Dr. Gillian and his team were recognized as a Top Doc practice in Northern Virginia Magazine for 2017!
Dr. Gillian was asked to write an editorial for the General Surgery News publication. They felt that as the President of the American Society of General Surgeons that he may have some thoughts on what it means to function as a General Surgeon in todays medical system. We hope you enjoy it. Dr. Gillian’s article
Dr. Gillian was asked to comment on the topic of long term PPI risks. Certainly this is subject on many peoples’ minds and they often ask for our opinion on the subject when they visit with us. In many cases it is the primary motivator for reviewing alternative therapies like the Nissen Fundoplication and the LINX procedure with us. His review can be found on the INOVA BLOG.
Despite running a very busy surgical practice Dr. Gillian enjoys teaching residents and visiting surgeons some of the techniques he has developed over the years in all areas of laparoscopic surgery. Surgeons travel to watch Dr. Gillian perform a variety of procedures at INOVA Alexandria Hospital and Virginia Hospital Center. Many of these educational events have focused on laparoscopic inguinal hernia repair, laparoscopic incisional hernia repair, and the evaluation and correction of defects that cause heartbur/reflux and GERD. This would include Laparoscopic Nissen Fundoplication and the LINX procedure. Dr. Gillian runs one of only 4 training centers in the USA for LINX. Our methods for evaluation of these patients in the HEARTBURN CENTER with 24 hr pH and esophageal function testing with impedance technology is typically part of the training day.
Dr. G. Kevin Gillian and Virginia Hospital Center hosted the first East Coast training for LINX® on September 17-18. Dr. Gillian is the founder and director of the Heartburn Center at Virginia Hospital Center and was the first surgeon to implant a LINX device in Virginia and the DC Metro area. Their dedication to evaluating and treating this disease has culminated in the development of the leading LINX center on the East Coast. Visiting surgeons from around the country observed surgical procedures and received training on LINX, a minimally invasive revolutionary treatment for reflux.
LINX is a small implant comprised of interlinked titanium beads with magnetic cores. The magnetic attraction between the beads augments the existing esophageal sphincter’s barrier function to prevent reflux. The device is implanted using a standard minimally invasive laparoscopic procedure and for many patients it is an alternative to the more anatomically disruptive fundoplication, commonly used in surgical anti-reflux procedures. The LINX Reflux Management System is indicated for those patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximum medical therapy for the treatment of reflux.
According to Dr. Gillian, “After nearly 18 years of managing and operating on patients with GERD the LINX procedure is the first novel procedure to demonstrate effective symptom control, durability and safety while reducing some of the side effects associated with the classic surgical treatments. Since our first patient was treated in July of 2013 we have been very satisfied with the symptom control and rapid return to normal daily activities that this procedure allows for. After performing 75 of these procedures in the last two years we are confident that this procedure is going to play a major role in the control of reflux in the millions of patients in this country who are not satisfied with their medical management.”
Dr. Gillian has been training surgeons in a variety of laparoscopic surgical procedures both in the United States and abroad in Europe and Asia for years but found this experience special. “Being able to introduce such an exciting and revolutionary procedure to surgeons who are already established and successful in their own community is a privilege. I enjoy the two-way learning experience as I share my experience with these doctors and entertain their challenging questions while learning from the insights they share with me. “
The Disease
Gastroesophageal Reflux Disease is a chronic, often progressive disease resulting from a weak lower esophageal sphincter that allows harmful gastric fluid to reflux into the esophagus, resulting in both pain and injury to the esophageal lining. Symptoms of GERD include heartburn and regurgitation, often associated with chronic sleep disruption, and may also include persistent cough, excessive throat clearing, hoarseness and a feeling of a “lump” in the throat. Acid reflux medications, such as Prevacid®, Nexium®, and Prilosec®, affect gastric acid production, but do not repair the sphincter defect, allowing continued reflux. GERD is associated with a pre-cancerous condition known as Barrett’s esophagus, which increases the risk of esophageal cancer.
The LINX Reflux Management System
LINX is a small implant comprised of interlinked titanium beads with magnetic cores. The magnetic attraction between the beads augments the existing esophageal sphincter’s barrier function to prevent reflux. The device is implanted using a standard minimally invasive laparoscopic procedure and is an alternative to the more anatomically disruptive fundoplication, commonly used in surgical anti-reflux procedures. The LINX® Reflux Management System is indicated for those patients diagnosed with Gastroesophageal Reflux Disease (GERD) as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximum medical therapy for the treatment of reflux.
LINX does require a surgical procedure and is associated with potential risks, contraindications and life style modifications. For more information on LINX, including a statement of risks, please visit www.linxforlife.com.
LINX was approved by the FDA in 2012 and is the only available medical device shown to be safe and effective for the treatment of gastroesophageal reflux disease (GERD).
Dr. Gillian may be reached in his office at the Virginia Heartburn and Hernia Institute, 703 372 2280 or via the Heartburn Center at Virginia Hospital Center at 703 717 4373.
The Adrenal Glands sit above our kidneys and are responsible for some very complicated processes in our body. They contain cells that secrete a variety of hormones that participate in the auto regulation of many functions in our body. Adrenal hormones and by products control our blood pressure, sex hormones, stress hormones,how we metabolize sugars and help control how our circadian rhythms work. The substances that are manufactured and releases by these glands are involved in much of what keeps us alive and makes us who we we are. When abnormalities or tumors affect these glands they can have profound effects on how we feel and function. Fortunately we have two glands and if one has to be removed for various reasons the second is more than capable of handling all the duties.
Adrenal surgery is complicated and requires a significant amount of surgical experience to minimize risks and to provide the best outcomes. These glands can be removed by either traditional open surgery or laparoscopic surgery. The benefit of laparoscopic adrenalectomy is that it can accomplish all the goals of open surgery with the benefit of decreased pain and a reduced recovery time in experienced hands.
There are various reasons why a patient will need their an adrenal gland removed. Sometimes the gland is secreting too much of a hormone and it is creating problems for the patient with respect to metabolism, blood pressure or sexual function. There may be a mass or adenoma that is hyper-functional or worrisome for malignancy. Every case is unique and requires special management and coordination between the surgeon, the endocrinologist and the anesthesia staff.
Dr. Gillian is experienced in this type of surgery and would be happy to review your particular case with you or your doctor.
Torax Medical announced completion of a landmark study confirming the long-term results of the LINX® Reflux Management System in controlling reflux-related symptoms and eliminating dependence on acid suppression medications called proton pump inhibitors (PPIs). Findings from the clinical study demonstrated that the LINX procedure normalized the amount of acid in the esophagus, while safely and effectively relieving heartburn and regurgitation, and improving quality of life without the need for PPIs. The LINX device was approved by the FDA in early 2012 and is currently the only medical device approved by the FDA to be safe and effective for the treatment of gastro-esophageal reflux disease (GERD). Authors of the clinical study, published this week in a leading medical journal; concluded LINX should now be considered a first-line anti-reflux therapy for appropriate patients.
All patients included in the LINX study had pathologic levels of acid in their esophagus, had compromised quality of life from their reflux disease and were refractory to continuous PPI therapy (median duration of treatment with PPIs was 5 years). The study’s efficacy endpoints for success at 5 years, restored quality of life and reduced PPI dependence, were both met.
Robert Ganz, MD, FASGE, Chief of Gastroenterology, Abbott Northwestern Hospital and Associate Professor of Medicine, University of Minnesota commented, “This study demonstrates the LINX procedure provides significant and durable improvement in heartburn, regurgitation, PPI independence and quality of life. Patients can now have a relatively simple procedure to restore their sphincter function and avoid the invasiveness required in fundoplication procedures. In my view, LINX represents the next generation of anti-reflux treatment.”
85 percent of patients were free from daily dependence on PPIs
Bothersome heartburn was reduced to 11.9% from 89% at baseline
Bothersome regurgitation was reduced to 1.2% from 57% at baseline
Because medications are less effective at managing regurgitation, the near elimination of regurgitation in this clinical study after LINX represents an extraordinary benefit for patients with this life-altering symptom. Importantly, no new safety risks emerged during the 5-year follow-up period. If needed, the device can be removed and the rates for reoperation were less than the expected range for other anti-reflux procedures at 5 years. Overall, patients in this clinical study achieved significant clinical benefits from the LINX procedure; these benefits are now shown to be sustained at 5 years.
Gastro-esophageal Reflux Disease (GERD) is a chronic, often progressive disease resulting from a weak lower esophageal sphincter that allows harmful gastric fluid to reflux into the esophagus, resulting in both pain and injury to the esophageal lining. Symptoms of GERD include heartburn and regurgitation, often associated with chronic sleep disruption, and may also include persistent cough, excessive throat clearing, hoarseness and a feeling of a “lump” in the throat. Acid reflux medications, such as Prevacid®, Nexium®, and Prilosec®, affect gastric acid production, but do not repair the sphincter defect, allowing continued reflux. The FDA has issued a series of statements on possible side effects of long-term PPI use including: possible fracture risk, low magnesium levels, and clostridium difficile-associated diarrhea. More recently, a study out of Stanford University published in the journal PLOS ONE showed PPI use may increase the risk of heart attack.1 Anti-reflux surgery called Nissen fundoplication reconstructs a new reflux barrier using a portion of the patient’s stomach which is wrapped around the lower portion of the esophagus. GERD is associated with a pre-cancerous condition known as Barrett’s esophagus, which increases the risk of esophageal cancer.
LINX is a small implant comprised of interlinked titanium beads with magnetic cores. The magnetic attraction between the beads augments the existing esophageal sphincter’s barrier function to prevent reflux. The device is implanted using a standard minimally invasive laparoscopic procedure and is an alternative to the more anatomically disruptive fundoplication, commonly used in surgical anti-reflux procedures. The LINX Reflux Management System is indicated for those patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximum medical therapy for the treatment of reflux.
LINX does require a surgical procedure and is associated with potential risks, contraindications and life style modifications. For more information on LINX, including a statement of risks, please visit www.linxforlife.com.
http://www.marketwatch.com/story/new-5-year-results-of-a-landmark-study-confirm-linx-procedure-as-a-beneficial-treatment-for-gastro-esophageal-reflux-disease-2015-09-14?utm_source=LINX+Corporate&utm_campaign=fb90e33941-LINX_5_Year_Data9_15_15&utm_medium=email&utm_term=0_5a8f4ce641-fb90e33941-92898521&mc_cid=fb90e33941&mc_eid=3b615fbb81
Sports hernias have become a bit of an enigma for patients and doctors alike. Evaluating and treating patients at the Virginia Heartburn and Hernia Institute has given us a unique perspective on what types of injuries will respond to minimally invasive procedures. If you are a frustrated patient or clinician please review this article.
Of all the conditions evaluated in my office the one with the honor of having the most money and time spent on it
with the least satisfactory results prior to our evaluation are the patients with “sports hernias”. Not everyone is a “professional” or even a serious athlete although those groups do tend to dominate when it comes to spending a lot of their money on MRIs, physical therapy, acupuncture and visits to their favorite Orthopedic surgeon. I see plenty of casual athletes, clumsy gardeners, former active duty military, and yoga moms with the same complaints as famous athletes. The problem is the name. Hernias are supposed to be holes and “sports hernias” don’t have holes.
Orthopedic surgeon’s training focuses on bones, joints, cartilage and the structures that hold these things together- they don’t fix “holes”. General Surgeons are trained to do many complicated things that typically involve the softer part of our anatomy like the skin, breast disease, abdominal organs, etc. We are great at fixing “holes” in things be it in the intestine, a blood vessel or the abdominal wall (hernias). We have national societies in the field of General Surgery that are single-mindedly devoted to just fixing hernias. Some General Surgeons devote their entire career to figuring out how combine anatomy, technology and mesh products to give patients the best and most durable hernia repairs.
When an injured patient has exhausted and frustrated him or herself trying to get their groin pain to go away they may end up in the office of a General Surgeon at some point. If the gold-standard “turn your head and cough” fails to reveal a obvious outward bulge through the muscle (indicating a repairable defect or “hole” in the muscle), the patient is often told that they don’t seem to have a hernia and the cycle starts again with imaging studies, physical therapy and trips to the Orthopedic Surgeon.
So… who is right and who is wrong? Crazy as it seems everyone is right. The patient really has a problem, the Orthopedic Surgeon is correct in finding nothing wrong with the bone or joints and the General Surgeon is correct in stating that you do not have a hernia. What you have typically is a very poorly named constellation of injuries and partial tears in the lower abdominal wall that was created when your torso twisted one way while your leg was going the other. That torque creates tears in the tissues of the abdominal wall muscles and the fibers that anchor it to the pelvic bone. Repetitive activity makes it worse, rest may allow repair to occur in most people but not all. Because the pain often is localized to the inguinal crease or groin the patient may describe a pain pattern that sounds like hernia in the same region. Thus the name “sports hernia” has been inappropriately born and assigned.
It is hard for any applied therapy to have good results in any area of medicine if the physician involved is not really certain what they are treating. This is one of the reasons there is so much disagreement among “experts” and why there are so many variable therapies with variable results. To use a really horrible sports analogy- some times we get lucky and hit the ball even if our eyes are closed. It is not that anyone is intentionally doing the wrong thing it is just hard to get good results when the problem is not well defined or well understood.
To be blunt most General Surgeons have never been trained how to evaluate a sports hernia and many have never thought about the issue till someone shows up in their office. In that circumstance it makes sense to “do no harm” and send the patient back to the referring doctor save someone from what might be a pointless and potentially chronically painful operation.
Even among those Surgeons who either intentionally or unintentionally become involved in the evaluation of the “sports hernia” there is no universal agreement on what repair to do. Some have devoted their entire practice to the endeavor and most have settles into a routine surgical procedure that makes the most sense to them and gives them functional outcomes that they feel are predictable and reasonable. These procedures are typically done with an open groin incision. They can be fairly complicated and often require a specific post-operative regiment of physical therapy to achieve a maximal benefit. Patient will often travel great distances and spend a lot of time, effort and money seeking out these devoted centers. Some like myself believe that the majority of patients will do quite well with a laparoscopic minimally invasive repair with a rapid recovery and reserve the more intense “open” repairs for specific cases or treatment failures. The laparoscopic repair allows the damaged tissue to be reinforced or “splinted” internally with a lightweight mesh. It probably doesn’t hurt any of my patient’s feelings that their insurance actually covers these repairs and it is rare that any post surgical “rehab” is required.
It is hard to accurately judge the results of interventions when it comes to the “sports hernia” patient. There currently exists no standard of care with respect to evaluation and intervention. How can one really judge the failure of conservative management of these conditions when every patient has different expectations of physical performance? How do we evaluate the quality of the surgery when there are no standards of when to intervene or what to do when we get to the operating room? Fortunately this is a benign condition and for most patients they have the luxury of time to find a treating physician that understands this badly named problem.
G. Kevin Gillian, M.D., F.A.C.S.
Virginia Hernia and Heartburn Institute
Medicare spending on anti reflux and heartburn prescriptions is enormous. A recent Wall Street Journal article reported that Nexium was the single most costly drug in terms of overall cost. At first glance the numbers are mindboggling. There were 8,192,362 prescription claims for Nexium in 2013 for Medicare.
