Surgical Approaches to Foregut Conditions with Dr. James Mark Harris

Those suffering from foregut diseases can often find a long-term cure through surgery. James Mark Harris, M.D., is a general surgeon in the MUSC Health Floyd Medical Group - Florence and has extensive experience in foregut surgery. In this episode, he talks about the often complex foregut procedures he offers and how they can change the lives of his patients with diseases such as gastroesophageal reflux disease, chronic hearrtburn, and severe acid reflux.

“The symptoms of reflux are almost immediately taken care of from the time we finish surgery ... If a patient has a large hiatal hernia or a large paraesophageal hernia, they'll feel relief of that pressure sensation they have in the upper stomach or the lower chest almost immediately.”
—James Mark Harris, M.D.

Topics Covered In This Show

• From an anatomic standpoint, the foregut consists of the esophagus, the stomach and the upper portions of the gastrointestinal tract. After food is chewed and swallowed, the food travels down the esophagus, through the stomach into the intestinal tract, where it is broken down into the nutrients for adequate intake of proteins, calories, vitamins and minerals.
• Common foregut diseases include hiatal hernias, paraesophageal hernias, chronic reflux, esophagitis (inflammation of the esophagus), esophageal cancer, esophageal dysmotility, and achalasia (a thickening of the muscle in the lower esophagus that acts as a valve), Harris says.
• Those suffering with foregut diseases often show symptoms such as: problems with swallowing, bad heartburn, regurgitation issues, chronic cough, sore throat, upper respiratory infections, vocal cord changes from irritation.
• Delayed treatment or care for reflux can really lead to serious conditions such as esophageal cancer. Harris says studies have shown a rise in cases of lower esophageal adenocarcinomas, which is related to chronic acid exposure and reflux.
• Researchers estimate that about 20% of people in the United States have gastroesophageal reflux disease, though incidences don’t follow a particular demographic or age group. Those with increased weight or diabetes are more likely to develop reflux as well as those with anatomic defects such as a hiatal hernia, he says.
• Lifestyle modifications can prevent or alleviate reflux before resorting to surgery. These include eating smaller, frequent meals, and avoiding simultaneous eating and drinking which can liquify food, making it easier to reflux. It's also advised to sit upright while eating and to avoid foods that relax the lower esophageal sphincter, such as caffeine, chocolate, and acidic foods like tomato products or certain juices. Additionally, heavy smoking or alcohol consumption should be avoided.
• The use of robotics has grown significantly in various general surgical procedures, leading to faster patient recovery, increased safety, and the ability to limit potential complications with the range of tools available.
• At MUSC, the da Vinci XI robotic system has revolutionized minimally invasive surgery, allowing for full control of instruments and cameras from a console. This enhances surgical precision, ring a superior operation due to articulating arms that replicate open surgery stitching and provide a clearer view of the dissection at high resolution.

Read the show transcript below

Erin Spain, M.S. [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. People with forget diseases can often find a long term cure through surgery. Dr. Mark Harris is a general surgeon and the MUSC Health Floyd Medical Group with extensive experience and foregut surgery. He joins me today to talk about the often complex procedures he offers and how they can change the lives of his patients with diseases such as gastro esophageal reflux disease, chronic heartburn and severe acid reflux. Welcome to the show, Dr. Harris.

James Mark Harris, M.D. [00:00:51] Thank you.

Erin Spain, M.S. [00:00:52] Tell me about the foregut. It's responsible for so many important functions, such as swallowing and digestion. Explain it to me and how vital it is to our daily lives.

James Mark Harris, M.D. [00:01:03] Well, from an anatomic standpoint to the foregut is comprised of the esophagus and the stomach, essentially, and the upper portions of the gastrointestinal tract. After the food is chewed and swallowed, the food travels down the esophagus and enters the stomach, and the stomach does its magic and produces acid so that it can digest our food and make a more liquid so that it passes into our intestinal tract and is easily able to be broken down into the nutrients that are absorbed so that we get the adequate intake of proteins, calories and vitamins and minerals that are necessary for physiologic function.

Erin Spain, M.S. [00:01:39] Here at MUSC Health, you're seeing patients with some common foregut diseases. Tell me about these patients who you see, what are they experiencing? What are they diagnosed with?

James Mark Harris, M.D. [00:01:49] Most of my referrals are coming from the gastroenterology department because they tend to see these patients first because of symptoms and we see a lot of hiatal hernias, paraesophageal hernias, patients with chronic reflux, the complications of reflux such as bad esophagitis, which is inflammation of the esophagus from chronic acid exposure, which over time that can lead to structuring or narrowing of the lower esophagus and potentially lead to esophageal cancer with long term exposure.

Erin Spain, M.S. [00:02:16] At what point are people referred to you for surgery? Some people come to you, they're pretty sick.

James Mark Harris, M.D. [00:02:21] Most people have problems with swallowing or they will have heartburn That's just not controlled. I mean, we have a lot of great medications now.

When I first started surgery, we had what we call the histamine blockers. Like, you know, we had Tagamet was the first one that came out. And then you started having Pepcid and Zantac and some other medications that would help. And these do help, but they're kind of limited and how long they last. Then the proton pump inhibitors, they came out. And these actually affect the acid producing system within the stomach to decrease acid completely, which has revolutionized a lot because we don't see as much ulcer disease from the stomach.

We don't see as much esophagitis in the patients that are taking these. So patients get referred to me mainly if they're having difficulty swallowing and it's not controlled with medications if the reflux is not control. The medications do not stop hiatal hernia. They do not stop reflux. All that they do is take that acid down so that the acid is not causing symptoms.

So patients, especially with hiatal hernias, they can have a tremendous amount of regurgitation, they can have chronic cough, they can have sore throat, they can have upper respiratory infections that tend to be recurrent. They can have vocal chord changes from irritation. They can't eat certain foods and meals because of the reflux and regurgitation. So I'm seeing those patients. I'm seeing patients that have achalasia, which leads to problems with the esophagus.
It stops its motility, meaning it doesn't contract and push things through. It will dilate patients weight loss or chronic vomiting can really they can't eat. Which is usually the gastroenterologists will diagnose and send to me. You know, the hernia is a lot of them are discovered with CT scans, they may have had vague symptoms and they see me for that.

Erin Spain, M.S. [00:04:02] Is somebody is not able to get treatment or care for reflux. It can really lead to some serious conditions. Tell me about that.

James Mark Harris, M.D. [00:04:10] On the benign standpoint, esophagitis, which is irritation or inflammation of the esophagus, it's almost like a burning, if you will, of the esophagus from the gastric acid and it erodes the protective lining and it can cause pain, difficulty swallowing. You can get strictures which over time, chronic reflux and chronic esophagitis can lead to scarring, which is narrowing up the esophagus. And it's difficult to swallow and pass things through.

Now unchecked, over time, chronic reflux can lead to esophageal cancer. It's a different type of esophageal cancer than the main body. We're actually seeing a rise in lower esophageal adenocarcinomas, which is a glandular disease and as related to chronic acid exposure and reflux. So getting the reflux under control, especially if it's pathologic, is key.

Erin Spain, M.S. [00:04:58] You are also able to help people with certain cancers through foregut surgery. Tell me about that.

James Mark Harris, M.D. [00:05:04] We do gastric surgery as well. Gastric cancers. We were able to do that either minimally invasive or open, depending on the nature of the disease process. There are some localized forms of gastric tumors called GIST tumors, gastrointestinal stromal cell tumors. And these can be removed minimally invasively, robotically laparoscopically.

We perform those operations. And in addition to that, we also do some serious non-cancer surgery, such as severe ulcer disease that is not able to be treated with medications. And the worst case scenario, perforations foregut, which occur with ulcer disease as well.

Erin Spain, M.S. [00:05:38] After these procedures, which for the majority of them are minimally invasive, what can a patient expect? Are they able to regain function or feel better afterwards?

James Mark Harris, M.D. [00:05:48] The reflux is generally treated immediately now because of the surgery, and depending on how extensive it is, they can have some dietary modifications for a while because you get swelling. But generally, patients are in the hospital a day or two after surgery at that. And because we do it minimally invasive, back to normal activity in two weeks. Diet, you know, to be on kind of a soft diet for upwards to a month to allow the swelling to go down and then gradually increase a diet to a normal consistency.

Erin Spain, M.S. [00:06:16] So researchers estimate that about 20% of people in the United States have gastroesophageal reflux disease. Tell me who is likely to get this?

James Mark Harris, M.D. [00:06:26] You know, it's variable. A lot of folks overweight will have it. Some people who have the anatomic defects with the hiatal hernia, a vast majority of them will have reflux. It doesn't necessarily fit a demographic, you know, because I've had very skinny patients with bad reflux. I've had overweight patients with the reflux, and it just happens to be fairly random.

You know, increased weight will definitely increase the risk of reflux. And that's just, again, with the pressure differential that we see. Diabetics can get a lot of reflux, too, because they get secondary conditions of the stomach like gastroparesis, where the stomach doesn't contract really well and doesn't empty well. It's got to go somewhere. If it's not going downstream, then it has a higher propensity to go up into the esophagus.

Erin Spain, M.S. [00:07:09] Besides, perhaps weight loss, is there things that people can do to prevent this or make it better before going to surgery?

James Mark Harris, M.D. [00:07:16] Yes. And, you know, every patient with reflux doesn't need surgery. We reserve the surgery for those patients who are refractory or have the anatomic changes that we can fix and know that we can help them. Just run of the mill reflux. I mean, we recommend small, frequent meals.

I tell the patients not to eat and drink at the same time because if they drink, it liquefies their food. It makes it more, more liquid, so it's easier to go up the esophagus. We recommend sitting upright, not, lounging in the La-Z-Boy while watching a game, trying to eat, you know, to eat smaller, more frequent meals rather than large meals at one time.

And there are certain foods that will actually increase your risk of reflux because they relax the lower esophageal sphincter. Caffeine, chocolate, they have methylxanthines in them that causes relaxation of the lower esophageal sphincter. Any tomato or tomato products because of the citric acid in there. The same is true for like orange juice and grapefruit juice.

Obviously alcohol and tobacco will do the same thing. So patients who are smoking or drink consistently or heavily, we recommend they avoid that.

Other lifestyle changes, I always tell patients who have a lot of reflux that, you know, elevating the head of the bed will help either putting a block under the head of the bed, getting a wedge pillow that keeps their head slightly elevated above the abdomen will help. Not wearing tight constrictive clothing, especially around the abdomen. You know, the era of spandex and all of that, putting pressure in that area will increases abdominal pressure. So, again, it's got to go somewhere. So it's going to force it back up into the esophagus.

Erin Spain, M.S. [00:08:43] Is this more of a problem as people age as well?

James Mark Harris, M.D. [00:08:46] You can see it at all ages. I mean, I see it from the 20s all the way up until later in life. I mean, we all have a little bit of reflux all the time. Our body's natural compensatory mechanism is to either swallow air or swallow, and our esophagus will push things back down. And, you know, absolutely everyone who's eaten the wrong thing has had a little bit of heartburn at some point. But the patients who have it have it bad. I mean, that's a constant problem.

Erin Spain, M.S. [00:09:10] Well, share with me the latest surgical techniques that you're using at MUSC Health Floyd Medical Group to treat these conditions.

James Mark Harris, M.D. [00:09:18] Well, I started out doing this a long time ago, 20-something years ago with my mentor. We were doing it laparoscopically. Now we have transitioned and we have a robotic platform that we're using and we use a daVinci xi system, which in my opinion has revolutionized minimally invasive surgery.

I am in full control when I'm in the in the operating room on the robot, we actually sit at a console away from the patient after we've gained access, hooked up to robotic arms. I have complete control of my instruments. I have complete control of my camera so that I'm seeing it doing everything that I want to do.

And I don't have to rely on an assistant to move or to move the camera. And I'm able to have a lot of tools at my disposal. And I think we actually get a better operation because. Laparoscopy is very difficult to sew laparoscopically like we would if we were open.

But with the robot, because of our articulating arms and the angles we can sew just like if we were open and get a better closure of the hiatus, I think we're able to visually able to see the amount of dissection at a higher resolution. I'm able to put the camera all the way up into the chest or behind the heart when we're dissecting the esophagus to make sure that we have enough length. And I have different retraction points. I would never go back to doing it laparoscopically, having done it robotically now for a while.

Erin Spain, M.S. [00:10:33] And for patients who are listening, this really is the cutting edge of surgery. And maybe explain that to them and how MUSC Health is able to offer this type of surgery and care and how that's different than maybe other places in the state.

James Mark Harris, M.D. [00:10:47] I think robots have been around for a little while there. A couple of advancements in robotics over the last few years; It really has hit general surgery. It was used by as it was used by urologist a lot with prostate cancer. And I think that the application for general surgeon, you know, as people have pushed the envelope and done more, they found that it was a great platform, especially for for gut and for abdominal wall reconstruction. And now there's not a whole lot that we can't do with the robot that we do open. You know, the limitations are we've just got to be able to see and to be able to gain access to the abdominal cavity.

So we have expanded our robotic program to the point where we're doing a wide range of general surgical procedures. And again, I don't think that I would ever go back to the laparoscopic approach to this. I myself have had robotic surgery, So so I'm a big proponent of that process because I think it gets patients back to normal activity faster. I think it is safer. I think that the amount of tools at our disposal limits, the amount of potential complications while we're doing the surgery.

Erin Spain, M.S. [00:11:51] You mentioned that you have a specialization in this type of surgery using the robot. Why is it important for patients to seek out an experienced surgeon like you for forget surgery?

James Mark Harris, M.D. [00:12:02] It all depends on how well you were trained. There are some programs that don't do much of this when they're training and there some programs that just have a small amount. I think it's important because the wrong operation or an inadequate operation can lead to bad complications.

A patient is having significant reflux or they're having significant problems or they may have been diagnosed previously were more than happy to see patient can self-refer to our office or go through their primary care doctor and ask for a referral or a referral to gastroenterology because we work hand in hand and they know when to send patients to me and when not the vast majority of my patients for are coming from the gastroenterology department. They help me coordinate all of the workup as well because again, there are a lot of pieces to the puzzle before we ever decide on which is the appropriate operation to do.

Erin Spain, M.S. [00:12:49] Tell me about some of these success stories that you've seen. How are people feeling after they have surgery?

James Mark Harris, M.D. [00:12:55] The symptoms of reflux are almost immediately taken care of from the time we finished surgery because we limit the amount of refluxate that can come up from the stomach into the esophagus. If a patient has a large hiatal hernia or large esophageal hernia, they'll feel relief of that pressure sensation they have in the upper stomach or the lower chest almost immediately. Now, patients are going to be tender after surgery and, you know, some more than others. And even though we do it minimally, invasively, but I will tell you that most people are back to full activity within two weeks and their soreness is gone. I love it. I couldn't see myself doing anything else, especially in medicine.

Erin Spain, M.S. [00:13:31] What do you do to optimize your health and live well?

James Mark Harris, M.D. [00:13:34] Well, I try to stay active if I’m feeling reflux — I actually have a small hiatal hernia I know from endoscopy — and if I have reflux symptoms, I will manipulate my diet or avoid eating before I go to bed and those things that we talk about..

Erin Spain, M.S. [00:13:47] Thank you so much, Dr. Mark Harris, for coming on the show and explaining this really interesting, complex surgery and what's available to our patients. We appreciate it.

James Mark Harris, M.D. [00:13:56] Well, thank you.

Erin Spain, M.S. [00:14:01] For more information on this podcast, check out AdvancewithMUSCHealth.org