Laparoscopic Nissen fundoplication after failed EsophyX fundoplication

Endoscopic Treatment of Gastroesophageal Reflux Disease

There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.

Quantifying physiologic parameters of the gastroesophageal junction during re-operative anti-reflux surgery

BACKGROUND

Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS.

METHODS

Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation.

RESULTS

Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2 years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm2 and DI 1.1 (IQR - 2.4, - 0.6) mm2/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS.

CONCLUSIONS

During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.

The evolution of TIF: transoral incisionless fundoplication

Transoral incisionless fundoplication (TIF) was introduced in 2006 as a concerted effort to produce a natural orifice procedure for reflux. Since that time, the device, as well as the procedure technique, has evolved. Significant research has been published during each stage of the evolution, and this has led to considerable confusion and a co-mingling of outcomes, which obscures the results of the current device and procedure. This report is intended to review the identified stages and literature associated with each stage to date and to review the current state of treatment outcomes.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

Endoscopic techniques for treating gastroesophageal reflux

PURPOSE OF REVIEW

Nearly, a third of patients with medically refractory gastroesophageal reflux disease (GERD) will desire an additional nonsurgical treatment option. Recently, endoscopic therapy has been reintroduced as a minimally invasive antireflux barrier treatment, after addressing prior efficacy and safety concerns. Over the last two decades, additional experience and new technologies have resulted in devices and protocols with favorable short-term outcomes and safety profiles. The current literature in endoscopic antireflux therapies covers new devices, long-term follow-up data and further safety experience. This review discusses the endoscopic antireflux devices on the market and most recent studies in this area.

RECENT FINDINGS

Quality of life and reflux symptom score improvement is observed in 73-90% of patients through a 36-48 month follow-up period, with 41-77% remaining off all reflux medicines. Composite data from several thousand cases indicate a low rate (0.93-2.4%) of serious complications and no late adverse effects, including gas-bloat syndrome.

SUMMARY

In this review, we describe the four endoscopic antireflux devices on market and summarize the current data in the literature. The short and long-term data demonstrate durable symptom improvement and favorable safety profile. Endoscopic antireflux treatment should be considered in the management of GERD.

The Spectrum of Surgical Remediation of Transoral Incisionless Fundoplication-Related Failures

AIM

To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF).

METHODS

This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregut symptoms. Upper gastrointestinal workup characterized 1 patient as having normal post-TIF anatomy and 10 as having anatomic failure. Ambulatory pH testing was performed in 7 patients and was abnormal in all. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all accessible polypropylene T-fasteners.

RESULTS

All patients had esophageal salvage and have not required a reoperation. Anatomical findings included hiatal hernia (7), esophageal diverticulum (2), hiatal mesh erosion of esophagus (1), long-segment esophageal stricture (1), and normal anatomy (1). Remedial operations included laparoscopic explant of fasteners in all patients with conversion to fundoplication (7), resection/imbrication of esophageal diverticulum (2), Heller myotomy (1), and mesh explant and complex esophageal repair (1). Mean operative time was 177 minutes and median length of stay 3 days (range 2-13 days). At mean follow-up of 10.7 months (range 1-42 months), 7 patients had persistent complaints. Esophagogastroduodenoscopy was repeated in these 7 patients and was normal (n = 3), mild stenosis requiring dilation (n = 2), Los Angeles grade B esophagitis (n = 1), and Barrett's esophagus (n = 1).

CONCLUSION

Anatomic distortion of the distal esophagus after TIF can be significant, making subsequent operations complex. After remedial surgery, few patients will continue to have troublesome symptoms such as dysphagia.

Long-Term Outcomes of Transoral Incisionless Fundoplication in a High-Risk Pediatric Population

INTRODUCTION

Laparoscopic Nissen fundoplication (LNF) is the standard for surgical treatment of gastroesophageal reflux disease (GERD), but postoperative complications and pain are common in patients with severe neurological impairment (NI) and those undergoing reoperative procedures. Transoral incisionless fundoplication (TIF) is an endoscopic alternative to treat GERD. Long-term results in pediatric populations are unknown.

METHODS

Eleven patients who underwent TIF between January 2008 and September 2010 were included. A retrospective chart review was performed to evaluate long-term patient outcomes. Median follow-up was 5.6 years (range = 0.42-8.76 years).

RESULTS

Average patient age was 16.5 ± 5.1 years. Severe NI was present in 81.8% (9/11) of patients, and 63.6% (7/11) had undergone one or more prior fundoplication attempts. Overall, symptomatic reflux recurred or persisted in 54.5% (6/11) of patients. Recurrent symptoms were more common among those who had previous fundoplications than those who did not (71.4% [5/7] vs. 25% [1/4]). Four patients went on to require reoperation, including one laparoscopic Nissen and three disconnects. At last follow-up, 81.8% (9/11) of patients were still on antireflux medications.

CONCLUSIONS

This is the first report of long-term outcomes for treatment of GERD using TIF in a pediatric population. The recurrence rate was high, likely related to the fact that the population treated was extremely high risk. Recurrence was higher in patients with a prior fundoplication, perhaps identifying prior antireflux operations as a relative contraindication to TIF. Nevertheless, complications were low, and a subset of patients did receive a durable benefit from the procedure.

Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

Gastro-esophageal reflux disease (GERD) is a very common disorder that results primarily from the loss of an effective antireflux barrier, which forms a mechanical obstacle to the retrograde movement of gastric content. GERD can be currently treated by medical therapy, surgical or endoscopic transoral intervention. Medical therapy is the most common approach, though concerns have been increasingly raised in recent years about the potential side effects of continuous long-term medication, drug intolerance or unresponsiveness, and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may in some cases have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. In the last few years, transoral incisionless fundoplication (TIF) has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy. This review describes the steps of the TIF technique, using the EsophyX(®) device and the MUSE(TM) system. Complications and their management are described in detail, and the recent literature regarding the outcomes is reviewed. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, by serosa-to-serosa plications which include the muscle layers. To date the procedure has achieved lasting improvement of GERD symptoms (up to six years), cessation or reduction of proton pump inhibitor medication in about 75% of patients, and improvement of functional findings, measured by either pH or impedance monitoring.

Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease

OBJECTIVES

Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence.

METHODS

Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months.

RESULTS

A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.

CONCLUSION

Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.

Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM: To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication (TIF).

METHODS: TIF is a new endoscopic approach for treating gastroesophageal reflux disease (GERD). In cases of TIF failure, subsequent laparoscopic fundoplication may be required. All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication. Primary outcome measures included operative time, blood loss, length of hospital stay and complications encountered.

RESULTS: A total of 5 patients underwent revisional laparoscopic Nissen fundoplication (LNF) or gastrojejunostomy for recurrent GERD at a median interval of 24 mo (range: 16-34 mo) after TIF. Patients had recurrent reflux symptoms at an average of 1 mo following TIF (range: 1-9 mo). Average operative time for revisional surgical intervention was 127 min (range: 65-240 min) and all surgeries were performed with a minimal blood loss (< 50 mL). There were no cases of gastric or esophageal perforation. Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously. Median length of hospitalization was 2 d (range: 1-3 d). All patients had resolution of symptoms at the last follow up.

CONCLUSION: LNF is a feasible and safe option in a patient who has persistent GERD after a TIF. Previous TIF did not result in additional operative morbidity.

Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study

BACKGROUND

Transoral incisionless fundoplication (TIF) with the EsophyX™ device creates an antireflux valve with good functional results in patients with gastro-esophageal reflux disease (GERD). The aim of this study was to assess the long-term effect of TIF 2.0 on pathological reflux and symptoms in GERD patients with daily dependence on proton pump inhibitors (PPI).

METHODS

Fifty patients underwent TIF. All underwent GERD-HRQL and GERD-QUAL questionnaires, upper GI endoscopy, esophageal manometry, and 24-h pH-impedance before and 6, 12, and 24 months after TIF, and subsequent yearly clinical re-evaluation.

RESULTS

Patients were followed for up to six years (mean 52.7 ± 19.7 months). In all, 83.7, 79.6, 87.8, and 84.4% of patients stopped or halved the PPI therapy 6, 12, 24, and 36 months after TIF. Three-year figure remained stable up to 6 years. Symptom scores off PPI were significantly lower at 6, 12, 24, and 36 months. At 6 months, Hill's grade I of the newly created valve persisted in all pre-procedure Hill's grade I patients, in 66.7% of grade II and 58.3% of grade III. This figure remained substantially unchanged at 12 and 24 months, too. Impedance monitoring indicated significantly fewer total and acid refluxes after treatment (p = 0.01). Factors predicting good outcomes were pre-procedure Hill's grade I-II, no hiatal hernia or hernia ≤2 cm (p = 0.03), absence of ineffective esophageal motility (p < 0.0001), and number of fasteners deployed (p = 0.01).

CONCLUSIONS

TIF by the EsophyX achieved lasting elimination of daily dependence on PPI in 75-80% of patients for up to 6 years. TIF seems an effective therapy for selected symptomatic GERD patients.

Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective

BACKGROUND

Transoral incisionless fundoplication (TIF) treats gastroesophageal reflux disease (GERD) by creating a full-thickness esophagogastric plication using transmural fasteners. If unsuccessful, revision laparoscopic anti-reflux surgery (rLARS) may be performed. This study evaluated operative findings and clinical outcomes of rLARS in 28 patients with prior primary TIF.

METHODS

Intraoperative findings, complications, and symptomatic outcomes with GERD health-related quality of life (GERD-HRQL) were evaluated prospectively in patients having rLARS after TIF. Results are median with interquartile range (IQR).

RESULTS

Between 03/2009 and 08/2013, 28 patients underwent rLARS at 14 (13-50) months post-TIF for recurrent symptoms after initial improvement. Pre-rLARS endoscopies found hiatal hernia (9) and wrap disruption (12). All revisions were completed laparoscopically in 88 (70-90) min. Eight patients underwent partial fundoplication, the rest Nissen. No intraoperative or postoperative complications occurred. Operative findings included: No axial hernia in 65%; Dense adhesions in 14%; Fasteners incorporating the lateral crus in 95%; Traction diverticuli from esophagus to crura in 21%. Residual plication was noted anteriorly in 75%, posteriorly in 0%. Operative approaches: (1) Areas where the TIF fundoplication remained were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of 'fold'. (2) Fasteners were cut and left to migrate into the lumen, rather than being pulled out. (3) In 8 patients with fusion of the lateral crus to TIF fundoplication and no axial hernia, revision fundoplication was performed without mediastinal mobilization but with posterior hernia repair. One patient required subsequent surgery for small paraesophageal hernia, one for refractory gas-bloat after rLARS. Dysphagia in 2 patients resolved with dilation. GERD-HRQL improved from a median of 20 (8-27) pre-TIF and 10 (1-20) pre-rLARS to 3 (0-4) at 28 months (12-40) post-rLARS (p = 0.020 for pre-rLARS to post-rLARS).

CONCLUSION

rLARS after TIF can be performed safely with excellent clinical outcomes.

Do endoscopic antireflux procedures fit in the current treatment paradigm of gastroesophageal reflux disease?

Gastroesophageal reflux disease (GERD) is a common condition requiring considerable medical resources. The mainstay of therapy is proton pump inhibitors (PPIs), which are effective at reducing acid reflux. In patients who have refractory acid reflux and esophagitis despite high-dose PPI, or are intolerant of the side effects of PPI therapy, surgical fundoplication is the primary therapy. The risk and cost gap between medical therapy and surgery has resulted in substantial interest in less-invasive endoscopic therapies. In this review, we discuss the underlying physiology of GERD along with the anatomic hurdles that must be overcome to develop an effective antireflux procedure. We also review the current published literature and assess the clinical efficacy of the devices that have been studied or currently are being investigated. Despite promising early studies, many of the devices fall short in high-quality randomized controlled trials. Furthermore, the physiologic aberration resulting in GERD oftentimes is addressed inadequately. Although there is certainly a need for less-invasive, safe, and effective therapy for reflux, therapy will need to withstand the established clinical efficacy of both PPI and surgical fundoplication. At present, we have the luxury of time to wait for such a device to become available.

Transoral incisionless fundoplication does not significantly increase morbidity of subsequent laparoscopic Nissen fundoplication

INTRODUCTION

Transoral incisionless fundoplication (TIF) has been used for endoscopic treatment of gastroesophageal reflux disease (GERD). Full-thickness polypropylene H-fasteners create a serosa-to-serosa gastroesophageal plication. A certain subset of TIF patients will require subsequent antireflux surgery to achieve adequate reflux control, and it is unknown whether this procedure increases the technical difficulty of laparoscopic Nissen fundoplication for recurrent GERD.

PATIENTS AND METHODS

Between 2008 and 2010, patients demonstrating objective evidence of recurrent gastroesophageal reflux following TIF using the Esophyx device (Endogastric Solutions, Redmond, WA) underwent laparoscopic Nissen fundoplication. The study end points included operative time, operative blood loss, gastric or esophageal perforation, and length of hospital stay.

RESULTS

In total, 7 patients underwent laparoscopic Nissen fundoplication for recurrent GERD at a median interval of 7 (range, 3-28) months after TIF. Revisional fundoplication required 97 (range, 48-122) minutes and was performed in all cases with minimal blood loss. There were no cases of esophageal or gastric perforation during the dissection of the previous fundoplication. A significant hiatal hernia was noted during 1 case, and all others revealed partially disrupted gastroesophageal fundoplications with visible dislodged polypropylene H-fasteners visible. All patients were discharged from the hospital on the first postoperative day.

CONCLUSIONS

Severe recurrent gastroesophageal reflux necessitating laparoscopic Nissen fundoplication occurs in a subset of patients following TIF. In this series, previous TIF did not result in prolonged operative times, significant operative hemorrhage, or iatrogenic hollow viscus injury. These data suggest that laparoscopic Nissen fundoplication can be safely performed in this patient population without increased operative morbidity.

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.

Transoral incisionless fundoplication with EsophyX® for treatment of gastro-oesphageal reflux disease

Gastro-oesphageal reflux disease results primarily from the loss of an effective antireflux barrier, which forms a mechanical barrier against the retrograde movement of gastric content. This review describes the technique of performing a transoral incisionless fundoplication with the EsophyX® device. Transoral incisionless fundoplication reconfigures the tissue so as to establish serosa-to-serosa plications which include the muscular layers, and construct 3-5 cm long valves 200-300° in circumference. The steps of the technique, as well as complications and their management are described in detail, and a recent literature review is also provided. At present, available prospective cohort studies indicate that transoral incisionless fundoplication using the EsophyX® device may be effective in approximately half PPI-responsive gastro-oesphageal reflux disease for up to 3 years' follow-up, without troublesome procedure-related persistent side effects.

Effectiveness of a transluminal endoscopic fundoplication for the treatment of pediatric gastroesophageal reflux disease

PURPOSE

Although laparoscopic Nissen fundoplication is the standard surgical treatment for gastroesophageal reflux disease (GERD), surgical complications and post-operative pain are not uncommon, especially for those patients who are neurologically impaired (NI) or undergoing re-operative procedures. To address this challenge, we utilized the transoral incisionless fundoplication (TIF) procedure to treat GERD via an endoscopic approach.

METHODS

Eleven TIF patients were included with an average age of 16.5 ± 5.1 years and weight of 45.7 ± 13.3 kg. NI was present in nine patients (82%), including a predominant number of patients with a history of seizures and gastrostomy tube feeding. Five patients had a history of a previous failed fundoplication requiring a re-operative procedure (45%). A retrospective chart review evaluated patient outcomes and post-operative complications.

RESULTS

The length of the TIF procedure was 113.3 ± 31.3 min with minimal blood loss. The length of stay was 1.2 ± 0.4 days, although one TIF patient was re-admitted for endoscopic clipping for gastric bleeding. At a follow-up of 8.2 ± 4.2 months, TIF effectively resolved GERD in 10 out of 11 children. A few of the patient's families reported complaints of gagging or dysphagia (30%, 3/11); however it was difficult to determine if complaints were due the procedures itself or baseline NI. All patients who had a follow-up upper GI or pH probe study showed no evidence of reflux. One TIF patient had no recurrent reflux but required an esophago-gastric disconnection for retching.

CONCLUSIONS

The TIF procedure can complement the current surgically and medically available options for children with GERD, especially in complicated patients such as those with NI. However, complications including hemorrhage emphasize the potential risk of the procedure. Further studies with more patients and a longer follow-up course must be conducted to better assess efficacy.

Reflux parameters as modified by EsophyX or laparoscopic fundoplication in refractory GERD

BACKGROUND

EsophyX is a novel transoral incisionless fundoplication device developed to mimic surgical fundoplication. EsophyX fundoplication improves acid reflux parameters in proton pump inhibitor (PPI)-responsive GERD patients but its efficacy in refractory GERD has been scarcely studied.

AIM

To assess reflux parameters before and after EsophyX or laparoscopic fundoplication and their relationship with symptoms in refractory GERD.

METHODS

In an open-label study, we enrolled prospectively patients with heartburn/regurgitation persisting despite high-dose PPI therapy. Impedance-pH monitoring was performed on PPI therapy before intervention and off PPI therapy 3 months after intervention.

RESULTS

Ten patients chose to undergo EsophyX (EndoGastric Solutions, Redmond, WA, USA) fundoplication while ten chose laparoscopic fundoplication, and the baseline characteristics were comparable. Distal and proximal refluxes were significantly reduced post-operatively in the surgical but not in the endoscopic group and the median values were significantly lower in the former than in the latter. The oesophageal acid exposure time was normal in 50% of cases after EsophyX and in 100% of cases after surgery (P=0.033); the number of distal refluxes was normal in 20% and 90% of cases (P=0.005) and the number of proximal refluxes was normal in 40% and 100% of cases (P=0.011), respectively. A positive persisting symptom-reflux association was found post-operatively in 6/10 patients in the EsophyX group and in 0/10 patients in the surgical group (P=0.011).

CONCLUSIONS

In patients with refractory GERD, EsophyX fundoplication is significantly less effective than laparoscopic fundoplication in improving reflux parameters and accordingly, in inducing symptom remission.

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.