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Bortolotti M. Is patient satisfaction sufficient to validate endoscopic anti-reflux treatments? World J Gastroenterol 2022; 28:3743-3746. [PMID: 36161053 PMCID: PMC9372810 DOI: 10.3748/wjg.v28.i28.3743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/08/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
Endoscopic anti-reflux treatment is emerging as a new option for gastro-esophageal reflux disease (GERD) treatment in patients with the same indications as for laparoscopic fundoplication. There are many techniques, the first of which are transoral incisionless fundoplication (TIF) and nonablative radio-frequency (STRETTA) that have been tested with comparative studies and randomized controlled trials, whereas the other more recent ones still require a deeper evaluation. The purpose of the latter is to verify whether reflux is abolished or significantly reduced after intervention, whether there is a valid high pressure zone at the gastroesophageal junction, and whether esophagitis, when present, has disappeared. Unfortunately in a certain number of cases, and especially in the more recently introduced ones, the evaluation has been based almost exclusively on subjective criteria, such as improvement in the quality of life, remission of heartburn and regurgitation, and reduction or suspension of antacid and antisecretory drug consumption. However, with the most studied techniques such as TIF and STRETTA, an improvement in symptoms better than that of laparoscopic fundoplication can often be observed, whereas the number of acid episodes and acid exposure time are similar or higher, as if the acid refluxes are better tolerated by these patients. The suspicion of a local hyposensitivity taking place after anti-reflux endoscopic intervention seems confirmed by a Bernstein test at least for STRETTA. This examination should be done for all the other techniques, both old and new, to identify the ones that reassure rather than cure. In conclusion, the evaluation of the effectiveness of the endoscopic anti-reflux techniques should not be based exclusively on subjective criteria, but should also be confirmed by objective examinations, because there might be a gap between the improvement in symptoms declared by the patient and the underlying pathophysiologic alterations of GERD.
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Affiliation(s)
- Mauro Bortolotti
- Department of Internal Medicine and Gastroenterology, S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna 40138, Italy
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Kolbeinsson HM, Lawson C, Banks-Venegoni A, Girgis R, Scheeres DE. Treatment of Gastroesophageal Reflux Disease After Lung Transplant Using Radiofrequency Ablation to the Lower Esophageal Sphincter (Stretta Procedure). Am Surg 2021; 88:1663-1668. [PMID: 33719597 DOI: 10.1177/0003134821998678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is associated with chronic lung allograft dysfunction after lung transplant. Treating GERD after lung transplant has been shown to improve lung allograft function. This case series describes the efficacy of the Stretta procedure to control GERD after lung transplant at our institution. METHODS Eleven patients underwent the Stretta procedure at our institution for GERD after lung transplant during the years 2016-2017. Pre- and post-Stretta reflux parameters were gathered. Pulmonary function was followed up until subsequent fundoplication surgery, death, or end of study observation. RESULTS Reflux on esophagram was noted in 9 patients before Stretta and 8 patients after Stretta. The median number of acid reflux events was 31.5 vs. 26 after Stretta (P = .95), and median percent time in reflux was 17.7% before vs. 14.5% after Stretta (P = .76). Median DeMeester score before Stretta was 65.5 (range: 33.2-169.8) vs. 42.5 (range: 19.2-109.8) after the procedure (P = .14). Median lower esophageal resting pressure was 20.7 mm Hg (n = 7) compared to 25.9 mm Hg (n = 9) on post-Stretta follow-up (P = .99). Median FEV1% predicted was 84% (41-97%) before compared to 71% (23-108%) at 1 year after the procedure (P = .14). Seven patients required fundoplication surgery for continued reflux. All patients were on triple immunosuppression, most commonly prednisone, tacrolimus, and mycophenolate (n = 9). DISCUSSION The Stretta procedure did not provide expected results at our institution after lung transplant surgery. Based on our limited series, we do not recommend routine use of the Stretta procedure for management of GERD in lung transplant patients.
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Affiliation(s)
- Hordur M Kolbeinsson
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Cameron Lawson
- Spectrum Health Lung Transplantation Program, Grand Rapids, MI, USA
| | - Amy Banks-Venegoni
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Division of General Surgery, 3591Spectrum Health Medical Group, Grand Rapids, MI, USA
| | - Reda Girgis
- Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Spectrum Health Lung Transplantation Program, Grand Rapids, MI, USA
| | - David E Scheeres
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA.,Michigan State College of Human Medicine, Grand Rapids, MI, USA.,Division of General Surgery, 3591Spectrum Health Medical Group, Grand Rapids, MI, USA
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Huynh P, Konda V, Sanguansataya S, Ward MA, Leeds SG. Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication. Surg Laparosc Endosc Percutan Tech 2020; 31:264-276. [PMID: 33347088 PMCID: PMC8154178 DOI: 10.1097/sle.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation. MATERIALS AND METHODS A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control. RESULTS Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH. CONCLUSIONS Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.
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Affiliation(s)
- Phuong Huynh
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
| | - Vani Konda
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas
| | | | - Marc A. Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
| | - Steven G. Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
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Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc 2017; 31:4865-4882. [PMID: 28233093 DOI: 10.1007/s00464-017-5431-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/20/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The endoscopic radiofrequency procedure (Stretta) has been used for more than a decade to treat patients with gastroesophageal reflux disease (GERD). However, the efficacy of the procedure in improving objective and subjective clinical endpoints needs to be further established. AIM To determine the efficacy of the Stretta procedure in treating patients with GERD, using a systematic review and meta-analysis of controlled and cohort studies. METHODS We conducted a systematic search of the PubMed and Cochrane databases for English language clinical studies of the Stretta procedure, published from inception until May 2016. Randomized controlled trials (RCTs) and cohort studies that included the use of the Stretta procedure in GERD patients were included. A generalized inverse weighting was used for all outcomes. Results were calculated by both fixed effects and random effects model. RESULTS Twenty-eight studies (4 RCTs, 23 cohort studies, and 1 registry) representing 2468 unique Stretta patients were included in the meta-analysis. The (unweighted) mean follow-up time for the 28 studies was 25.4 [14.0, 36.7] months. The pooled results showed that the Stretta reduced (improved) the health-related quality of life score by -14.6 [-16.48, -12.73] (P < 0.001). Stretta also reduced (improved) the pooled heartburn standardized score by -1.53 [-1.97, -1.09] (P < 0.001). After Stretta treatment, only 49% of the patients using proton pump inhibitors (PPIs) at baseline required PPIs at follow-up (P < 0.001). The Stretta treatment reduced the incidence of erosive esophagitis by 24% (P < 0.001) and reduced esophageal acid exposure by a mean of -3.01 [-3.72, -2.30] (P < 0.001). Lower esophageal sphincter (LES) basal pressure was increased post Stretta therapy by a mean of 1.73 [-0.29, 3.74] mmHg (P = NS). CONCLUSIONS The Stretta procedure significantly improves subjective and objective clinical endpoints, except LES basal pressure, and therefore should be considered as a viable alternative in managing GERD.
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Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:283-8. [PMID: 22874675 DOI: 10.1097/sle.0b013e3182582e92] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment. METHODS Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry. RESULTS A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD-health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007). CONCLUSIONS Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.
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Zehetner J, Ravari F, Ayazi S, Skibba A, Darehzereshki A, Pelipad D, Mason RJ, Katkhouda N, Lipham JC. Minimally invasive surgical approach for the treatment of gastroparesis. Surg Endosc 2012; 27:61-6. [PMID: 22752276 DOI: 10.1007/s00464-012-2407-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 05/17/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy. METHODS A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3% vs. 23%, p = 0.06) and in-hospital mortality rate (2.7% vs. 3%, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26%) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7%, mortality 0). In total, 57% of patients were treated with GES while only 43% had final treatment with gastrectomy. Of the GES group, 63% rated their symptoms as improved versus 87% in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100% symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12). CONCLUSION The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.
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Affiliation(s)
- Joerg Zehetner
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Arts J, Bisschops R, Blondeau K, Farré R, Vos R, Holvoet L, Caenepeel P, Lerut A, Tack J. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol 2012; 107:222-30. [PMID: 22108449 DOI: 10.1038/ajg.2011.395] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several studies have reported symptom relief in gastro-esophageal reflux disease (GERD) patients treated with radiofrequency delivery (Stretta procedure) at the gastro-esophageal junction (GEJ), but the mechanism underlying this improvement is unclear. The objective of this study was to test the hypothesis that Stretta alters GEJ resistance. METHODS We conducted a double-blind randomized cross-over study of Stretta and sham treatment. Consecutive GERD patients were included in the study. The study was conducted in a tertiary care center. Patients underwent two upper gastrointestinal endoscopies with 3 months interval, during which active or sham Stretta treatment was performed in a randomized double-blind manner. Symptom assessment, endoscopy, manometry, 24-h esophageal pH monitoring, and a distensibility test of the GEJ were done before the start of the study and after 3 months. RESULTS Barostat distensibility test of the GEJ before and after administration of sildenafil was the main outcome measure. In all, 22 GERD patients (17 females, mean age 47±12 years) participated in the study; 11 in each group. Initial sham treatment did not affect any of the parameters studied. Three months after initial Stretta procedure, no changes were observed in esophageal acid exposure and lower esophageal sphincter (LES) pressure. In contrast, symptom score was significantly improved and GEJ compliance was significantly decreased. Administration of sildenafil, an esophageal smooth muscle relaxant, normalized GEJ compliance again to pre-Stretta level, arguing against GEJ fibrosis as the underlying mechanism. CONCLUSIONS The limitation of this study was reflux evaluation did not include impedance monitoring. In this sham-controlled study, Stretta improved GERD symptoms and decreased GEJ compliance. Decreased GEJ compliance, which reflects altered LES neuromuscular function, may contribute to symptomatic benefit by decreasing refluxate volume.
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Affiliation(s)
- J Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Aziz AMA, El-Khayat HR, Sadek A, Mattar SG, McNulty G, Kongkam P, Guda MF, Lehman GA. A prospective randomized trial of sham, single-dose Stretta, and double-dose Stretta for the treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:818-25. [PMID: 19730952 DOI: 10.1007/s00464-009-0671-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Accepted: 07/27/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a prevalent disorder that often requires long-term medical therapy or surgery. Radiofrequency (RF) energy delivery (Stretta procedure) has been shown in several studies to improve GERD symptoms and quality of life for approximately two-thirds of patients. The authors proposed that increasing the dose of Stretta would further improve the response to this therapy. METHODS For this study, 36 patients were randomized into three groups. In group A, 12 patients underwent a single session Stretta procedure. In group B, 12 patients under went a sham Stretta procedure (mirror of the active procedure in all aspects except there was no deployment of the electrodes). In group C, 12 patients underwent a single Stretta treatment followed by repeat Stretta if GERD health-related quality of life (HRQL) was not 75% improved after 4 months. For each patient, 56 RF lesions were created per session. The principal outcome was GERD HRQL improvement. The secondary outcomes were medication use, lower esophageal sphincter (LES) basal pressure, endoscopic grade of esophagitis, and esophageal acid exposure by pH probe. RESULTS The Stretta procedure was completed successfully for all the patients in both active treatment groups. At 12 months, the mean HRQL scores of those off medications, the LES basal pressure, the 24-h pH scores, and the proton pump inhibitor (PPI) daily dose consumption were significantly improved from baseline in both Stretta groups (p\0.01). The double Stretta was numerically but not significantly better than the single Stretta for mean HRQL, mean 24 h pH, mean LES pressure, and PPI use. Seven patients in the double Stretta treatment group had normalized their HRQL at 12 months compared with 2 patients in the single-treatment group (p = 0.035). The sham patients had a small but statistically significant decrease in their daily PPI dosages (p\0.05) and mean HRQL scores (p\0.05). No serious complications (bleeding, perforation, or death) occurred. However, two patients experienced significant delayed gastric emptying after the second Stretta treatment. CONCLUSIONS The Stretta procedure significantly reduced GERD HRQL, use of PPI drugs, esophageal acid exposure, LES pressure, and grade of esophagitis compared with the sham procedure. The double Stretta therapy had numerically superior outcomes for most parameters and a significantly more frequent normalization of HRQL scores compared with the single Stretta.
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Affiliation(s)
- Ayman M Abdel Aziz
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA.
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Parisien CJ, Corman ML. The Secca procedure for the treatment of fecal incontinence: definitive therapy or short-term solution. Clin Colon Rectal Surg 2010; 18:42-5. [PMID: 20011339 DOI: 10.1055/s-2005-864080] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The treatment of fecal incontinence by means of radiofrequency energy is based on the concept that collagen deposition and subsequent scarring may increase one's ability to recognize and retain stool and permit improved continence. The procedure is undertaken on an outpatient basis. Individuals may be considered candidates even if they have a potentially reparable defect since the technique does not limit one to the application of a subsequent procedure. Clearly, those for whom other treatment methods have failed and those who have no other reasonable option in the management of their fecal incontinence should be considered for this procedure. Preliminary results are quite encouraging, and the results of a prospective, sham-controlled, randomized clinical trial are awaited.
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Antireflux 'barriers': problems with patient recruitment for a new endoscopic antireflux procedure. Eur J Gastroenterol Hepatol 2009; 21:1110-8. [PMID: 19300273 DOI: 10.1097/meg.0b013e32832937c2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most first-generation endoscopic antireflux procedures (EARPs) have been withdrawn because of variable success rates, economic considerations, and/or complications. As a result, subsequent methods may meet 'skepticism' by physicians and patients. AIMS To identify potential barriers to patient recruitment for a new EARP METHODS: We prospectively analyzed our recruitment for a phase 2 study of a transoral incisionless fundoplication procedure. We contacted 50 private practices and 23 hospitals for potential referrals, and placed three newspaper advertisements. All patient replies were followed up by a phone call. Patients were then invited for a personal interview, and eligible patients underwent further preprocedure testing. In addition, poststudy questionnaires regarding their opinions about EARPs were sent to referring physicians. RESULTS Of 134 interviewed patients, only 10% (n=13) were successfully recruited. Candidates mostly responded to newspaper advertisements (87%) or were referred from our own institution (7%). Primary exclusion criteria included failure of proton pump inhibitor response (34%), lack of proton pump inhibitor use (20%), atypical symptoms (18%), or a large hiatal hernia (17%). Seventy percent of the responding physicians did not believe that new EARPs would be superior to previous methods. CONCLUSION The EARP market seems to be much smaller than anticipated, partially because of skepticism of referring physicians, and partially because of strict selection criteria.
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Dundon JM, Davis SS, Hazey JW, Narula V, Muscarella P, Melvin WS. Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) does not provide long-term symptom control. Surg Innov 2008; 15:297-301. [PMID: 18829607 DOI: 10.1177/1553350608324508] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The Stretta procedure (radiofrequency energy application to the lower esophageal sphincter) is a unique endoluminal technique for the management of gastroesophageal reflux. This article reports on the long-term effectiveness of the Stretta procedure in patients with significant gastroesophageal reflux disease (GERD) referred to a surgical practice. Patients who underwent Stretta with a minimum of 36 months follow-up were included. Thirty-two patients with an average follow-up of 53 months were included; 19 proceeded to anti-reflux surgery. Those not undergoing surgery showed a significant improvement in their GERD satisfaction from 3.14 to 1.46 (P = .0006) but had significantly lower preprocedure heartburn scores (2.43) than those who proceeded to surgery (3.66, P = .0401). The Stretta procedure was effective in reducing symptoms in 40% of patients. Responders had less severe preoperative heartburn. Radiofrequency energy delivery to the lower esophageal sphincter may be effective in selected patients for the treatment of gastroesophageal reflux.
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Affiliation(s)
- John M Dundon
- Center for Minimally Invasive Surgery, Department of Surgery, The Ohio State University, Columbus 43210, USA
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Anvari M. Endoscopic treatments for gastro-oesophageal reflux disease. Lancet 2008; 371:965-6. [PMID: 18358911 DOI: 10.1016/s0140-6736(08)60430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Mehran Anvari
- St Joseph's Healthcare, Hamilton ON, Canada L8N 4A6.
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Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Endoluminal fundoplication by a transoral device for the treatment of GERD: A feasibility study. Surg Endosc 2007; 22:333-42. [DOI: 10.1007/s00464-007-9618-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 07/10/2007] [Accepted: 08/29/2007] [Indexed: 01/11/2023]
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Systematic review: endoluminal therapy for gastro-oesophageal reflux disease: evidence from clinical trials. Eur J Gastroenterol Hepatol 2007; 19:1125-39. [PMID: 17998840 DOI: 10.1097/meg.0b013e3282f16a21] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
During the last few decades many endoscopic interventions have been developed as an alternative for the treatment of gastro-oesophageal reflux disease (GORD). In many countries, these interventions are thus being performed in the general clinical setting. The aim of this study is to systematically review the evidence on the effect of endoscopic therapies for GORD. A systematic search of the literature on this subject in English, indexed in MEDLINE (1966 to May 2007) and in the Cochrane Library, was carried out. For the study selection, retrospective and prospective open-label and randomized, sham-controlled trials were taken into account. The exclusion criteria included the following: case series that included fewer than 10 patients, abstracts, studies involving children or those with a follow-up shorter than 3 months. For data extraction, two reviewers, using standardized forms, independently abstracted data on study design and methods, population, sample size, function studies (e.g. pH-metry), type of endoscopic treatment, follow-up, health-related and quality of life scores, outcomes and complications. Data synthesis involved the following: 43 studies, including four randomized, sham-controlled trials that met the inclusion criteria, out of 4182 citations. The primary end point in most studies was the reduction of the use of proton pump inhibitors (PPIs) by more than 50%. In view of these findings, the majority of studies suggested the efficacy of endoluminal therapies for the control of symptoms in GORD. In the sham-controlled studies, the effect of placebo was, nevertheless, as high as 50%. Most studies were small feasibility studies, with follow-ups of less than 1 year. No study comparing endoscopic techniques with other established treatment options such as PPIs existed. All endoscopic therapies were associated with a small but important percentage of mild to severe complications, which included perforation, abscess and death. In conclusion, the data from most of the short-term follow-up and the few sham-controlled studies demonstrate that subgroups of patients experienced improvement or resolution of typical GORD symptoms and decreased PPI usage. Currently, however, there are not enough scientific and clinical data on safety, efficacy and durability to support the use of endoluminal therapies for GORD in routine clinical practice.
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Arts J, Sifrim D, Rutgeerts P, Lerut A, Janssens J, Tack J. Influence of radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) on symptoms, acid exposure, and esophageal sensitivity to acid perfusion in gastroesophagal reflux disease. Dig Dis Sci 2007; 52:2170-7. [PMID: 17436101 DOI: 10.1007/s10620-006-9695-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2006] [Accepted: 11/26/2006] [Indexed: 12/16/2022]
Abstract
Several studies have demonstrated that radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) induces symptom relief in gastroesophageal reflux disease (GERD), although improvement of acid exposure on pH monitoring was usually limited. A role for decreased esophageal sensitivity has been suggested. Our aim was to evaluate the influence of Stretta on symptoms, acid exposure, and sensitivity to esophageal acid perfusion in GERD. Thirteen patients with established proton pump inhibitor (PPI)-dependent GERD (three males; mean age, 51+/-10 years) participated in the study. Before and 6 months after the procedure symptom score, pH monitoring and Bernstein acid perfusion test were performed. The latter was done by infusing HCl (pH 0.1) at a rate of 6 ml/min 15 cm proximal to the gastroesophageal junction for a maximum of 30 min or until the patients experienced heartburn. Results were compared by Student's t-test. Stretta procedure time was 51+/-4 min and no complications occurred. After 6 months, the symptom score was significantly improved (12.5+/-2.0 to 7.5+/-2.1; P<0.05), seven patients no longer needed daily PPI, and acid exposure was significantly decreased (11.6%+/-1.6% to 8.5%+/-1.8% of time pH<4; P<0.05). The time needed to induce heartburn during acid perfusion decreased from 9.5+/-2.3 to 18.1+/-3.4 min (P=0.01), and five patients became insensitive to 30-min acid perfusion, versus none at baseline (P=0.04). In conclusion, the Stretta procedure induces subjective improvement of GERD symptoms and decreases esophageal acid exposure. In addition, esophageal acid sensitivity is decreased 6 months after the Stretta procedure. The mechanism underlying this finding and its relevance to symptom control require further studies.
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Affiliation(s)
- J Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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19
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Meier PN, Nietzschmann T, Akin I, Klose S, Manns MP. Improvement of objective GERD parameters after radiofrequency energy delivery: a European study. Scand J Gastroenterol 2007; 42:911-6. [PMID: 17613919 DOI: 10.1080/00365520601155191] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The Stretta procedure is an endoluminal radiofrequency energy delivery system for the treatment of gastroesophageal reflux disease (GERD). The purpose of this study was to present, for the first time, the Stretta treatment experience from European centers. MATERIAL AND METHODS Sixty patients with a history of GERD from six European centers underwent Stretta treatment from May 2001 to June 2003. All patients were at least partly responsive to daily proton-pump inhibitors. Esophageal motility, endoscopy, and ambulatory 24-h pH studies were done in all patients at baseline and 6 and 12 months after treatment. We evaluated medication use, satisfaction, GERD-health-related quality of life, 24-h pH-metry, manometry, and endoscopy. RESULTS Sixty patients (31 M, 29 F, mean age 47+/-13 years, mean years of GERD 7.4+/-7.2) were treated with the Stretta procedure. At 12 months after treatment, 75% of the patients needed no medication or less medication than before treatment. They were more satisfied with their symptom control and had statistically significantly fewer GERD symptoms (mean lower esophageal sphincter (LES) pressure improved from 14.8+/-9.1 to 16.7+/-10.0 mmHg, p=0.002 and mean total reflux time from 16.7+/-12.8 to 8.8+/-6.6%, p=0.001). Quality of life (mean score decreased from 19.2+/-9.0 to 6.6+/-7.3, p<0.0001) and overall physical and mental health also improved significantly. CONCLUSIONS The experience with the Stretta procedure performed at centers in Europe confirms that it is well tolerated and effective in the treatment of GERD. It has a favorable impact on medication requirements, LES pressure, esophageal acid exposure, and GERD symptom scores. The Stretta procedure should be considered for patients who are not satisfied with drug therapy, and who are considering anti-reflux surgery.
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Affiliation(s)
- Peter N Meier
- Henriettenstiftung, Medizinische Klinik II, Akademisches Lehrkrankenhaus, Hannover, Germany.
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20
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Cadière GB, Rajan A, Rqibate M, Germay O, Dapri G, Himpens J, Gawlicka AK. Endoluminal fundoplication (ELF)--evolution of EsophyX, a new surgical device for transoral surgery. MINIM INVASIV THER 2007; 15:348-55. [PMID: 17190659 DOI: 10.1080/13645700601040024] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A novel endoluminal fundoplication (ELF) technique using a trans-oral and fastener-deploying device (EsophyX, EndoGastric Solutions) was developed and evaluated for feasibility, safety and the treatment of gastroesophageal reflux disease (GERD) in a series of bench, animal, human (phase 1, phase 2, commercial registry) studies. The studies verified biological compatibility, durability and non-toxicity of the polypropylene fasteners as well as the feasibility of the ELF technique. The results of the preclinical testing indicated that the EsophyX device was shown to be safe, and capable of deploying fasteners directly into tissue and forming an interrupted suture line at the base of the gastro-esophageal valve (GEV). Moreover, the studies demonstrated that the ELF technique performed using the EsophyX device resulted in the creation of new GEVs of 3-5 cm in length and a circumference of 200 degrees -310 degrees , which maintained their anatomical aspects at six months. The ELF-created GEVs appeared similar to those created by laparoscopic anti-reflux surgery (LARS). The ELF procedure also resulted in reduction of all small hiatal hernias (2 cm in size) and restoration of the angle of His. The ELF procedure provides an anatomical approach similar to that of LARS for the treatment of GERD.
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Affiliation(s)
- G B Cadière
- Department of Gastrointestinal Surgery, Saint-Pierre University Hospital, European School of Laparoscopic Surgery, 322 Rue Hautem 1000 Brussels, Belgium.
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21
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Falk GW, Fennerty MB, Rothstein RI. AGA Institute technical review on the use of endoscopic therapy for gastroesophageal reflux disease. Gastroenterology 2006; 131:1315-36. [PMID: 17030199 DOI: 10.1053/j.gastro.2006.08.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Gary W Falk
- Department of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic, Cleveland, OH, USA
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22
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von Rahden BHA, Stein HJ. Endoscopic treatment modalities for gastroesophageal reflux disease (GERD). Eur Surg 2006. [DOI: 10.1007/s10353-006-0263-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Malik A, Mellinger JD, Hazey JW, Dunkin BJ, MacFadyen BV. Endoluminal and transluminal surgery: current status and future possibilities. Surg Endosc 2006; 20:1179-92. [PMID: 16865615 DOI: 10.1007/s00464-005-0711-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Accepted: 04/09/2006] [Indexed: 12/21/2022]
Abstract
The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include "incisionless," "endoluminal," "transluminal," and "natural orifice" transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.
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Affiliation(s)
- A Malik
- Department of Surgery, Medical College of Georgia, Room BI 4074, 1120 15th St., Augusta, GA 30912, USA
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24
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Iqbal A, Salinas V, Filipi CJ. Endoscopic therapies of gastroesophageal reflux disease. World J Gastroenterol 2006; 12:2641-55. [PMID: 16718747 PMCID: PMC4130969 DOI: 10.3748/wjg.v12.i17.2641] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Revised: 08/13/2006] [Accepted: 08/30/2005] [Indexed: 02/06/2023] Open
Abstract
The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease (GERD). The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.
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Affiliation(s)
- Atif Iqbal
- Department of Surgery, University of Missouri Columbia, One Hospital Drive, 65211, USA
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25
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Chen YK. Endoscopic approaches to the treatment of gastroesophageal reflux disease. Curr Opin Gastroenterol 2005; 21:595-600. [PMID: 16093776 DOI: 10.1097/01.mog.0000174224.82406.aa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Endoscopic therapies for gastroesophageal reflux disease represent a minimally invasive alternative to medical or surgical treatment. These devices include suturing, radiofrequency energy, and bulking agent technologies. Research into the use of these technologies in gastroesophageal reflux disease continues to accelerate, and the last 2 years have witnessed significant developments that may affect current and future clinical practice. RECENT FINDINGS Long-term data from nonrandomized clinical trials have become available in the last 2 years for many gastroesophageal reflux disease endotherapies, providing some insight into their durability. Furthermore, two multicenter and one single-center sham-controlled trials were published recently, allowing comparison between groups. SUMMARY Although it is premature to propose the superiority of any individual approach, emerging data in this rapidly evolving field may inform current and future directions in the research and treatment of gastroesophageal reflux disease.
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Affiliation(s)
- Yang K Chen
- University of Colorado Hospital, Denver, Colorado, USA.
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26
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Abstract
The Stretta procedure is safe and effective for the treatment of GERD. There are well-documented clinical trial data supporting its use, including a randomized sham-controlled study, single- and multi-center prospective trials, and community practice reports. The complication rate is within the acceptable range for therapeutic endoscopic procedures and less than the published complication rate for laparoscopic fundoplication. The durability of effect also is established beyond 2 years in several studies. Stretta should be added to the GERD management algorithm specifically for patients considering an antireflux surgical procedure but who are not accepting of the risks of surgery and anesthesia. These patients typically present with incomplete GERD control, despite optimal antisecretory drug therapy, or intolerance to medical therapy. Stretta should be considered only for patients who fit the anatomic inclusion criteria, whereas antireflux surgery should be reserved for those who do not. The decision to undergo antireflux surgery or Stretta must be based on the relative risks and benefits of each procedure. Although antireflux surgery provides better control of esophageal acid exposure than Stretta, the outcomes for GERD symptoms, quality of life, and reduction in PPI use are comparable. Stretta has a low risk of acute adverse events, has no reported cases of long-term dysphagia, and obviates general anesthesia and hospitalization, whereas antireflux surgery has a reported adverse event rate of approximately 2%, a considerable incidence of dysphagia, and requires general anesthesia and 1 to 2 days in the hospital. Another advantage of the Stretta procedure is that antireflux surgery still can be performed in the case of failures. In conclusion, the Stretta procedure offers a minimally invasive, safe, and effective alternative to antireflux surgery for those patients who have GERD who are controlled unsatisfactorily on antisecretory medications, who are considering surgery, and who meet the anatomic criteria that make the procedure technically feasible and safe.
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Affiliation(s)
- Ronald W Yeh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Alway Building M-211, 300 Pasteur Drive, Stanford, CA 94305, USA
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27
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Abstract
Gastroesophageal reflux disease (GERD) is a chronic condition affect-ing over 7% of the US population. The primary objective of therapy is symptom relief, with secondary goals to heal esophagitis, prevent reflux-related complications, and maintain remission. There are several new endoscopic therapies (ETs) for treatment of GERD, generating considerable interest. An outpatient procedure, performed without an incision and general anesthesia, is attractive to patients and these therapies are being rapidly introduced, despite lack of long-term follow-up and randomized trials. In this article, the authors review endoscopic procedures, including technical aspects, mechanisms of action, safety, efficacy, and tolerability. Patient selection and relevant human studies are reviewed to clarify advantages and disadvantages of ET compared with conventional procedures.
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Affiliation(s)
- Alberto de Hoyos
- Cardiothoracic Surgery, Northwestern Memorial Hospital, 215 East Huron 10-105, Chicago, IL 60611, USA
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28
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Portale G, Filipi CJ, Peters JH. A current assessment of endoluminal approaches to the treatment of gastroesophageal reflux disease. Surg Innov 2005; 11:225-34. [PMID: 15756391 DOI: 10.1177/155335060401100405] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the past decade, a number of endoscopic techniques have been developed as alternatives to medical and surgical treatment of gastroesophageal reflux disease (GERD). The driving force was to provide an outpatient transoral, endoscopic procedure effective in controlling reflux in a portion of patients with GERD. Three major technologies emerged, although each use different approaches to augment the barrier function of the lower esophageal sphincter, mechanisms may be similar. These include Endocinch which tightens the gastroesophageal junction via a set of suture plications around the lower esophageal sphincter, Stretta, which delivers radiofrequency energy at the cardia, and Enteryx, which is an inert polymer injected into the muscle layer of the gastroesophageal junction. To date, the underlying mechanism of action of these procedures has not been completely elucidated, although each alters the compliance of the GEJ and thus its ability to respond to a "refluxogenic stress". The target population currently consists of proton pump inhibitor-dependent GERD patients, with little or no hiatal hernia and without severe esophagitis or Barrett's. The Stretta procedure is the only procedure to date to be subjected to a sham-controlled trial. Registries of complications suggest that these techniques are relatively safe, but serious morbidity including rare mortality have been reported. All can be performed on an outpatient basis. Future comparative studies with predetermined end points, validated outcome measures, prolonged follow-up, and complete complication registries are needed to determine the role of endoscopic procedures in the clinical practice of patients with GERD. Evolution of the current technologies will almost certainly occur, and a commonly performed, efficacious endoscopic antireflux procedure is likely to emerge.
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Affiliation(s)
- Giuseppe Portale
- Division of Thoracic and Foregut Surgery, University of Southern California, Los Angeles, CA, USA
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29
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Cipolletta L, Rotondano G, Dughera L, Repici A, Bianco MA, De Angelis C, Vingiani AM, Battaglia E. Delivery of radiofrequency energy to the gastroesophageal junction (Stretta procedure) for the treatment of gastroesophageal reflux disease. Surg Endosc 2005; 19:849-53. [PMID: 15868272 DOI: 10.1007/s00464-004-2169-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Accepted: 12/15/2004] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radiofrequency (RF) energy treatment is increasingly offered before invasive surgical procedures for selected patients with gastroesophageal reflux disease (GERD). METHODS Thirty-two patients undergoing the Stretta procedure were prospectively evaluated with upper endoscopy, manometry, 24-hour pH testing, SF-36 surveys, and GERD-specific questionnaires (GERD HRQL). RESULTS Significant clinical improvement was observed in 91% of patients (29/32). Mean heartburn and GERD HRQL scores decreased (p = 0.001 and p = 0.003, respectively), and physical SF-36 increased (p = 0.05). At a minimum follow-up of 12 months, median esophageal acid exposure decreased (p = 0.79) and was normalized in eight patients. Median lower esophageal sphincter (LES) pressure was unchanged. Esophagitis healed in six of eight patients, but two patients with nonerosive disease developed asymptomatic grade A esophagitis during follow-up. At 12 months, 56% of patients were off proton pump inhibits. Morbidity was minimal. CONCLUSIONS RF delivery to LES is safe and significantly improves symptoms and quality of life in selected GERD patients.
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Affiliation(s)
- L Cipolletta
- Division of Gastroenterology and Digestive Endoscopy, ASLNA5 Hospital Maresca, Torre del Greco, Italy.
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Lutfi RE, Torquati A, Kaiser J, Holzman M, Richards WO. Three year’s experience with the Stretta procedure: did it really make a difference? Surg Endosc 2004; 19:289-95. [PMID: 15624052 DOI: 10.1007/s00464-004-8938-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2004] [Accepted: 08/25/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endoscopic treatment is merging as a new option for GERD treatment. Many modalities have been used with modest short-term success, but no long-term follow-ups have been published. We present our 3-yr experience at Vanderbilt University using endoscopic radiofrequency energy (Stretta procedure) for GERD treatment. METHODS Patients with follow-up >6 months were prospectively studied under IRB protocol. All were mailed SF-12 health status questionnaire and GERD specific quality-of-life (QOLRAD) questionnaires, queries about satisfaction with Stretta, and medication use. All were invited for 24-hour pH study. RESULTS Eighty-six Stretta procedures were performed between 8/2000 and 7/2003 on 85 patients; all were outpatients, 89% under conscious sedation. Seventy-seven patients qualified for the study; 61 completed the survey, 24 returned for pH study. Follow-up was 26.2 +/- 7.5 months (6-36). All were on daily PPIs, with proven GERD by pH study or endoscopy. Mean preoperative acid exposure time was 7.8+/-2.6%, mean DeMeester score was 40.2+/-17.6. Postoperative mean acid exposure time was 5.1+/-3.3 (p=0.001), DeMeester score was 29.5+/-20.5 (p=0.041). Normal postoperative acid exposure time (pH<4 in <4.2%) was achieved in 42% of patients tested. Patients were then divided according to medication use at the end of f/u in 2 groups: Responders (off or >50% decrease in PPI dose), and nonresponders (on >50% of original PPI dose, or had fundoplication). Response rate was 60% (39 patients), 8 nonresponders underwent fundoplication (12%). Satisfaction rate was 73%. Statistically significant difference was found between the 2 groups in all measurements; SF-12 physical and mental score for responders were 45.5+/-10.2, and 52.6+/-7.8; and for nonresponders were 37.8+/-11.2 and 40.9+/-11.3 (p=0.012, p=0.0001), respectively. Statistically significant difference was also found between responders and nonresponders in postoperative acid exposure (4.5+/-3.34 vs 7.2+/-2.3, p=0.034), and DeMeester score (26.3+/-20.4 vs 39.7+/-20.2, p=0.05). Paired T test was used to compare pre- and postoperative acid exposure in each group; statistically significant difference was found only among responders: total reflux time was 7.50+/-2.3 preop and 4.5+/-3.34 postop (p=0.0001), whereas for nonresponders it was 8.6+/-3.7 and 7.2+/-2.3 (p=0.8), DeMeester scores pre- and postop among responders were 40.0+/-19.7 and 26.3+/-20.4, respectively (p=0.016), whereas for nonresponders it was 40.5+/-14.3 and 39.7+/-20.2 (p=0.79). CONCLUSIONS Stretta is a safe modestly effective, totally endoscopic treatment for GERD. Symptomatic improvement when achieved is often associated with correlating improvement in distal acid exposure. This exposure normalizes in nearly half the treated patients.
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Affiliation(s)
- R E Lutfi
- Department of Surgery, Vanderbilt University Medical Center, D-5219 MCN, Nashville, TN 37232, USA
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31
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Rosemurgy AS, Arnaoutakis DJ, Thometz DP, Binitie O, Giarelli NB, Bloomston M, Goldin SG, Albrink MH. Reoperative Fundoplications are Effective Treatment for Dysphagia and Recurrent Gastroesophageal Reflux. Am Surg 2004. [DOI: 10.1177/000313480407001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
With wide application of antireflux surgery, reoperations for failed fundoplications are increasingly seen. This study was undertaken to document outcomes after reoperative fundoplications. Sixty-four patients, 26 men and 38 women, of average age 55 years ± 15.6 (SD), underwent reoperative antireflux surgery between 1992 and 2003. Fundoplication prior to reoperation had been undertaken via celiotomy in 27 and laparoscopically in 37. Both before and after reoperative antireflux surgery, patients scored their reflux and dysphagia on a Likert Scale (0 = none, 10 = continuous). Reoperation was undertaken because of dysphagia in 16 per cent, recurrent reflux in 52 per cent (median DeMeester Score 52), or both in 27 per cent. Failure leading to reoperation was due to hiatal failure in 28 per cent, wrap failure in 19 per cent, both in 33 per cent, and slipped Nissen fundoplication in 20 per cent. Laparoscopic reoperations were completed in 49 of 54 patients (91%); 15 had reoperations undertaken via celiotomy. Eighty-eight per cent of reoperations were Nissen fundoplications. With reoperation, Dysphagia Scores improved from 9.5 ± 0.7 to 2.6 ± 2.8, and Reflux Scores improved from 9.1 ± 1.4 to 1.8 ± 2.7. Seventy-nine per cent of patients with reflux prior to reoperation, 100 per cent with dysphagia, and 74 per cent with both noted excellent or good outcomes after reoperation. We conclude that failure after fundoplication occurs. Reoperations reduce the severity of dysphagia and reflux, thus salvaging excellent and good outcomes in most. Laparoscopic reoperations are generally possible. Reoperative fundoplications are effective treatment for dysphagia and recurrent gastroesophageal reflux, and their application is encouraged.
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Affiliation(s)
| | | | - Donald P. Thometz
- From the Department of Surgery, University of South Florida, Tampa, Florida
| | - Odion Binitie
- From the Department of Surgery, University of South Florida, Tampa, Florida
| | | | - Mark Bloomston
- From the Department of Surgery, University of South Florida, Tampa, Florida
| | - Steve G. Goldin
- From the Department of Surgery, University of South Florida, Tampa, Florida
| | - Michael H. Albrink
- From the Department of Surgery, University of South Florida, Tampa, Florida
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32
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Elli EF, Jacobsen G, Horgan S. Endoscopic treatment of gastroesophageal reflux. J Laparoendosc Adv Surg Tech A 2004; 14:244-9. [PMID: 15345166 DOI: 10.1089/lap.2004.14.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The treatment of gastroesophageal reflux (GERD) has improved dramatically in recent years. The new endoluminal treatments may bring a relatively simple, minimally invasive therapy that can be simultaneously applied in patients with GERD undergoing diagnostic upper endoscopy. Although the initial results are promising, these new techniques are generating some controversy and require further evaluation with randomized studies and longer follow-ups to define their precise role in the long-term management of the gastroesophageal reflux disease.
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Affiliation(s)
- Enrique F Elli
- Minimally Invasive Surgery Center, University of Illinois at Chicago, Illinois, USA
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33
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Torquati A, Houston HL, Kaiser J, Holzman MD, Richards WO. Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease. Surg Endosc 2004; 18:1475-9. [PMID: 15791372 DOI: 10.1007/s00464-003-9181-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2003] [Accepted: 03/04/2004] [Indexed: 12/15/2022]
Abstract
BACKGROUND The endoscopic delivery of temperature-controlled radiofrequency energy to the gastroesophageal junction (Stretta procedure) recently has been shown effective for patients with gastroesophageal reflux disease (GERD). However, its effectiveness has been assessed mainly over short periods (6-12 months). This study aimed to evaluate long-term results of the Stretta procedure. METHODS All patients undergoing the Stretta procedure since August 2000 were prospectively evaluated under an institutional review board-approved protocol. All patients with a follow-up period longer than 18 months were recruited for a 24-h pH study and mailed a follow-up survey, which included the following: Short Form 12 (SF-12) health status questionnaire, GERD-specific quality-of-life questionnaire (QOLRAD), and queries regarding long-term satisfaction and medication use. RESULTS The Stretta procedure was performed on 82 patients, and 41 patients with a follow-up period longer than 18 months qualified for the study. Follow-up surveys were completed by 36 patients (88%) during a mean follow-up period of 27.1 +/- 3.7 months. Of these 36 patients, 30 (83%) were highly satisfied with the procedure and would have it performed again. More than half of the Fifty Stretta patients (56%) had completely discontinued their use of proton pump inhibitors (PPIs), and an additional 31% had reduced their dose significantly. The mean PPI equivalent doses were 37.8 +/- 22.2 mg/day before the Stretta procedure and 11.6 +/- 14.6 mg/day at 27-month follow-up assessment (p = 0.001). According to the patient outcomes for daily PPI use (yes/no), the patients were divided into two groups: responders (n = 20) and nonresponders (n = 16). The responder group scored higher in QOLRAD score (p = 0.0001), SF-12 physical score (p = 0.038), and SF-12 mental score (p = 0.003). In the 24-hour pH study, the responder group demonstrated a significant decrease in distal esophageal acid exposure time (6.4% +/- 1.5% to 3.1% +/- 1.4%; p = 0.0001). CONCLUSION The Stretta procedure results in a statistical significant long-term decrease in GERD symptoms and PPI use. The treatment effect is durable beyond 2 years, and 56% of patients had discontinued their user of all antisecretory drugs.
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Affiliation(s)
- A Torquati
- Department of Surgery, Vanderbilt University Medical Center, D-5219 MCN, Nashville, TN 37232, USA
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Lutfi RE, Torquati A, Richards WO. Endoscopic treatment modalities for gastroesophageal reflux disease. Surg Endosc 2004; 18:1299-315. [PMID: 15803228 DOI: 10.1007/s00464-003-8292-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Accepted: 03/04/2004] [Indexed: 02/08/2023]
Abstract
A debate has been going for decades between surgeons and gastroenterologists about the treatment of choice for gastroesophageal reflux disease (GERD). The lower esophageal sphincter (LES) has been historically far from the reach of gastroenterologists, who adopted the symptomatic treatment as their approach to reflux disease through reduction of gastric acid. As for surgeons, reaching the LES was only possible by invading the thoracic or abdominal cavity. Although their approach was later refined to become "minimally" invasive, it was still deemed too invasive by others to allow it to be the "gold standard." Simple logic should lead one to think about the "natural route" as the easiest way to reach the LES. This concept has opened the door for the new era of GERD treatment through "endoscopic modality." Seven different techniques are currently being used to treat patients with GERD. We review the mechanism of action, potential side effects, efficacy, durability, and results from the most recent or largest experience of each. This review shows that endoscopic treatment has definitely earned its place as a viable option for GERD treatment in selected patients. With the available data from clinical trials, it is not possible to determine the best modality available, and the endoscopic treatment of choice is to be determined with further studies.
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Affiliation(s)
- R E Lutfi
- Department of Surgery, Vanderbilt University School of Medicine, D 5203 MCN, Nashville, TN 37232-2577, USA
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Schumacher B, Neuhaus H. [Endoscopic therapy methods for gastroesophageal reflux]. Chirurg 2004; 76:359-69. [PMID: 15232692 DOI: 10.1007/s00104-004-0907-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastroesophageal reflux disease (GERD) is prevalent in 10% of the population. In addition to the established therapy, endoscopic antireflux procedures have been developed to improve the gastroesophageal reflux barrier. This can achieved by endoscopically placed sutures, application of radio frequency energy, or injection of biocompatible materials. These new techniques might be effective in some patients with GERD. To date, there are limited data on the effectiveness and safety of these methods. During a follow-up of 1-2 years, subjective parameters improved in 70-75% of the test patients such that no antisecretory treatment was required. Further, randomized, placebo-controlled studies are needed for objective evaluation of these promising new methods.
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Lutfi RE, Torquati A, Richards WO. The endoscopic radiofrequency approach to management of GERD. Curr Opin Otolaryngol Head Neck Surg 2004; 12:191-6. [PMID: 15167028 DOI: 10.1097/01.moo.0000122307.13359.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Endoscopic treatment has been recently introduced as a new option for treating gastroesophageal reflux disease. In this article the authors review the radiofrequency approach known as the Stretta procedure, as more evidence has linked reflux to upper airway disease. RECENT FINDINGS Since 1968, when laryngeal disorders were linked to gastroesophageal reflux disease, more upper airway diseases such as chronic laryngitis, subglottic stenosis, and even laryngeal carcinoma were found to be occasionally caused by extraesophageal reflux. Most otolaryngologists treat these patients with proton pump inhibitors, which improve symptoms in two thirds of patients. Antireflux surgery remains the treatment of choice, relieving symptoms in more than 90% of patients. Endoscopic treatment has recently emerged as an option for treatment of gastroesophageal reflux disease. The Stretta procedure delivers radiofrequency energy to the gastroesophageal junction. This has proved to be effective in controlling reflux by inhibiting transient, inappropriate lower esophageal sphincter relaxation, increasing postprandial lower esophageal spincter pressure, and decreasing lower esophageal sphincter compliance. Stretta is among the earliest endoscopic technologies to be approved by the Food and Drug Administration for the treatment of reflux. It has the longest term follow-up published to this date, and the most durable effect. It is performed under intravenous sedation on an outpatient basis and has a low incidence of complications. SUMMARY The Stretta procedure is an endoscopic, noninvasive modality for the treatment of gastroesophageal reflux disease. It should be considered in the treatment of reflux-related upper airway diseases.
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Affiliation(s)
- Rami E Lutfi
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Abstract
The Stretta procedure is a noninvasive alternative for individuals suffering from gastroesophageal reflux disease, the most common disorder of the digestive tract. Over 40% of the population reports symptoms of reflux. Primary treatment is medication therapy with proton pump inhibitors and lifestyle changes. For patients whose symptoms have not been adequately controlled by proton-pump inhibitors or those unwilling to take medication indefinitely, surgery has been the only option. Laparoscopic Nissen fundoplication is the most common surgery for reflux. Recently, noninvasive options have been studied. This article discusses the Stretta procedure, the application of radiofrequency energy to the lower esophageal sphincter. The Stretta procedure is performed in conjunction with an esophagogastroduodenoscopy under conscious sedation in the endoscopy lab.
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Abstract
While medical therapy, particularly with proton pump inhibitors, is effective for the large majority of patients with reflux disease, there remains a subset of patients who are dissatisfied, due to cost, side effects of medications, or persistent symptoms such as regurgitation. For this population, surgical fundoplication has been, and remains, an appropriate option. A new class of endoluminal interventions, attempting to create a mechanical antireflux barrier, has emerged recently. Three such devices are currently approved and available, and a number of others are in various stages of evaluation. This article will review the approved technologies, as well as selected promising emerging ones. with particular emphasis on the scientific evidence available to date supporting their efficacy.
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Affiliation(s)
- Brian W Behm
- East Bay Center for Digestive Health, 3300 Webster Street, Suite 312, Oakland, CA 94609, USA
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Freston JW, Triadafilopoulos G. Review article: approaches to the long-term management of adults with GERD-proton pump inhibitor therapy, laparoscopic fundoplication or endoscopic therapy? Aliment Pharmacol Ther 2004; 19 Suppl 1:35-42. [PMID: 14725577 DOI: 10.1111/j.0953-0673.2004.01837.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The goals of gastro-oesophageal reflux disease (GERD) treatment are to control symptoms, heal the injured oesophageal mucosa, and prevent complications. Pharmacological therapy is effective in producing acute symptom relief and mucosal healing, as well as the long-term maintenance of remission. Proton pump inhibitors are the mainstay of GERD therapy. However, the need for daily administration, failure to provide complete symptom relief and costs of these agents may limit their use in some patients, prompting a consideration of alternative treatment strategies. Laparoscopic fundoplication may achieve symptom relief and healing of the oesophagitis in these individuals, but its invasiveness, cost and inherent surgical risks have created an interest in endoscopic therapies for GERD, with several emerging during the past few years. These interventions may either be viewed as an alternative therapy or as 'bridge' therapy, with patients still choosing to be treated with acid anti-secretory drugs or fundoplication if the endoscopic procedure fails to provide adequate symptom relief or if symptoms recur. Patient selection is critical for the success of fundoplication as well as endoscopic procedures, with ideal candidates being those with well-established endoscopically documented GERD, abnormal pH monitoring, normal oesophageal motility studies, and who have experienced at least partial symptom relief with proton pump inhibitor therapy. Hiatal hernia is not a contra-indication to fundoplication, while endoscopic intervention is best suited for those with a hiatal hernia of less than 3 cm in length. The long-term efficacy, cost-effectiveness, and impact of endoscopic procedures on extra-oesophageal manifestations of GERD and risk for GERD-related complications has not been determined.
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Affiliation(s)
- J W Freston
- University of Connecticut Health Center, Farmington Avenue, Farmington, CT 06030-1111, USA.
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Abstract
Gastro-oesophageal reflux disease represents an extremely common disorder which has a substantial impact on patients' quality of life and use of health care resources. Gastro-oesophageal reflux disease is a chronic relapsing disease for which a lifelong solution is needed. Until now the two competing therapeutic modalities have been the medical and surgical therapies. Quite recently a third option has become available. A number of endoscopic anti-reflux procedures have been described, with the common goal of creating an anti-reflux barrier, thus obviating long-term proton pump inhibitors and the cost and potential risk of laparoscopic Nissen fundoplication. In this review the different techniques are thoroughly examined and the results are critically evaluated, giving special emphasis to efficacy, safety and durability of these new anti-reflux procedures. Available data show that these anti-reflux techniques produce significant improvement in gastro-oesophageal reflux disease symptomatology and quality of life as well as reduce the use of anti-reflux medication, without causing serious morbidity or mortality. However, the majority of these techniques have failed to adequately control oesophageal acid reflux. Endoscopic anti-reflux therapies therefore sound very attractive-being less invasive than surgery-and show a significant promise, but are still in the early stages of assessment. Large-scale randomized multi-centre trials comparing control groups with sham procedures are essential to confirm their efficacy. Further studies are also necessary to determine what modifications these techniques require in order to produce maximum clinical efficacy and durability. However, considering that current therapies (both medical and surgical) of gastro-oesophageal reflux disease are highly effective, the need for such new endoscopic modalities may be questionable. Moreover, appropriate trials in dedicated centres should be carried out to assure that the enthusiasm commonly associated with new technology is justified and can be generalized to open-access endoscopists.
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Affiliation(s)
- S Contini
- Department of Surgery, School of Medicine and Dentistry, University of Parma, Parma, Italy.
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Abstract
The Stretta procedure is increasingly offered as first-line therapy before more invasive surgical procedures for selected patients with gastroesophageal reflux disease (GERD). Although a new addition to the clinical armamentarium, thus far the Stretta procedure appears to be a safe and effective technology for the treatment of GERD, with well-documented clinical trial data supporting its efficacy, safety, and patient satisfaction.
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Richards WO, Houston HL, Torquati A, Khaitan L, Holzman MD, Sharp KW. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg 2003; 237:638-47; discussion 648-9. [PMID: 12724630 PMCID: PMC1514514 DOI: 10.1097/01.sla.0000064358.25509.36] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). SUMMARY BACKGROUND DATA The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. METHODS All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. RESULTS Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. CONCLUSIONS The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.
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[Endoscopic (endoluminal) treatment of gastroesophageal reflux disease]. ANNALES DE CHIRURGIE 2003; 128:225-31. [PMID: 12853018 DOI: 10.1016/s0003-3944(03)00090-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New endoscopic (endoluminal) methods have been developed recently for the treatment of gastroesophageal reflux disease. The options are endoluminal gastroplasty, delivery of radiofrequency to the lower oesophagus reducing transient relaxation of the lower sphincter, or implantation of polymer in the lower oesophagus. The respective results of these procedures are detailed and discussed. The lack of long term follow-up and the number of procedures do not allow to validate the endoluminal procedures which remain in the field of clinical research. When the medical treatment fails or in case of complication, the glod standard is still the laparoscopic fundoplication. But it is possible in the future that one or more endoluminal techniques could change the management of reflux disease.
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