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Harwani Y, Butala S, More B, Shukla V, Patel A. Endoscopic full-thickness plication along with argon plasma coagulation for treatment of proton pump inhibitor dependent gastroesophageal reflux disease. World J Gastrointest Endosc 2024; 16:250-258. [PMID: 38813575 PMCID: PMC11130550 DOI: 10.4253/wjge.v16.i5.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/28/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Most endoscopic anti-reflux interventions for gastroesophageal reflux disease (GERD) management are technically challenging to practice with inadequate data to support it utility. Therefore, this study was carried to evaluate the effectiveness and safety newer endoscopic full-thickness fundoplication (EFTP) device along with Argon Plasma Coagulation to treat individuals with GERD. AIM To evaluate the effectiveness and safety newer EFTP device along with Argon Plasma Coagulation to treat individuals with GERD. METHODS This study was a single-center comparative analysis conducted on patients treated at a Noble Institute of Gastroenterology, Ahmedabad, hospital between 2020 and 2022. The research aimed to retrospectively analyze patient data on GERD symptoms and proton pump inhibitor (PPI) dependence who underwent EFTP using the GERD-X system along with argon plasma coagulation (APC). The primary endpoint was the mean change in the total gastroesophageal reflux disease health-related quality of life (GERD-HRQL) score compared to the baseline measurement at the 3-month follow-up. Secondary endpoints encompassed enhancements in the overall GERD-HRQL score, improvements in GERD symptom scores at the 3 and changes in PPI usage at the 3 and 12-month time points. RESULTS In this study, patients most were in Hill Class II, and over half had ineffective esophageal motility. Following the EFTP procedure, there were significant improvements in heartburn and regurgitation scores, as well as GERD-HRQL scores (P < 0.001). PPI use significantly decreased, with 82.6% not needing PPIs or prokinetics at end of 1 year. No significant adverse events related to the procedures were observed in either group. CONCLUSION The EFTP along with APC procedure shows promise in addressing GERD symptoms and improving patients' quality of life, particularly for suitable candidates. Moreover, the application of a lone clip with APC yielded superior outcomes and exhibited greater cost-effectiveness.
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Affiliation(s)
- Yogesh Harwani
- Department of Gastroenterology, Nobel Gastro Hospital, Ahmedabad 408409, Gujarat, India
| | - Shreya Butala
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Balaji More
- Department of Pharmacology, Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, Puducherry, India
| | - Varun Shukla
- Department of Gastroenterology, Noble Institute of Gastroenterology, Ahmedabad 380009, Gujrat, India
| | - Anand Patel
- Department of Gastroenterology, Noble Institute of Gastroenterology, Ahmedabad 380009, Gujrat, India
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Kalapala R, Karyampudi A, Nabi Z, Darisetty S, Jagtap N, Ramchandani M, Gupta R, Lakhtakia S, Goud R, Venkat Rao G, Sharma P, Reddy DN. Endoscopic full-thickness plication for the treatment of PPI-dependent GERD: results from a randomised, sham controlled trial. Gut 2022; 71:686-694. [PMID: 33849942 PMCID: PMC8921577 DOI: 10.1136/gutjnl-2020-321811] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The majority of endoscopic antireflux procedures for GERD are cumbersome to use and randomised long-term data are sparse. We conducted such a trial to determine the efficacy and safety of a novel, easy to use endoscopic full-thickness fundoplication (EFTP) device in patients with GERD. DESIGN Patients with proton pump inhibitor (PPI)-dependent GERD were randomised to either EFTP or a sham procedure in 1:1 ratio. The primary endpoint was ≥50% improvement in the health-related quality of life (GERD-HRQL) score at 3 months. Secondary end points included improvement in GERD-HRQL, reflux symptom scores, PPI usage, oesophageal acid exposure and reflux episodes and endoscopic findings at 3, 6 and 12 months. RESULTS Seventy patients were randomised; 35 in each group with a median (IQR) age of 36 (29-42) years, 71.4% males. 70% had non-erosive reflux disease on endoscopy with a mean DeMeester score of 18.9 (±19.93). The mean (±SD) duration of EFTP procedure was 17.4 (±4) min. The primary end point was more frequently achieved in the EFTP group (65.7% vs 2.9%; p<0.001). Median (IQR) % improvement in GERD-HRQL was significantly higher in the EFTP group at 6 (81.4 (60.9-100.0) versus 8.0 (2.2-21.6); p<0.001) and 12 (92.3 (84.4-100.0) versus 9.1 (4.8-36.0); p<0.001) months. In the EFTP group, 62.8% patients were off-PPI at 12 months compared with 11.4% in the sham group (p<0.001). pH-metry parameters partially improved at 3 months, (n=70; total reflux episodes in EFTP arm and non-acid reflux episodes for EFTP vs sham) but not at 12 months (n=27); endoscopic oesophagitis was seen in 0% in the treatment (n=18) and 5 (29.4%) in the control group (n=17) at 12 months. No major procedure-related adverse events were encountered in either group. CONCLUSION EFTP using a novel device is safe and effective in improving quality of life in patients with PPI dependent mostly non-erosive reflux disease at short and long terms; objective parameters showed a limited response rate. TRIAL REGISTRATION NUMBER NCT03322553.
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Affiliation(s)
- Rakesh Kalapala
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Arun Karyampudi
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Santosh Darisetty
- Anaesthesia, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nitin Jagtap
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Gastroenterology, Asian Institute of Gastroenetrology, Hyderabad, Andhra Pradesh, India
| | - Rajesh Gupta
- Asian Institute of Gatroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Gastroenterology, Asian Institute of Gastroenetrology, Hyderabad, Andhra Pradesh, India
| | - Rajesh Goud
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - G Venkat Rao
- Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - D Nageshwar Reddy
- Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, Andhra Pradesh, India
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3
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Abstract
Minimally invasive endoscopic antireflux therapies are critical for bridging the gap between medical and surgical treatments for gastroesophageal reflux disease (GERD). Although multiple endoscopic devices have been developed, perhaps some of the most exciting options that are currently evolving are the full-thickness suturing techniques using widely available and low-cost platforms. Full-thickness endoscopic suturing can allow for a highly durable recreation of the anatomic and functional components of a lower esophageal sphincter, which are deficient in patients with GERD. Proper patient selection, endoscopic hiatal hernia evaluation, and standardized suturing methods are necessary to ensure success of endoscopic suturing for antireflux therapy.
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Iwakiri K, Kinoshita Y, Habu Y, Oshima T, Manabe N, Fujiwara Y, Nagahara A, Kawamura O, Iwakiri R, Ozawa S, Ashida K, Ohara S, Kashiwagi H, Adachi K, Higuchi K, Miwa H, Fujimoto K, Kusano M, Hoshihara Y, Kawano T, Haruma K, Hongo M, Sugano K, Watanabe M, Shimosegawa T. Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015. J Gastroenterol 2016; 51:751-67. [PMID: 27325300 DOI: 10.1007/s00535-016-1227-8] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 02/04/2023]
Abstract
As an increase in gastroesophageal reflux disease (GERD) has been reported in Japan, and public interest in GERD has been increasing, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009. Six years have passed since its publication, and there have been a large number of reports in Japan concerning the epidemiology, pathophysiology, treatment, and Barrett's esophagus during this period. By incorporating the contents of these reports, the guidelines were completely revised, and a new edition was published in October 2015. The revised edition consists of eight items: epidemiology, pathophysiology, diagnosis, internal treatment, surgical treatment, esophagitis after surgery of the upper gastrointestinal tract, extraesophageal symptoms, and Barrett's esophagus. This paper summarizes these guidelines, particularly the parts related to the treatment for GERD. In the present revision, aggressive proton pump inhibitor (PPI) maintenance therapy is recommended for severe erosive GERD, and on-demand therapy or continuous maintenance therapy is recommended for mild erosive GERD or PPI-responsive non-erosive GERD. Moreover, PPI-resistant GERD (insufficient symptomatic improvement and/or esophageal mucosal break persisting despite the administration of PPI at a standard dose for 8 weeks) is defined, and a standard-dose PPI twice a day, change in PPI, change in the PPI timing of dosing, addition of a prokinetic drug, addition of rikkunshito (traditional Japanese herbal medicine), and addition of histamine H2-receptor antagonist are recommended for its treatment. If no improvement is observed even after these treatments, pathophysiological evaluation with esophageal impedance-pH monitoring or esophageal manometry at an expert facility for diseases of the esophagus is recommended.
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Affiliation(s)
- Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Sendagi 1-1-5, Bunkyo-ku, Tokyo, 113-8603, Japan. .,Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan.
| | - Yoshikazu Kinoshita
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Yasuki Habu
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Tadayuki Oshima
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Noriaki Manabe
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Yasuhiro Fujiwara
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Akihito Nagahara
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Osamu Kawamura
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Ryuichi Iwakiri
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Soji Ozawa
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kiyoshi Ashida
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Shuichi Ohara
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Hideyuki Kashiwagi
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kyoichi Adachi
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kazuhide Higuchi
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Hiroto Miwa
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kazuma Fujimoto
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Motoyasu Kusano
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Yoshio Hoshihara
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Tatsuyuki Kawano
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Ken Haruma
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Michio Hongo
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kentaro Sugano
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the "Evidence-based Clinical Practice Guidelines for Gastroesophageal Reflux Disease", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
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5
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Abstract
Over the past 2 decades, a number of new endoscopic techniques have been developed for management of gastroesophageal (GE) reflux disease symptoms as alternatives to medical management and surgical fundoplication. These devices include application of radiofrequency treatment (Stretta), endoscopic plication (EndoCinch, Plicator, Esophyx, MUSE), and injection of bulking agents (Enteryx, Gatekeeper, Plexiglas, Duragel). Their goal was symptom relief through reduction of tissue compliance and enhancement of anatomic resistance at the GE junction. In this review, we critically assess the research behind the efficacy, safety, and durability of these treatments to better understand their roles in contemporary GE reflux disease management.
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Schwartz MP, Schreinemakers JRC, Smout AJPM. Four-year follow-up of endoscopic gastroplication for the treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther 2013; 4:120-126. [PMID: 24199028 PMCID: PMC3817287 DOI: 10.4292/wjgpt.v4.i4.120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 10/09/2013] [Accepted: 10/16/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the long-term effect of Endocinch treatment for gastroesophageal reflux disease (GERD).
METHODS: After unblinding and crossover, 50 patients (32 males, 18 females; mean age 46 years) with pH-proven chronic GERD were recruited from an initial randomized, placebo-controlled, single-center study, and included in the present prospective open-label follow-up study. Initially, three gastroplications using the Endocinch device were placed under deep sedation in a standardized manner. Optional retreatment was offered in the first year with 1 or 2 extra gastroplications. At baseline, 3 mo after (re) treatment and yearly proton pump inhibitor (PPI) use, GERD symptoms, quality of life (QoL) scores, adverse events and treatment failures (defined as: patients using > 50% of their baseline PPI dose or receiving alternative antireflux therapy) were assessed. Intention-to-treat analysis was performed.
RESULTS: Median follow-up was 48 mo [interquartile range (IQR): 38-52]. Three patients were lost to follow-up. In 44% of patients retreatment was done after a median of 4 mo (IQR: 3-8). No serious adverse events occurred. At the end of follow-up, symptom scores and 4 out of 6 QoL subscales were improved (all P < 0.01 compared to baseline). However, 80% of patients required PPIs for their GERD symptoms. Ultimately, 64% of patients were classified as treatment failures. In 60% a post-procedural endoscopy was carried out, of which in 16% reflux esophagitis was diagnosed.
CONCLUSION: In the 4-year follow-up period, the subset of GERD patients that benefit from endoscopic gastroplication kept declining gradually, nearly half opted for retreatment and 80% required PPIs eventually.
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Woodland P, Amarasinghe G, Sifrim D. Emerging therapeutic options in GERD. Best Pract Res Clin Gastroenterol 2013; 27:455-67. [PMID: 23998982 DOI: 10.1016/j.bpg.2013.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 06/16/2013] [Accepted: 06/23/2013] [Indexed: 01/31/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a prevalent problem resulting in a high level of healthcare consultation and expenditure in the Western World. Although standard medical therapy (in the form of proton pump inhibitor drugs) is effective in the majority of cases, there remains a significant proportion who are refractory to treatment. In addition, surgical therapy (in the form of laparoscopic fundoplication) is not always effective, and in some can be associated with significant side-effects, particularly gas-bloat, flatulence and dysphagia. As such there remains an unmet need in GERD to develop new therapies for refractory cases, and to develop alternatives to fundoplication with fewer side-effects. This article discusses the current state of pharmacological and non-pharmacological emerging therapies for GERD.
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Affiliation(s)
- Philip Woodland
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Tokudome K, Funaki Y, Sasaki M, Izawa S, Tamura Y, Iida A, Ogasawara N, Konagaya T, Tokura Y, Kasugai K. Efficacy of endoluminal gastroplication in Japanese patients with proton pump inhibitor-resistant, non-erosive esophagitis. World J Gastroenterol 2012; 18:5940-7. [PMID: 23139611 PMCID: PMC3491602 DOI: 10.3748/wjg.v18.i41.5940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 07/16/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy, safety, and long-term outcomes of endoluminal gastroplication (ELGP) in patients with proton pump inhibitor (PPI)-resistant, non-erosive reflux disease (NERD).
METHODS: The subjects were NERD patients, diagnosed by upper endoscopy before PPI use, who had symptoms such as heartburn or reflux sensations two or more times a week even after 8 wk of full-dose PPI treatment. Prior to ELGP, while continuing full-dose PPI medication, patients’ symptoms and quality of life (QOL) were assessed using the questionnaire for the diagnosis of reflux disease, the frequency scale for symptoms of gastro-esophageal reflux disease (FSSG), gastrointestinal symptoms rating scale, a 36-item short-form. In addition, 24-h esophageal pH monitoring or 24-h intraesophageal pH/impedance (MII-pH) monitoring was performed. The Bard EndoCinchTM was used for ELGP, and 2 or 3 plications were made. After ELGP, all acid reducers were temporarily discontinued, and medication was resumed depending on the development and severity of symptoms. Three mo after ELGP, symptoms, QOL, pH or MII-pH monitoring, number of plications, and PPI medication were evaluated. Further, symptoms, number of plications, and PPI medication were evaluated 12 mo after ELGP to investigate long-term effects.
RESULTS: The mean FSSG score decreased significantly from before ELGP to 3 and 12 mo after ELGP (19.1 ± 10.5 to 10.3 ± 7.4 and 9.3 ± 9.9, P < 0.05, respectively). The total number of plications decreased gradually at 3 and 12 mo after ELGP (2.4 ± 0.8 to 1.2 ± 0.8 and 0.8 ± 1.0, P < 0.05, respectively). The FSSG scores in cases with no remaining plications and in cases with one or more remaining plications were 4.4 and 2.7, respectively, after 3 mo, and 2.0 and 2.8, respectively, after 12 mo, showing no correlation to plication loss. On pH monitoring, there was no difference in the percent time pH < 4 from before ELGP to 3 mo after. Impedance monitoring revealed no changes in the number of reflux episodes or the symptom index for reflux events from before ELGP to 3 mo after, but the symptom sensitivity index decreased significantly 3 mo after ELGP (16.1 ± 12.9 to 3.9 ± 8.3, P < 0.01). At 3 mo after ELGP, 6 patients (31.6%) had reduced their PPI medication by 50% or more, and 11 patients (57.9%) were able to discontinue PPI medication altogether. After 12 mo, 3 patients (16.7%) were able to reduce the amount of PPI medication by 50% or more, and 12 patients (66.7%) were able to discontinue PPI medication altogether. A high percentage of cases with remaining plications had discontinued PPIs medication after 3 mo, but there was no difference after 12 mo. No serious complications were observed in this study.
CONCLUSION: ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term in patients with PPI-refractory NERD.
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Narsule CK, Wee JO, Fernando HC. Endoscopic management of gastroesophageal reflux disease: a review. J Thorac Cardiovasc Surg 2012; 144:S74-9. [PMID: 22513318 DOI: 10.1016/j.jtcvs.2012.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 11/02/2011] [Accepted: 03/12/2012] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease is the most common esophageal disorder encountered in the United States. Gastroesophageal reflux disease symptoms are associated with a negative quality of life and increased healthcare costs and therefore require an effective management strategy. Although proton pump inhibitors remain the primary treatment of gastroesophageal reflux disease, they do not cure the disorder and can leave patients with persistent symptoms despite treatment. Moreover, patients are still at risk of developing such complications as peptic strictures, Barrett's metaplasia, and esophageal cancer. Although laparoscopic Nissen fundoplication has been the conventional alternative treatment for those patients who develop complications of gastroesophageal reflux disease, have intractable symptoms, or wish to discontinue taking proton pump inhibitors, investigators have persisted in developing a number of endoscopic approaches to the treatment of gastroesophageal reflux disease. The present report reviews the history of endoscopic treatments devised for the management of gastroesophageal reflux disease and explores the published data and outcomes associated with the latest approach-endoscopic fundoplication using the EsophyX2 device.
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Affiliation(s)
- Chaitan K Narsule
- Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, MA, USA
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Zagol B, Mikami D. Advances in transoral fundoplication for oesophageal reflux. Dig Liver Dis 2011; 43:361-4. [PMID: 21382755 DOI: 10.1016/j.dld.2011.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 01/04/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this review was to evaluate transoral fundoplication devices for gastro-oesophageal reflux disease that have been commercially available within the last 5 years. METHODS Literature databases including Medline and Pubmed were searched from January 2005 to November 2010. Both blinded and unblinded randomized studies were evaluated. RESULTS We reviewed the literature for evaluations of primary transoral endoluminal fundoplication devices which included EndoCinch, NDO Plicator, Esophyx, and Stretta. Reviews of all studies with greater than 20 patients were evaluated to assess the efficacy and safety of transoral fundoplication devices. These endoluminal devices were primary matched against sham procedures. The EndoCinch and Stretta procedures were the only devices compared to laparoscopic fundoplication, the current standard for surgical management of gastro-oesophageal reflux disease. CONCLUSION The field of endoluminal treatment of gastro-oesophageal reflux disease has gained popularity over the last several years. Endoluminal treatment of gastro-oesophageal reflux disease has been shown to be safe and effective in recent studies. We still believe more randomized prospective studies need to be carried out to determine if endoluminal therapies will be a durable option for patients with gastro-oesophageal reflux disease. Continuing research will further the advancement of endoluminal gastro-oesophageal reflux disease procedures in the future.
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Affiliation(s)
- Bradley Zagol
- Division of General Surgery, The Ohio State University Hospitals, Columbus, OH, United States
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St. Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg 2011; 46:163-8. [PMID: 21238659 PMCID: PMC3097032 DOI: 10.1016/j.jpedsurg.2010.09.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. METHODS After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. RESULTS One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) CONCLUSIONS Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
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Affiliation(s)
- Shawn D. St. Peter
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA,Corresponding author. Department of Surgery, Center for Prospective Clinical Trials, Children’s Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. S.D. St. Peter
| | | | | | - KuoJen Tsao
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | | | - Susan W. Sharp
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Donna Bartle
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
| | - Tracey Morgan
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
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Louis H, Devière J. Ensocopic-endoluminal therapies. A critical appraisal. Best Pract Res Clin Gastroenterol 2010; 24:969-79. [PMID: 21126708 DOI: 10.1016/j.bpg.2010.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 10/07/2010] [Indexed: 02/06/2023]
Abstract
Due to its large prevalence, gastro-oesophageal reflux disease is an ideal target for companies developing medical devices designed to cure reflux. Indeed, because medications leave part of the patients unsatisfied, there is a potential place for alternative therapies, capable of restoring an efficacious anti-reflux barrier, but without the drawbacks of surgery. For more than a decade, several novel endoluminal therapies were developed, clinically evaluated, put on the market and, for many of them, withdrawn due to economic considerations, lack of efficacy or complications. These therapies were designed to act on the gastro-oesophageal junction and reinforce mechanically the anti-reflux barrier by three different ways: suturing, radiofrequency energy application, or implantation of foreign materials. Most of the published data come from open uncontrolled studies with short-term enthusiastic results. There are a few randomized control trials assessing the true efficacy of these modalities, showing often less impressive results than the open studies did, due to a high placebo effect in mild gastro-oesophageal reflux disease. Although endoscopic treatment of gastro-oesophageal disease is still an interesting topic of investigation, one can draw some lessons from the recent experiences and foresee which place these techniques could find in the management of patients suffering from reflux.
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Affiliation(s)
- Hubert Louis
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Gastroesophageal reflux disease: medical or surgical treatment? Gastroenterol Res Pract 2009; 2009:371580. [PMID: 20069112 PMCID: PMC2804043 DOI: 10.1155/2009/371580] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 10/14/2009] [Accepted: 10/26/2009] [Indexed: 12/14/2022] Open
Abstract
Background. Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease. Methods and Results. Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients. Conclusion. Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases.
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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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Ozawa S, Kumai K, Higuchi K, Arakawa T, Kato M, Asaka M, Katada N, Kuwano H, Kitajima M. Short-term and long-term outcome of endoluminal gastroplication for the treatment of GERD: the first multicenter trial in Japan. J Gastroenterol 2009; 44:675-84. [PMID: 19440812 DOI: 10.1007/s00535-009-0064-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Accepted: 03/13/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Endoluminal gastroplication (ELGP) was the first endoscopic therapy for gastroesophageal reflux disease (GERD). Data on the long-term outcomes, including the plication status and data from Asian populations, are limited. The aim of this study was to evaluate the short-term and long-term effectiveness and safety of ELGP for GERD in the Japanese population. METHODS This was an open-label, prospective, multicenter trial of ELGP. Forty-eight patients with GERD were enrolled. The procedure involved placing circumferential plications 1-2 cm below the GE junction using the EndoCinch system. Outcome measurements were improvement of heartburn, medication use, endoscopic Los Angeles grade, durability of plications, 24-h esophageal acid exposure, esophageal manometry, and frequency of adverse events. RESULTS During the 24-month follow-up, the rate of complete resolution of heartburn ranged from 54 to 66%, the rate of discontinuation or reduction of PPI/H2RA use ranged from 65 to 76%, and the rate of endoscopic classification to grade O ranged from 66 to 81%. The status with more than one plication remaining was associated with higher rates of improvement of heartburn, PPI/H2RA use, and endoscopic findings as compared with those associated with the loss of all plications. A modest decrease of the esophageal acid exposure level, but no change of the manometric parameters, was observed after ELGP. No serious adverse events were observed. CONCLUSIONS In this 24-month follow-up study conducted in Japanese subjects, ELGP was found to be effective in about 60% of patients with GERD, and the procedure was safe.
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Affiliation(s)
- Soji Ozawa
- Department of General and Gastrointestinal Surgery, School of Medicine, Fujita Health University, 3-6-10 Otobashi, Nakagawa-ku, Nagoya, Aichi, 454-8509, Japan.
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Abstract
PURPOSE OF REVIEW We critically analyze existing endoscopy-based interventions for gastroesophageal reflux disease (GERD). The focus is on the effectiveness of available procedures and to delineate goals for future research. RECENT FINDINGS Recent evaluations of the EndoCinch system reveal poor long-term results and no significant improvement over sham therapy due to poor apposition of mucosa with stitches. Recent studies with transoral incisionless fundoplication demonstrate improvement in GERD symptoms, quality of life, esophageal acid exposure, esophagitis, resting lower esophageal sphincter pressure and medication use. The SRS endoscopic stapling system creates a partial fundoplication wrap, and a preliminary study demonstrated improved symptoms and acid exposure. The Stretta system delivers radiofrequency energy to the gastroesophageal junction. A large prospective series demonstrates sustained improvement in GERD symptoms, quality of life and proton pump inhibitor therapy elimination after radiofrequency ablation at the gastroesophageal junction. A sham-controlled study showed improvement in symptoms at 6 months. SUMMARY EndoCinch plication requires further study and modification of technique before it can be recommended for general clinical use. Transoral incisionless fundoplication is a very promising procedure in its early stages of development. Further evaluation of procedure safety and durability is needed. Radiofrequency ablation therapy has been reintroduced and may have potential in patients with refractory GERD.
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von Renteln D, Schiefke I, Fuchs KH, Raczynski S, Philipper M, Breithaupt W, Caca K, Neuhaus H. Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease using multiple Plicator implants: 12-month multicenter study results. Surg Endosc 2009; 23:1866-75. [PMID: 19440792 DOI: 10.1007/s00464-009-0490-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 02/23/2009] [Accepted: 03/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND The full-thickness Plicator (Ethicon Endosurgery, Sommerville, NJ, USA) was developed for endoscopic treatment of gastroesophageal reflux disease (GERD). The goal is to restructure the antireflux barrier by delivering transmural pledgeted sutures through the gastric cardia. To date, studies using this device have involved the placement of a single suture to create the plication. The purpose of this study was to evaluate the 12-month safety and efficacy of this procedure using multiple implants to restructure the gastroesophageal (GE) junction. METHODS A multicenter, prospective, open-label trial was conducted at four tertiary centers. Eligibility criteria included symptomatic GERD [GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire, off of medication], and pathologic reflux (abnormal 24-h pH) requiring daily proton pump inhibitor therapy. Patients with Barrett's epithelium, esophageal dysmotility, hiatal hernia > 3 cm, and esophagitis (grade III or greater) were excluded. All patients underwent endoscopic full-thickness plication with linear placement of at least two transmural pledgeted sutures in the anterior gastric cardia. RESULTS Forty-one patients were treated. Twelve months post treatment, 74% of patients demonstrated improvement in GERD-HRQL scores by > or = 50%, with mean decrease of 17.6 points compared with baseline (7.8 vs. 25.4, p < 0.001). Using an intention-to-treat model, 63% of patients had symptomatic improvements of > or = 50%, with mean GERD-HRQL decrease of 15.0 (11.0 vs. 26.0, p < 0.001). The need for daily proton pump inhibitor (PPI) therapy was eliminated in 69% of patients at 12 months on a per-protocol basis, and 59% on an intention-to-treat basis. Adverse events included postprocedure abdominal pain (44%), shoulder pain (24%), and chest pain (17%). No long-term adverse events occurred. CONCLUSIONS Endoscopic full-thickness plication using multiple Plicator implants can be used safely and effectively to improve GERD symptoms and reduce medication use.
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Affiliation(s)
- D von Renteln
- Department of Gastroenterology, Hepatology and Oncology, Klinikum Ludwigsburg, Teaching Hospital of the Heidelberg University, Ludwigsburg, Germany.
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Chen D, Barber C, McLoughlin P, Thavaneswaran P, Jamieson GG, Maddern GJ. Systematic review of endoscopic treatments for gastro-oesophageal reflux disease. Br J Surg 2009; 96:128-36. [PMID: 19160349 DOI: 10.1002/bjs.6440] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this review was to assess the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease. METHODS Literature databases including Medline, Embase and PubMed were searched up to May 2006 without language restriction. Randomized controlled trials and non-randomized comparative studies with at least ten patients in each study arm, and case series studies of at least ten patients, were included. RESULTS A total of 33 studies examining seven endoscopic procedures (Stretta procedure, Bard EndoCinch, Wilson-Cook Endoscopic Suturing Device, NDO Plicator, Enteryx, Gatekeeper Reflux Repair System and Plexiglas) were included in the review. Of the three procedures that were tested against sham controls (Stretta procedure, Bard EndoCinch and Enteryx), patient outcomes in the treatment group were either as good as, or significantly better than, those of control patients in terms of heartburn symptoms, quality of life and medication usage. However, for the two procedures that were tested against laparoscopic fundoplication (Stretta) procedure and Bard EndoCinch), outcomes for patients in the endoscopic group were either as good as, or inferior to, those for the laparoscopic group. CONCLUSION At present there is insufficient evidence to determine the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease, particularly in the long term.
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Affiliation(s)
- D Chen
- Department of Surgery, University of Adelaide and The Queen Elizabeth Hospital, South Australia, Australia
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Abstract
Approximately 20% of patients with gastroesophageal reflux disease (GERD) have symptoms refractory to long-term proton pump inhibitor (PPI) therapy. Furthermore, PPI therapy is expensive. Fundoplication is considered the gold standard of GERD therapy in terms of normalization of esophageal acid exposure and symptom control; however, this exposes the patient to the risks of surgery and anesthesia. Therefore, an endoscopic approach to treating GERD that obviates the need for PPIs and avoids surgical morbidity is desirable. Several endoscopic methods have been used, including radiofrequency ablation, implantation of foreign substances as bulking agents, and various tissue apposition strategies. The emerging field of GERD endotherapy is promising, but more rigorous, sham-controlled, long-term studies are required to elucidate its exact role in clinical practice. This review discusses the evolution of these concepts, describes specific endoscopic devices that have been developed, and explores the future of endotherapies as viable treatment alternatives for GERD.
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Affiliation(s)
- Marvin Ryou
- Brigham & Women's Hospital, Division of Gastroenterology, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Rothstein RI. Endoscopic therapy of gastroesophageal reflux disease: outcomes of the randomized-controlled trials done to date. J Clin Gastroenterol 2008; 42:594-602. [PMID: 18364577 DOI: 10.1097/mcg.0b013e31816bcde5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Endoscopic therapies to treat gastroesophageal reflux disease have been developed as another option for patients with reflux symptoms who do not want to continue medications indefinitely or are unwilling to undergo surgical intervention. The endoscopic treatments can be divided into those that pleat or plicate the upper stomach, deliver thermal energy into the lower esophageal sphincter, or inject or implant biopolymers into the gastroesophageal junction. Although capable to improve reflux symptoms for the majority of treated patients for a short while, durability has been variable among the various treatments, and there have been safety issues with some of the therapies. Although symptom improvement has been universally shown in short-term follow-up, there has been variable outcome for reduced need of antisecretory medications and pH studies show normalization of the distal esophageal acid exposure for only the minority of treated patients. Patients with significant reflux esophagitis or Barrett esophagus are not typically candidates for this antireflux intervention. Except for the NDO Plicator, in sham-controlled studies, there have been no significant differences between treated and sham-treated individuals for ability to discontinue medications or normalize pH. One issue in interpreting the results of these preliminary studies is the influence of the learning curve of a new technology. Another is that the devices and techniques have not been optimized. Currently, only the Davol/Bard EndoCinch and the NDO Plicator are available for commercial use. There are several newer devices under study or in development, and further testing and experience will demonstrate their capabilities in the treatment of gastroesophageal reflux disease.
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Affiliation(s)
- Richard I Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth Medical School, Lebanon, NH 03756, USA.
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Liao CC, Lee CL, Lin BR, Bai CH, Hsieh YH, Wu CH, Gostout CJ. Endoluminal gastroplication for the treatment of gastroesophageal reflux disease: a 2-year prospective pilot study from Taiwan. J Gastroenterol Hepatol 2008; 23:398-405. [PMID: 18318824 DOI: 10.1111/j.1440-1746.2007.04906.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIM Endoluminal gastroplication (ELGP) offers a minimally invasive option for the treatment of gastroesophageal reflux disease (GERD) in Western countries. However, long-term outcomes of ELGP in Asian populations have not been investigated. The aim of this prospective study was to evaluate the long-term benefits of ELGP in Asian patients with GERD. METHODS Taiwanese patients diagnosed with GERD were enrolled and had the procedure performed with EndoCinch. The assessment included symptom scoring, validated GERD questionnaires, esophagogastroduodenoscopy, esophageal manometry and 24-h pH monitoring before and after the procedure over a 2-year period. RESULTS Twenty-one consecutive patients were recruited and underwent ELGP. Patients reported improved heartburn symptom score (mean 64.0 vs 21.1, P < 0.001), regurgitation frequency score (mean 2.4 vs 1.3, P < 0.001), and GERD health-related quality of life (mean 23.1 vs 10.1, P < 0.001) at 24 months. The mean total time of pH < 4 reduced from 121.7 min to 67.1 min (P = 0.008) and mean DeMeester score reduced from 32.9 to 17.6 (P = 0.011) at 3 months. Antisecretory drug discontinuation rate was 81%, 57%, 52% and 48% at 1, 6, 12 and 24 months, respectively. Of the patients who had a favorable initial response to ELGP at 1 month, 41% resumed antisecretory medications at 24 months follow-up. All adverse events were mild and transient. CONCLUSIONS Endoluminal gastroplication is a safe and modestly effective endotherapy for patients with GERD. It significantly improved symptoms in an Asian population. Approximately one in two patients continues to be off medication at 24 months follow-up. However, the long-term efficacy and durability are still to be determined.
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Affiliation(s)
- Chien-Chung Liao
- Division of Gastroenterology, Department of Internal Medicine, Cathay General Hospital, Hsinchu, and School of Medicine, China Medical University, Taichung, Taiwan
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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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Schwartz MP, Smout AJPM. Review article: The endoscopic treatment of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2007; 26 Suppl 2:1-6. [PMID: 18081642 DOI: 10.1111/j.1365-2036.2007.03473.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Over the last 10 years a number of endoscopic procedures for treating gastro-oesophageal reflux disease (GORD) have been developed (suturing, injections, implants and radiofrequency ablation), thus obviating the need for long-term proton pump inhibitors (PPI) and the potential morbidity of laparoscopic fundoplication. AIM To present an update of the literature studying the clinical efficacy of endoscopic antireflux procedures, and to discuss further developments. METHODS A PubMed search was performed for endoscopic suturing, antireflux treatment, endoscopic gastroplication, polymer injection, radiofrequency ablation of GORD. Own recent research was compared with existing data. Information concerning GORD endotherapy were gathered. RESULTS Uncontrolled studies have reported promising clinical results on the short to intermediate term for most endoscopic GORD procedures, but the placebo effect remained unknown. It is, therefore, commendable that the three main procedures (Endocinch, Stretta and Enteryx) have now all been tested against a sham procedure. Although all three techniques were able to improve symptoms, quality of life and PPI use, oesophageal acid reduction was unremarkable. Endocinch and Stretta are safe outpatient procedures. Concerns about the durability of Endocinch have risen. Polymer injection (Enteryx) and gel prosthesis implantation (Gatekeeper) were recalled for severe complications and lack of efficacy, respectively. CONCLUSIONS Endotherapy has shown the potential to treat (uncomplicated) GORD. However, some early procedures have failed or proven unsafe. Further developments and studies are necessary to determine what modifications to these techniques are required to produce optimal efficacy and durability. Until then, widespread clinical use of endotherapy for GORD should probably be avoided.
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Affiliation(s)
- M P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, The Netherlands.
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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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Pleskow D, Rothstein R, Kozarek R, Haber G, Gostout C, Lo S, Hawes R, Lembo A. Endoscopic full-thickness plication for the treatment of GERD: Five-year long-term multicenter results. Surg Endosc 2007; 22:326-32. [PMID: 18027032 DOI: 10.1007/s00464-007-9667-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 09/24/2007] [Accepted: 10/09/2007] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Plicator (NDO Surgical, Inc., Mansfield, MA) endoscopically places a full-thickness permanent suture to augment the antireflux barrier. At 3-years post-treatment, published results demonstrated a reduction in subjects' gastroesophageal reflux disease (GERD) symptoms and related medication use. AIM To evaluate the Plicator's safety and durability of effect at improving GERD symptoms at 5-years post-treatment. METHODS A total of 33 chronic GERD sufferers across seven sites were followed for approximately 5 years (median follow-up: 59 months, range 50-65 months) after receiving a single full-thickness plication approximately 1 cm below the gastroesophageal (GE) junction in the anterior gastric cardia. At baseline, 30 out of 33 subjects required daily proton-pump inhibitor (PPI) therapy. RESULTS Of the subjects who were PPI dependent prior to treatment 67% (20/30) remained off daily PPI therapy at 60 months and 5-year median GERD health-related quality-of-life (HRQL) scores show significant improvement from baseline off-meds scores (10 versus 19, p < 0.001). Additionally, 50% (16/32) of subjects achieved >or= 50% score improvement in GERD-HRQL. No new adverse events were identified and all device-related events occurred acutely. These results were comparable to the results seen at 36 months follow-up. CONCLUSIONS Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 5-years post procedure with no long-term adverse events post treatment.
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Affiliation(s)
- Douglas Pleskow
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, DA-501, Boston, MA 02215, USA
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Liu JJ. Endoscopic treatment for gastroesophageal reflux disease: should you learn the techniques? CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:213-5. [PMID: 17431508 PMCID: PMC2657692 DOI: 10.1155/2007/812967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Julia J Liu
- University of Alberta Hospital, Edmonton, Albert, Canada.
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Abstract
Today, there are several modalities to treat gastroesophageal reflux disease (GERD) (medications, endoscopic therapies, surgery) and such therapies can be used either singly, or in tandem, or in combination with the others, aiming at "normalization" of the patient's GERD-related quality of life and, if possible, esophageal acid exposure. Several intermediate end points or clinically significant outcomes have not been reached by some therapeutic modalities and no single modality is or can be perfect. Statistically significant improvements in these intermediate end points have been shown in "some" but not all studies. Although healing of esophagitis can be accomplished with either medical or surgical therapy, there is inadequate data with endotherapies, because most patients treated with endotherapies have had prior trials of proton pump inhibitors (PPIs) and hence healed their esophagitis. Effective prevention of complications, such as esophageal adenocarcinoma, remains challenging for all modalities. Patients who have not normalized their GERD-related quality of life with once or twice daily PPI therapy should undergo functional esophageal evaluation with pH testing and esophageal motility study and they should be evaluated by both an endoscopist and a surgeon. The decision on how to proceed should be made on the basis of the criteria for endotherapy and surgery, availability of local endoscopic and surgical expertise and patients' preference. Such multimodality therapy model is in many ways similar to the long-term management of coronary artery disease where pharmacotherapy, angioplasty, and bypass surgery are frequently used in tandem or in combination. Multimodality therapy aiming at normalization of GERD-related quality of life is an option today, and should be available to all patients in need of therapy. The target population for GERD endotherapy currently consists of PPI-dependent GERD patients, who have a small (<2-cm-long) or no sliding hiatal hernia, and without severe esophagitis or Barrett esophagus. Thus far, only Stretta and the NDO plicator have been studied in sham-controlled trials. Registries of complications suggest that these techniques are relatively safe, but serious morbidity, including rare mortality have been reported (for a continuous update on complications related to endoscopic therapies see: http://www.fda.gov/cdrh/maude.html). All can be performed on an outpatient basis, under intravenous sedation and local pharyngeal anesthesia. Future comparative studies with predetermined clinically significant end points, validated outcome measures, prolonged follow-up, and complete complication registries will eventually determine the precise role of endoscopic procedures for the patients with GERD.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305-5187, USA.
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Conchillo JM, Schwartz MP, Selimah M, Samsom M, Arts J, Tack J, Sifrim D, Smout AJPM. Role of intra-oesophageal impedance monitoring in the evaluation of endoscopic gastroplication for gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2007; 26:61-8. [PMID: 17555422 DOI: 10.1111/j.1365-2036.2007.03353.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the evaluation of several endoscopic antireflux procedures, a discrepancy in the degree of improvement between symptoms and objective reflux parameters as measured by pH-metry has been reported. AIM To assess the additional value of impedance monitoring in the evaluation of endoscopic gastroplication for gastro-oesophageal reflux disease. METHODS Eighteen patients with gastro-oesophageal reflux disease were treated with three endoscopic gastroplications, and underwent 24 h pH-impedance monitoring before and 3 months after treatment. RESULTS Total reflux exposure time as assessed by pH-metry and impedance monitoring was significantly decreased after treatment (P = 0.047 and <0.001, respectively). When assessed with impedance monitoring, the mean number of reflux episodes was significantly decreased after the procedure (82 vs. 56, pre vs. post, P < 0.001). Furthermore, the mean numbers of liquid and acid reflux episodes in patients with symptomatic improvement were significantly reduced after treatment (P = 0.04 and 0.02, respectively). After treatment, mean volume clearance time (s) and mean number of proximal reflux episodes were significantly decreased (P < 0.001 and 0.002, respectively). CONCLUSIONS Impedance monitoring can identify the specific effect of endoscopic gastroplication on the different types of reflux episodes with regard to gas-liquid composition and pH, as well as on volume clearance and the proximal extent of the refluxate.
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Affiliation(s)
- J M Conchillo
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands.
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Abstract
In patients with chronic and recurrent sinusitis, laryngopharyngeal reflux disease may play a significant role. Laryngopharyngeal reflux disease differs from gastroesophageal reflux disease in the extent of reflux (into the hypopharynx and above) as well as timing (occurring more often when the patient is upright). Most patients are unaware of the extent of their symptoms, and diagnostic tools such as pH probe, multichannel intraluminal impedance, and manometry are required for adequate diagnosis. Although therapy with lifestyle modification and acid-suppressive agents may improve reflux in the majority of patients, for many with persistent symptoms, endoscopic or surgical intervention is required to reduce reflux successfully.
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Affiliation(s)
- David Weldon
- Scott and White Clinic, 1600 University Drive East, College Station, TX 77845, USA.
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Liu JJ, Glickman JN, Li X, Maurer R, Ashley SW, Brooks DC, Carr-Locke DL, Saltzman JR. Smooth muscle remodeling of the gastroesophageal junction after endoluminal gastroplication. Gastrointest Endosc 2007; 65:1023-7. [PMID: 17324412 DOI: 10.1016/j.gie.2006.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 06/05/2006] [Indexed: 01/30/2023]
Abstract
BACKGROUND Endoluminal gastroplication has been shown to reduce symptoms of gastroesophageal reflux disease and to induce focal hypertrophy of the gastroesophageal junction (GEJ) muscularis propria. Despite suture loss, some patients have persistent symptomatic resolution. OBJECTIVE This study was designed to examine the durability of smooth muscle hypertrophy after suture removal. DESIGN Seven pigs underwent upper endoscopy with endoscopic ultrasonography (EGD/EUS) at baseline to evaluate GEJ muscularis propria layer. Endoluminal gastroplication was performed at week 1 with placement of 2 sutures at the GEJ. Repeat EGD/EUS was performed at week 3 and week 5. Three of the 7 pigs were killed for histologic analysis. The remaining 4 pigs had sutures removed and survived for 9, 11, and 13 weeks; serial weekly EGD/EUS was performed until the animal was killed. RESULTS The GEJ muscularis propria thickness by EUS was 1.1+/-0.1 mm at baseline, 4.7+/-1.9 mm at week 3, and 4.4+/-1.1 mm at week 5. The muscularis propria thickness by histologic examination in the 3 animals with sutures intact were 6.2+/-0.3 mm near the suture site and 4.7+/-0.5 mm at the opposing wall to the suture site. For the 4 animals with sutures removed, the measurements were 6.9+/-0.2 mm (suture site) and 4.7+/-0.5 mm (opposing wall), respectively. CONCLUSIONS The GEJ smooth muscle cell hypertrophy induced by endoluminal gastroplication persisted after removal of mucosal sutures. These changes may be responsible for persistent symptomatic response despite suture loss in patients.
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Affiliation(s)
- Julia J Liu
- Division of Gastroenterology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Abstract
In GERD patients in whom pharmacological therapies are ineffective and anti-reflux surgery is not indicated, a viable option could be proposed. To date, several endoscopic antireflux procedures, involving sewing, injection and/or implant, and radiofrequency are available. The sewing techniques demonstrated good clinical results, with reduction in proton pump inhibitors consumption; despite significant changes in esophageal manometry and/or acid exposure time reduction and healing of esophagitis were noted only in few patients.
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Affiliation(s)
- Michele Marchese
- Digestive Endoscopy Unit, Catholic University of Rome, Largo Francesco Vito 1, 00168 Rome, Italy
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Higuchi K, Fujiwara Y, Okazaki H, Tabuchi M, Kameda N, Kadouchi K, Machida H, Tanigawa T, Shiba M, Watanabe T, Tominaga K, Oshitani N, Arakawa T. Feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with gastroesophageal reflux disease: first report from Asia. J Gastroenterol 2007; 42:205-10. [PMID: 17380278 DOI: 10.1007/s00535-006-1944-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 12/14/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND In recent years, various endoscopic treatments have become available to treat gastroesophageal reflux disease (GERD) in Western countries. The Stretta procedure, which uses radiofrequency energy, is one type of safe and effective endoluminal treatment for GERD. However, the feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with GERD, who differ from Western peoples in their physiological characteristics, are not known. In 2006, we imported a Stretta system from the United States and investigated important clinical aspects of the system in Japanese patients with GERD. METHODS This study was an open-label trial that enrolled patients with GERD who desired to undergo the Stretta procedure. Heartburn scores, medication use, overall satisfaction with the procedure, and adverse events were evaluated. RESULTS Nine patients received the Stretta treatment between February and September 2006. Esophagogastroduodenoscopy just after treatment revealed a remarkable reduction in the expansion of the gastric cardia and small erosions in all patients. At 3 or 6 months after treatment, heartburn scores were significantly improved compared with pretreatment scores (5.0 +/- 1.7 pretreatment vs. 0.7 +/- 1.4 posttreatment, P=0.007). In six of nine patients (66.7%), treatment significantly (P=0.009) decreased medication use. There were no major adverse events. All patients were satisfied with this treatment. CONCLUSIONS The Stretta procedure safely reduced GERD symptoms and decreased medication use in Japanese patients with GERD. This treatment may thus be very useful for such patients, and it is hoped that a nationwide trial will be undertaken in Japan to obtain more extensive data.
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Affiliation(s)
- Kazuhide Higuchi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Pleskow D, Rothstein R, Kozarek R, Haber G, Gostout C, Lembo A. Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results. Surg Endosc 2006; 21:439-44. [PMID: 17180259 DOI: 10.1007/s00464-006-9121-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Revised: 08/11/2006] [Accepted: 09/25/2006] [Indexed: 01/03/2023]
Abstract
BACKGROUND The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication. METHODS Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect. RESULTS Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%). CONCLUSIONS Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.
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Affiliation(s)
- D Pleskow
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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Schauer P, Chand B, Brethauer S. New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery. Surg Endosc 2006; 21:347-56. [PMID: 17180295 DOI: 10.1007/s00464-006-9008-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 06/07/2006] [Indexed: 12/19/2022]
Abstract
Endoluminal and transgastric procedures are evolving concepts that combine the skills and techniques of flexible endoscopy with minimally invasive surgery. Precisely how this technology and skill set will be applied in the field of general surgery is not yet known, but the treatment of obesity with an endoluminal or transgastric procedure holds great promise. As the demand for bariatric surgery increases, efforts will be directed toward developing less morbid and less costly treatment options that can provide substantial weight loss and resolution of comorbid conditions. Natural orifice bariatric procedures may include short-term weight loss in preparation for a definitive laparoscopic procedure, revisional procedures to reduce stoma or pouch size or repair fistulas, or primary therapy that provides durable weight loss. The latter application will undoubtedly appeal to patients and referring physicians if it can be performed as an outpatient procedure with significantly less morbidity than a laparoscopic procedure. Early preclinical and clinical work has been published in this area, but many technical obstacles must be overcome before a primary endoluminal or transgastric bariatric procedure can be offered. This article reviews the endoluminal and transgastric technology currently available, the endoluminal procedures currently performed, and the future of these technologies with respect to bariatric surgery.
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Affiliation(s)
- P Schauer
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
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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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Rothstein R, Filipi C, Caca K, Pruitt R, Mergener K, Torquati A, Haber G, Chen Y, Chang K, Wong D, Deviere J, Pleskow D, Lightdale C, Ades A, Kozarek R, Richards W, Lembo A. Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease: A randomized, sham-controlled trial. Gastroenterology 2006; 131:704-12. [PMID: 16952539 DOI: 10.1053/j.gastro.2006.07.004] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 06/08/2006] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to determine the effectiveness of endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease (GERD) in comparison with a sham procedure. METHODS Patients with symptomatic GERD requiring maintenance proton pump inhibitor (PPI) therapy were entered into a randomized, single-blind, prospective, multicenter trial. Seventy-eight patients were randomly assigned to undergo endoscopic full-thickness restructuring of the gastric cardia with transmural suture. Eighty-one patients underwent a sham procedure. Group assignments were revealed following the 3-month evaluation. The primary end point was > or =50% improvement in GERD health-related quality of life (HRQL) score. Secondary end points included medication use and esophageal acid exposure. RESULTS By intention-to-treat analysis, at 3 months, the proportion of patients achieving > or =50% improvement in GERD-HRQL score was significantly greater in the active group (56%) compared with the sham group (18.5%; P < .001). Complete cessation of PPI therapy was higher among patients in the active group than in the sham group by intention-to-treat analysis (50% vs 24%; P = .002). The percent reduction in median percent time pH < 4 was significantly improved within the active group versus baseline (7 vs 10, 18%, P < .001) but not in the sham group (10 vs 9, -3%, P = .686). Between-group analysis revealed the active therapy to be superior to the sham in improving median percent time pH < 4 (P = .010). There were no perforations or deaths. CONCLUSIONS Endoscopic full-thickness plication more effectively reduces GERD symptoms, PPI use, and esophageal acid exposure than a sham procedure.
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Affiliation(s)
- Richard Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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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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Abstract
PURPOSE OF REVIEW Endoscopic antireflux procedures have generated much interest among clinicians and patients. These devices utilize a variety of methods in an attempt to decrease reflux of gastric contents. This work reviews the most notable results of endoscopic antireflux procedure studies published in 2005. RECENT FINDINGS A variety of studies of different technologies have been published this year. Only a few of these studies report data beyond 12 months to establish longer term efficacy. One sham controlled multicenter trial was published this year. After case reports of complications related to Enteryx (Boston Scientific Corp, Natick, Massachusetts, USA) use, this US Food and Drug Administration-approved device was voluntarily removed from the market. SUMMARY A review of the literature demonstrates a paucity of long-term studies, as well as a lack of data comparing the devices to active medical therapy. The majority of studies are open-label trials with subjective endpoints, and such study designs are very susceptible to placebo effect. No one technology has demonstrated superiority to another. Additional studies with vigorous attention to methodology, safety evaluation, cost analysis and clinically meaningful endpoints will be required.
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Affiliation(s)
- Joseph E Cassara
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina Schools of Medicine and Public Health, Chapel Hill, North Carolina, USA.
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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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Liu JJ, Carr-Locke DL, Osterman MT, Li X, Maurer R, Brooks DC, Ashley SW, Saltzman JR. Endoscopic treatment for atypical manifestations of gastroesophageal reflux disease. Am J Gastroenterol 2006; 101:440-5. [PMID: 16542278 DOI: 10.1111/j.1572-0241.2006.00496.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Atypical manifestations are common in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the response of atypical manifestations of GERD to endoscopic antireflux treatment. METHODS Patients with atypical manifestations of GERD including hoarseness, cough, wheezing, and non-cardiac chest pain were studied. Endoscopic antireflux treatment consisted of placement of sutures below the squamo-columnar junction. Clinical response was defined as complete resolution of the atypical symptom. Patients were followed clinically for up to 3 yr after the procedure. Short-term response was evaluated within 6 months of the procedure, and long-term follow-up was determined 1-3 yr after the procedure. RESULTS Forty-three patients met the inclusion criteria; four patients underwent repeat procedures during the study period and were excluded from the analysis. Long-term follow-up was available in all 39 patients. Short-term response counts were: hoarseness, 12 of 19 patients, cough, 17 of 19; wheezing, 8 of 9; and chest pain, 13 of 18. Long-term follow-up of patients (mean of 18 months) for these symptoms was not significantly different compared to short-term response. CONCLUSIONS Endoscopic suturing of the gastroesophageal junction appears to be a possible treatment option for atypical manifestations of GERD and future studies are needed to determine its role in management.
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Affiliation(s)
- Julia J Liu
- Division of Gastroenterology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Domagk D, Menzel J, Seidel M, Ullerich H, Pohle T, Heinecke A, Domschke W, Kucharzik T. Endoluminal gastroplasty (EndoCinch) versus endoscopic polymer implantation (Enteryx) for treatment of gastroesophageal reflux disease: 6-month results of a prospective, randomized trial. Am J Gastroenterol 2006; 101:422-30. [PMID: 16542275 DOI: 10.1111/j.1572-0241.2006.00533.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to compare and determine the efficiency and safety of two newly introduced endoscopic antireflux procedures in the treatment of gastroesophageal reflux disease (GERD). METHODS In a prospective, randomized trial, endoluminal gastroplasty (EndoCinch) was compared with polymer injection (Enteryx) employing 51 consecutive patients dependent on proton pump inhibitor therapy. Follow-up evaluation included drug consumption, symptoms, quality-of-life scoring, endoscopy, pH monitoring, manometry, and documentation of adverse events. RESULTS Twenty-six patients were assigned to EndoCinch treatment, 23 patients received Enteryx implantation, and two patients dropped out before applying endoscopic therapy. At 6 months, proton pump inhibitor therapy could be stopped or dosage was reduced by > or =50% in 20 of 26 (77%) EndoCinch-treated patients and in 20 of 23 patients treated by Enteryx (87%, p= 0.365), which differed significantly in both groups compared to the pre-interventional status (p < 0.0001). Esophageal acid reflux (pH < 4) decreased from 14.5% to 9.6% in EndoCinch-treated patients (p= 0.071) and from 15.5% to 13.9% in patients treated by Enteryx (p= 0.930). Heartburn symptom score, modified DeMeester score, gastrointestinal life quality index, and SF-36 physical health survey score improved significantly in both groups postinterventionally (p < 0.0001). Approximately 25% of the patients in both groups required retreatment in an attempt to achieve symptom control. CONCLUSIONS This is the first prospective, randomized study directly comparing two endoscopic anti-GERD techniques. EndoCinch and Enteryx seem to be equally successful in the treatment of GERD significantly reducing the proton pump inhibitor dosages, and also by improving symptoms of patients. Both endoluminal antireflux procedures may be promising therapeutic options; long-term evaluation will have to show if the positive initial results can be maintained.
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Affiliation(s)
- Dirk Domagk
- Department of Medicine B, University of Muenster, Albert-Schweitzer-Strasse 33, D-48129 Muenster, Germany
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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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