Comparison of transesophageal endoscopic plication (TEP) with laparoscopic Nissen fundoplication (LNF) in the treatment of uncomplicated reflux disease

Endoscopic Advances in the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.

Endoscopic plication compared to laparoscopic fundoplication in the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis

INTRODUCTION

Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication.

METHODS AND PROCEDURES

Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score.

RESULTS

We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6 years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6 kg/m² ENDO vs 26.2 kg/m² LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8 mmHg ENDO vs 9.0 mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I² = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I² = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I² = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I² = 98%).

CONCLUSIONS

This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.

Evaluation of Antireflux Mucosectomy for Severe Gastroesophageal Reflux Disease: Medium-Term Results of a Pilot Study

Background

Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease).

Methods

Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events.

Results

Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%.

Conclusions

In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.

Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.

Antireflux endoluminal therapies: past and present

The basic principle of antireflux procedures employing endoscopic intervention aims to create a mechanical barrier to prevent primary pathophysiology in gastroesophageal reflux disease (GERD). We review, highlight, and discuss the past and present status of endoluminal therapy. Currently, there are 3 commonly employed anti-reflux endoluminal procedures: fundoplication or suturing techniques (EndoCinch, NDO, and EsophyX), intramural injection or implant techniques (enhancing lower esophageal sphincter (LES) volume and/or strengthening compliance of the LES-Enteryx and Gatekeeper), and radiofrequency ablation of LES and cardia. EndoCinch plication requires further study and modification of technique before it can be recommended because of durability issues. Esophynx, the transoral incisionless fundoplication, may reduce hiatal hernias and increase LES length. Preliminary studies have shown promising reduction in symptoms and medication use but evidence concerning safety and long-term durability is still pending. The safety issue with injection technique is the main concern as evident from the incidences of implant withdrawals after reported major adverse events. Future research with cautious monitoring is required before any new implant material can be recommended for commercial application. Radiofrequency ablation therapy is regaining popularity in treating refractory symptoms despite PPI use due to improved efficacy, durability, and safety after years of refinement of protocol.

Advances in transoral fundoplication for oesophageal reflux

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.

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.

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.

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.

Advanced endoscopic technologies

The use of endoscopy for diagnosing and treating ailments of the alimentary tract has evolved steadily over the past few decades, with tremendous growth and innovation in the past few years. Initially, endoscopy relied on rigid telescopes, direct visualization, and dangerously exothermic sources of illumination. The introduction of fiber optics, charge-coupled-device cameras, and increasingly efficient light sources has enabled researchers to investigate areas of the human gastrointestinal tract through flexible endoscopy not previously thought to be reachable without formal surgical exploration. The more recent advances in scope platforms, devices, and techniques have allowed researchers to push the envelope of endoscopic diagnostics and therapeutics to greater heights. Specific new platforms include ColonoSight and mother-daughter endoscopes such as the ShapeLock TransPort and the SpyGlass direct visualization system. Specific devices include the EndoCinch suturing system, the full-thickness Plicator procedure, Esophyx, the Stretta system, and the HALO(360) system. Specific new techniques include small-caliber endoscopy, endoscopic mucosal and submucosal resection, and natural orifice translumenal endoscopic surgery (NOTES). This article describes the most relevant recent advances in endoscopic innovation with regard to platform design, devices, and techniques anticipated to serve as the foundation for further research and design for developing generations of endoscopic technologies to come.

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.

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.

Murine Muscle Precursor Cells Survived and Integrated in a Cryoinjured Gastroesophageal Junction

BACKGROUND

Mini-invasive techniques for gastroesophageal reflux disease (GERD), such as endoscopic injections of inert materials, have been introduced in recent years. However, results are still preliminary. Cell injection has emerged as an alternative strategy in both vesicoureteral reflux and incontinence. Here we report, for the first time, the injection of muscle precursor cells (MPCs) in the gastroesophageal junction (GEJ).

MATERIALS AND METHODS

MPCs were derived from expanded satellite cells isolated from skeletal muscle fibers of green fluorescent protein (GFP) positive mice. Via laparotomy, GFP-negative mice were subjected to cryoinjury of GEJ followed by injection of MPCs (experimental animals), bone marrow derived cells, or saline (controls).

RESULTS

Immunofluorescence analyses of experimental GEJs demonstrated coexpression of GFP and desmin in grafted cells. GFP+ muscle neofibers were evident at 4 wk after injection. Coexpression of GFP and smooth muscle actin was also observed at 2 wk.

CONCLUSIONS

Satellite cells could be easily harvested, expanded in culture, and used as injectable substance in the GEJ. These results could be the background for the development of a new injection technique for GERD treatment, which might combine bulging and functional actions.

Surgical treatment of obesity

Obesity is very prevalent. Most treatments fail owing to hard-wired survival mechanisms, linking stress and appetite, which have become grossly maladaptive in the industrial era. Antiobesity (bariatric) surgery is a seemingly drastic, efficacious therapy for this serious disease of energy surfeit. Technical progress during the last two decades has greatly improved its safety. The surgical principles of gastric restriction and/or gastrointestinal diversion have remained largely unchanged over 40 years, although mechanisms of action have been elucidated concomitant with advances in knowledge of the molecular biology of energy balance and appetite regulation. Results of bariatric surgery in large case-series followed for at least 10 years consistently demonstrate amelioration of components of the insulin-resistance metabolic syndrome and other comorbidities, significantly improving quality of life. Furthermore, bariatric surgery has convincingly been demonstrated to reduce mortality compared with nonoperative methods. This surgery requires substantial preoperative and postoperative evaluation, teaching, and monitoring to optimize outcomes. In the absence of effective societal changes to restore a healthy energy balance, bariatric surgery is an important tool for treating a very serious disease.

Endoluminal fundoplication

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.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.

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

Perendoscopic treatments of gastroesophageal reflux have been used in clinical practice following FDA approval of the first two devices in 2000. A number of clinical trials predominantly short-term have been performed almost uniformly demonstrating patient improvement in GERD symptomatology and reduction or elimination of antacids. However, only two of these endo reflux treatment trials have included the essential elements of strict patient entry criteria, randomization, attempts at blending, and intention-to-treat analysis. Two new endoscopic antireflux trials are published in this issue of the journal. The first study compares the EndoCinch sewing device to the Enteryx copolymer injection procedure. The second report compares the EndoCinch technique to the laparoscopic fundoplication procedure. Unfortunately, both studies lack a sham-control population and have other important flaws in design. Basically, all these techniques improved GERD symptoms and well-being and decreased the patients PPI requirement during follow-up period. However, none of the endoscopic procedures reduced acid reflux impressively or improved lower esophageal sphincter tone, a consistent negative outcome with all these techniques. Morbidity was associated with all the procedures and Enteryx has been withdrawn recently from clinical use by the manufacturer because of significant complications. The efficacy durability and safety of these devices in treating GERD patients is in question. A moratorium on the continued use of the procedures in clinical practice seems appropriate at this time.