Endoscopic day case antireflux radiofrequency (Stretta) therapy improves quality of life and reduce proton pump inhibitor (PPI) dependency in patients with gastro-oesophageal reflux disease: a prospective study from a UK tertiary centre

Efficacy and safety of antireflux mucosectomy versus radiofrequency ablation of the lower esophageal sphincter for the treatment of GERD: a systematic review and meta-analysis

BACKGROUND AND AIMS

GERD affects 10% to 30% of the population. Endoscopic antireflux therapies have been proposed for carefully selected patients. In this study, we compared outcomes between endoscopic antireflux mucosectomy (ARMS) and endoscopic radiofrequency ablation of the lower esophageal sphincter (Stretta procedure) for the treatment of GERD.

METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after ARMS and Stretta procedures. The main outcomes were patient satisfaction, GERD Health-Related Quality of Life (GERD-HRQL) scores, proton pump inhibitor (PPI) use, and DeMeester scores. Secondary outcomes were postprocedural adverse events. A meta-analysis of proportions and linear regression models was used to assess the effect of each endoscopic procedure on the different outcomes.

RESULTS

Sixty-six studies comprising 3767 patients were included, with 3074 patients (81.60%) undergoing Stretta and 693 (18.40%) ARMS. The weighted pooled patient satisfaction rates were 65% (95% confidence interval [CI], 52-76) for ARMS and 77% (95% CI, 64-87) for Stretta. Both treatments significantly reduced PPI use (from 100% to 40.18% for ARMS vs from 99.42% to 48.51% for Stretta, P = .20) and improved GERD-HRQL scores (pre 19.75 to post 8.24 for ARMS vs pre 21.02 to post 10.45 for Stretta, P = .70). DeMeester scores improved similarly after both procedures (pre 44.99 to post 15.02 for ARMS vs pre 52.29 to post 28.99 for Stretta, P = .48). ARMS was associated with higher overall morbidity (25% vs 17%, P = .001) and greater risks of stricture (odds ratio [OR], 13.03; 95% CI, 7.83-21.71), bleeding (OR, 13.16; 95% CI, 8.60-20.15), and perforation (OR, 13.03; 95% CI, 7.82-21.71) compared with Stretta.

CONCLUSIONS

Both Stretta and ARMS are effective endoscopic treatment modalities for GERD. Although their clinical efficacy appears to be similar, the increased risk of dysphagia, bleeding, and perforation after ARMS should not be underestimated.

Endoscopic Management Options for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a prevalent condition that affects a significant portion of the Western population. Despite its benign pathophysiology, it has the potential to cause serious complications over time, ranging from conditions that are benign, premalignant, and/or malignant. Traditional treatment options include lifestyle measures, anti-secretory medications (e.g., proton pump inhibitor (PPI)), and surgical options (e.g., Nissen and Toupet fundoplication). However, recent studies have revealed long-term side effects of anti-secretory medications. Moreover, surgical options, though effective, are considered invasive and associated with potential complications. In the current age of ongoing research in minimally invasive options, endoscopic treatment of GERD has become popular. As a result, procedures such as radiofrequency treatment and transoral incisionless fundoplication (TIF) have gained FDA approval and are currently being covered by most insurance. In this review article, we will discuss pre-procedural workup, appropriate patient selection, advantages, disadvantages, procedure techniques, and follow-up of patients who undergo various endoscopic treatments for GERD. In addition, we will review the short and long-term success of these techniques in improving quality of life, use of PPI, and improvement in symptoms considering published data in high-quality peer-reviewed journals.

Endoscopic Non-ablative Radiofrequency Treatment (Stretta) for Gastroesophageal Reflux Disease (GERD)

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is very common in the general population and poses a large societal socio-economic burden. In this article, we review the evidence supporting non-ablative radiofrequency treatment (Stretta) for the endoscopic management of GERD and we compare it to pharmacologic and other minimally invasive and surgical interventions.

RECENT FINDINGS

Proton pump inhibitors (PPI) are a key therapy for GERD. For patients without associated significant sliding hiatal hernia, who have inadequate relief of their reflux symptoms, Stretta and other endoscopic therapies, such as transoral fundoplication (TIF), may improve symptoms and GERD-related quality of life. Unfortunately, there are no recent large randomized controlled trials, and most of the evidence is based on meta-analyses and small scale, prospective and retrospective single center efforts. Comparisons of Stretta efficacy to other anti-reflux endoscopic modalities and anti-reflux surgery (ARS) are also presented. There are several endoscopic and minimally invasive modalities to manage PPI-refractory GERD acting through various mechanisms that have been found effective in managing GERD symptoms and quality of life. Among them, Stretta has the longest track record of efficacy and safety. Larger-scale and longer-term comparative efficacy trials in selected populations of patients with acid reflux with and without hiatal hernia will be needed.

Efficacy and safety of endoscopic cardia peripheral tissue scar formation (ECSF) for the treatment of refractory gastroesophageal reflux disease: A systematic review with meta-analysis

BACKGROUND

Endoscopic treatment is increasingly used for refractory gastroesophageal reflux disease (rGERD). Unlike the mechanism of conventional surgical fundoplication, gastroesophageal junction ligation, anti-reflux mucosal intervention, and radiofrequency ablation have extremely similar anti-reflux mechanisms; hence, we collectively refer to them as endoscopic cardia peripheral tissue scar formation (ECSF). We conducted a systematic review and meta-analysis to assess the safety and efficacy of ECSF in treating rGERD.

METHODS

We performed a comprehensive search of several databases, including PubMed, Embase, Medline, China Knowledge Network, and Wanfang, to ensure a systematic approach for data collection between January 2011 and July 2023. Forest plots were used to summarize and combine the GERD-health-related quality of life (HRQL), gastroesophageal reflux questionnaire score, and DeMeester scores, acid exposure time, lower esophageal sphincter pressure, esophagitis, proton pump inhibitors use, and patient satisfaction.

RESULTS

This study comprised 37 studies, including 1732 patients. After ECSF, significant improvement in gastroesophageal reflux disease health-related quality of life score (mean difference [MD] = 18.27 95% CI: 14.81-21.74), gastroesophageal reflux questionnaire score (MD = 4.85 95% CI: 3.96-5.75), DeMeester score (MD = 42.34, 95% CI: 31.37-53.30), acid exposure time (MD = 7.98, 95% CI: 6.03-9.92), and lower esophageal sphincter pressure was observed (MD = -5.01, 95% CI: -8.39 to 1.62). The incidence of serious adverse effects after ECSF was 1.1% (95% CI: 0.9%-1.2%), and postoperatively, 67.4% (95% CI: 66.4%-68.2%) of patients could discontinue proton pump inhibitor-like drugs, and the treatment outcome was observed to be satisfactory in over 80% of the patients. Subgroup analyses of the various procedures showed that all 3 types improved several objective or subjective patient indicators.

CONCLUSIONS

Based on the current meta-analysis, we conclude that rGERD can be safely and effectively treated with ECSF as an endoscopic procedure.

Endoscopic radiofrequency Stretta therapy reduces proton pump inhibitor dependency and the need for anti-reflux surgery for refractory gastroesophageal reflux disease

BACKGROUND/AIMS

Radiofrequency treatment of the gastroesophageal junction using the Stretta procedure for treating gastroesophageal reflux disease (GERD) is observed to improve the symptoms and proton pump inhibitor (PPI) dependence and reduce the need for anti-reflux operations. As one of the largest studies in Europe, we evaluated the clinical outcomes of Stretta in patients with medically refractory GERD.

METHODS

A tertiary UK center evaluated all patients with refractory GERD who underwent Stretta between 2014 and 2022. Patients and primary care professionals were contacted to obtain information regarding the initiation of PPI and reintervention after Stretta.

RESULTS

Of the 195 patients (median age, 55 years; 116 women [59.5%]) who underwent Stretta, PPI-free period (PFP) data were available for 144 (73.8%) patients. Overall, 66 patients (45.8%) did not receive PPI after a median follow-up of 55 months. Six patients (3.1%) underwent further interventions. The median PFP after Stretta was 41 months. There was a significant negative correlation between PFP and age (p=0.007), with no differences between sexes (p=0.96). Patients younger than 55 years of age had a longer PFP than their older counterparts (p=0.005). Younger males had a significantly longer PFP than older males (p=0.021). However, this was not observed in the female cohort (p=0.09) or between the younger men and women (p=0.66).

CONCLUSION

Our findings suggest that Stretta is a safe and feasible option for treating refractory GERD, especially in younger patients. It prevents further anti-reflux interventions in most patients and increases the lead-time to surgery in patients with refractory GERD.

Gastroesophageal reflux disease: recent innovations in endoscopic assessment and treatment

Innovations in endoscopy have brought about some impressive improvements in diagnosing and treating gastroesophageal reflux disease (GERD). GERD, as one of the most prevalent gastrointestinal disorders in the world, has always been on the cutting edge of endoscopic interventions. A primary diagnosis of GERD is based on symptoms and an initial trial of proton-pump inhibitor (PPI) therapy, which is devoid of adequately instructive value for therapeutic strategies. Endoscopy and optional biopsies can be used to directly observe and determine the abnormal structural and pathophysiological damage in the esophagus. The emergence of minimally invasive endoscopic therapy fills the gap between patients who are reluctant or insensitive to PPIs and candidates who are not indicated for surgical anti-reflux fundoplication. In this review, we discuss the utility of endoscopy and biopsy in patients with persistent GERD-related manifestations after proper medical anti-reflux treatment. Moreover, we portray a landscape of four current endoscopic GERD therapies and clarify the merits and disadvantages of each technique. Future research needs to concentrate on stratifying GERD patients based on personal conditions and elucidating the primary pathophysiology of GERD.

The Outcome of Endoscopic Radiofrequency Anti-Reflux Therapy (STRETTA) for Gastroesophageal Reflux Disease in Patients with Previous Gastric Surgery: A Prospective Cohort Study

BACKGROUND/AIMS

STRETTA improves the quality of life and reduces the need for anti-reflux medication in select patients, especially those with uncomplicated gastroesophageal reflux disease (GERD). We aimed to review the outcomes of STRETTA in patients with medically refractory GERD, who had undergone previous gastric surgery.

METHODS

This was a review of a prospective database in a British center. Since 2016, all GERD patients who underwent STRETTA and had a history of previous gastric surgery were studied (n=11). Anti-reflux medication pre- and post-STRETTA was evaluated. The outcomes were assessed objectively by the change in anti-reflux medication and subjectively through a pre- and post-procedure GERD-health-related quality of life (HRQL) questionnaire.

RESULTS

The median length of follow-up was 23 months. Nine patients demonstrated improved GERD-HRQL scores following STRETTA (82%). Of the 7 patients who underwent fundoplication, all reported improved symptoms, with 3 patients discontinuing the medication and 3 patients on a reduced dose of proton pump inhibitor. Four patients underwent surgery other than fundoplication, of which 2 reported improvement and discontinued the proton pump inhibitor. Two patients reported no improvement.

CONCLUSION

This study demonstrates that STRETTA is successful in reducing refractory GERD in patients with previous gastric surgery. The outcomes were comparable to published outcomes in patients with uncomplicated GERD with no previous history of gastric surgery.

Evaluation and Treatment of Patients with Persistent Reflux Symptoms Despite Proton Pump Inhibitor Treatment

Despite the exceptional efficacy of proton pump inhibitors (PPIs) in healing reflux esophagitis complicating gastroesophageal reflux disease (GERD), up to 40% of patients who take PPIs for GERD complain of persistent GERD symptoms. There is no clear consensus on the type, dosing, and duration of PPI therapy required to establish a diagnosis of PPI-refractory GERD symptoms, but most authorities do not consider patients "PPI-refractory" unless they have been on double-dose PPIs. This article discusses the mechanisms that might underlie heartburn that does not respond PPIs and an approach to the management of patients with PPI-refractory GERD symptoms.

Refractory Gastroesophageal Reflux Disease and Functional Heartburn

This report discusses the potential mechanisms that might underlie refractory GERD and functional heartburn, and how to distinguish among those mechanisms using a systematic evaluation that includes careful medical history, endoscopy with esophageal biopsy, esophageal manometry, and esophageal multichannel intraluminal impedance-pH monitoring. The report provides an approach to patient management that depends on the underlying mechanism identified by this systematic evaluation.