Episode 34
Rural Surgery on the Cutting Edge with Dr. Greg Gerrish
Episode Transcript
Dr. Randy Lehman [00:00:11]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back, listener, to another episode of The Rural American Surgeon. I am honored today to have a guest. He was referred to me by Dr. Gary Timmerman, who basically said, "You got to talk to this guy." And it sounds like you're from the same town and you're going to have some great stories to share about a practice in rural South Dakota. So thanks so much, Dr. Gerrish, for coming on my show.
Dr. Greg Gerrish [00:01:10]: My pleasure. It's exciting.
Dr. Randy Lehman [00:01:12]: Yeah. So. And you started practicing in 2016, and I'd just like for you to give your own introduction about your training background, what drew you to where you are, and what your practice looks like.
Dr. Greg Gerrish [00:01:23]: Okay. I'll go way back. So this is kind of interesting, but my grandfather was a general surgeon, but he trained at Case Western in Cleveland. I think he eventually got burnt out of that and moved into a small town in Minnesota and eventually landed in this small town in mid-South Dakota called Mobridge. That's where my dad was born, or he was born in Cleveland, but he grew up in Mobridge. And then he later moved back to Chicago to be higher up in the College of Surgeons. So that's where he finished his career. My dad loved hunting and fishing. He loved South Dakota more than moving back to Chicago. So he became a general surgeon and he moved back and started his career in Watertown as well. He started in the early '80s. He has since retired. But that's where I got my background and exposure to surgery because those were the days where you could bring your kid to work day almost any day. So I've some of my early experiences in the OR were going to work with Dad, and I can remember just your basic appendectomies and gallbladders. But I can remember some nasty bowel obstructions and stuff like that. So it's imprinted early at that time.
Dr. Randy Lehman [00:02:38]: Were you able to go actually into the operating room then?
Dr. Greg Gerrish [00:02:41]: Yep. And I mean, they kept it pretty safe. I might scrub and just have my hands on the table, like a young student would.
Dr. Randy Lehman [00:02:49]: But yeah, this would be at what age?
Dr. Greg Gerrish [00:02:52]: I would bet 12. Yeah.
Dr. Randy Lehman [00:02:56]: Wow. So, yeah, well, I mean, I've done some of that in my own independent practice with my kids because I had my own office. And so that's minor surgical procedures. But of course not scrubbed in because they were, at that time, the oldest one was seven, but she definitely came into the room and talked with me sometimes while I was doing little local procedures in the office and whatnot. So you can do it in a way that it's very respectful and everything. But go on.
Dr. Greg Gerrish [00:03:23]: I wanted to be a surgeon probably in high school. It clicked. So then I had to start getting my stuff together. And so that was the plan all the way through, and I stuck with it. I went to undergrad at the University of South Dakota and medical school there and matched in general surgery at Hennepin County Medical Center in Minneapolis. When I finished that, I started here in 2016. Interestingly, they hired two surgeons on the same day. My partner, who is from my medical school class, Jacob Schaefer, graduated from residency at Gundersen. We started the same day, which was a pretty bold move on their part. It has really paid off because there's been a few retirements and a few that moved away. So we've kind of kept everything going strong.
Dr. Randy Lehman [00:04:14]: Yeah. Were you guys planning on coming there together, or were they two independent negotiations?
Dr. Greg Gerrish [00:04:20]: It took two independent negotiations, and when I heard he was coming, I was like, "Great. Sounds good." We got along very well in medical school. But that has been... we could talk about mentorship and rural surgery, how important that is. It was really helpful to have a partner in crime, so to speak, going through that too.
Dr. Randy Lehman [00:04:44]: Yeah, I could see that going really well. I could also see it not going so well, depending on if you're equally matched training- and skill-wise and your attitudes. So that's awesome that you guys are now basically almost 10 years in, nine years out, and doing what you've done. You told me some numbers that your productivity is extremely high and you're just both very busy surgeons. So there also has to be enough volume to go around.
Dr. Greg Gerrish [00:05:17]: That's correct.
Dr. Randy Lehman [00:05:18]: Which clearly you guys are. That goes for multiple things. The community has to trust the hospital to stay there, right? And you have to have enough people. So right at this point, is it just the two of you doing general surgery there, or do you have others now?
Dr. Greg Gerrish [00:05:34]: We hired a partner this year and then there's another clinic in town with a general surgeon too. So it's a little unique in that.
Dr. Randy Lehman [00:05:43]: But.
Dr. Greg Gerrish [00:05:43]: So there's four surgeons in town. 70,000 to 75,000 people catchment area, I would say, somewhere in there.
Dr. Randy Lehman [00:05:50]: Yeah, yeah. I read a study that said that the need for a general surgeon, the current general surgeons-to-population ratio is one to 19,000. But they said, well, we're underserved, and we need one per 14,000 population. In just my own area, I came into a practice where there are two surgeons, 12,000 in the county. But that's also different because there are hospitals right on the edge of the county in all directions. So that's your true small catchment area. The thing is, I grew up in the next county west, so I immediately went there and started telling all the primary care docs where I was, what my plans were, which I wanted to come to that hospital at some point, but they're part of a chain and everything. I got a lot of referrals from that area early on, and I was busy enough. But it's led to me looking at those numbers and like, you know, how much do you need? 75,000 for surgeons. That makes sense with that math. But the other thing is a rural surgeon is doing maybe a little bit different practice. I don't know what you can talk a little bit about what you do. But, you know, like most rural surgeons, I would say not doing esophagectomies, Whipples, or liver resections. They might have to be doing rectal surgery. So there's things that are in general surgery, lobectomy, vascular, that they don't do. But then you also are a lot of times a GI doctor as well, which you kind of mentioned to me, as well as other subspecialty things. And so that's my question. Does it really need to be one to... you know, it kind of depends what you're willing to offer to your town. I think if you're just saying, well, I'm just a classic general surgeon, hernias, gallbladders, but I'm not going to do the big-time trauma and other stuff, then you wouldn't be able to maybe maintain the busy practice that you have.
Dr. Greg Gerrish [00:07:43]: Yeah, yeah, you need more people. Unless you have some other things that you're doing like endoscopy or GI things. And there's a lot of things to fill in, but.
Dr. Randy Lehman [00:07:54]: So for your practice, what is... Speaker A: What are the things that get sent out, like from classic general surgery? And then what are the things that you may do that an urban surgeon doesn't?
Dr. Greg Gerrish [00:08:05]: Oh, okay. Let's just start with, like, what do I do on a regular basis? I'd say about 75 to 80% of my practice is endoscopy-based. Yeah, at least that. And then what am I doing on call? You're doing acute care surgery that can be about anything from bowel obstructions to GI bleeds. We try to keep a lot of that sort of thing. Head, neck, some thyroid, parathyroid, and no thoracic. Really, the practice has a lot of foregut, including endoscopy, colonoscopy, bowel resections, colon resections. I'm not going to be doing any hepatobiliary type things. No thanks, and really need to be in a higher volume center for that anyway. Then, like low rectal cancers, I'm not doing that. I'll send that out as well. Vascular, I don't do. Occasionally some weird stuff will creep in, like I'm the guy that does the below-the-knee amputations. I don't know how that happened. Just things like that. I do a lot of vasectomies in the office.
Dr. Randy Lehman [00:09:20]: Do you do any gyn?
Dr. Greg Gerrish [00:09:22]: No, well, we have three gyns in our town.
Dr. Randy Lehman [00:09:26]: Any ENT?
Dr. Greg Gerrish [00:09:29]: Just the thyroid, parathyroids. One of my good buddies does ENT, so we've got one in town.
Dr. Randy Lehman [00:09:37]: Okay. Do you do carpal tunnels or hand stuff?
Dr. Greg Gerrish [00:09:43]: No, the orthos have kind of found that niche. I never really wanted to fight over those.
Dr. Randy Lehman [00:09:49]: Yeah, that all sounds good. How about varicose veins?
Dr. Greg Gerrish [00:09:54]: We started doing them, but it was just like we weren't doing enough because the vascular guys were coming in about twice a week. There's a vein clinic in the area doing some, so it was just not enough. No, I don't do veins.
Dr. Randy Lehman [00:10:11]: Got it. Well, that is a pretty good introduction. I feel like I'm there with you. To ask a question almost seems like, why even ask? But the next question on the show is, why is rural surgery special to you? How would you answer that?
Dr. Greg Gerrish [00:10:29]: These are my people. I grew up here. I love it here. I've thought about how I really love surgery and getting good at it. It's like art. Sometimes I wonder about doing a fellowship and going to a bigger city, but then, no way. I'd rather live out here and serve my community.
Dr. Randy Lehman [00:10:57]: So what would you miss the most if you lived in the city?
Dr. Greg Gerrish [00:11:01]: I would miss a lot about the city, but it's just not for me. The hustle and bustle and craziness—I like the quietness. I like to get out in the country, hunt, fish, and get on the lake. I'd miss that a lot.
Dr. Randy Lehman [00:11:20]: Do you have childhood friends in the area you keep up with?
Dr. Greg Gerrish [00:11:25]: It's my hometown, which is good and bad. Sometimes it's like one degree of Kevin Bacon. If you don't know someone, you know someone who does. It can make things difficult but also makes you care more.
Dr. Randy Lehman [00:11:45]: I had someone on the show say the peer review for a rural surgeon is like Walmart and McDonald's because everyone knows what operation you did. In terms of your dad's place, how far was that from Watertown?
Dr. Greg Gerrish [00:12:09]: That was about three and a half hours, in the middle of the state.
Dr. Randy Lehman [00:12:13]: How about your mom?
Dr. Greg Gerrish [00:12:15]: She grew up in a small town near there and is also a physician—internal medicine. She's a pioneer for women in medicine. She lived about two hours away from here in a similar area to my dad's.
Dr. Randy Lehman [00:12:33]: And your spouse, what does she do?
Dr. Greg Gerrish [00:12:34]: She's a physician assistant. I met her in Minneapolis.
Dr. Randy Lehman [00:12:39]: Okay. So a lot of times, screaming here.
Dr. Greg Gerrish [00:12:45]: But she loves it now.
Dr. Randy Lehman [00:12:47]: Great. My situation in Indiana is similar. My mom and dad grew up in adjacent counties. My great-great-grandfather immigrated from Germany at age 12 as an orphan with some aunts. The way I tell the story, they put him on a boat saying, "Find your cousins in Indiana." That story runs deep. I've taken care of my mom’s former bus driver and babysitter. Every day there's someone connected—like, "Do you know so-and-so?" There's a real closeness, which explains it. Let's move on to the next segment of the show called How I Do It. We'll discuss how you perform particular operations, focusing on laparoscopic surgery today, mostly foregut. We may touch on the colon and how endoscopic management plays a role. Let's start with laparoscopic foregut and the scope of practice.
Dr. Greg Gerrish [00:14:10]: In the past two or three months, it's been a little slow, not sure why. As I said, endoscopy plays a big role in my practice. When I started, it was about what to do with hiatal hernia and GERD because there was no one doing anything. It was just PPIs for life. I went to this course in Hawaii, the Foregut Disease Foundation course, with my partner, which was eye-opening. It put everything together for me—why people get GERD, what a hiatal hernia is, why Barrett's develops, diving deep into these foregut issues. During endoscopies, I found a lot of smaller hiatal hernias and even intrathoracic stomachs. There's a lot for us to do. I guess I went off course, but steering back, what did you want?
Dr. Randy Lehman [00:15:18]: The primary operations—you're probably doing fundoplication for anti-reflux. Are you doing any LINX procedures?
Dr. Greg Gerrish [00:15:27]: A common procedure is laparoscopic hiatal hernia repair with LINX or partial fundo, which I prefer over full fundoplication. Occasionally a full Nissan.
Dr. Randy Lehman [00:15:46]: Yep.
Dr. Greg Gerrish [00:15:47]: Yeah.
Dr. Randy Lehman [00:15:48]: And are you doing any.
Dr. Greg Gerrish [00:15:50]: And not doing any TIF?
Dr. Randy Lehman [00:15:52]: Okay. And you don't do bariatric surgery, right?
Dr. Greg Gerrish [00:15:56]: Nope.
Dr. Randy Lehman [00:15:57]: Okay. And then are you doing anything to treat, like achalasia; like doing Heller myotomies or? That's such a rare condition.
Dr. Greg Gerrish [00:16:04]: It was such an infrequent thing. I just felt sending those out to someone that actually does them more frequently.
Dr. Randy Lehman [00:16:10]: Yeah, yeah.
Dr. Greg Gerrish [00:16:12]: Manage them endoscopically with, like, Botox and dilations. Because a lot of the... I'd say half the achalasias I found were really not surgical candidates anyway, so.
Dr. Randy Lehman [00:16:22]: So if you would say, like, this is a right down the middle, most common foregut patient. How do they present? How do you work them up? What operation do they get?
Dr. Greg Gerrish [00:16:31]: Okay, yeah, just a classic GERD refractory on medication or having reflux for 15 to 20 years. They may be coming to me for just their screening colonoscopy, and we add on an upper endoscopy because of those risk factors, and we'd find, you know, a small hiatal hernia where there's about 3-4 cm herniated up into the chest. Maybe some short segment Barrett's, maybe not. With these patients, I'll typically work them up with manometry. That's... Honestly, we can do Bravo studies as well. We do those frequently, and so that's a pretty common thing for us to do.
Dr. Randy Lehman [00:17:17]: Do you do your own manometry?
Dr. Greg Gerrish [00:17:19]: Yep. It seemed like it would be a lot to learn. It really wasn't. And same with the, like, Bravo studies. I didn't think that was that difficult to learn.
Dr. Randy Lehman [00:17:30]: Yeah. How did you learn it? I send it out. I—
Dr. Greg Gerrish [00:17:36]: Well, that Foregut Disease foundation course that I was... You know, they have special sections on learning manometries, and just through kind of some of those courses. You just picked it up.
Dr. Randy Lehman [00:17:48]: Yeah. Very good. And then obviously when Bravo came out, then you started doing that. And what is there? You're doing an upper GI on these people, too, with barium swallow or something?
Dr. Greg Gerrish [00:17:59]: I don't. I don't routinely do that now. My partner will like to throw in, like, a marshmallow bagel study, which is kind of an assessment of proper motility, but I haven't really been doing a lot of that.
Dr. Randy Lehman [00:18:11]: Okay. Do most of the people you feel like at some point get a CT scan of the upper abdomen or not necessarily there either?
Dr. Greg Gerrish [00:18:19]: Not routinely, but, man, a lot of these people have CT scans anyway. It's amazing how many times people come to me for reflux things, and as they're sitting in the office, I'll just, like, scroll through the chest CT that they had from nine years ago, and it's like, yeah, your stomach's in your chest. So this... Yeah, you're having some of these issues.
Dr. Randy Lehman [00:18:40]: I know. I have the same thing here. And that's where I'm... I'm on my—I'm on an island out here. That's why I love this podcast, because I get to pick the brain of, like, bright people that are doing good work all over the country. But I almost feel like, am I doing the right... Like, is... Am I crazy or are they crazy? You know, because these people are just being, like you said, thrown on PPIs for life or told that that's, like, part of life, and they had this hernia and no one else is fixing it. So, like, I almost say, like, am I not supposed to be fixing it? You know, I mean, I am. I have been doing more and more of it, and patients are so generally so happy. But I'm sort of, you know, imagine me four or five years behind you and kind of going through that. You know, I had to get my practice off the ground. Then this has become something that I just see more and more of. And so now I'm doing it. I think most of the primary care doctors around here are, like, you know, sending patients to me, but. And they're starting to see their patients back, that have good long-term results. But basically, you know, if you see it, you should offer the patient the option. Right? I mean, even options. Yeah, yeah. Right, yeah.
Dr. Greg Gerrish [00:19:51]: That's just the thing, because it's like, well, who do you operate on? Well, you don't operate on everyone that has GERD. Okay, we don't. No one has time for that.
Dr. Randy Lehman [00:20:01]: Right.
Dr. Greg Gerrish [00:20:01]: I operate on people that really have a strong desire to get off PPIs, or their symptoms aren't well managed on PPIs, or maybe there's some other things that they've got going on, like long segment Barrett's. I want to get that reflux control because I will bleed them later. Honestly, we can talk about that later. Or so like dysplastic Barrett's or long segment Barrett's. Or if they're anemic with a big or thoracic stomach and have those Cameron erosions and bleeding issues with that. Or if they just have a really large hernia and they're, like, relatively young and healthy and not comorbid because eventually they're going to turn into that 85-year-old lady that's got medical issues and anemic, and they're—I see that a lot, where it's to the point where it's like, yeah.
Dr. Randy Lehman [00:20:46]: And then they lose all that extra fat when they get old, and the stomach gets further up there and more mobile, and then it twists, and you got your black stomach, and it gets.
Dr. Greg Gerrish [00:20:54]: Yeah. Becomes volvulus later. So yeah.
Dr. Randy Lehman [00:20:58]: Okay, great. So that person will say it's a patient that's had Barrett's for, or they've had reflux—I'm sorry, not Barrett's, reflux for, you know, a decade or whatever, and they're, like, in their 40s or 50s and they have a 4 to 5 centimeter hiatal hernia. How does that discussion go in clinic in terms of when you're giving them the options?
Dr. Greg Gerrish [00:21:24]: So in my practice, it's typical that I will, you know, offer just like a partial fundoplication versus the LINX for surgical management. And if they're morbidly obese, then I, you know, would discuss the referral to bariatrics as well. For those patients, the discussion usually we'll talk about the surgery, the risks. So partial fundoplications find much less dysphagia and gas bloating, changes in, like, long-term changes in diet, eating habits, but comes at a cost of probably a higher recurrence rate of your hiatal hernia. In my experience, I've had more reoperations on partial fundoplications or fundoplications in general than the LINX. So the LINX I talk about, they have a quicker return to a regular diet, but it comes at the expense of a little bit more, like, long-term dysphagia. So I end up dilating about 10 to 20% of these people at some point. So it's a real thing. It's a big speed bump for people. So I try to have that discussion with people, and I still have patients that come by, and they're like, I can't believe it. We never talk. It's like, we talked about this. It's a thing. So. But the LINX I can understand, especially surgeons, like why are you putting a foreign body around the esophagus? That, that initially made me very nervous. And for good reasons, like the Angelchik and all that. And, yeah, we probably put in over 5 to 600 between my partner and I. And we've had one erosion, but. And that was actually not that hard to manage. I think we've taken out eight or nine of them as well, so it's going very well. But.
Dr. Randy Lehman [00:23:09]: Wow.
Dr. Greg Gerrish [00:23:10]: Yeah.
Dr. Randy Lehman [00:23:10]: So how'd you manage the erosion?
Dr. Greg Gerrish [00:23:12]: Well, there's supposed to be an endoscopic scissors that you could just clip the bead inside the esophagus and let it retract out, but nothing we could get would cut it. So we end up just doing a lot, like laparoscopic gastrotomy, pulling the bead, cutting it laparoscopically, and we're able to get it. What you don't want to do is create a wide-open hole into the esophagus. We just let those be because they'll retract out of the esophagus and into this big scar ball around the Lynx device, so it won't be a free leak. And then we just, so we just close the stomach, and I think we came back later to remove the rest of those beads.
Dr. Randy Lehman [00:23:55]: Okay. And you're doing all these laparoscopic, not robotic. Correct? Are you doing that?
Dr. Greg Gerrish [00:24:00]: We don't have a robot at our facility.
Dr. Randy Lehman [00:24:01]: Yeah. So why don't we, first off, let me clarify a little bit, because I had a little debate about this with somebody recently. You know, most of these are like, if it's a 5-centimeter, 4 to 5-centimeter hiatal hernia, how are you measuring that? Are you endoscopically marking where the diaphragm is and then where the GE junction is, and the distance between those is the size?
Dr. Greg Gerrish [00:24:32]: Yeah, that's a great question. So, yeah, you can see the pinch of the diaphragm. Like 40 ballpark is kind of where that's typically at, and then the length of the true GE junction. But that's going to be difficult because if you've got a longer segment of Barrett, you will see the Z line. So you can potentially get three different marking points. It can be quite tricky, and honestly, it's not very accurate to do it endoscopically. You're never really as accurate as you think you are because things move or those. So you could get the measurement of the diaphragm, the measurement of where you think the GE junction is, based on, like, a little pinch there of the lower esophageal sphincter. And then you could get the mark of the Z line, which is even more proximal to that, depending if they've got metaplasia.
Dr. Randy Lehman [00:25:18]: So, yeah, that's exactly the case that delayed me getting to this interview. Well, it's not that. It's that there was a gallbladder before that. That was pretty nasty.
Dr. Greg Gerrish [00:25:30]: Yeah, it's okay.
Dr. Randy Lehman [00:25:31]: But my last case that I did this morning was an EGD for long-standing GERD, and her diaphragm was at 39 cm, but she had salmon tongue peaks of mucosa, you know, pink mucosa tongues that were extending up with a total irregular and a couple of rests of tissue like that. So, I mean, I'm very suspicious for Barrett's. That would be a new diagnosis for her. And I took, so we can. Actually, I got a question about what you would do there. But then I measured that up to about, clearly there was a hiatal hernia, but, you know, measured that up to about 34 centimeters. So anyway, I end up saying 4 to 5 centimeter hiatal hernia, but like you said, you don't necessarily know. I ended up doing four quadrant biopsies from, like, I guess I didn't really see the pinch of the esophagus, but you would try to do that from where you think the end of the esophagus, the GE junction actually is, or. I mean, how do you know you're not getting fundus in that biopsy?
Dr. Greg Gerrish [00:26:35]: Okay, let's go on a little sidetrack on this one. So how do I manage my Barrett's? There's just like, how do I biopsy Barrett's and surveillance? I'm biopsying with cold forceps, like the Z line for sure, and I'll try to biopsy near, like, the true GE junction if I can tell where it's at. Those are going to be your highest incidence of finding dysplasia in those areas. Like a true Seattle protocol, if you're doing that. Like, I just diagnosed a guy with, like, 11 centimeters of Barrett this week. Nobody's doing that, like, 47, 40 biopsies, 44 biopsies. So what? Yeah, I have incorporated Watts 3D into my practice a lot, which is really helpful, and it's easy to get going. But it's a brush biopsy, so you're brushing the entire area. And they've got really good data on being more sensitive in finding dysplastic Barrett's and doing a better job than Seattle protocol biopsies. So that would be if you're doing a lot of this in your practice. It saves a ton of time. It's really nice. So it's kind of an adjunct to your cold biopsy forceps.
Dr. Randy Lehman [00:27:45]: Okay. And do you surveil Barrett's every three years?
Dr. Greg Gerrish [00:27:49]: Just depends on if it's a really long segment, that might be one year. If it's a history of dysplasia, or if I've done ablations on it, it might be one year. But if it's just a short 1 cm tongue of Barrett's in a low-risk patient, that's going to be three.
Dr. Randy Lehman [00:28:02]: Okay. And then when you go in to do that surveillance, then if it's a really short segment, you still do biopsies or do you always use the Watts 3D brush?
Dr. Greg Gerrish [00:28:11]: I will more likely than not use the Watts, but sometimes it's just so minimal that I'll just, like, you're pretty much getting everything with your cold biopsy forceps.
Dr. Randy Lehman [00:28:21]: Right.
Dr. Greg Gerrish [00:28:21]: But remember, some Barrett's, especially in women, will hide well below that Z line, and that Z line will look nice and might only show 1 cm, but if you go beneath that, you can still have Barrett's. So, yeah.
Dr. Randy Lehman [00:28:37]: Okay. All right, let's see. Where did we leave off? So we got the patient that, so the next question I had was, how do you classify that? You know, we've been using the word hiatal hernia, and I think we know what we're talking about, but paraesophageal hernia, how do you classify that? Paraesophageal hernia.
Dr. Greg Gerrish [00:28:59]: I don't get this when the insurance company wants me to say it that way. It's kind of all the same disease spectrum, right? And it's kind of hard to tell what exactly you're dealing with. But is the GE junction slipping up into the chest, or is it slipping alongside? Is the stomach slipping up alongside the esophagus? I don't know.
Dr. Randy Lehman [00:29:21]: Right.
Dr. Greg Gerrish [00:29:21]: Like I typically classify paraesophageal hernias, but it's, yeah, it's, to me, it's the same disease process, and it's causing the. Is what causes the reflux?
Dr. Randy Lehman [00:29:34]: So it's technically a type 1 sliding hiatal hernia that codes as just an anti-reflux procedure.
Dr. Greg Gerrish [00:29:40]: That's right.
Dr. Randy Lehman [00:29:41]: But a type 2, 3, or 4 paraesophageal hernia codes as a paraesophageal hernia repair. Well, type two I kind of get, but I don't really see that many type twos where it's just an isolated loop of the stomach going up. But a type one, like, at what point is it a type one, or is it a type three? You know, like when it's five centimeters and there's a bubble of stomach up above the diaphragm, like clearly the GE junction is displaced up there, and that's a type 3. But when it's just 1 cm and it goes up and down, like somewhere in between those two is now a type three.
Dr. Greg Gerrish [00:30:17]: Yes. It's kind of a conundrum. What I care about is that if it's sliding, it can still be the cause of this reflux issue. We're kind of potato, potato-ing a little bit with that. And maybe the definitions need to be more clear. But I hate that insurance companies have kind of picked up on, like, is it this type or this type? And it's like, well, it's kind of a spectrum. It depends if the patient is hiccuping right now or inhaling or breathing in or not. Yeah, so.
Dr. Randy Lehman [00:30:48]: But then there are some patients that truly do not have a hiatal hernia. And then those, you're still doing those anti-reflux surgeries and then you're billing it as the other one that you know.
Dr. Greg Gerrish [00:30:57]: Yeah. And those are a little bit, they will not get covered for Lynx. So those patients will almost strictly get a fundo.
Dr. Randy Lehman [00:31:05]: So. And you keep saying fundoplication and partial fundoplication, but do you do.
Dr. Randy Lehman [00:31:12]: What fundoplications do you do? Nissen, Dor, Toupet. What else?
Dr. Greg Gerrish [00:31:15]: I'm more of like a So I have been doing a lot more like Watson, which is kind of like a Dor plus a little bit. I guess it's a little bit like a 180-degree anterior. But my partner is doing partials like Toupet, so I've seen pretty similar results between the two of them, but just less. We're looking for less dysphagia postoperatively, a little bit less gas bloat and dumping in my experience too.
Dr. Randy Lehman [00:31:40]: But yeah, I gotta be honest, the Watson is a new one to me. So I'm looking, I'm looking it up as we speak.
Dr. Greg Gerrish [00:31:47]: Just think Dor, but you're getting it to go about 180 degrees anterior, and you're almost getting down to the pre-aortic fascia and, like, the right side of the esophagus. And it's kind of tacking it to the hiatus as well.
Dr. Randy Lehman [00:32:02]: Yeah.
Dr. Greg Gerrish [00:32:03]: For 180 degrees.
Dr. Randy Lehman [00:32:05]: I see the Google image here, pictures worth a thousand words. How many stitches do you use on your typical Watson? Let's see, I'd have to — like this picture on Google says about maybe one on the left side, one at the top, and then like four off to the, off to the patient's right side.
Dr. Greg Gerrish [00:32:22]: My guess, it'd be six or seven.
Dr. Randy Lehman [00:32:24]: Okay. Yeah, makes sense. And we'll talk in more detail because I really like to, you know, if you want to ever humble yourself, start a podcast about surgery and expose to the entire public everything you know. Right. Because it's not everything, but I.
Dr. Greg Gerrish [00:32:42]: This job can be humbling the way it is. So I don't know if I'm easy.
Dr. Randy Lehman [00:32:48]: To get cocky in surgery, hard to stay that way, humbling professional, but I could talk about this all day. So let's, let's get to like, the nitty gritty of this operation. Okay, so you're going to do a, we'll call it a type 3.5 centimeter paraesophageal hernia repair. And you take the patient to the operating room. How do you position them and where do you put your ports?
Dr. Greg Gerrish [00:33:10]: Okay, so I'm a supine guy. Nothing fancy there. So we get everything prepped. I don't really ever have an endoscopy available either, so some people like to scope everyone, and I don't routinely do that.
Dr. Randy Lehman [00:33:23]: Do you tuck the arms?
Dr. Greg Gerrish [00:33:24]: I. I tuck. No, I don't tuck the arms. Not. Not for this. So.
Dr. Randy Lehman [00:33:29]: And where do you. Which side do you stand on?
Dr. Greg Gerrish [00:33:32]: I'm on the patient's right.
Dr. Randy Lehman [00:33:34]: Okay, great. Because I put them in lithotomy and I stand between the legs, so.
Dr. Greg Gerrish [00:33:39]: And that's a preference.
Dr. Randy Lehman [00:33:40]: Different ways to do it. Where do you put your ports?
Dr. Greg Gerrish [00:33:43]: Okay, so I'm going to busy in and really laterally underneath the left costal margin with a 5-millimeter port. So it's almost as far down as the ribs will go. And so I use a lot of local. And I'm busy in there. And then I'm going to put measure using my knuckles. Right. So if I have that much distance between my ports, I'm happy. I'll put a five medial to that and then I'll put a ten about another knuckle. It's basically going to be straight above the umbilicus. Some people's anatomy is really different, but it's usually somewhere between the umbilicus and the xiphoid with that bigger 10 port.
Dr. Randy Lehman [00:34:24]: But it's in the midline.
Dr. Greg Gerrish [00:34:25]: It's usually in the midline. Yep. Sometimes it'll be, I'll flip to the right. I don't really care if it's midline or not. It's just usually there. And then another five is going to be like sub-xiphoid. That one usually actually comes through the falciform, where it's thin over the top of the liver, typically. Then I will take the trocar, like the inside of the trocar, the introducer, and make a little poke hole on the right subcostal margin and just put the trocar in. Then I can advance my liver retractor through that and secure that. So I don't even use a port for that.
Dr. Randy Lehman [00:34:59]: Okay. Which liver retractor do you use?
Dr. Greg Gerrish [00:35:01]: Oh, it's that. Is it heart-shaped? You get screwed up, and it's in the heart shape, but I can't remember what the exact name of it is.
Dr. Randy Lehman [00:35:09]: So it's not rigid. You don't have to, like, do contortions to get it in. It's just straight. You stick it in, then you twist a thing to make it go into the heart shape.
Dr. Greg Gerrish [00:35:16]: It's pretty soft. And then it, you know, it's kind of a snake. But it'll snake into a heart shape when you start tightening it up.
Dr. Randy Lehman [00:35:23]: Yeah, I use one that looks like a triangle, but same, same concept. But I put it through a five, so maybe I'll have to try this new.
Dr. Greg Gerrish [00:35:29]: You can stay in the hospital, you know, whatever five port costs.
Dr. Randy Lehman [00:35:32]: Yeah. And your camera then goes through that. Where's your camera?
Dr. Greg Gerrish [00:35:40]: Most of the case, my partner is going to be on the patient's left side, and they're going to have one retractor and the second port that they put in, which is going to be kind of in the middle of the left abdomen, that's their camera port. So my right hand is going to be using that 10 port, and my left hand is going to be using the sub-xiphoid port.
Dr. Randy Lehman [00:35:58]: Sure. Okay, and then you're gonna put the patient in reverse Trendelenburg.
Dr. Greg Gerrish [00:36:05]: Yep.
Dr. Randy Lehman [00:36:06]: And you've got probably 15 of insufflation and you're going to start your dissection where? In the pars flaccida.
Dr. Greg Gerrish [00:36:14]: That's right. So, depending on how big the hiatal hernia is, their assistant's doing some good retraction there. And it's usually my partner, so I can trust him. So there's no Penrose ever involved in that. But there could be if you were worried. So I start in the pars, and I work my way up, right. I'm going trying to shoot straight for the right cura because once I get onto the fascia of the right curra, I'm going to work my way just on the inside of that cura until I start getting the great wispies up inside the chest. That's how you know, you're like, that's the sweet spot. Everyone loves those wispies.
Dr. Randy Lehman [00:36:50]: Or ligature.
Dr. Greg Gerrish [00:36:51]: What? I'm a ligature guy.
Dr. Randy Lehman [00:36:52]: Yeah, same here. The 5-millimeter blunt or what? Which one?
Dr. Greg Gerrish [00:36:55]: I like the 5-millimeter Maryland.
Dr. Randy Lehman [00:36:58]: Okay. Yeah, yeah. Okay.
Dr. Greg Gerrish [00:37:02]: Sometimes you'll come across, and when you're doing that dissection between the pars and the hiatus, there'll be a little accessory vessel that goes to the liver too. I've had to spare a couple of those, but I usually will take that if it's small. But once I get into the chest and you get the nice wispies, then I'm going to go anteriorly over top of the esophagus and work my way. Try to get that upside-down smiley face to get the front esophageal attachments off right there. From there to get to the left curra and get those attachments off. Especially if I'm doing a fundoplication, I will just start going for the short gastrics. I don't do that for a LINX, but in a fundoplication, I will just back off and go back to the fundus and get those short gastrics and take that plane all the way up to the left curra because it just shows the backside of the stomach so much easier. And remember, when you're getting close to the hiatus, there's two layers of short gastrics there, so you think you're done, but there's usually one more short gastric in the way back that you gotta be careful on, because if you rip that, it's just in a bad spot to get to. But if you take that one up into the chest, you're now like posteriorly in the perfect plane to take off that last spinoesophageal ligament on the left crura.
Dr. Randy Lehman [00:38:23]: That's what if you do a short gastric?
Dr. Greg Gerrish [00:38:26]: Well, just, you know, you could. You probably could be able to get it and just pick it up and burn it there.
Dr. Randy Lehman [00:38:32]: But retract, retract, expose sometimes to break out the sucker. Do you use a sucker regularly?
Dr. Greg Gerrish [00:38:38]: It's not open routinely, no, but yeah, it's in a hold bin.
Dr. Randy Lehman [00:38:43]: Grasp and burn.
Dr. Greg Gerrish [00:38:45]: Yeah, yeah. You know, be careful.
Dr. Randy Lehman [00:38:47]: Yeah.
Dr. Greg Gerrish [00:38:48]: Step one, panic, right?
Dr. Randy Lehman [00:38:49]: Yes. Right. Don't panic and freak out. Okay, so then you basically.
Dr. Greg Gerrish [00:38:53]: Coming up. My goal is to get 360. Yeah, get 360 around. Around the G junction, if you can. It really. That depends on how big the hiatal hernia is, too. But you're trying to get into that wispy plane, you know, almost all the way around the esophagus and the posterior esophagus. You get into kind of the. Like that mesentery. Getting lymphatics and off the aorta.
Dr. Randy Lehman [00:39:14]: Talk to me about the. The phrenic nerve.
Dr. Greg Gerrish [00:39:19]: Yeah.
Dr. Randy Lehman [00:39:19]: Or the vagus nerve, I should say. Yeah.
Dr. Greg Gerrish [00:39:22]: Yep. So you can. Oftentimes you get in the wispies and you're gonna identify the phrenic nerve. It could be. It's kind of all over the place.
Dr. Randy Lehman [00:39:31]: I got you saying phrenic nerve. We're talking vagus nerve.
Dr. Greg Gerrish [00:39:35]: Just try to catch me. It's all good. Just to know if. Yeah. So, yeah, I try to identify it wherever I can. So if I see it first up in the chest and all that, those nice wispy tissues, and then we'll kind of trace it down, but once, and we'll go out of our way to try to find it. But once I have it, I will kind of isolate it, push it towards the esophagus, and then work underneath it to lift all that tissue up and away. But. And then with the Lynx, I actually want to make a window between the phrenic and the esophagus, or not the phrenic. Now you got me saying phrenic.
Dr. Randy Lehman [00:40:10]: I know that's my bad.
Dr. Greg Gerrish [00:40:13]: I want to make a window between the vagus and the esophagus, because that's where the Lynx will eventually go. So I will sometimes just take that opportunity. So now that we've kind of. We've gotten way up into the chest and those wispies and kind of reduce the. The stomach and gut and the esophagus down to where we want to be. That's what I think about just closing this. So I'll be honest. I'm not a mesh guy. In the hiatus, I think the pendulum's kind of swinging back that way, too. But I will occasionally put a mesh in if it's just really thin tissue or it's really got a lot of tension on it. But most of the time, I don't. If there's not a lot of tension in that crura, I'm not using a mesh.
Dr. Randy Lehman [00:40:57]: Yeah, that was really beat out of me at my training at Mayo because of course they're getting like multiple states or actually the whole country kind of getting referrals for mesh problems to them. I mean, they just told me never, ever, ever. And if you have to put a mesh to make an incision laterally in the left diaphragm and like a relaxing incision and stitch your mesh in there so that the tension comes off and you can close the hiatus primarily. I did, I did see that once in training, but I've. I've never actually seen any mesh placed at the hiatus, nor have I ever placed any myself.
Dr. Greg Gerrish [00:41:34]: I usually just get good big bites of my Surgidac endostitch suture. And I'm not trying to take little dinky bites, but I'm trying to preserve the fascia on those crura when I'm doing the dissection and I'm getting good amounts of tissue when I do those and not incorporating the aorta or something else. Just so two or three stitches is 95% of the time it's going to get that. Those crura together.
Dr. Randy Lehman [00:42:00]: Yeah.
Dr. Greg Gerrish [00:42:01]: Without pinching the esophagus together.
Dr. Randy Lehman [00:42:02]: The one I'm thinking of, you know, it's a giant type 4, you know, huge defect.
Dr. Greg Gerrish [00:42:07]: Yeah.
Dr. Randy Lehman [00:42:07]: 10 centimeter defect or whatever. And. And it just going to be so much tension. But I've also heard that now might be. I hate to. The other thing is, I might be perpetuating black pearls of false wisdom, but I heard that Dr. Demister would induce a. Let me just see if Demeter come on my podcast. Induce a pneumothorax to cause it to fall down.
Dr. Greg Gerrish [00:42:32]: I've heard him say it.
Dr. Randy Lehman [00:42:33]: Okay, so good. So confirmed. So, and then that pneumothorax would be on the. Which does it matter which side? Or could it be patient's left?
Dr. Greg Gerrish [00:42:43]: Probably.
Dr. Randy Lehman [00:42:44]: Okay. And then that would allow it to come down with less tension, at least while you're closing. Right there. Now you're using osarchnect or what you.
Dr. Greg Gerrish [00:42:52]: Can use in this. Yeah, there's a lot of different tips and tricks in this that you can use in that area. But yeah, I close it with an Osur.
Dr. Randy Lehman [00:43:00]: And do you do like figure eights or interrupt simple interrupts or figure eights?
Dr. Greg Gerrish [00:43:06]: I. I love the figure eights. I think it just distributes tension nicely through there.
Dr. Randy Lehman [00:43:11]: I agree. That's actually exactly what I do at the end of stitch. And so then give me a couple other tips if you got a lot of tension. You. You already mentioned the following. Save the fascia, take big bites, distribute tension with a figure of eight. We talked about the inducing pneumothorax thing.
Dr. Greg Gerrish [00:43:28]: Yeah. If that doesn't get you where you need to be, then that's when I'm considering mesh. If it's really tight or I can see my stitches are kind of pulling through, that's when I will use like a Phasix mesh. But Phasix is definitely going to induce a big inflammatory response and have a lot more dysphagia too. So.
Dr. Randy Lehman [00:43:44]: So how do you shape your mesh and put it in there then? If you were going to use a Phasix?
Dr. Greg Gerrish [00:43:48]: Mine's kind of like the. Oh, like a big circle with the hole in the middle of it pretty much is. Or like an upside-down U. But it's going to be connected at the top and I'll stitch it in on the inside of the crura or like over the top of my previous stitches. And I will use a. I will use a tacking device, but carefully. Like, I'm looking for the vessels underneath the phrenic vessels because there's usually some bigger vessels on the underside of the diaphragm. But I'm definitely not going to tack towards the heart or downward, like posteriorly.
Dr. Randy Lehman [00:44:21]: Yeah. I mean, I've heard of a pericardial effusion and, you know, things happening with. With tacks in that area. So did that Phasix. Is it that you're using? Is it pre-made to be placed in the hiatus or are you cutting it like that yourself?
Dr. Greg Gerrish [00:44:37]: I'm cutting it like that.
Dr. Randy Lehman [00:44:39]: Okay.
Dr. Greg Gerrish [00:44:39]: There's one that size pretty appropriately, though.
Dr. Randy Lehman [00:44:42]: Yeah. And so the. It's kind of like a keyhole, right?
Dr. Greg Gerrish [00:44:46]: Yep.
Dr. Randy Lehman [00:44:46]: In a circle. How big is the hole that you're putting? Is it like two centimeters or.
Dr. Greg Gerrish [00:44:52]: Yeah, two, two and a half centimeters.
Dr. Randy Lehman [00:44:54]: Two and a half.
Dr. Greg Gerrish [00:44:54]: I usually want it kind of just around the esophagus, but not touching or putting pressure on the esophagus.
Dr. Randy Lehman [00:45:00]: And the tails will come up anteriorly, like to come together. You don't put them behind, right?
Dr. Greg Gerrish [00:45:07]: Yeah. And try to just get them to overlap at least a little bit.
Dr. Randy Lehman [00:45:11]: Okay. Yeah. Those are great tips. Anything else that you want to share technically about that component?
Dr. Greg Gerrish [00:45:18]: No. No.
Dr. Randy Lehman [00:45:20]: Have you done any without your partner?
Dr. Greg Gerrish [00:45:23]: A few. Yeah.
Dr. Randy Lehman [00:45:25]: How'd it go?
Dr. Greg Gerrish [00:45:26]: It's so much easier with him, man.
Dr. Randy Lehman [00:45:27]: Yeah.
Dr. Greg Gerrish [00:45:28]: It's just. You don't even have to think. He just, like, the exposure is already there. It's just. It's just fun. But it goes fine. We have a PA2 that can do those things, but there are certain ones that I wouldn't. I just have, like, the bigger intrathoracic stomachs, and, you know, if someone's really obese or something, I would have them there, but. Yeah.
Dr. Randy Lehman [00:45:45]: Have you ever had to convert to open?
Dr. Greg Gerrish [00:45:48]: No.
Dr. Randy Lehman [00:45:49]: Okay. And you've done hundreds. Sounds like.
Dr. Greg Gerrish [00:45:53]: I would say probably 800 to 900 for gut surgeries in nine years.
Dr. Randy Lehman [00:46:00]: Yeah. Well, that's fantastic. I had one that. It was a type 4. And of course, it's like a, you know, teacher at my school and all this stuff, and it was stuck. It was stuck up there like it was incarcerated. And I really felt uncomfortable laparoscopically. And I ended up placing an epigastric hand port and reducing it that way, which I'm not telling anybody to do that. But I. You know, you find yourself in a situation, and it's like, I don't feel safe doing anything, you know, more. I mean, my other alternative is, like, leave it and bail out. But I felt like I was there.
Dr. Greg Gerrish [00:46:42]: To reduce the hernia, so I had one that was. So he had a recurrent hiatal hernia after Nissen from, like, 10, 20 years ago. So a long time ago. And his Nissen had herniated up in the chest, and it was just stuck on the bottom side of the left diaphragm, like, up inside there. And I just couldn't. It was just plastered there. And he also doesn't have really much pulmonary reserve. So I end up backing out and just said, sorry, you know, and he wouldn't. I think he got it evaluated at your alma mater. And they said, no, we're. You're good. No, no. Thanks.
Dr. Randy Lehman [00:47:17]: But yeah.
Dr. Greg Gerrish [00:47:18]: Anyway.
Dr. Randy Lehman [00:47:19]: A couple other questions. Have you ever seen or heard of a Belzy Mark IV fundoplication? Have you ever done one?
Dr. Greg Gerrish [00:47:27]: Yeah, I kind of thought a chest or thoracic component fundoplication might have been the best way to approach that patient that I just talked to you about.
Dr. Randy Lehman [00:47:33]: Right. That's what makes me think of it. So I actually. I think I did four of them in residency because we had a guy that did a bunch of them, had a spoon, you know, to throw the stitches, like, through the chest. And of course, he just loved them. And so that would be for a person who's had 2, 3, 4 previous foregut surgeries from an abdominal approach, and you're expecting that to be hostile and you're trying to get a repair. Any other comments about that? I mean, if you had that patient, then you're sending them to a university setting and kind of letting them make the final decision or what?
Dr. Greg Gerrish [00:48:14]: Yeah, yeah. Just if I can't do it in my little small town doesn't mean it's maybe not possible, but just not something I'm comfortable doing here, you know?
Dr. Randy Lehman [00:48:25]: Yeah, I don't know. That surgeon retired. I don't know where I would send somebody to get a. To get a Belzy.
Dr. Greg Gerrish [00:48:33]: Yeah.
Dr. Randy Lehman [00:48:36]: Maybe I'll find a time where.
Dr. Greg Gerrish [00:48:37]: No one's doing Belses anymore. They're probably. It's probably an aging thing, but yeah, it doesn't mean it's wrong. It just.
Dr. Randy Lehman [00:48:44]: The other question I had is how about management of that 85-year-old frail lady with a type 4 who's symptomatic and do you have. I have something which I guess I could go first or you could go first.
Dr. Greg Gerrish [00:49:00]: If they can tolerate a surgery, I'll do it. I think people. Patients do a lot better. I think there's. It's been a while since I've looked at this data, but we talked about this at that conference once and they do pretty well with these surgeries. The typical symptom that these ladies have is anemia. I see a lot of these and they have been scoped up and down for 10, 20 years for this anemia that they've had forever and ever. But I'll be pretty aggressive. If I think they can tolerate the operation well, I'll do it because in my mind it's almost the recovery for a typical one of these surgeries is similar to a lap chole for me. I may not be aggressive with a LINX or a really tight Nissen, that's a different thing. But the gastropexy is becoming a lot more common. Like the old-fashioned putting a PEG or gastrostomy tube in them just to keep them from reherniating up in the chest is. I think it's making a comeback.
Dr. Randy Lehman [00:49:56]: But yeah, so that's exactly the patient that I'm talking about, which I did like I don't know, four months ago or so. And it was a lady that was really, really hesitant about major surgery and stuff. And that's what I ended up doing was two PEG tubes. So I just put it in, put her as steep as I could, head up, drug the stomach with the scope as far as I could. It's really unsatisfying. But drug it as far as I could and then put my first PEG and then put another PEG as two anchors pulled them in the clinic six weeks later. I could not believe it. She was symptomatically quite improved. I think from a safety perspective of her not volvulizing, I would say she's basically totally protected, you know.
Dr. Greg Gerrish [00:50:39]: Yep.
Dr. Randy Lehman [00:50:39]: And so for the right patient, that was the option I was going to suggest.
Dr. Greg Gerrish [00:50:46]: That's a good little surgery story because I could totally see something like that being an option at some point.
Dr. Randy Lehman [00:50:53]: Yeah. And the other thing that. That I do with my fundos is if I. I usually do a Toupet in a younger, healthier patient, but if it's a big. Like type 4 or big type 3, and especially an older patient, I just assume that they have some esophageal dysmotility. I don't usually do a manometry in that situation, and I just assume that their esophagus doesn't work right. And I always just do a Dor. Maybe a Watson or a Dor, you should say. But, you know, just an anterior thing to kind of bolster the stomach down there, but not try. You know, their esophagus is not going to push well. And if they have any element of it being too tight down below, you know, then we're gonna have a problem. Do you use a bougie?
Dr. Greg Gerrish [00:51:40]: No.
Dr. Randy Lehman [00:51:41]: Okay.
Dr. Greg Gerrish [00:51:42]: Like a hard. That's like a hard. No. Because when I'm doing a partial fundo, usually, and the worst complications I've heard of from this type of surgery is the bougie accidentally going somewhere where it wasn't supposed to go or being advanced by someone that maybe doesn't have the skill set to be advancing bougies and causing the problem. So. Scared of.
Dr. Randy Lehman [00:52:02]: Yeah, got it. No, I use a bougie, a 50 French bougie, and then wrap over the top foot with the partial funnel still. But so how does the partial fund. I guess I see what you're saying, because a full wrap, that's what's protecting you from going too far. But you and I are both still having some patients that are going to require a dilation at some point anyway. Do you think that there's any chance you could prevent a higher percentage of.
Dr. Greg Gerrish [00:52:30]: That with some partials? I think because I'm only wrapping, like, 180 degrees with the partials.
Dr. Randy Lehman [00:52:46]: So, yeah, I don't think I have had any of my anterior partial fundos that I've had to dilate yet. Now, I'm not, I don't have as many numbers as you do, but the Toupets I've had to dilate. I made, I think, two. One guy went and ate a McRib the next day, like, come on. And then I had to emergently take that out, and it's like, give me a break. So, do you keep them in the hospital a day?
Dr. Greg Gerrish [00:53:12]: Most of the time, no. It's kind of outpatient, and that's the plan. We talk about that from the get-go. If it's someone elderly or with comorbidities, or maybe you got into the pleura and they're hypoxic, but most of the time, no, they go home.
Dr. Randy Lehman [00:53:30]: Do you have to do something from an insurance perspective on this? I think I was told by some administrators or somebody that there's something on the inpatient-only list, so you have to call them an inpatient.
Dr. Greg Gerrish [00:53:43]: I haven't had any. I don't know how to bill their code, to be honest with you.
Dr. Randy Lehman [00:53:49]: I mostly have been keeping them overnight, and it keeps everybody happy. But what do you do with the diet afterwards?
Dr. Greg Gerrish [00:53:58]: The partial fundos are more of a soft diet. I don't go six weeks of full liquids or anything, but softer foods. With the LINX, it has its own kind of diet. They actually want you to be eating about once an hour or something just to keep it moving.
Dr. Randy Lehman [00:54:17]: If somebody was interested, say they have the skill set to do laparoscopic fundoplication, maybe they have or haven't been doing it, and they're not doing LINX but wanted to add that to their practice, where would you recommend they go?
Dr. Greg Gerrish [00:54:32]: Going to that Foregut Disease Foundation course just once will be very eye-opening.
Dr. Randy Lehman [00:54:36]: Yeah, I think I'm gonna go in February.
Dr. Greg Gerrish [00:54:38]: You should. It's great. Well, Hawaii in February—there's nothing wrong with that. It'll be very enlightening and gives you perspective on how to think about these things. Did you go...
Dr. Randy Lehman [00:54:50]: Do you go regularly or just that one time?
Dr. Greg Gerrish [00:54:52]: I have gone regularly. I've probably been to five or six, missed a couple of years here and there.
Dr. Randy Lehman [00:54:58]: Have you ever been to the comprehensive general surgery review course for Mayo in Hawaii?
Dr. Greg Gerrish [00:55:04]: No, I haven't because I'm always going to this one, and I can only go to one.
Dr. Randy Lehman [00:55:08]: It's also in February. I think it's like the week or two before this one.
Dr. Greg Gerrish [00:55:13]: Always very close because one of my partners will go to that one or something like that.
Dr. Randy Lehman [00:55:20]: Of course, it's like a reunion for me. I go, talk to all the people I trained with.
Dr. Greg Gerrish [00:55:24]: Yeah.
Dr. Randy Lehman [00:55:25]: Okay, cool. I'm trying to think if there's anything else I missed. So, we did the... You secured the anterior fundoplication with the same suture dac?
Dr. Greg Gerrish [00:55:35]: Yep.
Dr. Randy Lehman [00:55:36]: And you said like five to six to seven sutures, maybe a little bit more on the right side. Then basically you're just pulling your ports out, letting the patient go home the same day, and they're able to do a soft diet pretty quickly. Do you do follow-up EGD or anything? What's your follow-up like?
Dr. Greg Gerrish [00:55:56]: Only if they need surveillance for Barrett's, yep.
Dr. Randy Lehman [00:56:01]: The textbook says that the fundoplication does not cause Barrett's to regress.
Dr. Greg Gerrish [00:56:08]: That's...
Dr. Randy Lehman [00:56:09]: Do you think that's true?
Dr. Greg Gerrish [00:56:12]: I know I've had short segments regress, especially with the LINX. If you've got longer segments, good luck. I've actually seen the majority of patients with sub-centimeter Barrett's regress after you control their reflux. There are some papers coming out about that too.
Dr. Randy Lehman [00:56:32]: Okay, good. I think that's probably... I don't think we should go into lap colon surgery. That's a lot of great detail. My listener appreciates it. Maybe I can twist your arm to come back and talk to us about some other stuff. The only other thing I did want to ask is about the management of Barrett's. Are you doing RFA even...
Dr. Greg Gerrish [00:56:56]: Yeah.
Dr. Randy Lehman [00:56:56]: So, can you tell me real quick how that is in your practice?
Dr. Greg Gerrish [00:57:00]: One of the things I wanted to talk about is how endoscopy is, like, all-encompassing. What can you provide for this patient? About 10 years ago at my institution, it was endoscopy, endoscopy. You've got Barrett's, we put you on the PPI, see you later. That's it. They weren't getting Seattle protocol. They weren't getting anything. Now we've got options to treat these patients. When you're looking for it, you find a lot more. So, finding a Barrett's patient—I'm doing cold biopsies. I'm doing a thing called tissue cipher, which looks at the genes being expressed by the biopsies. Like, is their Barrett's tissue expressing like EGF1 or more concerning tissue? It gives a risk factor of their lifetime risk of developing adenocarcinoma. So that's helpful in predicting who's going to progress. Then I'm doing the WATS 3D as well, to kind of replace Seattle protocol. In these, I find some patients dysplastic, low or high grade, or longer segments, which are higher risk. At that point, you have a conversation with the patient. It's not hard to convince a high-grade to undergo RFA, but some patients don't like hearing, "You're telling me that I've got 10 cm of this precancerous stuff in my esophagus, and we're just going to watch it." That doesn't sit well with them. We may recommend ablation.
Dr. Randy Lehman [00:58:44]: And that's for a person that does not have high-grade.
Dr. Greg Gerrish [00:58:48]: Yeah, that's anyone with non-dysplastic Barrett's with a longer segment, like 5 cm or greater. Some hoops to jump through with insurances either.
Dr. Randy Lehman [00:59:01]: And I've had to write a few letters for those.
Dr. Randy Lehman [00:59:04]: Summarize what you said before, the three things you're doing for diagnosis are the biopsies, the tissue cipher, and the WATS 3D.
Dr. Greg Gerrish [00:59:13]: Yep.
Dr. Randy Lehman [00:59:14]: How do you choose when to do it, like basically if you go in and they don't have a known history of Barrett's and you see something suspicious for Barrett's. Do you do all three?
Dr. Greg Gerrish [00:59:25]: Well, if the pathologist diagnoses Barrett's, that’ll get sent to tissue cipher. So that tissue gets sent.
Dr. Randy Lehman [00:59:33]: The tissue cipher, the same tissue. Okay.
Dr. Greg Gerrish [00:59:35]: Yeah. Then I do the WATS if I see visible Barrett's.
Dr. Randy Lehman [00:59:41]: Okay. Even if it hasn't been.
Dr. Greg Gerrish [00:59:43]: Yes, even if it hasn't been. If it's the first time, if it's like a 1 cm thing, then I might. I may not. But oftentimes you're getting like 3 to 4 centimeter Barrett's. So it's pretty easy to tell that's what you got going on.
Dr. Randy Lehman [00:59:56]: But you can't send the Watts 3D specimen for tissue cipher. Or can you?
Dr. Greg Gerrish [01:00:01]: I don't think so, no. It's a different company.
Dr. Randy Lehman [01:00:03]: Okay. And who drove the tissue cipher? Was it you or the pathologist?
Dr. Greg Gerrish [01:00:08]: Me.
Dr. Randy Lehman [01:00:09]: Okay. And you learned about it at the conference?
Dr. Greg Gerrish [01:00:12]: Yeah.
Dr. Randy Lehman [01:00:12]: You know, it keeps coming back to this very good something. And then the RFA. Can you talk us through, like, how it goes through the EGD scope? Yep.
Dr. Greg Gerrish [01:00:24]: So there's. It's usually the first one's a general anesthesia, so it's a little bit more than what you think. So you go down with your scope and you kind of assess the top of the gastric folds and where the Z-line is to kind of get a marker of how much you're doing. There are different catheter tips depending on how extensive you're going to get. There's one long one that's 360 degrees where a balloon inflates underneath it, like a dilation balloon. And then it will apply a burn circumferentially. That's typically for your bigger or first treatments. Then as the Barrett's progresses in the future, if there's not very much, you may use some smaller catheters that burn.
Dr. Randy Lehman [01:01:06]: But they just burn at the ship.
Dr. Greg Gerrish [01:01:10]: They will burn like the side of it. It's like a little paddles. There are little paddles.
Dr. Randy Lehman [01:01:14]: These come through your working channel on your EGD scope.
Dr. Greg Gerrish [01:01:18]: There's the big balloon one. It goes along the side of the scope, so it's on its own. And one is like a cap that attaches to the end of the scope. And then there's one smaller one that goes through the scope.
Dr. Randy Lehman [01:01:31]: And if somebody wanted to start doing this, talk to a rep or how. I mean, how would you? Is there a course or something?
Dr. Greg Gerrish [01:01:37]: You talk to a rep and they'd probably put you through a course, at least have someone come and do. You'd stack up a few and do that.
Dr. Randy Lehman [01:01:45]: You also brought bravo to your town, right?
Dr. Greg Gerrish [01:01:47]: Yep.
Dr. Randy Lehman [01:01:49]: So you must not have any GI in town.
Dr. Greg Gerrish [01:01:52]: No. Yeah. No, there's not. Okay. But I will say the radiofrequency ablation. The patients that hurts, they can be pretty, like when. If they. If you ask them what hurt worse, the hiatal hernia repair and LINX or the RFA. It's RFA hands down. Like, that hurts. I mean, you're burning your esophagus, but.
Dr. Randy Lehman [01:02:14]: You still let them go home? Yeah, just with pain medication. And then if I had, say, 10-centimeter Barrett's, what would you tell me the expected result would be? After my treatment, my first treatment with RFA, how many times do I need a second treatment?
Dr. Greg Gerrish [01:02:33]: It's most. Most of the time you're going to take three to four treatments, at least with that long of a segment. If it's a shorter segment, maybe not. But that's. It's. Yeah. I feel like you usually get like 60 to 70% to resolve every time you do it, so you're kind of chipping away at it. But the second and third treatment are. So for some reason, they don't. They hurt way less than the first one. The first one's always the. That's the one that gets them.
Dr. Randy Lehman [01:02:57]: Yeah. And after you're done, when you come back and rescope them, when the Barrett's is gone, you're diagnosing it by biopsy. But how does the lining look like, squamous lining? Normal.
Dr. Greg Gerrish [01:03:09]: Yeah.
Dr. Randy Lehman [01:03:10]: It goes back to looking normal. Okay.
Dr. Greg Gerrish [01:03:11]: Yep. Key is good reflux control. So I typically like to do the reflux surgery before. Had good results with that. Some GIs will do it different, like the opposite where they.
Dr. Randy Lehman [01:03:24]: But try to get the Barrett's under control, then do their. Yeah, that doesn't make as much sense. Okay, well, that is such an awesome practice that you have and excellent tips that I would say. I definitely didn't know everything you said, and so I'm sure my listener would have picked something up as well. Why don't we ask if you've got a financial tip in our financial corner to share with a listener as well?
Dr. Greg Gerrish [01:03:49]: Don't buy Octocoin. That's all I got. I'm not a. I've just been kind of right down the road. I haven't. I don't try to spend too much, you know, to stay within my means. I didn't buy a big fancy house, and I came out. I just finally got my first new car this year, so that's. I'm not. I think you're much more savvy in that department than I am, so.
Dr. Randy Lehman [01:04:14]: Well, take your time, you know, and just. There's no rush on all that. And most of the studies on that would say that after $70,000 to $100,000, people's happiness doesn't go up per year of annual income. So, I mean, yeah, definitely, I would not want to. To be trying to get my happiness from somebody else by showing them the things that I can buy you know, but that's. That's great. A lot of our tips are kind of like that, so. And you have a classic rural surgery story for us.
Dr. Greg Gerrish [01:04:49]: Okay. Yeah, it's a little bit odd, but it's gonna be. It's a kind of a fun one. So I'll just start from the beginning without kind of giving away what happens, but.
Dr. Randy Lehman [01:04:59]: Okay.
Dr. Greg Gerrish [01:05:00]: So I'm on call one weekend. I was trying to get this patient with the GI bleed to get her colonoscopy done on a Friday so that I may not have to come and round on her because I was. I didn't have anything else going on at that time, but she's kind of a pain and she refuses her prep. On Friday, she decides that she'll do it, so she preps on over Friday. And so Saturday morning, and it's time for a colonoscopy. I have to wait for the orthopedic doc to get the hip pin. So it's like 11:30 on a Saturday, and it's like summer. Like, nothing's going on. I'm just sitting there twiddling my thumbs, and then I overhear this overhead page, trauma level one, ER, three minutes. And I was like, that's odd. Like three minutes. Like, usually they give you always like a 10, 20 minute phone call at a time. So I kind of walk down there and I walk in the ER, the trauma bay, just as the, like, the CRNA is tubing this guy. I hear that he was stabbed in the chest. He's got like one here. I'm like, what? Well, he was already coding, so we've got a thoracotomy set right there. So I just. I asked them to paint her beta on his chest. And I just remember laughing because one of the nurses had three beta time sticks and started painting. So I was. That made me laugh. I was like, no, get that bottle and just spray it on there. So we did that. It took me longer to find a ten blade than anything. So. So, you know, I do a thoracotomy and I open his pericardium and get a bunch of blood to come out and there's a little hole there. Put my finger on it. But he's still in cardiac arrest. So I get epinephrine and just put it right in. And all of a sudden, it's like, okay, we're going. It's working. So. And at that point, it became quite a pain in the butt because that EPI really got things going. It was like, like stitching like a wild cat. I mean, it was just all over the place trying to throw stitches in there, but.
Dr. Randy Lehman [01:07:04]: So you actually put it through the stab wound in the heart?
Dr. Greg Gerrish [01:07:08]: No, I did a thoracotomy already.
Dr. Randy Lehman [01:07:16]: Where'd you put the epi into the heart?
Dr. Greg Gerrish [01:07:19]: Heart, like, into the ventricles, like in two or three different spots. I don't remember.
Dr. Randy Lehman [01:07:24]: I just got it.
Dr. Greg Gerrish [01:07:26]: By that point, my OR crew, which was supposed to help me do the colonoscopy, was kind of like right behind me. And it just happened to be like, these solid techs and nurses that are like, you know, my go-to's that can do anything. So we just put a few stitches in that laceration. It was like, right at the apex of the right ventricle. And it was pretty hard to stitch because it was just beating, like going crazy. But so, yeah, let me, I didn't close the chest. I just put a big Ioban over the top of it, washed it out really well, and he got sent out to a place where there's actually a thoracic surgeon. So then I went and did my colonoscopy, and then I got to go home. So things happen. It's kind of, you know.
Dr. Randy Lehman [01:08:13]: So this napping must have happened very close to the hospital or what?
Dr. Greg Gerrish [01:08:17]: Oh, yeah, yeah. So he, the fire department's about a mile away maybe, and they were holding in service for some of their equipment, and he got stabbed, like, apparently less than a block away from the fire department. So all these paramedics are outside doing their service, and he didn't even make it to their, like, he collapsed in the street out in front of the. So I just called out an ambulance and threw him in and just brought him in.
Dr. Randy Lehman [01:08:44]: Unbelievable.
Dr. Greg Gerrish [01:08:45]: It was. You know, he's so kind. There's so many things about that guy that it's like.
Dr. Randy Lehman [01:08:50]: So he made it?
Dr. Greg Gerrish [01:08:51]: Yeah, he lived. Yeah.
Dr. Randy Lehman [01:08:55]: Unbelievable. Thanks to you. That's amazing. So tell me how you did your thoracotomy. Like, it wasn't a sternotomy, it was a thoracotomy.
Dr. Greg Gerrish [01:09:03]: No, just a left lateral, like, nipple to, you know, as far back as the bed goes, and just 10 blade down to ribs. 10 blades over the rib, hands in, pull.
Dr. Randy Lehman [01:09:17]: You have two ribs retractor.
Dr. Greg Gerrish [01:09:19]: Yeah, we actually have a thoracotomy set in the trauma bay.
Dr. Randy Lehman [01:09:23]: Okay. And then you're saying, I'm sorry to cut you off. You had to cut some ribs with, you have a rib cutter down there too.
Dr. Greg Gerrish [01:09:28]: There's a rib cutter in the trauma, and that thoracotomy tray's cut too. And just put the rib spreader in and spun it around, open it up, and I was able to get my hand in there.
Dr. Randy Lehman [01:09:40]: And open the pericardium. Any tips for opening the pericardium?
Dr. Greg Gerrish [01:09:45]: Just stay anterior if you can, so you don't get back and get that phrenic nerve.
Dr. Randy Lehman [01:09:49]: There you go.
Dr. Greg Gerrish [01:09:50]: For our listeners that have been listening, going full circle.
Dr. Randy Lehman [01:09:54]: If there's a listener, it's one person, right? And their earbuds, and I only talk to one person at a time, so it's fine.
Dr. Greg Gerrish [01:10:01]: I had done it a few times because I was at Hennepin. I actually had one successful one with an 18-year-old back then and three or four non-successful. So, but yeah, that's just the way it goes.
Dr. Randy Lehman [01:10:11]: Right. And what kind of stitch did you stitch the ventricle up with?
Dr. Greg Gerrish [01:10:14]: That was an old Prolene because I needed a really big needle. Yeah. So I've heard of people taking a mattress fully and blowing it up and sticking it through the hole so that they can control that bleeding.
Dr. Randy Lehman [01:10:23]: Did you do anything like that?
Dr. Greg Gerrish [01:10:29]: That might have worked, but my, I had my, my thumb was just like perfectly sealing that hole, and then I was able to get a Satinsky on it actually, and that held it. So I just was able to, I tried to put a couple of mattress stitches in, but it was just in such a spot that it was really difficult to get that to hold. So I just went back and forth, just imbricated back and forth, and tied it down. It finally held.
Dr. Randy Lehman [01:10:53]: Oh, under the. Yeah, sure. And then did you use any pledges?
Dr. Greg Gerrish [01:10:58]: No, I didn't have.
Dr. Randy Lehman [01:11:01]: Yeah, I don't think we have where I'm at, that's for sure.
Dr. Greg Gerrish [01:11:04]: At that point, to have someone go try to find a pledge, it would have been like.
Dr. Randy Lehman [01:11:07]: Yeah, no, but I've heard also, I think I've heard of people using the pericardium as a pledge too.
Dr. Greg Gerrish [01:11:19]: Yeah, you probably could. Actually, the key is not cinching down so hard that you're just ripping through all of the tissue. Like, it's got to be just lay down that knot nice. Yeah, that was the.
Dr. Randy Lehman [01:11:37]: What a crazy case. And what's your, are you a level 2 trauma center then?
Dr. Greg Gerrish [01:11:40]: Yeah, actually we're, I think it's, or I don't even know if we have a designation. We'd be more like a level three or four, but I'm the trauma director. It's more that the hospital just doesn't want to pay for an accreditation because it doesn't really add to the bottom line.
Dr. Randy Lehman [01:11:55]: Yeah, but when it's there, I mean, yeah, it's amazing that you were in House.
Dr. Greg Gerrish [01:12:00]: I mean, that was so lucky. I mean, there's so many things about that guy's story that were just like the stars and moon and the galaxies aligned so perfectly for that guy.
Dr. Randy Lehman [01:12:11]: Everything except for the stab that morning, too. That was really not fortuitous. All right, well, this has been my pleasure and my treat. Thank you so much for coming on, Dr. Gerrish.
Dr. Greg Gerrish [01:12:25]: Yeah, it's been fun. I'm gonna go outside. It's a beautiful South Dakota day now, so I get to go. Lake time. Yep.
Dr. Randy Lehman [01:12:31]: Keeping you out. That's awesome. All right, thank you again to our listener for being here for this episode of The Rural American Surgeon. Don't forget to give us a like and share this with the people that are in your circle, especially anybody that's interested in rural surgery. We're trying to create a sort of a surgeon's lounge for the rural surgeon to talk about these things that I don't know about you, but I don't have a lot of opportunity to talk with people about this just sitting around. And so thank you for your stories. Thanks for listening, and I will see you on the next episode of The Rural American Surgeon.
