Enteryx

Endoscopic treatment of refractory gastroesohageal reflux disease

Though efficient acid suppression with proton pump inhibitors (PPIs) remains the mainstay of treatment of gastroesophageal reflux disease (GERD), some of the patients showed refractory response to PPIs, necessitating further intervention. After increasing dose of PPIs and other kinds of pharmacological intervention adopting prokinetics or others, variable endoscopic treatments are introduced for the treatment of these refractory cases. The detailed introduction regarding endoscopic treatment for GERD is forwarded in this review article. Implantation of reabsorbable or synthetic materials in the distal esophagus was tried in vain and is expelled from the market due to limited efficacy and serious complication. Radiofrequency energy delivery (Stretta) and transoral incisionless fundoplication (EsophyX) are actively tried currently.

A prospective randomized trial of sham, single-dose Stretta, and double-dose Stretta for the treatment of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is a prevalent disorder that often requires long-term medical therapy or surgery. Radiofrequency (RF) energy delivery (Stretta procedure) has been shown in several studies to improve GERD symptoms and quality of life for approximately two-thirds of patients. The authors proposed that increasing the dose of Stretta would further improve the response to this therapy.

METHODS

For this study, 36 patients were randomized into three groups. In group A, 12 patients underwent a single session Stretta procedure. In group B, 12 patients under went a sham Stretta procedure (mirror of the active procedure in all aspects except there was no deployment of the electrodes). In group C, 12 patients underwent a single Stretta treatment followed by repeat Stretta if GERD health-related quality of life (HRQL) was not 75% improved after 4 months. For each patient, 56 RF lesions were created per session. The principal outcome was GERD HRQL improvement. The secondary outcomes were medication use, lower esophageal sphincter (LES) basal pressure, endoscopic grade of esophagitis, and esophageal acid exposure by pH probe.

RESULTS

The Stretta procedure was completed successfully for all the patients in both active treatment groups. At 12 months, the mean HRQL scores of those off medications, the LES basal pressure, the 24-h pH scores, and the proton pump inhibitor (PPI) daily dose consumption were significantly improved from baseline in both Stretta groups (p\0.01). The double Stretta was numerically but not significantly better than the single Stretta for mean HRQL, mean 24 h pH, mean LES pressure, and PPI use. Seven patients in the double Stretta treatment group had normalized their HRQL at 12 months compared with 2 patients in the single-treatment group (p = 0.035). The sham patients had a small but statistically significant decrease in their daily PPI dosages (p\0.05) and mean HRQL scores (p\0.05). No serious complications (bleeding, perforation, or death) occurred. However, two patients experienced significant delayed gastric emptying after the second Stretta treatment.

CONCLUSIONS

The Stretta procedure significantly reduced GERD HRQL, use of PPI drugs, esophageal acid exposure, LES pressure, and grade of esophagitis compared with the sham procedure. The double Stretta therapy had numerically superior outcomes for most parameters and a significantly more frequent normalization of HRQL scores compared with the single Stretta.

Managing gastroesophageal reflux disease for the lifetime of the patient: evaluating the long-term options

Lifetime management goals of gastroesophageal reflux disease (GERD) are to control esophageal as well as extraesophageal symptoms, maintain a stable noninflamed esophageal mucosa, and prevent complications. Large randomized clinical trials and >16 years of worldwide experience have confirmed the high rate of efficacy and excellent safety profile of proton pump inhibitor (PPI) therapy in individuals with all grades of GERD, making these agents the mainstay of treatment. Despite these outcomes, some individuals may desire an alternative to pharmacologic therapy. In such patients, laparoscopic fundoplication may produce symptom relief and healing of esophagitis, but its invasiveness, cost, and inherent surgical risks have created an interest in a variety of endoscopic therapies for reflux disease. Several short-term uncontrolled trials of these endoscopic therapies have reported encouraging preliminary results; however, careful patient selection as well as clinician experience is critical for their success. In addition to clinician expertise with the procedure, success has been observed only in patients with nonerosive GERD and a hiatal hernia <3 cm, abnormal pH monitoring, and normal esophageal motility studies, as well as in those who have experienced at least partial symptom relief with PPI therapy. Endoscopic therapy should not be considered the standard of care in patients with erosive disease or large hiatal hernias.