Gregory Leo Salzman, M.D., is a leading practitioner and researcher in gastroenterology and internal medicine. In private practice for more than 15 years, he is affiliated with several hospitals in both Northern Kentucky and Cincinnati including Grant County Hospital, Northern Kentucky Rehabilitation Hospital, St. Elizabeth’s Medical Center, St. Luke’s Hospital, Bethesda Hospital, and the Jewish Hospital of Cincinnati. Additionally, Dr. Salzman has served as president of medical staff at St. Elizabeth’s and has served on numerous hospital committees.
Reflux1: What is it that first attracted you to this field?
Dr. Salzman: I love being able to sit down with patients and find out what bothers them and then do something to make them better. I like being an internist who can actually use what I know to make something better immediately. That’s one of the reasons I like Enteryx. I’ve been waiting for that technology since I first read about it in Germany several years ago. I was anxious to see how it would work out. The first studies that were published were so encouraging. I still think they are encouraging. I like the idea of being able to go and hear my patients say they have this terrible chest pain and heartburn that nothing helps and they can’t tolerate, and then be able to offer something like Enteryx. So many patients tell me afterwards they can’t believe the difference. Once they get through the acute healing phase, it’s been wonderful for them. That’s really gratifying.
Reflux1: What’s the biggest challenge working with reflux?
Dr. Salzman: Well the biggest challenge is that we still don’t know who the ideal candidate is for our treatments. There are people who don’t get better with our interventions and that is frustrating. You want to do the best you can for your patients and I would like everyone to be better with everything we do but it just doesn’t work out that way. We have to get smarter and study to figure out who gets better with our therapy and who doesn’t. That’s a challenge that will never end in medicine. We always have to study and get smarter to figure out who is going to be best served by our methods and treatments.
Reflux1: What questions do patients frequently ask you?
Dr. Salzman: I think the most frequently asked question is about recurring chest pains. Most heartburn sufferers are usually seen by their primary caregivers so I see people who are suffering from more severe chest pain, as well as trouble swallowing.
Reflux1: How do you handle their questions about chest pain?
Dr. Salzman: The first thing we rule out is cardiac disease or other potential problems of the chest. I start off with a physical and some other testing so we can narrow it down to reflux disease. I ask questions, usually in regard to regurgitation, trouble swallowing or frequent throat clearing then gauge from their answers. These are things that tip you off plus the fact that their chest pain usually occurs at rest rather than during exercise.
Reflux1: Why do people suffering from reflux have chest pains?
Dr. Salzman: Chest pain happens for a couple of reasons. Sometime you will have pain because of esophageal ulcerations but that’s not common. The most common reason for chest pain is an esophageal spasm, which is an acid-induced spasm.
Reflux1: What other concerns do patient have when they first come to see you?
Dr. Salzman: Nocturnal regurgitation or heartburn is a big item. Regurgitation is an issue that is not always well addressed in our medical therapy and nocturnal symptoms are sometimes not well addressed even with the twice a day proton pump inhibitor (PPI) therapies. The patients want to talk about other options on how to treat those symptoms.
Reflux1: How do you start treatments?
Dr. Salzman: I usually start with a therapeutic trial to see if that will relieve the pain before proceeding with an endoscope. Typically I use a proton pump inhibitor for that. For the vast majority of patients with reflux, medical therapy will suffice, at least to start with. With an acute presentation you really want to start with the medical therapy to relieve the symptoms immediately. When the medication doesn’t work then we discuss all the options for treatment.
Reflux1: What options do you recommend?
Dr. Salzman: I discuss the various options with my patients and start off with fundoplication procedure. That’s the surgery where the surgeon will go in with a laparoscope and create a flap at the top of the stomach and bottom of the esophagus – where the two join – that forms a barrier that prevents acid reflux. This is probably effective in 75 – 80 percent of all patients. There is some risk of side effects and in rare cases, even death. I compare that with other treatments we give, for which I have a preference, the endoluminal therapies. We talk about these other options such as the new procedure called the Endocinch, which is a machine that places sutures in the esophageal sphincter. We also discuss the Stretta procedure that provides a thermal lesion in the muscles causing foreshortening that seem to help reflux, although, it doesn’t look as good as it did initially. And then we finally look at the NDO plicator that places a stitch in the upper part of the stomach. Then we discuss the experience we have had with Enteryx, which I like.
Reflux1: Why do you prefer Enteryx?
Dr. Salzman: I like Enteryx because it’s something as a gastroenterologist I am familiar with. It takes more training to do it well, but, it provides us with a way to give reliable relief for probably 65 – 75 percent of our patients. It may take two treatments to be fully effective and get them off their medical therapy permanently. Of all the procedures out there, Enteryx makes the most technological sense to me. You place a polymer right on the place that is the weak link in the system where there is excessive relaxation or an incompetent esophageal sphincter that allows for too much reflux. The risks involved are minimal so I think we can offer it to a large number of patients.
Reflux1: How do the side effects of the different procedures compare?
Dr. Salzman: Every procedure has its inherent risks. I talk frankly with my patients about all the potential complications. We have complications with everything we do – including surgery. Enteryx is an out-patient procedure so it doesn’t require hospitalization. Approximately 80 percent of the patients have chest pain but it’s short-lived and it’s usually resolved within a week to two weeks. They have trouble swallowing for typically a day afterwards and they will smell like garlic the day of the procedure because the liquid in which the biopolymer is dissolved smells like garlic when it’s expelled through exhalation. We then discuss the more severe complications. There have been some of these in the course of the 3,000 procedures done worldwide. One patient died from hemorrhaging and there was an esophageal abscess with a patient who was a diabetic, for example. However, fundoplication surgery also has a mortality rate of about 15 out of 10,000 by comparison.
Reflux1: Is Enteryx a challenging procedure for the physician?
Dr. Salzman: Enteryx is a new procedure so you must do everything by the book and Boston Scientific has been really good at iterating how it should be done. Glen Layman in Indianapolis, who is a pioneer in this procedure, trained me and he was very good at instructing many gastroenterologists. I think this is a very safe procedure if you follow the simple rules. Technically it’s not difficult. But it does take some patience to inject the polymer. You have to make sure you achieve the right plane fluoroscopically when you inject the needle into the muscle. You have to inject slowly and sometimes it requires repositioning. But I think after you have experience with about 10 cases, it is fairly simple to do. You need to budget about 30 – 45 minutes for this procedure.
Reflux1: How does it compare to other procedures?
Dr. Salzman: I’m not big on the Stretta procedure because it damages the nerve fibers in the lower esophagus so that people may not actually feel the reflux when it occurs and this could lead to unrecognized damage. The endocinch procedure also has some drawbacks. The studies show the results aren’t durable enough that I would want to offer it to my patients. First of all, the stitches pull out and the sham studies done by Dr. Rothstein show it doesn’t get people off the proton pump inhibitors. Finally the NDO plicator procedure was associated with significant complications in its initial trial, including one gastric perforation.
Reflux1: How do you determine if someone is a good candidate for Enteryx?
Dr. Salzman: We don’t do the operation for anyone with large hiatal hernias, for someone who can’t tolerate endoscopy, and for someone who has severe complications of reflux disease including strictures and Barrett’s. And, of course, we don’t treat women who are pregnant or someone extremely old. So the best candidates are those on a PPI who is not finding it fully effective or who can’t tolerate the side effects is as good candidate.
Reflux1: Do most patients want to get off their medication?
Dr. Salzman: Well there are some side effects with anti-reflux medication. The side effects can be as bad as the disease. People get headaches, abdominal pain or diarrhea. Sometimes they will come in with pain and diarrhea and you take them off the proton pump and all their bowel symptoms go away. It’s a real issue. A lot of people have to pay for the medication out of their pocket. Now that Prilosec is available over the counter it’s not as much of a financial burden. But you are still talking $30 – $40 per month and that’s indefinitely. There was a matter of adequate supply as well.
Reflux1: Is taking the medication more of an issue with younger patients?
Dr. Salzman: Well, it can be a burden for some. Number one, people don’t like to take medication, especially younger patients. If you ask your patients and they are being honest about how they take their medication, they will admit to missing doses here and there. Number two is that when you are young you don’t like the idea of being dependent on anyone or anything such as medication. Number three is that you have to look at what it’s like to take proton inhibitor for 50 – 60 years, which some young people are looking at doing. We assume it’s safe because we have data that extends for 15 – 16 years on PPI when they first put people on them in Europe. There was some initial concern that these medications would lead to carcinoid tumors in the stomach but that didn’t turn out to the case.
Reflux1: Do you think reflux is a new disease of the modern age?
Dr. Salzman: I think reflux has always been with us but we didn’t recognize it as such. It can manifest itself in a lot of different ways. Typical things are regurgitation; heartburn, trouble swallowing and some people have abdominal pain, asthma or laryngitis, chronic coughing and chest pain. It’s probably something that has been with us a long time just not recognized as reflux. When we got better at diagnosing GI diseases with the endoscopy and PH probe studies and then with even more sophisticated tests that look at enzymes. So, we are getting an idea that there is a lot more to this than just acid reflux. As we get more sophisticated testing we get more accurate with our diagnosis. We are just better at picking up what’s been a problem there all along.
Reflux1: Do you think we will start to see reflux divided into different types?
Dr. Salzman: Yes I think so. It’s like anything else. We tend to lump people together until we can identify discriminating factors for different patho-physiologies. For some people it’s going to be acid reflux. For some people it will be a combination of acid and bile. For others it will be more of a problem with a hypersensitive esophagus. Then there are of course other sub-categories we already recognize.
Reflux1: Does stress play a role in reflux?
Dr. Salzman: Yes I think it actually is. Well, stress is used to explain a lot things but I do think there is connection. The stress itself creates a situation where you have more acid secretions, more acid reflux because of that. Studies don’t support that, but my personal experience is that stress does play a part. But I don’t know if we are under any more stress now that we were previously. I don’t know if our generation suffers more stress than others.
Reflux1: What about diet? Does our consumption of fatty foods and our weight have anything to do with reflux?
Dr. Salzman: I think that is a much more substantiated contributing factor. Obesity is an epidemic and everyone recognizes that. In our affluent society we have much more access to animal fat and both those things lead to more reflux. You have higher abdominal pressure, which leads to more reflux plus the fat in the stomach slows the stomach emptying and that causes reflux.
Reflux1: Do you also recommend a change in diet with your patients then?
Dr. Salzman: Well, the dietary factors haven’t really held up in scientific studies. My own personal experience is that it probably makes a difference in certain things. Avoiding fatty foods and deciding to lose weight probably do make a difference just from the standpoint of improved gastric emptying and reduced pressure on the abdominal cavity. I think all those things will improve their disease.
Reflux1: In the near future what kinds of improvements and new technologies would you like to see?
Dr. Salzman: Well I would like, through our studies, to be able to better define who are the ideal candidates for Enteryx vs. fundoplication vs. continued medical therapy. All will have role in treating different types of patients. We do need to do more research into who responds to Enteryx and who doesn’t. Not everyone responds and they are still symptomatic afterwards. It’s not clear how we can pick the ideal patient for Enteryx or patients for the other procedures. I think we will find there will be different groups of reflux patients and there will be one for whom a treatment is tailor made. We need to get the data to see who suits each procedure and that is going to take some time to sort out. We have lots of options now and good drugs that control most of the patient’s symptoms. I would like us to get to the point where we could really discriminate on the basis of history and physicals and a few tests which patient will get better with one therapy versus the other.
Reflux1: Any words of advice to a young doctor starting out in this field?
Dr. Salzman: The most important thing is to listen to the patients. The only reason we got into this profession is to listen to the patients and solve their problems. We are not here to do a procedure or prescribe medication. We are here to listen to our patients and find out what is really important to them. So long as we can listen to our patients and take the time to actually hear what they are telling us and then do our best to address their problems we will be good doctors.