Daniel Carl DeMarco, M.D., F.A.C.P. is the Medical Director of Endoscopy at Baylor University Medical Center in Dallas, Texas. Board certified in Internal Medicine and Gastroenterology, he is an attending physician at Baylor University Medical Center. He is also director of the Baylor Heartburn Center.
Reflux1: How did you come to specialize in this area of gastroenterology?
Dr. DeMarco: While I am a gastroenterologist in Dallas at Baylor University Medical Center, I see quite a few patients with serious diseases like liver failure. When the endoscopic treatments for reflux came available, I was very interested since it’s a new technique and interesting. It was refreshing to see patients with acid reflux disease as opposed to patients who were bleeding to death or dying from liver failure. I still do a lot of work with critically ill patients, but I also do a lot of endoscopic procedures.
Reflux1: You have been consistently voted one of America’s top physicians. What advice would you give to someone staring out in the field?
Dr. DeMarco: I don’t where to start. Be prepared for a lot of hard work and if they are starting with Gastroenterology, I would challenge them to get up to date and practice these advanced procedures rather than be content with the status quo.
Reflux1: What is your biggest challenge?
Dr. DeMarco: My biggest challenge is the technical demand of the procedures and wisdom in selecting patients appropriately; the challenge is that these advanced procedures are not for all patients.
Reflux1: What are your patients main concerns when they come to see you about endoscopic procedures?
Dr. DeMarco: Patients want to talk about the procedures, the side effects and how long the procedure is going to last.
Reflux1: Can you describe the procedures?
Dr. DeMarco: An endoscopy, which is what we do the most of, is usually a fiber-optic scope with an actual video camcorder at the end of it that we pass into the digestive track when the patient is under sedation. A colonoscopy examines the colon with an upper-GI endoscopy that looks at the stomach. We can also take biopsies with these procedures. Endoscopic ultrasonography is a newer procedure. We actually put a sonogram probe on the end of the scope to give us views of the bile ducts, the pancreas, the liver and even the structures around the esophagus; by looking from the inside, we are able to do maneuvers through the scope, which is called surgical endoscopy. We can do biopsies but also place stitches or clips, or even inject substances through the channel in the scope right into tissue to make a difference in patients’ symptoms.
Reflux1: What are the benefits from these new techniques?
Dr. DeMarco: This therapeutic endoscopy is less invasive. Our traditional technique for treating reflux, in addition to medicine, has involved a fundoplication, which is usually done through through a chest or abdomen incision. In the past, the result was a very long hospitalization – up to one week. In the last 12 to 15 years, we were able to do laparoscopic treatments and most patients were in the hospital a day or so. But that it is still fairly invasive but when you talk about doing something laparoscopic that still involves five little incisions into the abdomen and a pretty long procedure. Over the past five years, endoscopic methods have evolved that don’t require hospitalization, particularly the Enteryx procedure, which involves injecting a polymer into the area. The results are quite promising. For the past two years or so, and around the world for the past three and a half years, we have been treating reflux by injecting polymer. It tends to snug up and make the lower esophagus sphincter a little more competent in keeping acid in the stomach and eliminating problems for patients who are plagued by constant reflux.
Reflux1: Have there been any side effects from using the polymer?
Dr. DeMarco: The side effects from the procedure itself involve a little bit of chest pain, some difficulty swallowing and sometimes a bit of a fever afterwards. We don’t have any problems with infections afterwards, but this is a foreign material that we are injecting into the body that stays there. It does incite what we call a foreign body reaction. Your body reacts to the polymer because it doesn’t belong in there, a normal bodily reaction; however, over the course of 24 – 48 hours, those symptoms dissipate and there are no real significant side effects.
Reflux1: How long does this procedure last?
Dr. DeMarco: As far as how long it’s going to last, I tell my patients that we don’t know. We have some three-year-old data – not all of it was done in the States – that indicates that 80 percent of the patients remain symptom free at three years. But, that is early data and I tell my patients that my goal is to get it to last even longer.
Reflux1: If there are any problems, can the polymer be easily replaced?
Dr. DeMarco: Occasionally, the polymer will slough off and while our data is quite limited, we have seen a need for the polymer to be replaced at times. It can be done a second time if there is a relapse.
Reflux1: Are stitches still a viable option or have polymer replaced them?
Dr. DeMarco: I think polymers have already replaced stitches for most of us, to be honest. I still use stitches occasionally, but there are a couple of problems with them. For one thing, it is much more difficult to put the stitches in than to do the polymer injections. In addition, stitches tend to work for quite some time, but since they are not very deep, they can come out in the course of six to 18 months. We have our patients go to the trouble of getting the stitches put in and they have come out, which is no big deal – except that the symptoms return.
Reflux1: Who would be the best candidate for the polymer procedure?
Dr. DeMarco: The best candidate for these endoscopic anti-reflux treatments or anti-reflux treatments, in general, are patients whose symptoms are controlled from the various anti-reflux medications such as Prilosec, Prevacid, Aciphex, Nexium, Protonix, but who are unable to do well off of their medications. So, if you have a young person who is faced with taking these medications for the rest of his/her life, he/she may be helped by these procedures. The hope is patients will get the same degree of relief without having to take their medications.
Reflux1: Who can’t have the endoscopic procedures done?
Dr. DeMarco: Patients who are very old, 75 to 85 years old, should probably stay on their medications. Other poor candidates are those with large Hiatal hernias, where a lot of the stomach comes up into the chest. These patients are technically more difficult to handle even though we are willing to try the procedure for them. The biggest group of patients who are not good candidates are those who don’t get relief from the medicines. When the medicine doesn’t work, usually the surgery doesn’t work either. There are 40 million people with a severe enough case of reflux to take medicine – that’s why the medicine sells so much. Less than 5 percent of those who take the medicine would not be able to have the procedure. However, not everyone has to have the surgery. If patients are happy taking the medicine then there is nothing wrong with them continuing their treatment.
Reflux1: What can someone suffering from reflux do to help their condition?
Dr. DeMarco: Believe it or not, all of the things they tell you about diet, lifestyle modification, elevating the head of the bed, etc. haven’t been shown to be all that effective. So, the first mainstay of treatment is medication – you want relief. Tums or Maalox work the fastest, while the medicines such Prilosec, which is now offered over the counter, and prescription drugs such as the proton pump inhibitors like Nexium, Protonix, Aciphex and Prevacid, work over the next couple of days or so. Of course, everyone should try not to be obese, try not to overeat, try not to eat late at night, try to stop drinking and quit smoking. However, that is as much a treatment for reflux as it is for your overall longevity. When the medicines work, I tend to let patients continue them for some time; eventually, we would like to have them stop simply because this is medication that suppresses the acid production in the body, yet the acid is there for a reason. There has also been some publicity regarding an increased risk of pneumonia in patients who take anti-reflux medications. If you can get them off of the medicines and they do well – great. But, if they continue to have problems, you may want to consider some kind of procedure to stop them from being dependent on medicines for the rest of their lives.
Reflux1: Is this a modern disease or have we just become better at recognizing and diagnosing it?
Dr. DeMarco: I think this is a modern disease. When you are worried about survival and your life expectancy is 35 years not 70 years, reflux is low on the list of concerns. However, now that Americans are living longer and our average weight is greater along with worsening habits such as smoking and drinking, I think reflux is a disease of the late 20th and early 21st century. Of course, it has always been with us but we have gotten better at treating it. The question that comes to everyone’s mind is “Is it natural to have a little bit of heartburn?” But, if you look at the studies of patients with reflux, and especially those with nocturnal symptoms who are awakened from sleep every night, their quality of life is affected. With these new proton pump inhibitors and procedures, people are realizing that they don’t have to suffer.
Reflux1: How can you find a good gastroenterologist who can do these procedures?
Dr. DeMarco: I think the best method is through referrals from your primary care doctor. He/she knows the community and will send you to someone that he/she has confidence in. Certainly there is a role for direct-to-consumer information. You can also go on to the Internet, but I prefer physician referrals first, for all kinds of reasons. Your primary care physician may say that these procedures are not for you and there is usually a very good reason for this claim. I also think that it’s important for your primary care physician to be informed about your up-to-date health.
Reflux1: Are all of these procedures going to change the profession?
Dr. DeMarco: Yes. I think we have two tiers now. We have a lot of gastroenterologists out in the community who do the routine procedures as far as colonoscopy and upper endoscopy. In addition, you now have gastroenterologists in the middle of big cities doing what we would call advanced endoscopy. Thus, our training has changed. Originally it took two years of additional training to become a gastroenterologist. Now, it takes three years and if you are going to be doing advanced endoscopy, we often require a fourth year.
Reflux1: Are you going to see any other advances in the endoscopic procedures?
Dr. DeMarco: Right now we are doing Laparosopic Fundoplication, where we take the top of the stomach and rotate it around the bottom to the esophagus to make a better barrier. We are looking at ways to that procedure endoscopically without any incisions whatsoever. Ten years ago, I didn’t think that we would be doing some of the things that we are doing today and I think 10 years from now, we will have even better techniques. In the past 25 years or so, we have just started to break the ice as far was what can be done. The sky is the limit because our instruments are being miniaturized – even the scopes are getting smaller. Right now, we can put stitches and clips in or inject polymer. At some point, we may have the ability to do surgery by cutting a whole in the stomach and then approaching the liver or gall bladder from the inside. Someday we may even be able to do weight reduction surgery from the inside.