Reflux 1: How did you decide to specialize in gastroenterology?
Dr. Yapp: In medical school, gastroenterologist-hepatologist Dr. Sorrell first piqued my interest in the field. When I went to Northwestern for an internship, I continued to be interested in gastroenterology and reflux disease. I worked with Peter Karilis, who is a very well known gastroenterologist and specializes in reflux disease. I had a fellowship in gastro-intestinal (GI) and liver disease at Yale. There, I worked with a number of physicians who reinforced my interest and passion for gastroenterology and hepatology.
Reflux1: That’s great. Can you tell me a little bit about your current focus in patient care or research?
Dr. Yapp: We are doing several clinical studies. One of our big studies is between Enteryx® and reflux disease. We’re very excited about the initial data we’ve found about Enteryx®. We are interested in pursuing research in that area, as well as working with patients and offering them options in terms of treating reflux disease.
Reflux1: I read that you were one of the first physicians to offer Enteryx® in the country. Can you tell our readers a little bit about Enteryx® the procedure?
Dr. Yapp: Enteryx® is a new and very ingenious treatment for reflux disease. Reflux disease is a condition where the gastric content often has high acid concentration, refluxing up into the esophagus and causing a variety of symptoms, anything from just heartburn-like symptoms to chest pain; it can cause all types of difficult-to-swallow strictures, reflux and pain. In some cases it can have extra-esophageal symptoms such as laryngitis, cough, and cause occasionally bitter taste in mouth, sores. The disease has a very wide spectrum of presentation, and is common. A large percentage of the population suffers from reflux disease on a daily basis.
Enteryx® is an ingenious treatment. Enteryx® actually gets to the very problem of reflux disease: The esophageal sphincter at the bottom of the esophagus. We try to boost the muscle tone in order that it acts as a better gastro esophageal reflux barrier. Under the guidance of an endoscope and x-ray visualization, we inject a small amount of this polymer in the lower esophageal sphincter. The procedure takes 30-45 minutes. We’ve had tremendous success with this, great patient satisfaction. The literature reports about 80% success rate with patients whose symptoms have significantly improved. We’ve been really excited about using this technique with patients that not only have typical reflux, but the more serious complications like chronic cough, laryngitis and other extra-esophageal manifestations, of reflux disease.
Reflux1: How easy is the physician training for this procedure? Does Boston Scientific offer a fairly comprehensive training process?
Dr. Yapp: Boston Scientific does a great job with this. I think almost any gastroenterologist who’s been trained sufficiently in doing endoscopies can do this procedure. It is a little more complex and a little more involved than standard endoscopy. The course that Boston Scientific designed allows a lot of hands-on experience. They have a day-and-a-half training course, where I’ve been honored to lead several of these lectures and courses. We cover different reflux diseases and treatments, and then we focus on what exactly Enteryx® is, and the details of how Enteryx® works. The next day, we have a live demonstration where several patients come in for the Enteryx® procedure. We actually show the positions and how we do it, and then after that the physicians have a chance to see a live demonstration. After that, [the physicians observe] an animal, either a pig model or an animal model demonstration of how Enteryx® works. It’s actually a great course, very thorough and effective and Boston Scientific is very good about training physicians. After participating in the course, most physicians are very comfortable in doing the Enteryx® procedure.
Reflux1: Fascinating. What are some of the risks involved in the procedure for a patient?
Dr. Yapp: It is an exceptionally safe procedure. There are several things a patient should know about before we do the procedure. It is common to have chest pain after the procedure. The pain could last for a few hours to a few weeks and is self-limited and relatively well controlled with medication. A small number of patients have some mild swallowing discomfort and some dysphasia [a complete or partial loss of ability to understand, speak, read and write]. This usually goes away after a few days to a few weeks as well. Up until a few months ago, there have been absolutely no significant morbidity or mortality associated with this. There was, tragically, a few weeks ago, a death that was probably associated with Enteryx®, but it was a freak accident, where the patient had an injury that the patient died several weeks into the procedure. But, it was an exceptionally unusual case. Enteryx® is such an inherently safe procedure and an effective procedure, with such a minimal risk of side effects. Enteryx® is a wonderful option you can offer patients who suffer from chronic reflux disease.
Reflux1: It’s good to hear you supporting the procedure, because it is apparent that you have performed so many Enteryx® procedures yourself that, with the exception of this single case, Enteryx® has usually greater benefits than risks.
Dr. Yapp: There is almost no procedure physicians can do, even a procedure that is minimally invasive, that is without risk. But as far as procedure go—and physicians do a lot of procedures that have associated risk—patients have tragically died from complications from all sorts of procedures. But Enteryx®, in my mind, is an exceptionally safe and easy-to-do procedure after adequate training. The physician needs to understand what he’s doing. For any patient who suffers from significant reflux, Enteryx is a treatment option.
Reflux1: Can you tell me a little bit about how your field has changed in the past few years? Is Enteryx® the biggest recent breakthrough? Are there any other technical procedures that you’re interested in pursuing?
Dr. Yapp: Going back to before I was in medical school, there were medications like Tagamet®, Zantac® or Pepcid® to treat reflux disease. These medicines were of some help in treating reflux disease, but many patients still had significant discomfort. Then medicine progressed to PPI’s, or proton-pump inhibitors—the next big step in treating reflux disease. There have been other procedures that have been recent FDA approved—the EndoCinch™ procedure and the Stretta®, which are very interesting. Prior to the introduction of Enteryx®, there were procedures that were somewhat tedious and not as effective as hoped. They were interesting and of some limited benefit, but the advent of Enteryx® was a big step forward in the treatment of reflux disease. There are other techniques that are being investigated in Europe. Maybe they’ll be introduced in this country soon, but this technology, using a polymerized substance injected into the lower esophageal sphincter, is going to be very important in the treatment of many GERD and regurgitating patients.
Reflux1: Do you have any advice for reflux patients about how they can take care of GERD at home, outside of nonsurgical or surgical procedures?
Dr. Yapp: There are a number of lifestyle modifications that we encourage, such as avoiding fatty foods and minimizing alcohol ingestion. We recommend all our patients to stop smoking, which is important for many health reasons, but in particular, smoking can aggravate reflux disease. We talk about other dietary changes that can help minimize reflux disease. We also emphasize and enforce weight control, weight loss as well as other lifestyle modifications. We have a number of patients who either can’t comply with those modifications, or even if they do, they have minimal improvement in their symptoms. Even with changes, many of these patients still require help, medications to help make it more comfortable for them. That’s one of the things that we are excited about in the treatment of reflux disease. We have a wide spectrum of options for patients to help them with this disease.
Reflux1: Do you have any final words?
Dr. Yapp: I am very interested in continuing to support Enteryx®. It’s a great technological step forward. Enteryx® is a nonsurgical procedure that most gastroenterologists trained in treating reflux disease should consider making one of the cornerstones of treatment. It is a viable option for patients who are suffering from severe reflux disease.
