Reflux1: What made you decide you wanted to be a doctor?
Dr. Snape: I became a doctor to help people by identifying the causes for the alterations in their health that we could then fix. I was interested from an early point in my career with altered GI function. During my fellowship, gastroenterology had begun to really change. There began to be a lot of tools available to us, endoscopes were being developed, measurement of gut contraction became possible. These exciting times led me into gastroenterology.
Reflux1: Can you tell Reflux1 readers a little more about what your training is and what you do now?
Dr. Snape: I did my fellowship training in gastroenterology at the Hospital of the University of Pennsylvania. There, I dealt with patients with motility issues by diagnosing and treating their motility problems under the tutelage of Sid Cohen. I stayed on the faculty of the University of Pennsylvania to extend observations on the control of colonic smooth muscle in patients who had problems with colonic motility. My present interest is in patients who have altered upper gut motility, which includes gastroesophageal reflux disease, gastroparesis and pseudo-obstruction affecting the esophagus, stomach, and upper small bowel.
Reflux1: When you say motility, that refers to the ability of the digestive tract to function and to move normally?
Dr. Snape: It refers, specifically, to the digestive tract’s ability to contract and to coordinate its contractions to move the contents of the digestive tract forward. So motility looks at a combination of contractions and transport. If there are alterations in the motility pattern these need to be fixed.
Reflux1: It seems like you began your career at a point in time that technological capabilities to treat the disorders you now deal with were expanding.
Dr. Snape: Right – Early in my career the techniques expanded our capacity to see inside the GI tract and the next explosion was being able to manipulate that the gastrointestinal tract through the endoscope allowing us to help patients.
Reflux1: Was the boom in imaging technology that came along with endoscopic capability something that also represented a big change?
Dr. Snape: Absolutely. We came from fiber-optic endoscopes to the video endoscope, which let us view what we were doing on a television screen rather than from a small port at the end of the endoscope. That was a major advance: we could really see things very acutely. We were able pass instruments into the gut and successfully use the instruments therapeutically since we could see better and could control the endoscope and the accessories more easily. In addition new techniques were be developed for the endoscope that also allowed us to provide more therapy. There have been huge leaps in a short period of time.
Reflux1: So one of the things you really like about gastroenterology is how you’ve been able to use these new technologies to help people more and more. How about some of the characteristic challenges or difficulties faced by doctors practicing gastroenterology?
Dr. Snape: As we improve our capabilities in treating patients with gastroenterological diseases, it has become more frustrating to be unable to technically alter a disease process that we can imagine helping. Examples are patients with gastroesophageal reflux disease, or patients whose stomachs do not empty. These are conditions that we can diagnose, and have begun to understand the underlying causes, but we still are having some difficulties in making therapeutic advances to treat all of the patients. However times are changing and we are seeing forward strides. In the lower esophageal sphincter region, we have a number of tools that allow us to treat the sphincter. We now are able to inject material into the esophagogastric junction or to sew the esophagogastric junction tighter, which has made a significant impact on the treatment of this disease. We are placing serosal electrodes in the stomach to stimulate emptying, but it will be an even bigger boon when we’re able to endoscopically install pacemakers for patients who have delay in gastric emptying.
Reflux1: Would you mind describing how the pacemakers you mentioned work?
Dr. Snape: Sure. The pacemaker stimulates the smooth muscle within the wall of the stomach. It entrains the muscle to contract either downwards (the way it’s supposed to) or backwards (the way it isn’t supposed to). So the patients whose stomachs won’t empty will do better if we treat them the normal way, but the patients who we’re treating for obesity will possibly do better if we stimulate them in reverse, and this way they would not be able to eat as much.
Reflux1: In the case of your patients who suffer from obesity, would a pacemaker be installed in conjunction with a procedure like gastric bypass, or in place of that?
Dr. Snape: It would be in conjunction. My thought is that the endoscopic treatment would be the beginning, and would allow some weight reduction in the morbidly obese patient to reduce the risk of a surgical procedure. These patients have a tremendous risk when they undergo a major surgery, both from the anesthesia and postoperative complications because their obesity places such a stress on the system. There is cardio-pulmonary strain from obesity and there is also an altered healing capacity. The patients have multiple metabolic and cardio-respiratory disturbances.
Reflux1: What do you see as the timeframe before the pacemaker technology is ready to be used more widely?
Dr. Snape: There are a number of companies that are devising techniques that seem potentially usable at this point. They’ve been demonstrated in animals to have an effect, and I think now we’re closer to being able to use them in humans. I think that could be within the next 18 to 24 months.
Reflux1: What are some other developments that you see coming up within the next 5 to 10 years?
Dr. Snape: Robotics are in their infancy in surgical operations. There are a number of ideas to use robotics for therapeutic endoscopy. These are being adapted to endoscopic treatment of GERD. If we were able to control the endoscopic capsule and use it therapeutically, that would be exciting. These are advances that are not that far away, and I think we’ll be there soon.
Reflux1: From a patient perspective, do you foresee patients being apprehensive to some of these newer forms of treatment as they come out? To say, "We’re going to put a robot inside your digestive tract," even though that’s a very exciting idea on one level, might be a big concept for patients to accept when it comes to their own bodies.
Dr. Snape: I think that the patients will accept it. Patients are interested in the best technique to treat their disease. Younger people will be aging and becoming patients. They will accept newer techniques.
Reflux1: The point you brought up – that the average age of people seeking treatment for digestive disorders is younger – supports what some experts are calling an obesity epidemic in the United States, and also to the frequency with which digestive and obesity-related disorders are occurring in younger populations, though they used to be rare in those age groups twenty years ago.
Dr. Snape: It’s true, and there’s definitely a lot more recognition of digestive disease. GERD is now recognized as a disease with a significant morbidity. Inflammatory bowel disease and irritable bowel syndrome are now recognized as disturbances in the control mechanisms of the body.
Reflux1: For readers who are looking for a good gastroenterologist, what are some important points to keep in mind?
Dr. Snape: I think it depends on exactly what the problem is. If they’re looking for preventive care for a relatively mild problem I think there are different requirements. I think in that case the requirements are easy accessibility, and being able to get to the doctor without disrupting the rest of their lives, so that would be dependent on location and also finding someone who’s interactive with their primary care doctor. If they have a more severe problem, then they have a different set of needs. I think they need an individual who’s comfortable with new therapeutic advances, and who is tuned in to the advances in medical care. I think at that point the patient has got to realize that some of the medical care will not have been done in large numbers of patients, but that they are at the very forefront of treatment. It depends on the severity of the disease and the complexity of the disease, and it matters least when it’s less severe, and it matters most when it’s most severe.
Reflux1: Is there anything else that you feel it’s particularly important for people to know about gastroenterology, from either a doctor or a patient angle?
Dr. Snape: There is a huge amount of information available to patients on the Internet, and the difficulty is to figure out which is important and which is nonsense. How does the patient sort through the different websites? Websites such as the American Gastroenterological Association, the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy or ASGE are good.
American Society for Gastrointestinal Endoscopy: http://www.asge.org
American Gastroenterological Association: http://www.gastro.org
Dr. Snape's Practice at California Pacific Medical Center