Gastroesopheal Reflux Disease

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current in General Surgery is edited by Jeffrey Ponsky, Dina Bolez, and Harveen Lamba in partnership with Global Cat MD and is recorded and produced at Cleveland Clinic in Cleveland, Ohio. Hello, this is Doctor Jeff Ponsky. Uh, I'm a surgeon at the Cleveland Clinic, and I'm here today with Doctor Michael Rosen, who's professor of Surgery at the Cleveland Clinic Learner College of Medicine. And welcome to our, uh, podcast on uh Stay Current. We're going to talk today about another surgical problem as a uh continuing effort to provide uh medical education for our audience, and today's topic is going to be gastroesophageal reflux, again from the surgeon's perspective. And welcome, Mike. Thanks for being here. Thanks very much for having me. I'm looking forward to it. All right, so, uh, again, this is just a casual discussion between us and so we'll start out based on a patient and we'll say, what if you see a patient, say a 40 year old person who comes to you, uh, let's say a female and says, uh, uh, Doctor Rosen, I've been having, uh, severe heartburn. This has been going on for a couple of years and I keep taking, uh, Tums and Rolaids, and they help. Uh, but this heartburn is interfering with my life now. It's just sort of very bad. What would you do? So, I think when you see a patient like that, particularly as a surgeon, if you're seeing them the first time and they really haven't had any workup, I, I think that surgery should be looked at and disease of gastroesophageal reflux is very far down on the treatment line. And you really want to understand what the symptoms that the patient is experiencing, Are they appropriately taking medicine for anti-reflux and what workup have they had to date? So, this is one of, uh, uh, this is a fellow, uh, in your program, and she comes up to you and she says, look, oh, I work together with you every day. I've been healthy. I have no problem. I'm an athlete. I jog, but I have a high tension life. And this is a nuisance for me now. And I haven't started any medication because, you know, I've just been waiting for an expert to help me, and so that's why she's seeing you. So, what would you do with her? Fair enough. So, I think if somebody's come in, never been, had a trial of PPIs, never been on any medicine, I, I think in that situation, I would treat them much like how I would assume most primary care physicians do, is I would put them on a trial of 6 weeks of PPIs to see. So, what dose would you start with? I would start with 20 mg a day of Prilosec. OK, and they can get that over the counter. Over the counter. All right. So, you start that on her, just as a, a curiosity. Uh, we all go to that. Everybody does that. Why don't we use H2 blockers for this? I think you have to take them more often. They don't last as long and it's just more convenient to take a once a day drug. All right, so PPIs are more effective and they, we know that PPIs will reduce gastric acid secretion more than H2 blockers. We'll get back to H2 blockers later, but, OK, so you, you do this with her, uh, uh, and, uh, she comes back in 6 weeks. You happen to see her every day. But in 6 weeks, she says to you and she comes and makes an office appointment, I am terrific. This once a day medicine has saved my life. I am happy. I'm having no symptoms. It doesn't interfere with my life at all. What's going on now? Can I continue to take these and what's the story? So I certainly think there's mounting data that a lifetime of proton pump inhibitors, it has consequences associated with it. So, so I think at that moment, what I would do is stop them. And see if the symptoms came back. She didn't want you to stop them. Of course not. But I would see if the symptoms came back. OK. So, you would try to stop them for how long, a month? At least a month. Typically, if they're, if, if they were really working within a couple of days, you're going to know if you have a problem. And she comes back and says, you know, I don't like you anymore because I was feeling so great and now I'm starting to have heartburn again. OK, so, at that point, you definitely need an EGD. Uh, there's no question at a minimum workup and that, uh, in, in my opinion, that patient needs a scope. So, you opened her eyes quite widely because she says, I was feeling great. I'm taking this simple medication. Once a day, it was helping me and now you want me to have an endoscopy? Why? At a minimum, to assess the esophagitis and in particular to rule out Barrett's. OK, so, it's important to do this to rule out Barrett's esophagus. Uh, Barrett's esophagus is subtle, it may be asymptomatic and uh very, uh, you know, hidden, and obviously the risk is for future gastric cancer through low grade, high grade dysplasia progression. And so if she doesn't have Barrett's esophagus, you do endoscopy, she does not have esiphagitis and she does not have Barrett's. She wants to know how often she needs an endoscopy now. OK. So, let's take that specific patient. So, if you, if you have a patient that does not have esophagitis, No hiatal hernia and no Barrett's. 2016, I would want more of a workup before I'd keep them on PPIs indefinitely. Especially a young active person with osteoporosis and, and, and some of the other issues. Oh, those are some potential consequences. OK. I would, once you get these people on it, especially since it's over the counter, I'd want to make sure I was actually treating the appropriate disease. OK, so what would you do? So, in, in that patient, especially if it was my fellow a reasonable person, I, I would tell them that we don't have evidence that concludes that you have gastroesophageal reflux disease or esophagitis. I, and I'd want to confirm that diagnosis with a PH study. OK. So what kind of PH study would you get? I would do a Bravo study just cause it's easier. So, a Bravo study is a little bit better for the patient because they don't have a tube hanging out of their nose. We do an upper endoscopy, put the little bit of a, Uh, of a, uh, capsule, which is a suction capsule, 6 centimeters above the EG junction, and we can measure 48 hours of pH data. Theoretically, we could have done that at the time of the first endoscopy to assure that the patient doesn't have to have two endoscopies. Uh, would you do that on or off PPIs? I mean, I would always prefer to do it off PPIs. I, to me, interestingly, to me, I like to do that specifically for one reason. I like the Bravo test to tell me symptom correlation. Uh, because as we talk about surgery, it's important to I think set patient's expectations about what you're going to make better because it's related to reflux and what might not be related to reflux and it's not going to change. All right, so let's, let's go into this now. So, let's assume that we do a, uh, 48 hour bravo. By the way, we're gonna discuss, do you need manometry in this patient at this point? At this point, you don't. Uh, in, in fairness, in my practice, if I think that somebody is going to go potentially down the operative road. Then my workup consists of endoscopy with a Bravo study, as you said, it just makes life easier, and then a manometry, cause we're not going to have a surgical discussion without manometry. OK. So, the manometry is something you're going to have to do before you operate. Correct. And, uh, it, we'll talk about what else it can add, but a lot of patients don't like manometry. So, here you're trying to prove acid exposure. Is that right? Correct. OK. So I, I'm trying to make the diagnosis, Just for her. OK. So, this is a patient who you're gonna now manage off PPIs with maybe Tums or something like that until she has her stuff after a week, and you do that exam and it, let's say it shows a pH, uh, below 4, 6% of the time or 8% of the time and her Demeter score is 20. What do you want to do? So I would see her back and at that point, I, I would have a discussion that, uh, it sounds like she's having mild reflux and um. I would certainly have a deep discussion about lifestyle modifications, uh, and, and particularly weight loss, if that's possible. Um, and if there's, you know, drinking coffee, alcohol, all the things to try and reduce reflux, uh, symptoms, I would go down that route heavily with that low of a score. No esophagitis and, and, uh, And certainly no Barrett's, um, and I would try proton pump inhibitors, uh, to try and manage her. And she says to you, Doctor Rosen, in two weeks, I am good again. I am happy again. I'll see you when I need you, and you see her in the hall a year from then, and she says, you know, I take these things, I forget sometimes, but I'm good. I'm not having many symptoms. What are the things to look for in somebody who's on chronic PPIs? And by the way, 3/4 of doctors in this hospital probably take PPIs over the counter. I've been on PPIs for probably 15 years. Yeah, so many of us take PPIs. My bones don't feel weak and I don't feel like I have Alzheimer's, but I don't really know. So we know that in women in particular, osteoporosis in the long term, what might you do to, uh, to protect her? I mean, I think you can put them on calcium supplementation, uh, although I think that if not taken well can cause. Some stomach irritation as well. You can get bone density. Sometimes. Yeah. As well, right. Yeah. So, periodic bone density examinations may be good. So, let's just go a little farther. And that was a good, that was an out of the park home run, and she loves you and gave you wine for Christmas and that's great. OK. But you see a similar patient now, And this patient was sent by an internist or a gastroenterologist, and this patient has been having similar symptoms. But the PPIs worked initially and now there's a lot of breakthrough. And he put her on PPIs twice a day, 20 BID, and she's still having symptoms. Uh, she's, uh, can't eat after 6 o'clock at night because she has a lot of heartburn and regurgitation. And what do you want to do with this patient? So, obviously, a little bit more information, uh, what her, uh, BMI is. Let's say her BMI is 28. 28. OK. So, um, and I, I always just, although it sounds like she is, just want to know a little bit about how they're taking the medicine cause it's not uncommon. How do you take the medicine? So, so, I think it's important for a PPI that you take it within 30 minutes of a meal and you want. After the meal? I typically recommend before a meal. Before the meal before. OK. And you want food to be in the stomach to slow the progression. Uh, of the pill going through your body so that it can last for an appropriate amount of time. So OK. Before I go to twice a day, I make sure people are taking it. Uh, a lot of people take it either at night just before they go to bed, which is the worst time to do it, or in the morning and skip breakfast. So as long as they're taking it appropriately 30 minutes before a meal and, and, and, and they're doing a reasonable job of that and they're still having breakthrough pain, then I would call that symptomatic reflux that's not being controlled with medicine, that twice a day already. Uh, so I would work that patient up and, uh, they would obviously have had to have, uh, an EGD. If they hadn't, I would order an EGD with a bravo at that time, cause I'm considering surgery on them and manometry. So, tell me about manometry. This is an interesting test and, uh, never a popular one. And we put a little catheter down the esophagus through the nose, have them drink a little bit and measure their swallows. What do you look for when you see the results of a manometry? So, I think the basic reason that patients need to understand why we're getting manometry, in my opinion, number one is to rule out achallaia, cause obviously the, Symptoms can be very simple. It's fun that you say number one to rule out. Number one. Tell us why. Because if you wrap somebody with ankylasia, you have really destroyed their esophageal function. So let me just interrupt you here. Before you started doing for gut surgery for Nissan's, for, for reflux, how many halermyotomies did you do for yasia? Wait, before, before you got into doing manometry and you were operating on how many people did I find for yasia, rare, rare. And now that we do manometry looking for reflux, we actually find patients with alagia. Why? Why do we find them? How do they have heartburn? Oh, well, I mean, somebody with achylasia has heartburn because of stasis and, and, uh. And they ferment the food in their esophagus, so it causes heartburn. Correct. All right, so we end up finding achylaia when we're looking for a reason for reflux in some of these people. Rarely, but when you do, you feel good that you found out. Absolutely good. So, OK, so, we look for achylasia, Else do you look for? Uh, so you're going to look for total relaxation of the LAS with swallowing. Correct. Correct. OK. And what else? Uh, I mean, I'd like to see a low resting pressure, the low esophageal sphincter to go along with the story of, of reflux disease. I also like to be able to tailor the fundoplication based on, uh, uh, distal esophageal amplitudes. And, and although, There's probably not a specific cutoff, and a lot of it has to do with symptomatic correlation to me with dysphagia and the difference between a floppy Nissan and a toupee. I think it's debatable now. It, it, I certainly want to have a detailed discussion if somebody has what appears to be poor oesophageal motility due to reflux, not alasia, about postoperative dysphagia expectations over a long period of time, and at times the difference between doing a full wrap and a. Two packs. All right, so, let's just talk about this a little bit because, you know, surgeons are sometimes a little bit miffed about which operation to do and there's some debate in the literature. So, let's assume that the patient has normal peristalsis with an amplitude of 30 millimeters of mercury with each swallow, even higher a little bit, and total relaxation of the LAS. The Demeter score, let's say, is, uh, 28 or something like that. And, uh, the patient has an endoscopy, which is normal with no Barrett's esophagus and no, maybe a 2 centimeter hiatus hernia. The patient is miserable and wants you to do something. What operation would you recommend? That patient's going to get a full, a Nissan. A Nissen fundoplication, 360 degree wrap, and tell us about, just quickly, the steps you do in the operation. You do it laparoscopically? Do it laparoscopically. Uh, to me, uh, I, I don't do a minimalistic type dissection. I take down, kind of reestablish the GE junction. Take down the frontal esophageal ligament ligament, uh, go up in the chest. I actually think when you do this laparoscopically, one of the disadvantages of laparoscopy, Is we don't get a lot of scar tissue, and I think one of the ways to reduce recurrences is to actually do a full mediastinal dissection and create ability for that area to scar down. And you also get more length on the esophagus. More length, which I think is, which is critical. Right. I do take down the short gasterisk when I do it. I just think it's easier to not twist it and, and see exactly what you're bringing around. I think it's important to bring the posterior aspect of the stomach to the anterior aspect of the stomach so that you kind of have a ridge of short gastrics behind the GE junction. I think the way that a Nissan is created is highly variable, and one of the downsides of this operation that makes it hard to reproduce the data is everybody does it just a little bit differently, and there's not really great standardization, and it's easy to twist. It's easy to bring anterior wall to anterior wall. Um, so I think that's absolutely critical. Uh, so let me stop you here. It is so important, you know, we, when I do this with residents and fellows, we're so anxious to take down the short gastrics and to get a good retrogastric space and to then bring the thing around, do the shoeshine maneuver. Everybody's so happy that they just create the wrap quickly and Don't think about the geometry of the wrap that you alluded to, and the most important part of the operation is taking the time to get the geometry of that wrap. And if you actually put it together and look at it and it doesn't look right, don't be afraid to take it down and reestablish it. One of the things that I've made a mistake on and others have in the, in the past is when you grab that post. Exterior, the greater curved part that's on the left. If you grab it too low to do your wrap, you're actually, uh, too high on the right and too low on the left, and you're actually trapping a portion of the fundus up above, and, and that's wrong. So, the geometry is critically important. How many stitches do you, uh, how many stitches do you put in the, uh, In the wrap? In the wrap. So I can tell you from, uh, when I was younger, one of the common mistakes I would make was that I thought I have all this intraabdominal esophageal length, and I would feel the need to wrap all of that. And I think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia. So I typically do 3 stitches, um, in that I like it to be about 2 centimeters, nothing longer. Uh, the sutures that I typically use silk sutures to do this, and my first stitch is stomach to stomach, and then I can take that knot and I can move the wrap, make sure I like where it lies, make sure I'm happy where it's at. OK. And then my, I'll put a stitch below then to set it right where I want it at the GE junction just above it. That's stomach, esophagus, stomach. And then I'll go just above that stomach, esophagus. Do you fix the posterior wrap to the crura in any way as a last, as my last stitch, I bring the, uh, I do, I call it a posterior gastrocecty I take the posterior aspect of the stomach to that. I don't like to do it, which I know you do it, uh, beforehand, uh, because I, I think that's a little bit cheating that the stomach should be sitting there without tension. And not trying to run away. For once, I might have to agree with you. You might do it better than I do. I love it. Um, so let's talk about the curl closure. How tight do you close the curb posteriorly? So earlier in my career, I used a bougie, uh, to do that, uh, 56 French bougie. I, I, I had in one of my, uh, friends watched a video of, uh, anesthesiologist perforating the esophagus, doing that, uh, and, and as I got more experienced. I think you need it less and less. Um, so, I don't use a bougie anymore, uh, and, and I close it, uh, enough where the esophagus comfortably has that little V sunlight below it. And I would probably say, as I've gotten older and older, I make it tighter and tighter. Well, I have seen some that have had been taken down, but Ron Hinder, who was a pioneer in this, in the United States, used to describe the triangle of air, which you've described below the esophagus. Because if a bougie were there, it would fill that space. Right. I agree with you. I don't use a bougie routinely anymore as well. All right, so we have that operation. Now, let's get a little bit more complex and use the, uh, the, uh, the manometry to, uh, tailor our operation. What if I told you that the patient had, uh, uh, some connective tissue disease? And uh, the, the, the patient's uh manometry showed that the peristalsis was a little bit below 20. There was peristalsis, uh, but it was weak. The LES was also very weak, and, uh, what are you thinking when you see that patient? Well, I think in those type of patients, uh, I think the key is to have a clear discussion of, uh, we don't want to cure one problem to create another disease. And so I typically start with those types of patients to say clearly that The best operation we have to prevent reflux is a Nissent fundoplication, and while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier. So, we need to be able to make your, Reflux symptoms better without making it so you can't swallow. So, in my practice, that's going to be a toupee for the vast majority of. Why don't you describe that operation for us? So, for a toupee, again, I also do a, a formal esophageal dissection with the pen rose around it, go up into the chest, mobilize to get enough intraabdominal esophagus. So I really do think that's probably at least as important as when you do the wrap. And then I also, for a toupee, take down the short gastric, because I just think it's easier for me to keep the orientation. And know where things are and that's going to be a posterior 270 degree wrap. I do that again. I make it a little bit longer, so this is probably about 2.5, maybe almost 3 centimeters long, and I will typically do 3 sutures on either side, uh, and then I will. Two sutures to where? Through I, I will do this as esophagus to stomach on either side. Just that. Yes. And then I will do a posterior gastropy of stomach to, uh, to the posterior cruise. You don't do it to each side. To the cruise, I don't like to do that because I think it angulates things in an awkward fashion and it's pulling the stomach. So, you close the posteriorly, yes. As they used to, some used to leave it open. You close it posteriorly and fix it posteriorly in one place. Correct. How many stitches do you do posteriorly? Typically one. Just one. Long as it's sitting where I want, everything is sitting in it. OK. So, this is very interesting. We know that, that you're trying to, uh, uh, I want to just state that the reason you're doing the toupee is to avoid pseudoackalasia here. Right. Which is a whole other story. So, let's talk about some of the problems that can occur after anti-reflux surgery. Um, And this is a standard approach. Uh, some of the other problems obviously is dysphagia, and we all know that even done perfectly, uh, patients can get dysphagia. When do you start to worry about dysphagia in the post-operative period? So I'm gonna answer that as a, as a global thing for all the young people who are listening to this. I would say the hardest transition of becoming and attending 12 years ago and doing 4 gut surgery. was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints. And issues and when to intervene on that. And I think that's a lifelong lesson to learn, but I would say it is critical, and this is clear to patients in my pre-op discussion. That this operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves throughout your body. So it's good at that, but there are other things that you're going to have to deal with after this operation. And so I typically let folks know that this operation is its tightest right after surgery, and it's going to get looser over time. And so my expectation. Is that they have dysphagia and interestingly, the person I worry about the most is the person who shows up two weeks after an innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble. Yeah. Uh, long term. So I, I, my expectation is early dysphagia. I certainly wouldn't worry about it whatsoever for the 1st 6 weeks, uh, even if they had to maintain a liquid diet. And I probably would not consider intervening endoscopically until three months with no progression and no ability to tolerate anything besides liquids. OK? So, this is rare, but let's say you have a patient who's 6 months out or 8 months out and they're still having, this stage of the solids. Well, how'd you work them up and what would you do? So, first, I would get an upper GI in that patient just to get an idea and make sure the hernia hasn't come back, uh, make sure there's no anatomic reason for that, and to look at where the hang up, uh, is. And, and assuming that I made it too tight, uh, which would be my, as long as there wasn't a recurrence there, I would think that I probably calibrated it a little bit tight. Uh, then my next move would be to do an endoscopy. Endoscopy with stretching or dilatation. I mean, I don't do the endoscopy. I send it to you, but I, I, I would say that my expectation would be for dilatation. All right. So, let me just tell you that I understand that progression and, and time does help. Let, let's assume that you saw a year later, this patient has been complaining of dysphagia and, Do the upper GI and they have a slightly dilated esophagus with almost a bird's beak down there. What would you do? First, I'd go back. This is, by the way. Confirm I got manometry. So, you had your manometry. I had my manometry. Manometry showed perfect relaxation and good peristalsis before. And, and my EGD showed tight GE junction, no, Occurrence. It was dilated with no. This EGD, EG, now EGD. Yeah. At this time. Yeah. EGD at this time shows a dilated esophagus with a retained pool of fluid and a tight EG junction. So, obviously I, I'm very concerned about pseudoacallaia in that situation. So, I, I would want to get manometry done. And the manometry shows lack of peristalsis and non relaxing LAS now. OK. So I think at that point you have to have a conversation with the patient that, you know, likely due to the wrap potentially just being too tight and this long of dysphagia, the esophagus is burned out and it's no longer able to pump the food through. So, you know, in those patients, I think before you rush into the operating room, and we're gonna be in the operating room, I think you always want to make sure the nutrition is optimized because a lot of these people have had difficulty eating for quite some time, so. I'll certainly make sure nutrition's optimized. If it wasn't, I'd consider a peg and feeding them beforehand, uh, but assuming it's optimized. Nutrition is fine in this patient. Nutrition is fine. So, uh, you know, in that patient, I think you probably have two options. Uh, what I would do most likely would be to plan to go back, take down the Nissan, do a hilarmyotomy, and I would probably add a door, uh, to that, in that type of situation. All right. So another approach that I've used, That David Ratner described is to take down the Nissan, do a long Keller, and convert it to a toupee so you're on both sides. You don't have to absolutely do the door, but a toupee, a toupee because of both, you, you mean just to pull it open, or yeah, the toupee would pull both pull it open. And, uh, and provide some anti-reflux. We used to do that in allasia as a primary operation. So I wouldn't argue with either one of those approaches, but you would intervene because pseudoacalasia is a different disease now. Would you take down the whole wrap or would you not take down the whole wrap to make it a toupee? I have not taken down the whole wrap. I've opened the wrap, OK, pinned it at 180 degrees, and done a big. Uh, Heller between them and had fairly good results with that. But I think that that's something, uh, you know, pseudoacalasia is a real disease and now they have allaia of sorts. So, so my argument for not, not taking down the wrap is, I, I think when you're doing a reoperative for gut surgery, uh, just like complex hernias or whatever, it, the best thing to do is have the plan to go in and start over again. Now, if I got in and I thought, That I couldn't take the wrap down. I might fall back on that, but I, I think for complex reoperative for gut surgery. You have to start over because dysphagia, was it twisted a little bit? All those things get hard to sort out. So, you're saying you would take down the wrap. I would always, I, oh, I would always plan to take down the wrap, realizing that sometimes if I couldn't get it. Uh, if I couldn't get it, or maybe some days I don't need to, you can divide it and leave it as. Yeah. As half a wrap. As a toupee. So, let me just, uh, finish this little discussion with the patient who has these recurrent symptoms, but has terrible pain, dysphagia, and you do your upper GI and you see that she's got a slip missing with a good piece of fundus, maybe two inches or three inches above the wrap. What would you do in that patient, and she's very symptomatic, very symptomatic. Again, as long as she's not obese, uh, you know, uh, I would just, I'm just going to put out if, if she was morbidly obese and I would say a BMI over 35, uh, I would refer to my bariatric, and you would do recommend a gastric bypas, OK, but assuming that's not the case, assuming that because I, I do think that's just important to mention, that's a great operation for morbidly obese patients. In fact, over what for a primary case in a patient who's morbidly obese. What BMI do you start looking at why as a primary operation instead of a Nissan? 35. 35. And I think it's really important because the Nissan doesn't work well in morbidly obese patients. Yeah. OK. So, let's talk about the patient with the herniated wrap. What do you do there? So, a herniated wrap in a symptomatic patient, uh, again, uh, for reoperative surgery, I, I do think it is important to reevaluate them from the start. So I, I personally would get a 48 hour bravo study just to understand what their symptom correlation is to have an honest discussion about what I can make them feel better. I would repeat the manometry certainly if I hadn't done it before, I would want to know what that manometry was and see whether their symptoms related to something else. Um, I, I think in those type of patients, the only other re-operative patients you wanna know about is what their gastric emptying function is if you're doing re-operative surgery, especially if you didn't do it the first time, because the symptoms delayed gastric emptying overlap a lot and might have led to some of the problems with that. So I always particularly am looking for nausea and vomiting because those are red flags to me. Be careful going even in the primary situation if nausea and vomiting is a large component. Of my for gut patients' complaints, I am putting the brakes on rushing to do this and and really wanna understand what's going on. So assuming all that's not there and I got a slip wrap and all my other stuff just looks like that's what it is, I'm gonna take that patient back, take down the wrap, redo. Everything and give them a listen. All right, so here we are in the operating room, Doctor Rosa. You're a great surgeon, and I sent you this case because it's one of my recurrences. OK. Got a slipped and that's into the chest. How do you approach this reoperative slippednessen? Sure. OK, so, uh, anytime you're doing a reoperative surgery, uh, after somebody's had prior for surgery, and I'm not pointing this at you even though it's, it wouldn't be me, of course. Uh, so, so my first part of the operation starts with looking at where the prior surgeon put their incisions. And if somebody had a Nissan and they have an incision in the belly button, you know it's an easy day because they never went up in the chest and they never dissected up in the chest. If you see all 5 incisions and the lowest one is 5 centimeters from the umbilicus, you know that person. Real operate or at least we're in the situation to do it. So that's number one. The second thing I'm gonna do is I'm gonna get back in and, and, and what I like to do is the first kind of goal of my operation is to get me to the right crews. I think that's the most important part of the operation simply because then I know where the cava is and where you can get in big trouble. I've seen a re-operative surgery. Is where the liver and the wrap are obliterating the right cruise. You drift off of the wrap and you wind up in the cave. So what I like to do is first get the liver off the wrap. Yes, uh, and I tend to use a harmonic for that. I use a, uh, I, I'll actually hook, I'll use a hook or scissors and I'll accept bleeding because my plan is to put the paddle, which is a 12 millimeter retractor, there to compress any bit of bleeding, and that's one time you can injure the wrap, which I'm planning to use later on with the. Harmonic. So, so I'll do it if I have to, but I prefer it to be sharp. OK, good. Uh, and I take that down, get my paddle in, and I want to go specifically for the right cruise, and I want that right cruise at the base. Most people haven't taken the dissection low enough down to the base of the cruise, where you can wind up getting that cruise. And if I get the cruise, then I get a choice of going to the right or straight up the cruise with that anatomy, so I know where my cava is and I'm going to start taking the wrap down. The only other thing I've learned in this, the reason why a lot of these things come back is there's just not scar tissue in the chest. So, if you're really struggling down there, my second move is to get up in the chest wherever I can find a hole and then work my way back. One of the tricks I used to like to do is to get between the, between the wrap and the esophagus was on the left side of the wrap, is that I could often wiggle an instrument between the esophagus, On the left side of the wrap in order to take it apart. Yep. So that's after you get it down. But I think the key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. So this has to be identifying name structures, digging them out in a very systematic fashion, and not being erratic or you get lost quick. So, you see there and you're taking this all down. And uh let's assume that you see the vagus nerve is uh been injured there. The anterior vagus nerve has been injured because it was under the wrap and it's in this mess. What do you do? Well, uh, I, I think in a re-operative situation like this, uh, as long as I knew or felt comfortable that the posterior vagus was OK, uh, in this setting, I would probably do nothing, uh, acutely in the operating room, um, postoperatively on my upper GI, which I would for re-operative surgery I would get the first or second day for sure. I would look at that stomach was emptying just as a poor man's gastric emptying study. And if it wasn't that I was concerned about any other vagal injuries, I personally would go early to Botox, uh, of the pyloris. I wouldn't do a pyloroplasty. At the time of this operation unless I was convinced that I, I took both nerves. OK. Even then, there's some evidence that it may not matter. Correct. Uh, I wanna thank you for your time today. I hope everyone enjoyed this as much as I did. Getting Doctor Rosen to sit and talk this long is unusual, and we're going to be back with a whole series of, uh, podcasts and, uh, gastrointestinal surgery. So thank you once again for joining us. We hope you enjoyed this show of stay current and general surgery. You can listen, watch, or read all content by downloading the Stay Current in Surgery app. Please send questions or comments to us attacurrent podcast@gmail.com. We'll see you next time.