1. Drs. Sharona B. Ross & Alexander Rosemurgy
The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery
Drs. Sharona B. Ross & Alexander Rosemurgy

2. Trusting Your Tummy Have you ever:
Had butterflies or a knot in your stomach?
Followed a gut instinct?
Felt you couldn’t stomach a situation?
Experienced a gut-wrenching sensation?
Our bodies have ways of communicating with us (even though we do not always tend to listen!) and our stomachs are no exception. Our true emotions often manifest themselves within the gut. Think your tummy has never tried to tell you something? Think again!
Have you ever:
Had butterflies in your stomach, which signal nervousness or a knot in your stomach, which signals anxiety or worry?
Followed a gut instinct or feeling, which acts as a six sense?
Felt that you just could not stomach a certain situation or experienced a gut-wrenching sensation or situation?
REFERENCES:
The Sensitive Gut, by Harvard Medical School

3. Tummy Talk Gas, burping, bloating, heartburn, diarrhea, constipation
We often suffer in silence and hope it passes
Could be something we ate, nerves or a poor diet
Could be more serious, a symptom of a greater underlying problem
Passing Gas, burping and bloating are normal and natural and are often caused by either swallowed air or the breakdown of food through digestion. Excess air can be swallowed when you eat or drink too fast, talk while you eat, smoke, chew gum, drink carbonated beverages or drink through a straw. The odor from gas comes from sulfur, which is made by bacteria in our large intestine. When gas doesn't pass through belching or flatulence, it can build up in the stomach and intestines and lead to bloating.
Heartburn is an uncomfortable burning sensation felt up through the middle of the chest. It affects up to 1 in 3 Americans at least once a month. Diarrhea (the opposite of constipation) is defines as loose and watery stools that are expelled too often. Diarrhea is the body saying “No!” to whatever is lurking in the intestines, causing an upset.
Constipation is the slow movement of feces through the large intestine that can result in hard, dry stool that is painful and/or difficult to pass. Constipation affects more women than men and increases with age.
Though usually innocent and often embarrassing, we tend to treat these often normal events quietly with over the counter medications and suffer in silence until they pass. Often the result of something we ate, nerves or a poor diet, they are sometimes symptoms of greater and more serious problems.
REFERENCES:

4. Digestive Disorders
As embarrassing as intestinal symptoms can be, don’t let embarrassment keep you from seeking help – in most cases, treatment is available.
Digestive Disorders include many, often complex disorders that affect the digestive system. They can be mild or potentially life-threatening. Some are chronic and others will pass in time and with the right treatment.
As embarrassing as intestinal symptoms can be, don’t let embarrassment keep you from seeking help – in most cases, treatment is available.
REFERENCES:

5. What You Will Learn Today
The most common digestive disorders:
symptoms,
causes and
risk factors
Ways to prevent and treat digestive disorders
How to maintain a healthy digestive system
Today we will discuss in detail:
How the digestive system, also referred to as the gut, the alimentary canal or gastrointestinal tract, functions
Why a healthy digestive system is so important
Examine some of the most common digestive disorders and learn about their symptoms, causes and what factors can put you at a higher than normal risk
Ways to help prevent and treat digestive disorders and maintain a healthy digestive system

6. Your Digestive System
Digestion allows our bodies to get the energy and nutrients they need from the foods we eat
Digestion allows our bodies to get the energy and nutrients it needs from the foods we eat.
The digestive system is made up of the digestive tract, which is a chain of hollow organs, including the mouth, esophagus, stomach, small intestine, large intestine (also referred to as the colon) rectum, and anus that are joined in a long twisting tube, and other organs that help the body break down and absorb food.
The digestive system starts working even before you take your first bite of food and will keep busy digesting your food over the next few hours – or days – depending on what you have eaten. Saliva begins to form in the mouth when we eat (or smell or even think about food!) and it starts to break down the food enough to be swallowed. This swallowing is the last voluntary act that will occur in a the following series of involuntary events.
Food enters the esophagus and the lower esophageal sphincter (LES), the trap door that allows food in, opens up and then closes once the food has been received. It is the upper and lower esophageal sphincters that allow food to travel in the right direction. Also at the back of your throat is your windpipe. When you swallow, a flap (the epiglottis) closes down over the opening of the windpipe. If you have ever experienced food “going down the wrong way” it means it went down your windpipe by mistake.
Once food has entered the esophagus, it doesn't just drop right into your stomach. The muscles in the walls of the esophagus contact and squeeze the food through the esophagus into the stomach, which has three main functions:
1-to store the food you've eaten
2-to break down the food into a liquid-like mixture
3-to empty the liquid-like mixture into the small intestine
The stomach mixes and churns up all the small balls of food received from the esophagus. It does this with help from the muscles in the stomach walls and gastric juices (that also come from the stomach's walls). Gastric juices not only help break down food but also help kill any bacteria that might present.
The small intestine is a 22 foot long tube that's packed in beneath your stomach. It helps breaks down the food mixture even more to better allow absorption of vitamins, minerals, proteins, carbohydrates, and fats. It does this with help from the pancreas, liver, and gallbladder; organs that send different juices to the first section of the small intestine. These juices help digest food and further allow the body to absorb vital nutrients. The pancreas makes juices that help the body digest fats and protein.
Juice from the liver, called bile, help absorb fats into the bloodstream.
The gallbladder stores the bile until it is needed.
Food may remain as long as 4 hours in the small intestine and become a thin, watery mixture. In the end, the nutrients from your food pass from the intestine into the blood, where the body can better benefit from the nutrients in your food.
The nutrient-rich blood comes directly to the liver for processing. The liver filters out toxic substances and/or wastes.
All the leftover waste goes on to the large intestine. The large intestine is wider and shorter than the small intestine.
Once most of the nutrients are removed from the food mixture, there is waste left over that needs to be passed from the body.
Before it goes, it passes through the part of the large intestine called the colon, where the body gets its last chance to absorb the water and some minerals into the blood. As the water leaves, the waste product gets harder as it moves along, until it becomes a solid (stool).
The large intestine pushes the stool into the rectum. The solid waste remains until a bowel movement occurs. The stool exits the body through the anus.
The entire digestive process is controlled by the enteric nervous system (or ENS), which is an interactive nerve complex in the gut that communicates with the brain via the spinal cord.
REFERENCES:
The Sensitive Gut, by Harvard Medical School

7. Why is a healthy Digestive System so important?
A healthy digestive system prevents disruption to our daily lives
Problems of the digestive system can
Make everyday living very difficult, sometimes impossible
cause pain, discomfort, “accidents”, lead to very serious health complications
People often take their healthy digestive system for granted, not thinking about how unpleasant it can be to suffer with a digestive disorder, whether it be temporary or chronic. Digestive disorders can make everyday living very difficult, limit your activities and cause pain, discomfort, embarrassing and messy accidents and lead to very serious health complications and disease.
REFERENCES:

8. Common Types Gastro-Esophageal Reflux Disease (GERD)
Esophageal Cancer
Gallbladder Disease
Pancreatitis
Chronic Constipation
Diverticular Disease
Colorectal Cancer
Second leading cause of cancer-related deaths
These digestive disorders, syndromes and diseases represent some common digestive problems:
Inflammatory Bowel Disease, or IBD – the two most common types of IBD are Crohn’s Disease and ulcerative colitis
Irritable Bowel Syndrome, or IBS
Gastro esophageal reflux disease, or GERD
Colorectal Cancer
Diverticular Disease
Peptic Ulcer Disease and H. Pylori
Pancreatitis
AND
Chronic Constipation

9. Gastro-Esophageal Reflux Disease (GERD)
Chronic digestive disease
Persistent reflux
stomach acid flowing up (refluxing) into the esophagus
Most common symptom is heartburn
Cause of GERD unknown
Treatment:
Relief of symptoms: lifestyle changes & medicine
Prolong use of PPI medications may result in esophageal cancer
Cure: Surgery
Gastro esophageal reflux disease, or GERD is a more serious form of gastro esophageal reflux (GER), also known as acid reflux or regurgitation. This occurs when the lower esophageal sphincter (LES), the “trap door” that allows food in and closes afterwards to prevent stomach contents from coming up, either opens spontaneously or does not close properly. Digestive juices (acids) rise up with the food and food or fluid can be tasted in the back of the mouth. Refluxed stomach acid that comes in contact with the lining of the esophagus can cause a burning sensation in the chest or throat, namely heartburn or acid indigestion. Persistent reflux experienced more than twice a week is considered GERD, and can lead to serious health issues. GERD can affect people of all ages.
Other symptoms include:
Frequent heartburn (also referred to as acid indigestion). This is a burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the mid-abdomen.
The most common symptoms of GERD are:
Trouble swallowing.
Asthma-like symptoms
Dry cough
obesity
Other factors that may contribute to GERD include:
The cause of GERD remains unclear.
Common foods that can worsen reflux symptoms include:
There is no known cure for GERD. Over the counter antacids may help, or your doctor may prescribe medications. In some cases, surgery may be recommended.
smoking
Drinks with caffeine like coffee and cola
Chocolate
Citrus fruits
Garlic and onions
High-fat foods
Alcohol
AND
Spicy dishes
Mints and mint flavorings
Quitting smoking, losing weight, eating smaller meals, staying upright (and not lying down) after eating, avoiding eating 2 to 3 hours before bed and engaging in relaxation techniques may all improve GERD symptoms.
Tomatoes and tomato-based foods

10. Gallbladder Disease Symptoms: Diagnosis: Treatment:
nausea & vomiting, bloating, constant right upper abdominal pain lasting for several hours after consumption of fatty foods
Diagnosis:
History, physical exam, RUQ u/s, HIDA
Treatment:
Surgery to remove the gallbladder

11. Pancreatitis Inflammation of the pancreas Chronic Acute
Repeated attacks of acute pancreatitis
Symptoms
Chronic abdominal pain, nausea vomiting, weight loss, diarrhea
Common cause
chronic, heavy alcohol use
Treatment includes
medications, hospitalization, nutritional support
Acute
Symptoms
Abdominal pain, fever, nausea, vomiting
Common causes
gallstones
chronic, heavy alcohol use
Treatment includes
medications, hospitalizations
The pancreas is a gland that secretes digestible juices and also hormones that help the body regulate glucose. Pancreatitis is inflammation of the pancreas that results in damage to pancreatic tissue.
Pancreatitis can be acute or chronic.
Symptoms of acute pancreatitis include:
Abdominal swelling and tenderness
Fever
Nausea and vomiting
The most common cause of acute pancreatits, in which inflammation occurs suddenly, is the presence of gallstones. Heavy, long-term alcohol use is another common cause. Other causes include certain medications and infections.
Acute pancreatitis requires hospitalization and medications.
Gallstones that cause acute pancreatitis will need to be removed.
Chronic pancreatitis does not heal or improve and leads to permanent damage.
Symptoms of chronic pancreatitis include:
Upper abdominal pain
Nausea, vomiting
Weight loss
Diarrhea
The most common cause of chronic pancreatitis is long-term, heavy alcohol use. Other causes include:
Other medical conditions, such as hereditary pancreatic disorders and cystic fibrosis
Some medications
Unknown causes.
Both acute and chronic pancreatitis can require surgery to treat complications and/or remove a section of the pancreas.

12. Chronic Constipation Persistent over years — even decades!
Unresponsive to treatment
More common in women
Treatment/management includes
adding fiber to your diet
increasing fluid intake
exercising more often
Many people experience constipation from time to time, but some experience persistent constipation that can last years – even decades. Even though no abnormality of the bowel present, the constipation persists: this is known as functional or chronic constipation.
The cause of chronic constipation is thought to stem from hormones, or with muscles and nerves in the colon, rectum or anus. It is more common in women than in men.
The most important thing you can do to prevent and treat constipation is to add fiber to your diet. Drinking more water and increasing your amount of physical activity are other measures that can be taken. Over the counter medicines and prescription medications may also be recommended.

13. Diverticular Disease Diverticulosis Diverticulitis
Small pouches in the lining of the colon
Symptoms:
bloating, constipation
Diverticulitis
Pouches become inflamed
Most common symptom:
lower left abdominal pain
Treatments:
diet changes, medications
For repeated attacksSurgery
Many people have little bulging pouches, each referred to as a diverticulum, in the lining on the large intestine (colon). These form when pressure build up inside the colon wall, usually from constipation. Multiple pouches are referred to as diverticula and the condition of having diverticula (multiple small pouches) is a condition known as diverticulosis. It may surprise you to know that approximately half of people over 60 years of age have diverticulosis.
Symptoms of diverticulosis include lower abdominal pain, bloating and constipation. Many will not experience any symptoms at all.
The likely cause of diverticulosis is a low-fiber diet and adding more fiber to your diet is often the only treatment required.
Diverticulitis occurs when these pouches become inflamed. Up to a quarter of those with diverticulosis will develop deverticulitis.
The most common symptom of diverticulitis is pain in the lower right abdomen, which can range from a tenderness to a severe pain.
Other symptoms include nausea, vomiting, fever and chills and/or a change in bowel habits. Diverticulitis can lead to infection, bleeding and blockages in the colon, which always requires treatment. Treatment can include modifications to be made to your diet, medications, rest and possible surgery.
Diverticulosis and diverticulitis together are referred to as diverticular disease.

14. Colorectal Cancer SEE YOUR DOCTOR Most common symptoms Causes
Blood in stool, unexplained weight loss
Causes
Causes unknown
Most common risk factors
Increasing age
Family history
Smoking
Poor lifestyle habits
SEE YOUR DOCTOR
Cancer occurs when abnormal cells divide uncontrollably and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems.
Colon cancer affects the large intestine (colon), the lower part of the digestive system. Rectal cancer is cancer of the last 6 inches of the colon. Together, they are referred to as colorectal cancers.
The wall of the colon and rectum is made up of several layers of tissue: colorectal cancer starts in the innermost layer and can grow through some or all of the other layers. In many cases, colorectal cancers develop slowly over the years. Before a cancer develops, a growth of tissue or tumor usually begins as a non-cancerous polyp on the inner lining of the colon or rectum. Some, but not all, polyps can turn into cancer. Polyps can be tiny and produce few symptoms. Regular screenings can help you prevent colon cancer by identifying polyps early, before they become cancer.
Colorectal cancer is the second leading cause of cancer-related death in the US.
Symptoms of colon cancer may include:
Changes in bowel habits
Blood in your stool
Persistent abdominal discomfort, such as cramps, gas or pain
Abdominal pain with a bowel movement
A feeling that your bowel doesn't empty completely
Weakness or fatigue
Unexplained weight loss
Blood in your stool may be a sign of cancer but can also indicate many other conditions.
It is not known what causes colon cancer, but
Increasing Age
Genetics
Obesity
Smoking
Excessive alcohol consumption
A sedentary lifestyle
A poor diet low in fiber and high in fat
Other conditions, such as IBD
can all increase your risk.
Cancers of the digestive system include colorectal, anal, stomach, liver, esophageal, pancreatic, gallbladder and mouth cancers.

15. Recommended Tests & Screenings
Some Common Tests for Cancer:
Colonoscopy
Every 10 years
Flexible sigmoidoscopy
Every five years
Barium enema
Fecal Occult Blood testing
Annually
New Tests:
Virtual Colonoscopy
Every five years
SEE YOUR DOCTOR
You may have already had some of the tests listed here.
It is the belief of The American Cancer Society that preventing colorectal cancer should be an important reason for getting tested. Finding and removing polyps can help prevent colorectal cancer. Tests that have the best chance of finding both polyps and cancer are preferred.
Starting at age 50, women and men at average risk for developing colorectal cancer should undergo one of the following tests:
Colonoscopy every 10 years: a thin tube (colonoscope) with a tiny lens is inserted through the anus and into the colon, where the inside of the colon can be viewed on a screen.
Flexible sigmoidoscopy every 5 years: Similar to a colonoscopy, a shorter tube (flexible sigmoidoscope), is used to look at the lower portion (sigmoid) of the colon.
Barium enema every 5 years: This procedure is also known as a lower GI and is a series of x-rays of the lower gastrointestinal tract. A liquid containing barium, (a metallic compound) is put into the rectum to coat the lower GI tract and the x-rays are taken.
Fecal occult blood test (FOBT) every year: this test is used to find “occult”, meaning hidden blood in the feces. This screening test is done with a take-home kit.
New tests include:
CT colonography (virtual colonoscopy) every 5 years: a newer procedure in which a series of computed tomography (CT) x-rays are taken and put together to create detailed images of the colon.
Stool DNA test (sDNA), interval undetermined: screening clinical trials are being done in the US for this new screening approach. Research continues to increase its accuracy and decide how often test should be done.
More frequent or earlier screening may be recommended if you're at high risk of colon cancer. It is important to discuss the benefits and risks of each screening option with your doctor.

16. General Risk Factors Non-controllable Controllable Increasing age
Genetics
Certain medications
Certain conditions or diseases
Controllable
Being Overweight
Unhealthy Lifestyle Habits
Smoking
Sedentary lifestyle
Poor diet and eating habits
High stress levels
Excessive alcohol consumption
“Trigger” and unsafe foods
As you can see, digestive disorders have many different symptoms, causes or suspected triggers and vary from being functional to debilitating. They do, however share some common general risk factors, which include non-controllable and controllable factors.
Some non-controllable factors include:
Increasing age: Almost all digestive disorders are more common in older people, especially those over 50 years of age.
Genetics: Genes are known or at least thought to play a role in many digestive disorders. Know your family medical history and review it with your health care provider.
Certain medications or treatments for other ailments, like radiation, can increase your risk of digestive disorders, as can other medical conditions or diseases, such as diabetes. Talk to your health care provider about your potentially increased risk of digestive disorders from medications you may be taking, treatments you may be receiving and other medical disorders you may have.
Controllable risk factors include:
Obesity: Obesity is a major risk factor and increases mortality rates from certain digestive disorders.
Smoking: Smoking is a major contributing factor to digestive, and many other, disorders.
A sedentary lifestyle: When you're inactive, waste stays in your colon longer and obesity alone is a risk factor.
A poor diet low in fiber and high in fat and calories.
Poor eating habits such as eating too fast and talking while you eat encourage excess air consumption and increases stress levels.
High stress levels: stress, thought by some to be a direct cause of many digestive problems and by almost all to at least aggravate digestive disorders and symptoms, can wreak havoc on your tummy.
Excessive alcohol consumption: long-term heavy alcohol use is a major risk factor for digestive, and other, disorders and diseases.
Consuming foods that are spicy, greasy, some milk products, caffeine and others can trigger uncomfortable symptoms.
Eating food that are undercooked, spoiled, unripe or contaminated is sure to cause digestive upset.

17. What You Can DO! (Medical)
Partner with your doctor
Physical examination
Complete review of your family medical history
Tests and screening
Clearly describe your symptoms
Digestive Diary
Your doctor can help you create a customized plan for you
to stay on top of your digestive health.
Your doctor will perform a physical examination, review your family medical history and may order tests or screenings for you to undergo.
Your family medical history can provide insights into the diseases and conditions common to your family. Your doctor can use this information to:
identify patterns that may be relevant to your own health
assess your risk of certain diseases
recommend changes to your diet and lifestyle habits that can lower your risks
determine what diagnostic tests to order
and identify a condition that might not otherwise have been considered.
Your doctor should also be made aware of other critical information — such as any medication or supplements you may be taking, your diet, weight, exercise routine, and lifestyle habits. These can all increase or lower your risk of developing certain disorders or diseases. You should update all of this information with your doctor every couple of years, and, of course, as it changes.
Make an appointment with your doctor today to discuss any symptoms you have been experiencing - be sure to keep a “digestive diary”: a detailed log of all symptoms, when they started and how you have been managing the discomfort.

18. Other Tests & Screenings
Diagnosis of digestive disorders may include the following:
Blood test
Stool test
Abdominal ultrasound
Barium swallow radiograph
PH monitoring exam
Computerized Tomography (CT) scan
Upper Endoscopy
Biopsy
Aside from the tests mentioned previously, these are other tests you may undergo to test for unexplained digestive symptoms:
Blood and stool tests are common diagnostic tests.
Abdominal Ultrasound - a handheld device glides over the abdomen which creates a picture (a sonogram) on a video monitor. If gallstones, for example, are causing inflammation, the sound waves will bounce off of them, indicating their location.
Barium swallow radiograph – this test involves drinking a liquid and having x-rays taken (used to look for problems with the esophagus).
PH monitoring exam - a small tube is placed into the espohagus to monitor stomach acid coming up into the esophagus (test for GERD)
Upper Endoscopy - a thin tube with a tiny camera is put down the throat to examine the esophagus
Biopsy - biopsy involves removal of tissue for further examination and diagnosis.

19. What You Can DO! (Non-Medical)
Eat a healthy diet
Stop smoking
Exercise and maintain a healthy weight
Reduce stress
Digestive dos & don’ts
There are many non-medical things you can do to improve and maintain your digestive health.
Read Slide

20. Digestive Tricks: Dos & Don’ts
Get enough sleep
Eat smaller meals
Eat and drink slowly
Get moving after meals
DON’T
Eat before bed and/or lie down after eating
Digestive Dos:
Sleep! Sleep is crucial for overall excellent health. Getting 7-8 hours of sleep a night is one of the best ways to improve and maintain your overall health.
Your system, especially if sensitive or already suffering from a digestive disorder, can best handle smaller meals, rather than large, five-course dinners!
Take your time while eating and drinking and swallow less air. Meals should be relaxed occasions: eating on the run can interfere with digestion.
Take a walk after eating and get everything “moving”.
Practice proper food safety and hygiene, which includes:
Sanitizing areas that have come into contact with raw meat, fish and eggs
Cook food to the proper temperature
Refrigerate perishables promptly – within 2 hours
Thoroughly wash all fruits and vegetables and dry with a paper towel to reduce bacteria
Wash your hands thoroughly before and after preparing foods and of course, after using the bathroom
Close the lid after flushing – studies have found e. coli bacteria on bathroom toothbrushes! Your brush can get contaminated from backsplash from the toilet!
Avoid eating before bed and refrain from lying down right after you eat.
As previously mentioned, refrain from eating foods that just don’t taste right or don’t look well prepared.
Lastly, when nature calls, don’t hold it in. Find facilities at your earliest opportunity and go!

21. Trust Your Tummy
A healthy digestive system is within your reach: `live well and trust what your tummy is telling you

22. Drs. Sharona B. Ross & Alexander Rosemurgy
The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery
Drs. Sharona B. Ross & Alexander Rosemurgy

23. Surgical Treatment for GERD
Fundoplication: constructs a valve mechanism which prevents acid from coming up into the esophagus
Three different operations:
Nissen fundoplication
Toupet fundoplication
Transoral incisionless fundoplication

24. Necessary Preoperative Testing
Upper Gastrointestinal Study
Evaluates the motility of the esophagus
Bravo/pH Study
Objective study measuring the frequency, severity, and duration of your reflux
Endoscopy

25. Approaches for an anti-reflux operation:
Open
Laparoscopic
Laparo-endoscoic Single Site (LESS) Surgery
Robotic
Transoral

26. Conventional Laparoscopy

27. What is LESS? “Scarless” surgery LESS surgery goes beyond “no scar”:
Faster return to normal activities
Less postoperative pain

33. What your belly button looks like postoperatively

34. What is Transoral?
It is an approach that uses the assistance of endoscopy to undertake the operation through the mouth
Deployment of “H-fasteners” allows the fundoplication to be secured
No incision is made

35. TIF

36. Our Experience We have undertaken over 1500 anti-reflux operations
Since 2008 all the laparoscopic anti-reflux operations have been through LESS

37. Results: There is a dramatic and satisfactory amelioration of symptoms
Postoperatively, when patients were queried if they would still have the operation: 88% said yes

40. Why Surgery
Medical Treatment for reflux is only FDA approved for 2 weeks, not for chronic use
PPI therapy increases the risk of osteoporosis, which women are already have an increased risk
Without a mechanistic fix the esophagus is exposed to both acid and bile salts which are both carcinogenic
30% of esophageal cancers are attributed to GERD

41. Surgical Treatment for Gallbladder Disease
Operation = Cholecystectomy
Most common operation in the US
Approaches:
Open
Laparoscopy
LESS
Robotic

43. General Anesthesia Versus Epidural Anesthesia
Anesthetics
General Anesthesia Versus Epidural Anesthesia

44. Epidural anesthesia has lower postoperative pain scores

45. LESS Cholecystectomy with Epidural Anesthesia
Provides the same salutatory benefits of conventional cholecystectomy with added benefits:
Decreased postoperative pain
No general anesthesia side effects
Improved cosmesis
Lower cost

46. Drs. Sharona B. Ross & Alexander Rosemurgy
The Southeastern Center for Digestive Disorders & Pancreatic Cancer Advanced Minimally Invasive and Robotic Surgery
Drs. Sharona B. Ross & Alexander Rosemurgy