had my followup appointment with my gi, today. he reviewed my biopsy results, in person, and discussed “next steps” with me.
i’m paraphrasing, as the conversation was pretty fast paced and he afforded me almost 40 minutes for questions, but this is the gist of the conversation.
he was advocating a “watchful waiting” stance, at the beginning of the appointment. he wanted me to have scopes every few months, just to see gauge my response to the medication. based on the results of that, he “might suggest” surgery to repair my hernia and the fundiplication. in short, i commented that my medication mostly kept my symptoms in check, but that (ironically, like tonight) i still have reflux that keeps me awake some nights and that he’d previously been bullish on surgical intervention. he didn’t disagree and gave me an in-house referral to “general surgery” and called out two names of women who have experience with laproscopic gastroesophageal work. he also mentioned that my insurance would probably also cover a consultation with another surgeon and that i could pick between the two, based on my initial consultations with the two surgeons. he gave me names of two surgeons at stanford that i might follow up with.
this first portion of the conversation was frustrating to me. i felt like he’d calmed on the outlook, over time and would have given different advice, if he’d just completed the scope. i think these feelings stem from his initial tone, when delivering the results, by phone. he’d sounded so suprised by the results and so sure that surgery was immediately appropriate.
i also had this disturbing feeling that the two surgeons from stanford (and the other extneral referals he gave me, through the course of the conversation) were college drinking buddies. my doctor is young, and while his bedside manner is really good, he’s still really young. note that i don’t hold this against him, having usually been one of the youngest people in my peer group, in professional environments.
regardless of decision to precede with surgical intervention, he explained that he still would like to check that the inflammation and ulceration he’d observed above my barrett’s had subsided. this would also give an additional opportunity for biopsies and pathology reports, potentially confirming the diagnosis of and grading of dysplasia.
i talked to my doctor, at length about ablation of my 7cm segment of barrett’s esophagus. in the end, he advocated the “watchful waiting” approach, but agreed that, at age 32, my case was atypical and may warrant an atypical approach. he stated that he diagnoses between one and two cases of barrett’s, every two weeks and had never seen a patient younger than 45 with barrett’s. we discussed ablation technique, in general terms and pdt in specifics. he said that ablation is typically reserved for high-grade displasia or high-grade with presence of stage 0+ cancer.
i asked about pdt (photodynamic therapy), emr (esophageal mucosal resection), and barrx.
my doctor stated that he’d routinely administered photodynamic therapy (pdt) in his medical fellowship and steered me clear of it. the exact phrase he used was “turns your esophagus into hamburger”. we used this time to discuss potential complications of ablation. these weren’t new to me and fall into two categories: scarring and perforation (taking too much tissue).
he said that emr was definately something he’d consider to be higher risk and also difficult to find a qualified surgeon.
he was not aware barrx, but knew of a local surgeon who has some experience with newer ablation technique. with me sitting in the office, he emailed this surgeon and agreed to call me upon reply. i was hesitant to use a phrase like, “can you add me to that thread?” outside a work context. my doctor seemed confused when i mentioned (barrx) rf, relative to ablation and mentioned “cryo” as what he thought of as a “newer procedure”. i was a little thrown, as i’d not uncovered anything about freezing. turns out that cryo spray ablation is a device and technique licensed by “csa medical“. it’s not yet fda approved for general use, but is in widespread surgical trials. why is it that all the good information about these procedures is always under the “for physicians” links? there are some good articles by dr. johnston (of the cleveland medical clinic), in that section. i also found a reasonably comprehensive overview of treatment options for barrett’s that refers to cryo spray.
my doctor highlighted something that i hadn’t previously considered. getting the nissen fundiplication might preclude some of the newer ablation procedures and if i’m going to persue that, i should look into it. the newer techiniques and devices tend to be in use in very tightly controlled trials or fda approved for very specific circumstances (general statement, not just for barrett’s ablation).
so, i have a scheduled date for my next scope and a date to talk to a surgeon at palo alto medical (consultation only). i’ve got external referals to some local surgeons. i’ve got alot of leg work to do over the coming weeks.