Clinical trials evaluating endoscopic GERD treatments: is it time for a moratorium on the clinical use of these procedures?

Minimally invasive endoscopic therapies for gastro-oesophageal reflux disease

The prevalence of the gastro-oesophageal reflux disease (GORD) in the western world is increasing. Uncontrolled GORD can lead to harmful long-term sequela such as oesophagitis, stricture formation, Barrett's oesophagus and oesophageal adenocarcinoma. Moreover, GORD has been shown to negatively impact quality of life. The current treatment paradigm for GORD consists of lifestyle modification, pharmacological control of gastric acid secretion or antireflux surgery. In recent years, several minimally invasive antireflux endoscopic therapies (ARET) have been developed which may play a role in bridging the unmet therapeutic gap between the medical and surgical treatment options. To ensure optimal patient outcomes following ARET, considered patient selection is crucial, which requires a mechanistic understanding of individual ARET options. Here, we will discuss the differences between ARETs along with an overview of the current evidence base. We also outline future research priorities that will help refine the future role of ARET.

Long-term follow-up results of endoscopic treatment of gastroesophageal reflux disease with the MUSE™ endoscopic stapling device

Background

The initial 6-month data for MUSE™ (Medigus, Omer, Israel) endoscopic stapling device were reported (Zacherl et al. in Surg Endosc 29:220–229, 2015). The current study aims to evaluate the long-term clinical outcome of 37 patients who received endoscopic gastroesophageal reflux disease (GERD) treatment with the MUSE™ device.

Methods

Efficacy and safety data for 37 patients were analyzed at baseline, 6 months, and 4 years post-procedure. In one center (IU), efficacy and safety data were evaluated at baseline, 6 months post-procedure, and then annually up to 4 years.

Results

No new complications have been reported in our long-term analysis. The proportions of patients who remained off daily PPI were 83.8 % (31/37) at 6 months and 69.4 % (25/36) at 4 years post-procedure. GERD-Health Related Quality of Life (HRQL) scores (off PPI) were significantly decreased from baseline to 6 months and 4 years post-procedure. The daily dosage of GERD medications, measured as omeprazole equivalents (mean ± SD, mg), decreased from 66.1 ± 33.2 at baseline to 10.8 ± 15.9 at 6 months and 12.8 ± 19.4 at 4 years post-procedure (P < 0.01).

Conclusions

In our multi-center prospective study, the MUSE™ stapling device appears to be safe and effective in improving symptom scores as well as reducing PPI use in patients with GERD. These results appeared to be equal to or better than those of the other devices for endoluminal GERD therapy. Future studies with larger patient series, sham control group, and greater number of staples are awaited.

Does Measurement of Esophagogastric Junction Distensibility by EndoFLIP Predict Therapy- responsiveness to Endoluminal Fundoplication in Patients With Gastroesophageal Reflux Disease?

Background/Aims

In patients with gastroesophageal reflux disease (GERD), an increased esophagogastric junction (EGJ) distensibility has been described. Assessment of EGJ distensibility with the endoscopic functional luminal imaging probe (EndoFLIP) technique might identify patients responsive to transoral incisionless fundoplication (TIF), whereas postoperative measurement of EGJ distensibility might provide insight into the antireflux mechanism of TIF. Therefore, we investigated the value of the EndoFLIP technique in GERD patients treated by TIF.

Methods

Forty-two GERD patients underwent EGJ distensibility measurement before TIF using the EndoFLIP technique. In a subgroup of 25 patients, EndoFLIP measurement was repeated both postoperative and at 6 months follow-up. Treatment outcome was assessed according to esophageal acid exposure time (AET; objective outcome) and symptom scores (clinical outcome) 6 months after TIF.

Results

Multiple logistic regression analysis showed that preoperative EGJ distensibility (OR, 0.16; 95% CI, 0.03–0.78; P = 0.023) and preoperative AET (OR, 0.62; 95% CI, 0.42–0.90; P = 0.013) were independent predictors for objective treatment outcome but not for clinical outcome after TIF. The best cut-off value for objective outcome was 2.3 mm²/mmHg for preoperative EGJ distensibility and 11% for preoperative AET. EGJ distensibility decreased direct postoperative from 2.0 (1.2–3.3) to 1.4 (1.0–2.2) mm²/mmHg (P = 0.014), but increased to 2.2 (1.5–3.0) at 6 months follow-up (P = 0.925, compared to preoperative).

Conclusions

Preoperative EGJ distensibility and preoperative AET were independent predictors for objective treatment outcome but not for clinical outcome after TIF. According to our data, the EndoFLIP technique has no added value either in the preoperative diagnostic work-up or in the post-procedure evaluation of endoluminal antireflux therapy.

Laparoscopic Magnetic Sphincter Augmentation vs Laparoscopic Nissen Fundoplication: A Matched-Pair Analysis of 100 Patients

BACKGROUND

The efficacy and safety of magnetic sphincter augmentation (MSA) with the LINX device (Torax Medical) has been reported in several short-and long-term studies, rivaling historic results of laparoscopic Nissen fundoplication (LNF), but with fewer side effects. However, there have been no studies comparing patients with similar disease to validate these results.

STUDY DESIGN

We conducted a retrospective analysis of 1-year outcomes of patients undergoing MSA and LNF from June 2010 to June 2013. Patients were matched using propensity scores incorporating multiple preoperative variables. Outcomes were measured by GERD Health Related Quality of Life scores, proton-pump inhibitor use, satisfaction, and complications.

RESULTS

One hundred and seventy-nine patients met inclusion criteria, 62 MSA and 117 LNF. Propensity score matching identified 50 patients in both groups using the "best-fit" model with a caliper of 0.5 SD. At 1 year after surgery, both groups had similar GERD Health Related Quality of Life scores (4.2 MSA and 4.3 LNF; p = 0.897) and proton-pump inhibitor use (17% of MSA and 8.5% of LNF; p = 0.355). Although there was no difference in the number of patients reporting mild gas and bloating (27.6% MSA and 27.6% LNF; p = 1.000), there were no patients with severe gas and bloating in the MSA group compared with 10.6% in the LNF group (p = 0.022). More LNF patients were unable to belch (8.5% of MSA and 25.5% of LNF; p = 0.028) or vomit (4.3% of MSA and 21.3% of LNF; p = 0.004). The incidence of postoperative dysphagia was similar between the groups (46.8% MSA and 44.7% LNF; p = 0.766).

CONCLUSIONS

Analogous GERD patients had similar control of reflux symptoms after both MSA and LNF. The inabilities to belch and vomit were significantly fewer with MSA, along with a significantly lower incidence of severe gas-bloat symptoms. These results support the use of MSA as first-line therapy in patients with mild to moderate GERD.

Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication

BACKGROUND

Transoral incisionless fundoplication (TIF), a novel endoscopic procedure for treating gastroesophageal reflux disease (GERD), currently is under evaluation. In case of treatment failure, subsequent revisional laparoscopic antireflux surgery (rLARS) may be required. This study aimed to evaluate the feasibility, safety, and outcomes of revisional antireflux surgery after previous endoscopic fundoplication.

METHODS

Chronic GERD patients who underwent rLARS after a previous TIF procedure were included in the study. Pre- and postoperative assessment included GERD-related quality-of-life scores, proton pump inhibitor (PPI) usage, 24-h pH-metry, upper gastrointestinal endoscopy, and registration of adverse events.

RESULTS

Revisional laparoscopic Nissen fundoplication was feasible for all 15 patients included in the study without conversions to open surgery. Acid exposure of the distal esophagus improved significantly after rLARS, and esophagitis, PPI usage, and hiatal hernia decreased. Quality of life did not improve significantly after rLARS, and 33 % of the patients experienced dysphagia.

CONCLUSION

Revisional laparoscopic Nissen fundoplication was feasible and safe after unsuccessful endoscopic fundoplication, resulting in objective reflux control at the cost of a relatively high rate of dysphagia.

Managing gastroesophageal reflux disease in children: The role of endoscopy

Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.

Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice

BACKGROUND

Transoral incisionless fundoplication is a recently introduced endoluminal technique for the treatment of gastroesophageal reflux disease (GERD). The objective of this study was to determine outcomes in chronic GERD patients who were referred for surgical management.

METHODS

A cohort of 38 patients underwent transoral incisionless fundoplication (TIF) in a tertiary care setting. Pre- and post-procedure assessment included GERD-related quality of life questionnaires, proton pump inhibitor (PPI) usage, 24-h pH measurements, upper gastrointestinal endoscopy, esophageal manometry, and registration of adverse events. Duration of follow-up was 36 months.

RESULTS

Gastroesophageal valves were constructed of 4 cm (range, 4-6) in length and 220° (range, 180-240) in circumference. One serious adverse event occurred, consisting of intraluminal bleeding at a fastener site. Hiatal hernia was completely reduced in 56 % and esophagitis was cured in 47 % of patients. Postprocedure esophageal acid exposure did not significantly improve (p > 0.05). At 36 (range, 29-41) months follow-up 14 patients (36 %) had undergone revisional laparoscopic fundoplication. Quality of life scores of the remaining cohort showed significant improvement (p < 0.0001) and daily use of antisecretory medication was discontinued by 74 %.

CONCLUSIONS

Endoluminal fundoplication improved quality of life and reduced the need for PPIs in only a subgroup of patients at 3 years follow-up. The amount of patients requiring additional medication and revisional surgery was high.

Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice

BACKGROUND

Transoral incisionless fundoplication is a recently introduced endoluminal technique for the treatment of gastroesophageal reflux disease (GERD). The objective of this study was to determine outcomes in chronic GERD patients who were referred for surgical management.

METHODS

A cohort of 38 patients underwent transoral incisionless fundoplication (TIF) in a tertiary care setting. Pre- and post-procedure assessment included GERD-related quality of life questionnaires, proton pump inhibitor (PPI) usage, 24-h pH measurements, upper gastrointestinal endoscopy, esophageal manometry, and registration of adverse events. Duration of follow-up was 36 months.

RESULTS

Gastroesophageal valves were constructed of 4 cm (range, 4-6) in length and 220° (range, 180-240) in circumference. One serious adverse event occurred, consisting of intraluminal bleeding at a fastener site. Hiatal hernia was completely reduced in 56 % and esophagitis was cured in 47 % of patients. Postprocedure esophageal acid exposure did not significantly improve (p > 0.05). At 36 (range, 29-41) months follow-up 14 patients (36 %) had undergone revisional laparoscopic fundoplication. Quality of life scores of the remaining cohort showed significant improvement (p < 0.0001) and daily use of antisecretory medication was discontinued by 74 %.

CONCLUSIONS

Endoluminal fundoplication improved quality of life and reduced the need for PPIs in only a subgroup of patients at 3 years follow-up. The amount of patients requiring additional medication and revisional surgery was high.

Ensocopic-endoluminal therapies. A critical appraisal

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.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population

BACKGROUND

EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device.

METHODS

Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant.

RESULTS

The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure.

CONCLUSION

This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population

BACKGROUND

EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device.

METHODS

Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant.

RESULTS

The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure.

CONCLUSION

This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Endoscopic and laparoscopic treatment of gastroesophageal reflux

Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.

Recent advances in endoscopic antireflux techniques

Heartburn is the most common symptom associated with gastroesophageal reflux disease, and life-long proton pump inhibitor therapy is often required to control symptoms. Antireflux surgery is an alternative, but there may be significant side effects and the duration of therapeutic effect is variable. Several endoscopic antireflux techniques (E-ARTs) have been developed to enhance the function of the lower esophageal sphincter or alter the structure of the angle of His with the goal of recreating or augmenting the reflux barrier. Many methods are no longer available, and some await regulatory approval. This article reviews available data for the most common E-ARTs.

Evaluating outcomes of endoscopic full-thickness plication for gastroesophageal reflux disease (GERD) with impedance monitoring

BACKGROUND

Endoscopic full-thickness plication allows transmural suturing at the gastroesophageal junction to recreate the antireflux barrier. Multichannel intraluminal impedance monitoring (MII) can be used to detect nonacid or weakly acidic reflux, acidic swallows, and esophageal clearance time. This study used MII to evaluate the outcome of endoscopic full-thickness plication.

METHODS

In this study, 12 subsequent patients requiring maintenance proton pump inhibitor therapy underwent endoscopic full-thickness plication for treatment of gastroesophageal reflux disease. With patients off medication, MII was performed before and 6-months after endoscopic full-thickness plication.

RESULTS

The total median number of reflux episodes was significantly reduced from 105 to 64 (p = 0.016). The median number of acid reflux episodes decreased from 73 to 43 (p = 0.016). Nonacid reflux episodes decreased from 23 to 21 (p = 0.306). The median bolus clearance time was 12 s before treatment and 11 s at 6 months (p = 0.798). The median acid exposure time was reduced from 6.8% to 3.4% (p = 0.008), and the DeMeester scores were reduced from 19 to 12 (p = 0.008).

CONCLUSION

Endoscopic full-thickness plication significantly reduced total reflux episodes, acid reflux episodes, and total reflux exposure time. The DeMeester scores and total acid exposure time for the distal esophagus were significantly improved. No significant changes in nonacid reflux episodes and median bolus clearance time were encountered.

Antireflux 'barriers': problems with patient recruitment for a new endoscopic antireflux procedure

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.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

What is left of the endoscopic antireflux devices?

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.

A novel endoesophageal magnetic device to prevent gastroesophageal reflux

BACKGROUND

Endoscopic methods to prevent gastroesophageal reflux (GER) show scarce effectiveness and may narrow the esophageal lumen more or less stiffly, sometimes impairing bolus transit and leading to dysphagia. The aim of this study was to demonstrate the possibility of reinforcing lower esophageal sphincter (LES) tone by implanting endoluminally a magnetic device.

MATERIALS AND METHODS

The device consists of two small magnetic plaques to be implanted in the submucosa close to LES with opposite polarities facing so that they attract one other, closing the esophageal lumen. The magnets were implanted by means of a special endoluminal device in five esophageal-gastric ex vivo specimens taken from swine. Variation in endoluminal pressure at the LES level was measured by means of slow pull-through of a thin side-hole manometric catheter in each specimen, before and after insertion of the magnets.

RESULTS

The new high-pressure zone exhibited a length of about 2 cm and a pressure of 14.2+/-1.27 mmHg [mean +/- standard deviation (SD)], significantly (p<0.001) higher than that measured before insertion of the magnetic valve (1.5+/-0.26 mmHg).

CONCLUSIONS

The present research demonstrates that it is possible to create at the LES level a dynamic closure of a value considered sufficient to prevent GER, by implanting in the esophageal submucosa of anatomical specimens a magnetic device by means of a special endoluminal probe. Once effectiveness and tolerability of magnets covered by a biocompatible sheath have been demonstrated in vivo, this device could become a simple and effective nonsurgical solution to GER.

Systematic review of endoscopic treatments for gastro-oesophageal reflux disease

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.

A new injectable agent for the treatment of GERD: results of the Durasphere pilot trial

BACKGROUND

A variety of endoscopic modalities have been introduced to treat GERD, including radiofrequency energy, suturing, plication, and injection therapy.

OBJECTIVE

Our purpose was to assess the long-term safety and effectiveness of Durasphere (Carbon Medical Technologies, St Paul, Minn), a new injectable bulking agent, in the treatment of mild-moderate GERD.

DESIGN

Initial human pilot study.

SETTING

Single endoscopy center; study period from January 2005 to August 2006.

PATIENTS

Ten GERD subjects, confirmed by pH monitoring, on daily proton pump inhibitor (PPI) therapy, hiatal hernia <3 cm, and no or mild erosive esophagitis.

INTERVENTION

Endoscopic injection with Durasphere, a new submucosal bulking agent, at the gastroesophageal junction.

OUTCOMES

Change in symptom scores, PPI use, pH scores, and endoscopic findings; monitoring of safety profile.

RESULTS

Nine of 10 patients completed the 12-month trial. There were no adverse events. The procedure was well tolerated with minimal patient discomfort and no dysphagia. At 12 months 70% of patients discontinued all antacid medication completely; 90% of patients reduced PPI use by greater than 50%. DeMeester scores improved from a mean of 44.5 at baseline to 26.5 at 12 months; 4 patients achieved normal pH scores. There was no esophagitis at 12 months, and no erosion, ulceration or sloughing of material was noted at any injection site. The Durasphere material did not appear to migrate.

LIMITATIONS

Nonrandomized study design without a control group; small number of subjects.

CONCLUSIONS

Durasphere appears to be a promising new injectable bulking agent for the treatment of mild-moderate GERD, with demonstrable efficacy and no significant adverse events in a small cohort.

Endoscopic full-thickness plication for the treatment of GERD by application of multiple Plicator implants: a multicenter study (with video)

BACKGROUND

The full-thickness Plicator allows transmural suturing at the gastroesophageal (GE) junction to restructure the antireflux barrier. Studies of the Plicator procedure to date have been limited to placement of a single transmural suture to create the endoscopic gastroplication.

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of placing multiple transmural sutures for the treatment of GERD.

DESIGN

Open-label, prospective, multicenter study.

SETTING

Four tertiary-referral centers.

PATIENTS

Subjects with symptomatic GERD who require daily maintenance proton pump inhibitor (PPI) therapy. Study exclusions were hiatal hernia >3 cm, grades III and IV esophagitis, Barrett's epithelium, and esophageal dysmotility.

INTERVENTIONS

Forty-one patients received two or more transmural sutures placed linearly in the anterior gastric cardia approximately 1 cm below the GE junction.

MAIN OUTCOME MEASUREMENTS

Six months after the procedure, median GERD-health-related quality of life (HRQL) improved 76% compared with off-medication baseline (6.0 vs 25.0, P < .001), with 75% of patients (32/40) achieving >50% improvement in their baseline GERD-HRQL score. Six months after the procedure, daily PPI therapy was eliminated in 70% of patients (28/40). Heartburn symptoms improved 80% compared with off-medication baseline (16.0 vs 84.0, P < .001). Median esophagitis grade improved 75% compared with baseline (0.0 vs 1.0, P = .005). Esophageal pH assessed as median distal esophageal-acid exposure (percentage time pH < 4.0) improved 38% compared with baseline (9.0 vs 11.0, P < .020; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data) and manometric outcomes were also improved compared with baseline (median lower esophageal sphincter resting pressure improved 25% [10.0 vs 6.0, P < .017; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data]) and median amplitude of contraction improved 11% (70.0 vs 62.0, P < .037; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data).

LIMITATIONS

Small sample size. No randomized comparison with a single implant group.

CONCLUSIONS

Endoscopic full-thickness plication with multiple serially placed implants was safe and effective in reducing GERD symptoms, medication use, esophageal-acid exposure, and esophagitis.

Review article: endoscopic antireflux procedures - an unfulfilled promise?

BACKGROUND

Most published reviews concerning the endoscopic treatment of gastro-oesophageal reflux disease date back to 2005.

AIM

To provide an updated review that includes all papers published up to 2007.

METHODS

A Medline search from January 2005 to June 2007 was performed regarding endoscopic procedures aiming at treating gastro-oesophageal reflux disease. In addition, we retrieved the abstracts presented at Digestive Disease Week during the last 3 years. We included in the review both 'mechanistic' studies - that is, papers exploring the potential mechanism of action of the procedure/device - and studies trying to assess its clinical efficacy.

RESULTS

During the last 3 years, the number of published papers has declined, and some devices are not available any more. The alleged mechanism(s) of action of the various devices or procedures is (are) still not completely elucidated; however, some concerns have arisen as far as durability and potential detrimental effects. Moreover, all the aspects of endoscopic therapy, except for its safety, are either insufficiently explored or not investigated at all, or assessed only in particularly selected patient subgroups.

CONCLUSIONS

None of the proposed antireflux therapies has fulfilled the criteria of efficacy, safety, cost, durability and, possibly, of reversibility. There is at present no definite indication for endoscopic therapy of gastro-oesophageal reflux disease. We suggest a list of recommendations to be followed when a new endoscopic therapeutic procedure is to be assessed for use in clinical practice.

Long-term outcome of endoluminal gastroplication in the treatment of gastro-oesophageal reflux disease: effect of a second procedure

OBJECTIVE

Endoluminal gastroplication has been used with limited success for the treatment of gastro-oesophageal reflux disease (GORD). This method was used in 119 patients with GORD, and the results from short-term and long-term followup of symptoms and the use of acid suppression medication are reported. The purpose of this study was also to report on the effect of a second procedure on selected patients.

MATERIAL AND METHODS

The Bard EndoCinch endosuturing system was used for all procedures. Data were recorded at 3 and 12 months, and symptoms and medication use were registered by means of a telephone survey after an average of 41 months (range 27-55 months). A second procedure was carried out in 20 of the initial patients, and mean follow-up time was 39 months (range 15-51 months).

RESULTS

There were very few complications of the procedure. Heartburn severity score was reduced from an initial 21.4 to 12.4 (p < 0.01) and 13.4 (p < 0.01) at 3 and 12 months, respectively, corresponding to a reduction in the use of acid suppression from 8.7 doses per week (DD/w) to 4.0 (p < 0.01) and 5.6 DD/w (p < 0.01). At long-term follow-up there was a return towards baseline values for acid suppression use (6.4 DD/w, p = 0.06), whereas the heartburn severity score remained low (8.5, p < 0.01). Loss of sutures was significant, from an average of 2.51 applied sutures to 1.87 (p < 0.01) and 1.81 (p < 0.01) remaining sutures at 3 and 12 months, respectively. After the second procedure, the heartburn severity score fell from an initial 22.5 to 12.7 (p < 0.01) after 3 months and remained low at long-term follow-up (6.6, p < 0.01). The corresponding data for acid suppression use were 11.7, 3.6 (p < 0.01) and 5.2 (p < 0.01) DD/w. Number of sutures increased from an average of 2.15 sutures placed initially, with 2.65 sutures added at the second procedure, to an average of 2.80 remaining sutures (p < 0.01) at 3 months.

CONCLUSIONS

Endoluminal gastroplication has a significant, yet transient effect on symptom score and the use of acid suppressants in GORD patients. A selection of patients for a subsequent procedure may be of value.

Systematic review: endoluminal therapy for gastro-oesophageal reflux disease: evidence from clinical trials

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.

[Therapeutic innovations in gastroesophageal reflux]

Proton-pump inhibitors remain the most effective treatment for relieving symptoms, healing lesions and preventing recurrences of gastroesophageal reflux (GER). Drugs inhibiting transient relaxation of the lower esophageal sphincter have an unfavorable benefit/risk ratio. Endoscopic methods developed in recent years have not been shown effective in trials versus sham procedures. Surgical treatment is effective in GER but causes frequent uncomfortable side effects that are difficult to treat.

Endoluminal fundoplication (ELF)--evolution of EsophyX, a new surgical device for transoral surgery

A novel endoluminal fundoplication (ELF) technique using a trans-oral and fastener-deploying device (EsophyX, EndoGastric Solutions) was developed and evaluated for feasibility, safety and the treatment of gastroesophageal reflux disease (GERD) in a series of bench, animal, human (phase 1, phase 2, commercial registry) studies. The studies verified biological compatibility, durability and non-toxicity of the polypropylene fasteners as well as the feasibility of the ELF technique. The results of the preclinical testing indicated that the EsophyX device was shown to be safe, and capable of deploying fasteners directly into tissue and forming an interrupted suture line at the base of the gastro-esophageal valve (GEV). Moreover, the studies demonstrated that the ELF technique performed using the EsophyX device resulted in the creation of new GEVs of 3-5 cm in length and a circumference of 200 degrees -310 degrees , which maintained their anatomical aspects at six months. The ELF-created GEVs appeared similar to those created by laparoscopic anti-reflux surgery (LARS). The ELF procedure also resulted in reduction of all small hiatal hernias (2 cm in size) and restoration of the angle of His. The ELF procedure provides an anatomical approach similar to that of LARS for the treatment of GERD.

A randomized controlled trial of laparoscopic nissen fundoplication versus proton pump inhibitors for treatment of patients with chronic gastroesophageal reflux disease: One-year follow-up

A randomized controlled trial conducted in patients with gastroesophageal reflux disease compared optimized medical therapy using proton pump inhibitor (n = 52) with laparoscopic Nissen fundoplication (n = 52). Patients were monitored for 1 year. The primary end point was frequency of gastroesophageal reflux dis-ease symptoms. Surgical patients had improved symptoms, pH control, and overall quality of life health index after surgery at 1 year compared with the medical group. The overall gastroesophageal reflux disease symptom score at 1 year was unchanged in the medical patients, but improved in the surgical patients. Fourteen patients in the medical arm experienced symptom relapse requiring titration of the proton pump inhibitor dose, but 6 had satisfactory symptom remission. No surgical patients required additional treatment for symptom control. Patients controlled on long-term proton pump inhibitor therapy for chronic gastroesophageal reflux disease are excellent surgical candidates and should experience improved symptom control after surgery at 1 year.