It takes guts to take calculated risks with cutting-edge technology.
When I last interviewed Dr. Toss, a highly-experienced gastroenterologist, advanced endoscopist, and bariatric endoscopist at Bumrungrad International Hospital, he spoke to me about good gut health as well as the wealth of healthcare possibilities provided by Bumrungrad International Hospital, which is committed to investing in technology and procedures that can provide their patients with the best care possible. This time, in his usual impassioned way, he’s even more excited about the latest procedures in his field that the hospital has been a vanguard in.
“My dream is to make Bumrungrad the Johns Hopkins Hospital of the East.” To that end, he was instrumental in bringing the Transoral Incisionless Fundoplication (TIF) procedure to Thailand, making Bumrungrad the first centre in Southeast Asia to be qualified and approved for the procedure and one of only three in Asia. He talks about how this has changed the game for patients suffering with gastroesophageal reflux disease (GERD), as well as other treatments, such as the use of the cutting-edge Full Thickness Resection Device (FTRD) to take care of early and pre-cancerous digestive lesions without surgery.
However, he also shines a spotlight on the importance of a multi-disciplinary team. “Here at Bumrungrad Hospital, our team consults with each other constantly. This way we come up with the best procedure tailored to each patient,” he explains. “We have high ethical standards, and we don’t recommend procedures for profit – so even if a patient has requested an expensive surgery, if a more affordable procedure is best for that patient, that is what we will propose.” He speaks further on how their team is changing lives, one procedure at a time.
How has TIF changed the game for patients suffering from GERD and similar diseases?
It’s a relatively new treatment for patients who suffer from reflux disease. Treating it used to mostly involve lifestyle modification or, sometimes, a class of medications called proton pump inhibitors (PPI). However, some patients may take these medications for years and still not have any relief, so doctors may recommend surgical fundoplication, which is a big jump. This involves wrapping the stomach around the food pipe, but this can come with problems too; for example, the patient won’t be able to burp afterwards, which causes them a lot of discomfort.
TIF uses the same idea as surgical fundoplication but addresses the valve through the mouth. A long, hollow tube is inserted through your mouth, with the scope in the centre, and there is a hinge at the end that allows the camera to turn back 180 degrees and look up into the valve. This allows you to pull the valve and throw stitches, one pair at a time. We use hypoallergenic plastics that stay for only six months and fall off on their own, and the scar tissue will serve as the glue, creating a normally functioning valve without the risk of bleeding or surgical site infections.
More importantly, after the procedure, you can go straight back to work! The best version of this award-winning device was developed in 2019, and we are proud to say that it is available at Bumrungrad. It took us up to eight months to convince the company that produces TIF devices that we are qualified to do the procedure, as they are very particular about choosing only the experts who were well trained in top-notch academic centres in the United States to form our multidisciplinary heartburn team. You’ll need a qualified endoscopist, a qualified surgeon, and a qualified gastroenterologist for measuring acid and esophageal function. Luckily, we have all of those here at Bumrungrad.
Not all patients with reflux disease will benefit from TIF; some will still need surgery, depending on the case. So while TIF is good, and we are proud to have it, what we are even more proud of is our multi-disciplinary team.
What is the success rate and recovery period after the TIF procedure?
At six months, 90 percent of patients won’t need medication anymore. At five years, if you have typical symptoms such as heartburn or regurgitation, it’s almost a guarantee that 90 percent of them will be symptom-free. Only 1 in 3 patients will have to be put back on PPI, but only a single dosage per day. Almost 100 percent have said that they don’t regret doing the TIF procedure and are happy to take that one pill.
What is the FTRD, and which patients would benefit from the procedure? Why is it beneficial compared to more traditional procedures?
Now in 2023, when you’re diagnosed with precancerous or early cancerous lesions, you may not need surgery. Your digestive system has many layers, and usually the topmost layer is the one that has lesions. A Japanese medical team came up with a technique to inject the layer beneath and lift the lesion up so that it can be cut off – this is called endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD); it’s like peeling skin off an orange. But if the lesion goes into the soft tissue beneath, then you cannot lift it, and surgery used to be the only option. Before, this would mean cutting off half your stomach or colon, as they couldn’t be cut off in just a small section.
A German company came up with a device to control bleeding and perforations during surgery that is like a clam shell and can be attached to the tip of the endoscope. This has been used to treat perforation or bleeding. They realised that this device could be used to remove lesions by attaching a small wire to the tip of the device. Once the clamshell is closed with the lesion inside, the metal wire with running electricity serving as a knife can safely cut off the lesion. This way, you can take care of lesions anywhere that the scope can go. I’m also proud to say that we are the first hospital in the region to launch the FTRD.
A success story we’ve had here is of a patient who came to me at 38 years old, concerned about stomach cancer because he had a family history of it. Because of this history, we checked, and I found no mass, but he had a scar in the stomach, which was suspicious because he’d had no surgical procedures. While EMR or ESD were not feasible and the patient did not want to have half of his stomach removed surgically, we offered the FTRD, and it did turn out to be cancer! This was just 0.8 mm in length, a record for me. The patient is now back in Japan after a single night’s stay, and the day after, he could eat whatever he wanted!
Are there any further updates on bariatric endoscopy that you would like to give us that Bumgrungrad has incorporated?
Recently, a medicine called Semaglutide in self-injection form was approved for treating diabetes, and researchers noticed that a side effect was weight loss. In March 2021, a study was published in the New England Journal of Medicine, the highest tier of medical journals, on the use of obesity. Our first patient at Bumrungrad got the first semaglutide injection in April 2021, right after the Thai Federal Drug Association’s registration! What I’m so excited about is the combination therapy possibilities that this provides. We had a very successful case where we combined bariatric endoscopy with semaglutide, and our patient had a 43% weight reduction, similar to even the bigger surgical procedures! (bitly.ws/CRS9)
In the future, I’m looking forward to continuing to work collaboratively with the team on more cutting-edge technologies and combination therapies to make our patients’ lives better.