ u/s, HIDA • Treatment: • Surgery to remove the gallbladder

11. Acute Symptoms Abdominal pain, fever, nausea, vomiting Common causes gallstones chronic, heavy alcohol use Treatment includes medications, hospitalizations Chronic Repeated attacks of acute pancreatitis Symptoms Chronic abdominal pain, nausea vomiting, weight loss, diarrhea Common cause chronic, heavy alcohol use Treatment includes medications, hospitalization, nutritional support Pancreatitis Inflammation of the pancreas

12. Chronic Constipation • Persistent over years — even decades! • Unresponsive to treatment • More common in women • Treatment/management includes • adding fiber to your diet • increasing fluid intake • exercising more often

13. Diverticular Disease Diverticulosis • Small pouches in the lining of the colon • Symptoms: • bloating, constipation Diverticulitis • Pouches become inflamed • Most common symptom: • lower left abdominal pain • Treatments: • diet changes, medications • For repeated attacksSurgery

14. Colorectal Cancer • Most common symptoms • Blood in stool, unexplained weight loss • Causes • Causes unknown • Most common risk factors • Increasing age • Family history • Smoking • Poor lifestyle habits SEE YOUR DOCTOR

15. Recommended Tests & Screenings Some Common Tests for Cancer: • Colonoscopy • Every 10 years • Flexible sigmoidoscopy • Every five years • Barium enema • Every five years • Fecal Occult Blood testing • Annually New Tests: • Virtual Colonoscopy • Every five years SEE YOUR DOCTOR

16. General Risk Factors Non-controllable • Increasing age • Genetics • Certain medications • Certain conditions or diseases Controllable • Being Overweight • Unhealthy Lifestyle Habits • Smoking • Sedentary lifestyle • Poor diet and eating habits • High stress levels • Excessive alcohol consumption • “Trigger” and unsafe foods

17. What You Can DO! (Medical) Partner with your doctor • Physical examination • Complete review of your family medical history • Tests and screening • Clearly describe your symptoms • Digestive Diary Your doctor can help you create a customized plan for you to stay on top of your digestive health.

18. Other Tests & Screenings Diagnosis of digestive disorders may include the following: • Blood test • Stool test • Abdominal ultrasound • Barium swallow radiograph • PH monitoring exam • Computerized Tomography (CT) scan • Upper Endoscopy • Biopsy

19. What You Can DO! (Non-Medical) • Eat a healthy diet • Stop smoking • Exercise and maintain a healthy weight • Reduce stress • Digestive dos & don’ts

20. DO Get enough sleep Eat smaller meals Eat and drink slowly Get moving after meals DON’T Eat before bed and/or lie down after eating Digestive Tricks: Dos & Don’ts

21. Trust Your Tummy A healthy digestive system is within your reach: `live well and trust what your tummy is telling you

22. The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery Drs. Sharona B. Ross & Alexander Rosemurgy

23. Surgical Treatment for GERD • Fundoplication: constructs a valve mechanism which prevents acid from coming up into the esophagus • Three different operations: • Nissen fundoplication • Toupet fundoplication • Transoral incisionless fundoplication

24. Necessary Preoperative Testing • Upper Gastrointestinal Study • Evaluates the motility of the esophagus • Bravo/pH Study • Objective study measuring the frequency, severity, and duration of your reflux • Endoscopy

25. Approaches for an anti-reflux operation: • Open • Laparoscopic • Laparo-endoscoic Single Site (LESS) Surgery • Robotic • Transoral

26. Conventional Laparoscopy

27. What is LESS? • “Scarless” surgery • LESS surgery goes beyond “no scar”: • Faster return to normal activities • Less postoperative pain

33. What your belly button looks like postoperatively

34. What is Transoral? • It is an approach that uses the assistance of endoscopy to undertake the operation through the mouth • Deployment of “H-fasteners” allows the fundoplication to be secured • No incision is made

35. TIF

36. Our Experience • We have undertaken over 1500 anti-reflux operations • Since 2008 all the laparoscopic anti-reflux operations have been through LESS

37. Results: • There is a dramatic and satisfactory amelioration of symptoms • Postoperatively, when patients were queried if they would still have the operation: 88% said yes

40. Why Surgery • Medical Treatment for reflux is only FDA approved for 2 weeks, not for chronic use • PPI therapy increases the risk of osteoporosis, which women are already have an increased risk • Without a mechanistic fix the esophagus is exposed to both acid and bile salts which are both carcinogenic • 30% of esophageal cancers are attributed to GERD

41. Surgical Treatment for Gallbladder Disease • Operation = Cholecystectomy • Most common operation in the US • Approaches: • Open • Laparoscopy • LESS • Robotic

43. Anesthetics General Anesthesia Versus Epidural Anesthesia

44. Epidural anesthesia has lower postoperative pain scores

45. LESS Cholecystectomy with Epidural Anesthesia • Provides the same salutatory benefits of conventional cholecystectomy with added benefits: • Decreased postoperative pain • No general anesthesia side effects • Improved cosmesis • Lower cost

46. The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery Drs. Sharona B. Ross & Alexander Rosemurgy