The Stretta procedure for the treatment of GERD: a registry of 558 patients

Stretta: an effective, minimally invasive treatment for gastroesophageal reflux disease

The Stretta procedure is increasingly offered as first-line therapy before more invasive surgical procedures for selected patients with gastroesophageal reflux disease (GERD). Although a new addition to the clinical armamentarium, thus far the Stretta procedure appears to be a safe and effective technology for the treatment of GERD, with well-documented clinical trial data supporting its efficacy, safety, and patient satisfaction.

Endoscopic therapeutic esophageal interventions: old, new, borrowed and . . . methylene blue?

PURPOSE OF REVIEW

Endoscopic interventions in the esophagus continue to evolve. This article reviews some of the notable advances over the past year in endoscopic therapy for the esophagus.

RECENT FINDINGS

In 2002 several endoscopic therapies were reintroduced or modified. Ablative treatments, including Nd:YAG laser, photodynamic therapy, and thermal contact treatments have been shown to be effective for Barrett esophagus and some early esophageal cancers. The addition of endoscopic mucosal resection may improve these therapies. Endoscopic stenting remains the dominant endoscopic palliative modality for unresectable esophageal cancers, and modifications of this therapy have focused on reducing side effects and complications. Innovations in endoscopic treatments for strictures and bleeding esophageal varices have been proposed and may improve outcomes, although probably only marginally. Additional endoscopic antireflux procedures have been introduced, although the results of long-term studies still need to be published before their place in the treatment of gastroesophageal reflux disease can be determined.

SUMMARY

Rather than heralding novel endoscopic therapeutics, 2002 was a year of retooling and refining existing techniques.

Paradigm shift in the management of gastroesophageal reflux disease

OBJECTIVE

To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD).

SUMMARY BACKGROUND DATA

The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD.

METHODS

All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained.

RESULTS

Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure.

CONCLUSIONS

The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.

[Endoscopic (endoluminal) treatment of gastroesophageal reflux disease]

New endoscopic (endoluminal) methods have been developed recently for the treatment of gastroesophageal reflux disease. The options are endoluminal gastroplasty, delivery of radiofrequency to the lower oesophagus reducing transient relaxation of the lower sphincter, or implantation of polymer in the lower oesophagus. The respective results of these procedures are detailed and discussed. The lack of long term follow-up and the number of procedures do not allow to validate the endoluminal procedures which remain in the field of clinical research. When the medical treatment fails or in case of complication, the glod standard is still the laparoscopic fundoplication. But it is possible in the future that one or more endoluminal techniques could change the management of reflux disease.