Dr. George Triadafilopoulos earned his medical degree at the Aristotelian University Medical School in Thessaloniki, Greece and went on to complete his internship and residency at Wayne State University Affiliated Hospitals in Michigan and a clinical and research fellowship in gastroenterology at the Boston University Medical Center in Boston, MA. His research has covered many areas of gastroenterology, but mostly gastroesophageal reflux disease. An author of more than 180 articles, monographs, and book chapters Dr. Triadafilopoulos is the Editor-in-Chief of Gastrointestinal Endoscopy and a reviewer for many other professional journals, including the New England Journal of Medicine, Gastroenterology and the American Journal of Gastroenterology. He is a fellow of the American College of Gastroenterology and the American College of Physicians, and a member of numerous other professional societies, including the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy.
Dr. Triadafilopoulos is currently a Clinical Professor of Medicine at Stanford University School of Medicine in California.
Reflux1: When did you first know that you wanted to be a doctor?
Dr Triadafilopoulos: I first knew when I was thirteen years old.
Reflux1: How did you end up choosing your particular field?
Dr Triadafilopoulos: When I finished with medical school and I entered my residency, gastrointestinal endoscopy was just starting to be utilized. We could use endoscopy to look into the person’s stomach and bowels. That gave us a new window into the patient and it was very attractive to me. Not only could I combine the thinking, intellectual, and cognitive process used by someone with an internal medicine background, but I could also do a lot of things with my hands, using fascinating machines that can do an operation without making an external skin incision. That fascinated me so much I decided to become a gastroenterologist back in the early 1980s.
Reflux1: You started your career in your homeland Greece. Was there a big adjustment moving to the U.S.?
Dr Triadafilopoulos: Not really. It’s about the same. There is no real significant difference. Perhaps things are a bit more bureaucratically complicated here, with the complexities of the insurance system and the extreme degrees of litigation. But other than that, the U.S. technology and knowledge are the same throughout Europe, including Greece. I didn’t experience much of a cultural shock.
Reflux1: How have things changed since you first started practicing?
Dr Triadafilopoulos: Gastroenterology and gastrointestinal endoscopy have changed from the times when we would only look using the endoscope and make a diagnosis and then apply drug therapy. Now we are able to use endoscopy to perform endoscopic therapies, like for example, stop bleeding ulcers, remove growths, such as polyps and early cancer, or even gall stones. We can do all kinds of interventions with the endoscope that are very exciting and not only make the patient feel better but avoid surgery.
Reflux1: Has it changed the focus on what doctors need to be learning?
Dr Triadafilopoulos: Yes. This current generation of gastroenterologists learns a wider spectrum of things to use and apply through the endoscope than we did back in our day. The journey for me over the last 25 years has been a remarkable one because I was not only witnessing all this change but I was an early practitioner of all these new methods. It’s been a very rewarding career.
Reflux1: How have you balanced having a practice with the need to learn the new technologies and keep up with all the changes?
Dr Triadafilopoulos: Well it’s a difficult thing. You have to always be ahead of the game, keep your eyes open to learn new things and start applying them as soon as they are available to you and published in the literature. You have to make the extra effort to learn all these new techniques and implement them into your practice.
Reflux1: You also do quite a lot of research and writing. How do you fit that into your schedule?
Dr Triadafilopoulos: It’s difficult to balance all of it and it requires a lot of work. I work about 80 to 90 hours a week. But it’s fun, so I am not complaining. I enjoy what I am doing.
Reflux1: Have you found that patient’s expectations have changed because of the new technology?
Dr Triadafilopoulos: Patients’ expectations have dramatically changed. Not only do they know about the availability of these techniques but they also expect a minimally-invasive approach for any problem they may have. They would prefer we use an endoscopic procedure instead of surgery.
Reflux1: But is it possible to have every procedure be non-invasive?
Dr Triadafilopoulos: One day it will be, but not yet.
Reflux1: You treat a lot of reflux using the Stretta procedure that uses radio frequency energy. How does that procedure differ from the use of polymer?
Dr Triadafilopoulos: The endoscopic treatment of reflux has undergone a similar revolution over the past few years. Several technologies have been introduced into the U.S. market and the general world market. One of the technologies is the Stretta procedure that applies radio frequency energy into the muscle of the gastroesophageal junction or valve mechanism, tightening it up in order to prevent reflux. Another treatment is the injection of a polymer compound into the valve muscle again to tighten it up. Other procedures that are applied are stapling or suturing of that area to reconfigure the structure and function of that valve. All of these have been available for the past five years providing new options for patients. The comparison to each other is just a technical issue; one applies a heating effect, the other applies a foreign material, bulking the tissue. Other methods apply some kind of plication or suturing technique. There are differences that are important from a technical perspective but the overall result however is that each one of these procedures provides a new option for someone suffering from reflux who has not responded to medication.
Reflux1: There have been some problems with using polymer and recently Enteryx was recalled. Do you think the Stretta procedure will eventually replace the Enteryx technique?
Dr Triadafilopoulos: I think eventually yes. I presume at this point that Stretta is the only one with an approved code, so physicians can get reimbursed. The only competitors to Stretta at this point are the plication techniques, such as Endocinch and the Plicator. It’s possible that patients who might have chosen the Enteryx procedure would now choose Stretta.
Reflux1: How do you perform the Stretta technique?
Dr Triadafilopoulos: Well we use a special catheter with a balloon attached to the end. We inflate the balloon in the area of the sphincter muscle between the stomach and the esophagus and then we deploy special needles that penetrate the muscle and burn it in a very focal way. The muscle becomes a bit more rigid therefore not allowing acid to come up into the esophagus.
Reflux1: What kind of success rate does this method have?
Dr Triadafilopoulos: Our success rate is about 60 to 70 percent. By that I mean the patients feel there is a significant improvement or they can stop or reduce the medication they have been using. The procedure is not usually repeated but the effect is not necessarily final. It could be repeated to enhance the effect.
Reflux1: Are you seeing more reflux problems or have we just become better at diagnosing the problem?
Dr Triadafilopoulos: It’s both. I think we are seeing more because of our Western habits and obesity. But we are also seeing more because patients have become sensitized by the media about the symptoms and they are seeking help from their physicians. So it’s both.
Reflux1: How do you develop your treatment plan when your patients come to you?
Dr Triadafilopoulos: Well typically patients come to me after they have seen their primary care doctor who has prescribed medications. Typically these are very effective medications that are good for about 70 to 80 percent of all patients. The patients I end up seeing are those who have difficulties with reflux symptoms despite the medications.
Reflux1: So who would be the ideal candidate for the Stretta treatment?
Dr Triadafilopoulos: Patients who still have symptoms of reflux despite the fact they take medication once or twice a day and are seeking another solution, some kind of mechanical solution to solve their reflux problem.
Reflux1: Do you have a favorite piece of technology that makes your job easier?
Dr Triadafilopoulos: Well obviously computers have made quite a difference. They have allowed us to make things faster and cleaner. We can also use computers to understand different functions of the body. They have helped enormously in understanding the condition as well promoting new knowledge. All these things have made my life easier.
Reflux1: What breakthroughs would you like to see in the next 10 years with treating reflux?
Dr Triadafilopoulos: The biggest breakthrough would be finding out a way to control the sphincter muscle pharmacologically, without really having a mechanical intervention. If we can do that with a medicine that will be safe and will adjust the sphincter muscle and tighten it up as needed, that would probably be the best solution for this problem. There are efforts like this along the way but it’s still a fair way off.
Reflux1: When you have a patient who wants to learn more what resources do you point them to? Do you find the Internet a reliable source?
Dr Triadafilopoulos: The Internet is reliable although it can be overwhelming sometimes. I typically give my patients copies of articles I have written that somehow summarize where we are, along with copies of articles others have written. Patient information is very key in this process. You want to make sure they understand everything so they are able to select the options available to them and not make an unprepared and quick decision. I think it’s an important decision and they need to understand what each medicine has to offer them and juxtapose with what surgery has to offer them. Some people don’t want to take the medication; some people are considering endoscopic procedure. Others are at the end of their rope and can’t have a good day in spite of all the medication they are taking because the reflux is so bad. So having options and understanding all these options is a very critical element in the process.
Reflux1: Do you find that most of your patients are well informed by the time they are referred to you?
Dr Triadafilopoulos: I have patients who have come from long distances because somehow they have checked the Internet or their doctor told them about me. I do have some patients who are not particularly knowledgeable. Where I live and practice I deal with sophisticated people most of the time. That doesn’t necessarily cut down the time I spend with them since they have a lot more questions. They want to have a better explanation of what they have read. Sometimes they have read too much and they are confused so they want someone to put it together for them.
Reflux1: What is the biggest challenge you are facing today in the treatment of reflux?
Dr Triadafilopoulos: One of the challenges we face today is the lack of understanding and recognition from health insurance agencies that the problem of refractory reflux exists. Unfortunately these insurers do not acknowledge that there is a reflux that fails medical therapy and that endoscopic procedures or even surgery are frequently needed options for these patients. This has caused a lot of difficulties for those of us in this field.