Sustained improvement in symptoms of GERD and antisecretory drug use: 4-year follow-up of the Stretta procedure

The Role of GABA Receptors in Anesthesia and Sedation: An Updated Review

GABA (γ-aminobutyric acid) receptors are constituents of many inhibitory synapses within the central nervous system. They are formed by 5 subunits out of 19 various subunits: α1-6, β1-3, γ1-3, δ, ε, θ, π, and ρ1-3. Two main subtypes of GABA receptors have been identified, namely GABAA and GABAB. The GABAA receptor (GABAAR) is formed by a variety of combinations of five subunits, although both α and β subunits must be included to produce a GABA-gated ion channel. Other subunits are γ, δ, ε, π, and ϴ. GABAAR has many isoforms, that dictate, among other properties, their differing affinities and conductance. Drugs acting on GABAAR form the cornerstone of anesthesia and sedation practice. Some such GABAAR agonists used in anesthesia practice are propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. Ketamine, nitrous oxide, and xenon are not GABAR agonists and instead inhibit glutamate receptors-mainly NMDA receptors. Inspite of its many drawbacks such as pain in injection, quick and uncontrolled conversion from sedation to general anesthesia and dose-related cardiovascular depression, propofol remains the most popular GABAR agonist employed by anesthesia providers. In addition, being formulated in a lipid emulsion, contamination and bacterial growth is possible. Literature is rife with newer propofol formulations, aiming to address many of these drawbacks, and with some degree of success. A nonemulsion propofol formulation has been developed with cyclodextrins, which form inclusion complexes with drugs having lipophilic properties while maintaining aqueous solubility. Inhalational anesthetics are also GABA agonists. The binding sites are primarily located within α+/β- and β+/α- subunit interfaces, with residues in the α+/γ- interface. Isoflurane and sevoflurane might have slightly different binding sites providing unexpected degree of selectivity. Methoxyflurane has made a comeback in Europe for rapid provision of analgesia in the emergency departments. Penthrox (Galen, UK) is the special device designed for its administration. With better understanding of pharmacology of GABAAR agonists, newer sedative agents have been developed, which utilize "soft pharmacology," a term pertaining to agents that are rapidly metabolized into inactive metabolites after producing desired therapeutic effect(s). These newer "soft" GABAAR agonists have many properties of ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. Remimazolam, a modified midazolam and methoxycarbonyl-etomidate (MOC-etomidate), an ultrashort-acting etomidate analog are two such examples. Cyclopropyl methoxycarbonyl metomidate is another second-generation soft etomidate analog that has a greater potency and longer half-life than MOC-etomidate. Additionally, it might not cause adrenal axis suppression. Carboetomidate is another soft analog of etomidate with low affinity for 11β-hydroxylase and is, therefore, unlikely to have clinically significant adrenocortical suppressant effects. Alphaxalone, a GABAAR agonist, is recently formulated in combination with 7-sulfobutylether-β-cyclodextrin (SBECD), which has a low hypersensitivity profile.

Outcomes of Endoscopic Antireflux Mucosectomy for the Treatment of Gastroesophageal Reflux Disease: Systematic Review and Meta-analysis

OBJECTIVE

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders in western countries. Endoscopic procedures have recently emerged as an alternative therapy to surgery for patients with GERD. The aim of this study was to determine outcomes after endoscopic antireflux mucosectomy (ARMS).

METHODS

A systematic review and meta-analysis were performed to analyze outcomes after ARMS. The main outcomes included patients' satisfaction, GERD health-related quality of life, use of proton pump inhibitors, and DeMeester score. The secondary endpoint was postprocedural adverse events. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes.

RESULTS

A total of 22 studies comprising 654 patients were included for analysis. The mean age of patients was 51.83 (36 to 59.39) years, and the mean body mass index was 25.06 (23.5 to 27) kg/m 2 . The weighted pooled proportion of patient satisfaction after ARMS was 65% (95% CI: 52%-76%). The pooled proportion of patients taking proton pump inhibitors decreases from 100% to 40.84% ( P < 0.001). The mean GERD health-related quality of life scores (pre 19.48 vs post 7.90, P < 0.001) and DeMeester score (pre 44.99 vs post 15.02 P = 0.005) significantly improved after ARMS. Overall morbidity rate was 27% (95% CI: 13%-47%), with a weighted pooled proportion of perforation, stricture, and bleeding of 3% (95% CI: 2%-6%), 12% (95% CI: 9%-16%), and 6% (95% CI: 2%-17%), respectively.

CONCLUSIONS

Endoscopic ARMS for GERD is associated with symptomatic improvement, reduction of medical therapy, and enhanced quality of life. Refinements of the technique, however, are needed to decrease morbidity.

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 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.

The safety and efficacy of peroral endoscopic cardial constriction in gastroesophageal reflux disease

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) is one of the most common digestive disorders, which seriously affects the quality of life and brings a heavy burden to the medical care. Peroral endoscopic cardial constriction (PECC) can narrow the cardia through mucosal ligation to alleviate acid reflux symptoms. This study aims to assess the clinical efficacy of PECC.

METHODS

This was a retrospective case series including patients diagnosed with GERD and undergoing PECC from September 2019 to July 2021. GERD-Q questionnaire and GERD-QOL questionnaire were applied to evaluate the symptom severity and the impact of life because of GERD.

RESULTS

A total of 16 patients were included in our study. The mean GERD-Q score was 10.94 ± 2.11 before PECC, while 5.38 ± 3.90 after PECC. The mean GERD-QOL score was 43.60 ± 16.94 before PECC, while 73.65 ± 22.08 after PECC. 62.5% of patients were satisfied with the symptom control and no serious complications were reported in our study.

CONCLUSIONS

PECC is an efficient and safe minimally invasive endoscopic intervention for GERD. It can significantly improve GERD-related symptoms and quality of life.

Endoscopic management of gastroesophageal reflux disease: Panacea for proton pump inhibitors dependent/refractory patients

Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti-reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy and anti-reflux mucosal ablation have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.

Endoscopic Management of GERD

Gastroesophageal reflux disease (GERD) has consistently been the most frequently diagnosed gastrointestinal malady in the USA. The mainstay of therapy has traditionally been medical management, including lifestyle and dietary modifications as well as antacid medications. In those patients found to be refractory to medical management or with a contraindication to medications, the next step up has been surgical anti-reflux procedures. Recently, though innovative advancements in therapeutic endoscopy have created numerous options for the endoscopic management of GERD, in this review, we discuss the various endoscopic therapy options, as well as suggested strategies we use to recommend the most appropriate therapy for patients.

Comparison of 180° anti-reflux mucosectomy versus 270° anti-reflux mucosectomy for treatment of refractory gastroesophageal reflux disease: a retrospective study

BACKGROUND

Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD.

METHODS

This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed.

RESULTS

Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups.

CONCLUSION

Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.

Endoscopic approaches to gastroesophageal reflux disease

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is one of the most common chronic conditions affecting adults. A substantial proportion of patients continue to have symptoms despite medical therapy, and there has been increased demand for minimally invasive GERD therapy. We will examine currently available techniques and outcomes data on endoscopic approaches to the treatment of GERD.

RECENT FINDINGS

In the last 2 years, research has given rise to more robust understanding of not only the pathophysiology of GERD but also how to better manage the various phenotypes. We are learning the ideal patient to benefit from endoscopic GERD therapy. In this review, we describe the four major endoluminal techniques for treating GERD and summarize current data.

SUMMARY

Endoscopic therapies are well positioned to fill the 'therapy gap' between medical therapy and more invasive surgical procedures.

Treatment of Gastroesophageal Reflux Disease After Lung Transplant Using Radiofrequency Ablation to the Lower Esophageal Sphincter (Stretta Procedure)

BACKGROUND

Gastroesophageal reflux disease (GERD) is associated with chronic lung allograft dysfunction after lung transplant. Treating GERD after lung transplant has been shown to improve lung allograft function. This case series describes the efficacy of the Stretta procedure to control GERD after lung transplant at our institution.

METHODS

Eleven patients underwent the Stretta procedure at our institution for GERD after lung transplant during the years 2016-2017. Pre- and post-Stretta reflux parameters were gathered. Pulmonary function was followed up until subsequent fundoplication surgery, death, or end of study observation.

RESULTS

Reflux on esophagram was noted in 9 patients before Stretta and 8 patients after Stretta. The median number of acid reflux events was 31.5 vs. 26 after Stretta (P = .95), and median percent time in reflux was 17.7% before vs. 14.5% after Stretta (P = .76). Median DeMeester score before Stretta was 65.5 (range: 33.2-169.8) vs. 42.5 (range: 19.2-109.8) after the procedure (P = .14). Median lower esophageal resting pressure was 20.7 mm Hg (n = 7) compared to 25.9 mm Hg (n = 9) on post-Stretta follow-up (P = .99). Median FEV₁% predicted was 84% (41-97%) before compared to 71% (23-108%) at 1 year after the procedure (P = .14). Seven patients required fundoplication surgery for continued reflux. All patients were on triple immunosuppression, most commonly prednisone, tacrolimus, and mycophenolate (n = 9).

DISCUSSION

The Stretta procedure did not provide expected results at our institution after lung transplant surgery. Based on our limited series, we do not recommend routine use of the Stretta procedure for management of GERD in lung transplant patients.

Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication

BACKGROUND

Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation.

MATERIALS AND METHODS

A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control.

RESULTS

Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH.

CONCLUSIONS

Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.

Endoscopic treatments for GERD

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

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.

Nonablative Radiofrequency Treatment for Gastroesophageal Reflux Disease (STRETTA)

Gastroesophageal reflux disease (GERD) is the most frequent outpatient diagnosis in the United States. There has been significant development in the endoscopic treatment of GERD, with several devices that have reached the market. One of the endoscopic devices for the management of GERD in the United States is the Stretta system. This procedure uses radiofrequency energy, which is applied to the muscles of the lower esophageal sphincter and the gastric cardia resulting in an improvement of reflux symptoms. This review evaluates the most recent data on the efficacy, mechanisms of action, and safety of this procedure.

The Role of GABA Receptor Agonists in Anesthesia and Sedation

GABA (γ-aminobutyric acid) receptors, of which there are two types, are involved in inhibitory synapses within the central nervous system. The GABA_A receptor (GABAAR) has a central role in modern anesthesia and sedation practice, which is evident from the high proportion of agents that target the GABAAR. Many GABAAR agonists are used in anesthesia practice and sedation, including propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. There are advantages and disadvantages to each GABAAR agonist currently in clinical use. With increasing knowledge regarding the pharmacology of GABAAR agonists, however, newer sedative agents have been developed which employ 'soft pharmacology', a term used to describe the pharmacology of agents whereby their chemical configuration allows rapid metabolism into inactive metabolites after the desired therapeutic effect(s) has occurred. These newer 'soft' GABAAR agonists may well approach ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. This review provides an overview of the role that GABAAR agonists currently play in sedation and anesthesia, in addition to discussing the future role of novel GABAAR agonists in anesthesia and sedation.

Treatment of gastroesophageal reflux disease using radiofrequency ablation (Stretta procedure): An interim analysis of a randomized trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common chronic gastrointestinal disorder, affecting one third of the population worldwide. Recently, there has been a renewed interest in Stretta therapy in view of potential long-term side effects of PPIs and the durability of relief with fundoplication.

METHOD

Prospective randomized study comparing the Stretta treatment with controls receiving PPIs. Patient (> 18 years, n = 20) with symptoms of heartburn, regurgitation, abnormal esophageal acid exposure (≥ 4%), and endoscopically confirmed esophagitis were included into the study. The primary measure was improvement in quality of life (QOL) and decrease in the frequency and severity of GERD symptoms.

RESULTS

The mean age of the patients was 39 (± 15) years and controls were 34 (± 11) years. Three months after Stretta, 80% reported improvement in QOL compared to 40% in the control group. At the end of 3 months, significant (p < 0.05) improvement in GERD symptom score for heartburn, regurgitation, chest pain, and cough compared with the control group was observed. After Stretta treatment, 60% of the patients were free of PPIs whereas there was no change in the control group. Almost 80% of the patients on Stretta treatment were satisfied with the treatment compared to 30% of the patients in the control group.

CONCLUSION

Stretta was effective in the short-term for the management of GERD.

Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease

BACKGROUND

The endoscopic radiofrequency procedure (Stretta) has been used for more than a decade to treat patients with gastroesophageal reflux disease (GERD). However, the efficacy of the procedure in improving objective and subjective clinical endpoints needs to be further established.

AIM

To determine the efficacy of the Stretta procedure in treating patients with GERD, using a systematic review and meta-analysis of controlled and cohort studies.

METHODS

We conducted a systematic search of the PubMed and Cochrane databases for English language clinical studies of the Stretta procedure, published from inception until May 2016. Randomized controlled trials (RCTs) and cohort studies that included the use of the Stretta procedure in GERD patients were included. A generalized inverse weighting was used for all outcomes. Results were calculated by both fixed effects and random effects model.

RESULTS

Twenty-eight studies (4 RCTs, 23 cohort studies, and 1 registry) representing 2468 unique Stretta patients were included in the meta-analysis. The (unweighted) mean follow-up time for the 28 studies was 25.4 [14.0, 36.7] months. The pooled results showed that the Stretta reduced (improved) the health-related quality of life score by -14.6 [-16.48, -12.73] (P < 0.001). Stretta also reduced (improved) the pooled heartburn standardized score by -1.53 [-1.97, -1.09] (P < 0.001). After Stretta treatment, only 49% of the patients using proton pump inhibitors (PPIs) at baseline required PPIs at follow-up (P < 0.001). The Stretta treatment reduced the incidence of erosive esophagitis by 24% (P < 0.001) and reduced esophageal acid exposure by a mean of -3.01 [-3.72, -2.30] (P < 0.001). Lower esophageal sphincter (LES) basal pressure was increased post Stretta therapy by a mean of 1.73 [-0.29, 3.74] mmHg (P = NS).

CONCLUSIONS

The Stretta procedure significantly improves subjective and objective clinical endpoints, except LES basal pressure, and therefore should be considered as a viable alternative in managing GERD.

Early and Midterm Outcome After Laparoscopic Fundoplication and a Minimally Invasive Endoscopic Procedure in Patients with Gastroesophageal Reflux Disease: A Prospective Observational Study

BACKGROUND AND AIMS

Although the minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage gastroesophageal reflux disease (GERD), the benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study assessed the short-term and midterm outcomes associated with laparoscopic Toupet fundoplication (LTF) and the Stretta procedure.

PATIENTS AND METHODS

From January 2011 to January 2012, we allocated 80 patients to LTF and 85 to the Stretta procedure. Primary outcome measures, including symptom scores of heartburn, regurgitation, chest pain, belching, hiccup, cough, and asthma, as well as proton pump inhibitor (PPI) use, were analyzed at midterm follow-up (1-3 years).

RESULTS

Of the 165 patients, 125 patients following LTF (n=65) or the Stretta procedure (n=60) completed the designated 3-year follow-up and were included in the final analysis. At the end of the 3-year follow-up, the symptom scores were all significantly decreased compared with the corresponding values before the two procedures in both groups (P<.05). After LTF and the Stretta procedure, 47/65 (72.3%) and 41/60 (68.3%) patients, respectively, achieved complete PPI therapy independence (72.3% versus 68.3%, P=.627). Comparing with LTF, however, the Stretta procedure had less effect on improving typical symptoms of heartburn, regurgitation, and chest pain and reducing the rate of re-operation (11.8% versus 0%, P=.006).

CONCLUSIONS

LTF and the Stretta procedure were equally effective in controlling GERD symptoms and reducing PPI use. However, LTF can achieve more improvement on typical symptoms and has a lower rate of re-operation.

2014 SSAT State-of-the-Art Conference: advances in diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease affects at least 10 % of people in Western societies and produces troublesome symptoms and impairs patients' quality of life. The effective management of GERD is imperative as the diagnosis places a significant cost burden on the United States healthcare system with annual direct cost estimates exceeding 9 billion dollars annually. While effective for many patients, 30-40 % of patients receiving medical therapy with proton pump inhibitors experience troublesome breakthrough symptoms, and recent evidence suggests that this therapy subjects patients to increased risk of complications. Given the high cost of PPI therapy, patients are showing a decrease in willingness to continue with a therapy that provides incomplete relief; however, due to inconsistent outcomes and concern for procedure-related side effects following surgery, only 1 % of the GERD population undergoes anti-reflux surgery annually. The discrepancy between the number of patients who experience suboptimal medical treatment and the number considered for anti-reflux surgery indicates a large therapeutic gap in the management of GERD. The objective of the SSAT State-of-the-Art Conference was to examine technologic advances in the diagnosis and treatment of GERD and to evaluate the ways in which we assess the outcomes of these therapies to provide optimal patient care.

Transoral incisionless fundoplication for the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common and costly chronic medical condition affecting millions of patients. It is associated with substantial morbidity and negatively impacts quality of life. Reflux of gastric contents into the esophagus damages the esophageal mucosa and is associated with conditions including esophagitis and esophageal stricture. While GERD is most commonly seen in Western populations, changes in dietary patterns and the global increase in obesity have led to a pronounced increase in its prevalence worldwide. Medical and surgical GERD therapies are costly and pose considerable side effects, leading many to pursue effective endoscopic treatment options. Transoral incisionless fundoplication is an endoluminal procedure that offers patients a minimally invasive treatment option with the potential to eliminate the need for medical acid suppression with a low risk of side effects.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Long-term cost-effectiveness of medical, endoscopic and surgical management of gastroesophageal reflux disease

BACKGROUND

The long-term cost effectiveness of medical, endoscopic, and operative treatments for adults with gastroesophageal reflux disease (GERD) remains unclear. We sought to estimate the cost effectiveness of medical, endoscopic, and operative treatments for adults with GERD who require daily proton pump inhibitor (PPI) therapy.

METHODS

A Markov model was generated from the payer's perspective using a 6-month cycle and 30-year time horizon. The base-case patient was a 45-year-old man with symptomatic GERD taking 20 mg of omeprazole twice daily. Four treatment strategies were analyzed: PPI therapy, transoral incisionless fundoplication (EsophyX), radiofrequency energy application to the lower esophageal sphincter (Stretta) and laparoscopic Nissen fundoplication. The model parameters were selected using the published literature and institutional billing data. The main outcome measure was the incremental cost-effectiveness ratio (cost per quality-adjusted life-year gained) for each therapy.

RESULTS

In the base case analysis, which assumed a PPI cost of $234 over 6 months ($39 per month), Stretta and laparoscopic Nissen fundoplication were the most cost-effective options over a 30-year time period ($2,470.66 and $5,579.28 per QALY gained, respectively). If the cost of PPI therapy exceeded $90.63 per month over 30 years, laparoscopic Nissen fundoplication became the dominant treatment option. EsophyX was dominated by laparoscopic Nissen fundoplication at all points in time.

CONCLUSION

Low-cost PPIs, Stretta, and laparoscopic Nissen fundoplication all represent cost-effective treatment strategies. In this model, when PPIs exceed $90 per month, medical therapy is no longer cost effective. Procedural GERD therapy should be considered for patients who require high-dose or expensive PPIs.

Nonmedical therapeutic strategies for nonerosive reflux disease

There has been a marked decline over the last several years in drug development for gastroesophageal reflux disease and specifically for nonerosive reflux disease (NERD), despite there being many areas of unmet need. In contrast, we have seen a proliferation, during the same period of time, in development of novel, nonmedical therapeutic strategies for NERD using cutting-edge technology. Presently, compliance and lifestyle modifications are readily available noninvasive therapeutic interventions for NERD. Other nonmedical therapies include, the Stretta procedure, transoral incisionless fundoplication, and the magnetic sphincter augmentation device (LINX). Antireflux surgery, in experienced hands, has been repeatedly shown to be efficacious in resolving NERD-related symptoms. Psychological therapeutic interventions and alternative medicine techniques, such as acupuncture, continue to show promise, especially in NERD patients who failed antireflux treatment.

Durability of Stretta Radiofrequency Treatment for GERD: Results of an 8-Year Follow-Up

From June 2002 to March 2013 26 patients that underwent Stretta procedure (16 females, 10 males) reached to date an eight-year follow-up. Primary end point of the study was to verify the durability of the procedure at this time. All patients underwent clinical evaluation by upper endoscopy, oesophageal pressure, and pH studies. For each patient 8-year data were compared to those recorded at baseline and at 4 years. There was a significant decrease in both heartburn and GERD HRQL scores at 4 years (P = 0.001) and at 8 years (P = 0.003) as well as a significant increase of QoL scores at each control time (mental SF-36 and physical SF-36, P = 0.001). After 4 and 8 years, 21 patients (80.7%, P = 0.0001) and 20 patients (76.9%, P = 0.0001) were completely off PPIs. Median LES pressure did not show significant amelioration at 4 and 8 years and mean oesophageal acid exposure significantly improved at 4 years (P = 0.001) but returned to baseline values after 8 years. This further follow-up study of ours from four to eight years confirms that RF energy delivery for GERD provides durable improvement in symptoms and in quality of life and reduces antireflux drugs consumption.

Transoral mucosal excision sutured gastroplasty: a pilot study for GERD and obesity with two-year follow-up

INTRODUCTION

An outpatient transoral endoscopic procedure for gastroesophageal reflux disease (GERD) and obesity would be appealing if safe, effective, and durable. We present the first in human experience with a new system.

METHODS

Eight patients with GERD (3) and obesity (5) were selected according to a preapproved study protocol. All GERD patients had preprocedure manometry and pH monitoring to document GERD as well as quality of life and symptom questionnaires. Obese patients (body mass index >35) underwent a psychological evaluation and tests for comorbidities. Under general anesthesia, a procedure was performed at the gastroesophageal junction including mucosal excision, suturing of the excision beds for apposition, and suture knotting.

RESULTS

One patient with micrognathia could not undergo the required preprocedural passage of a 60 F dilator and was excluded. The first 2 GERD patients had incomplete procedures due to instrument malfunction. The subsequent 5 subjects had a successfully completed procedure. Four patients were treated for obesity and had an average excess weight loss of 30.3% at 2-year follow-up. Of these patients, one had an 8-mm outlet at the end of the procedure recognized on video review--a correctable error--and another vomited multiple times postoperatively and loosened the gastroplasty sutures. The treated GERD patient had resolution of reflux-related symptoms and is off all antisecretory medications at 2-year follow-up. Her DeMeester score was 8.9 at 24 months.

CONCLUSION

The initial human clinical experience showed promising results for effective and safe GERD and obesity therapy.

Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) often seek alternative therapy for inadequate symptom control, with over 40% not responding to medical treatment. We evaluated the long-term safety, efficacy, and durability of response to radiofrequency treatment of the lower esophageal sphincter (Stretta).

METHODS

Using an intent-to-treat analysis, we prospectively assessed 217 patients with medically refractory GERD before and after Stretta. There was no concurrent control group in the study. Primary outcome measure was normalization of GERD-health-related quality of life (GERD-HRQL) in 70% or greater of patients at 10 years. Secondary outcomes were 50% reduction or elimination of proton pump inhibitors (PPIs) and 60% or greater improvement in satisfaction at 10 years. Successful treatment was defined as achievement of secondary outcomes in a minimum of 50% of patients. Complications and effect on existing comorbidities were evaluated. The results of a 10-year study are reported.

RESULTS

The primary outcome was achieved in 72% of patients (95% confidence interval 65-79). For secondary outcomes, a 50% or greater reduction in PPI use occurred in 64% of patients, (41% eliminating PPIs entirely), and a 60% or greater increase in satisfaction occurred in 54% of patients. Both secondary endpoints were achieved. The most common side effect was short-term chest pain (50%). Pre-existing Barrett's metaplasia regressed in 85% of biopsied patients. No cases of esophageal cancer occurred.

CONCLUSIONS

In this single-group evaluation of 217 patients before and after Stretta, GERD-HRQL scores, satisfaction, and PPI use significantly improved and results were immediate and durable at 10 years.

Stretta Radiofrequency Treatment for GERD: A Safe and Effective Modality

Gastroesophageal reflux disease is one of the leading gastrointestinal disorders. Current treatments include lifestyle modifications, pharmacological therapies, surgical fundoplications, and, more recently, endoscopic procedures. The rising concern of long-term side effects of the popular proton-pump inhibitors and the more recent evidence raising doubts about the durability of fundoplication have spurred reinterest in endoscopic procedures to treat reflux disorders. In the aftermath of several innovative antireflux procedures that were introduced and failed clinically or financially over the past decade, there is lingering confusion regarding the merits of the presently available interventions. This paper focuses on one endoscopic procedure, Stretta, which now enjoys the longest experience, a recent meta-analysis, and robust data supporting its safety, efficacy, and durability. Stretta reduces esophageal acid exposure, decreases the frequency of transient lower esophageal relaxation, increases patient satisfaction, decreases medication use, and improves quality of life. As such, this procedure remains a valuable nonsurgical treatment option in the management of gastroesophageal reflux disease.

Surgical management of pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) is common in the pediatric population. Most cases represent physiologic GER and as the lower esophageal sphincter (LES) matures and a solid diet is introduced, many of these patients (>65%) experience spontaneous resolution of symptoms by two years of age. Those who continue to have symptoms and develop complications such as failure to thrive, secondary respiratory disease, and others are classified as having gastroesophageal reflux disease (GERD). Goals of GERD treatment include the resolution of symptoms and prevention of complications. Treatment options to achieve these goals include dietary or behavioral modifications, pharmacologic intervention, and surgical therapy. This paper will review the clinical presentation of GERD and discuss options for surgical management and outcomes in these patients.

Tissue engineering for neuromuscular disorders of the gastrointestinal tract

The digestive tract is designed for the optimal processing of food that nourishes all organ systems. The esophagus, stomach, small bowel, and colon are sophisticated neuromuscular tubes with specialized sphincters that transport ingested food-stuffs from one region to another. Peristaltic contractions move ingested solids and liquids from the esophagus into the stomach; the stomach mixes the ingested nutrients into chyme and empties chyme from the stomach into the duodenum. The to-and-fro movement of the small bowel maximizes absorption of fat, protein, and carbohydrates. Peristaltic contractions are necessary for colon function and defecation.

Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis

PURPOSE

Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment.

METHODS

Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry.

RESULTS

A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD-health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007).

CONCLUSIONS

Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.

[Introduction of a quality index in a Hungarian endoscopy unit]

The quality of endoscopic examinations substantially determines their value. In developed countries, Continuous Quality Management is used to improve it permanently. In Hungary there is no example for measuring quality in the field of gastrointestinal endoscopy.

AIM

The measurement and improvement of quality of endoscopy applying completeness index (cecum intubation rate) during colonoscopy.

PATIENTS AND METHODS

The authors defined base values retrospectively from 841 colonoscopy reports, performed in the last quarter of the year, before starting the project. The next two years (3160 colonoscopy in 2009 and 3167 in 2010) every three months they calculated the cecum intubation rate for each endoscopist.

RESULTS

The cecum intubation rate was 81.6% in the base period. When the authors excluded examinations with poor preparations and those with a previously unknown stenosis that prevented the total colonoscopy, the adjusted cecal intubation rate was 90.9%. In the next 2 years, the cecum intubation rate was 84.2% and 85.7% (p = 0.0394), while adjusted cecum intubation rate proved to be 92.3% and 92.6% (p = 0.381 NS) for the whole endoscopy unit. Of the 14 endoscopists only 6 reached an adjusted cecum intubation rate of 90%, but in the second year of the project 10 of them reached this rate and only one endoscopist remained below 87%. The endoscopists performing more than 100 colonoscopies per year had better adjusted cecum intubation rate (base 91.2%; 92.7% and 93.1% during the 2 project years) compared to those with less than 100 colonoscopies per year (base, 86.7%; project period, 85.5 and 89%).

CONCLUSIONS

The evaluation and publicity of the cecal intubation rate resulted in an improvement of the quality of colonoscopy. The authors also presented that endoscopists performing more than 100 colonoscopies per year have better endoscopic quality.

Alternative therapeutic approaches to chronic proton pump inhibitor treatment

Chronic consumption of proton pump inhibitors (PPIs) by patients with gastroesophageal reflux disease is very common, primarily because of their potent and profound effect on acid secretion that results in an unsurpassed rate of symptom resolution and esophageal healing. However, there have been a growing number of reports over the past few years about various side effects caused by chronic PPI treatment. Concerns have been raised by patients and physicians alike about the common practice of prescribing PPIs, often more than once daily, on a long-term basis. As a result, there has been a resurgence of interest in alternative therapeutic modalities for chronic PPI treatment. These include novel endoscopic and surgical techniques, as well as other available therapeutic strategies that are likely to be revisited, such as histamine-2-receptor antagonists, intermittent and on-demand PPI treatment, and antireflux surgery, among others.

Long-Term Results of Radiofrequency Energy Delivery for the Treatment of GERD: Results of a Prospective 48-Month Study

Since 2000, radiofrequency (RF) energy treatment has been increasingly offered as an alternative option to invasive surgical procedures for selected patients with gastroesophageal reflux disease (GERD). Out of 69 patients treated since June 2002 to December 2007 with the Stretta procedure, 56 of them reached by the end of 2010 a 48-month followup. RF treatment significantly improved heartburn scores, GERD-specific quality of life scores, and general quality of life scores at 24 and 48 months in 52 out of 56 patients (92,8%). At each control time both mean heartburn and GERD HRQL scores decreased (P = 0.001 and P = 0.003, resp.) and both mental SF-36 and physical SF-36 ameliorated (P = 0.001 and 0.05, resp.). At 48 months, 41 out of 56 patients (72,3%) were completely off PPIs. Morbidity was minimal, with only one relevant but transient complication. According to other literature data, this study shows that RF delivery to LES is safe and durably improves symptoms and quality of life in well-selected GERD patients.

Improvement of clinical parameters in patients with gastroesophageal reflux disease after radiofrequency energy delivery

AIM: To evaluate the efficacy of Stretta procedure with gastroesophageal reflux disease (GERD) based on symptom control, medication changes and oesophagitis grade.

METHODS: Ninety patients with a history of GERD underwent Stretta procedure from June 2007 to March 2010. All patients with GERD diagnosed by the presence of endoscopically evidenced oesophagitis or abnormal esophageal pH testing. We evaluated GERD-health-related quality of life, satisfaction, medication use and endoscopy at baseline, 6, 12 mo after treatment. Complications of the procedure were analyzed.

RESULTS: We found that patients experienced significant changes in symptoms of GERD after Stretta procedure. The onset of GERD symptom relief was less than 2 mo (70.0%) or 2 to 6 mo (16.7%). The mean GERD-HRQL score was 25.6 (baseline), 7.3 (6 mo, P < 0.01), and 8.1 (12 mo, P < 0.01).The mean heartburn score was 3.3 (baseline), and 1.2 (12 mo, P < 0.05). The percentage of patients with satisfactory GERD control improved from 31.1% at baseline to 86.7% after treatment, and patient satisfaction improved from 1.4 at baseline to 4.0 at 12 mo (P < 0.01). Medication usage decreased significantly from 100% of patients on proton pump inhibitors therapy at baseline to 76.7% of patients showing elimination of medications or only as needed use of antacids/H2-RA at 12 mo. An improvement in endoscopic grade of oesophagitis was seen in 33 of the 41 patients. All patients had either no erosions or only mild erosive disease (grade A) at 6 mo.

CONCLUSION: The experience with Stretta procedure confirms that it is well tolerated, safe, effective and durable in the treatment of GERD. The Stretta procedure provides the drug-refractory patients with a new minimally invasive method.

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.

A prospective randomized trial of sham, single-dose Stretta, and double-dose Stretta for the treatment of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is a prevalent disorder that often requires long-term medical therapy or surgery. Radiofrequency (RF) energy delivery (Stretta procedure) has been shown in several studies to improve GERD symptoms and quality of life for approximately two-thirds of patients. The authors proposed that increasing the dose of Stretta would further improve the response to this therapy.

METHODS

For this study, 36 patients were randomized into three groups. In group A, 12 patients underwent a single session Stretta procedure. In group B, 12 patients under went a sham Stretta procedure (mirror of the active procedure in all aspects except there was no deployment of the electrodes). In group C, 12 patients underwent a single Stretta treatment followed by repeat Stretta if GERD health-related quality of life (HRQL) was not 75% improved after 4 months. For each patient, 56 RF lesions were created per session. The principal outcome was GERD HRQL improvement. The secondary outcomes were medication use, lower esophageal sphincter (LES) basal pressure, endoscopic grade of esophagitis, and esophageal acid exposure by pH probe.

RESULTS

The Stretta procedure was completed successfully for all the patients in both active treatment groups. At 12 months, the mean HRQL scores of those off medications, the LES basal pressure, the 24-h pH scores, and the proton pump inhibitor (PPI) daily dose consumption were significantly improved from baseline in both Stretta groups (p\0.01). The double Stretta was numerically but not significantly better than the single Stretta for mean HRQL, mean 24 h pH, mean LES pressure, and PPI use. Seven patients in the double Stretta treatment group had normalized their HRQL at 12 months compared with 2 patients in the single-treatment group (p = 0.035). The sham patients had a small but statistically significant decrease in their daily PPI dosages (p\0.05) and mean HRQL scores (p\0.05). No serious complications (bleeding, perforation, or death) occurred. However, two patients experienced significant delayed gastric emptying after the second Stretta treatment.

CONCLUSIONS

The Stretta procedure significantly reduced GERD HRQL, use of PPI drugs, esophageal acid exposure, LES pressure, and grade of esophagitis compared with the sham procedure. The double Stretta therapy had numerically superior outcomes for most parameters and a significantly more frequent normalization of HRQL scores compared with the single Stretta.

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.

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.

Prospective, controlled assessment of the impact of formal evidence-based medicine teaching workshop on ability to appraise the medical literature

BACKGROUND

The ability to critically appraise the calibre of studies in medical literature is increasingly important for medical professionals.

AIM

This prospective controlled study evaluated the impact of a 6-h Evidence Based Medicine (EBM) Workshop on the critical appraisal skills of medical trainees.

METHODS

Individuals attended three 2-h workshops over a 3-week period, incorporating didactic lectures in statistics, clinical trial design, appraising research papers and practical examples. Appraisal skills were assessed pre- and post-training based on grading the quality of randomised control studies (level 1 evidence), cohort studies (level 2 evidence) and case-control studies (level 3 evidence) [From Oxford Centre for Evidence Based Medicine Levels of Evidence (2001), http://www.cebm.net/critical_appraisal.asp ].

RESULTS

Overall grading improved from 39% (pre-course) to 74% (post-course), P = 0.002, with grading of levels 1, 2 and 3 studies improving from 42 to 75%, 53 to 61% and 21 to 84%, respectively.

CONCLUSIONS

We conclude that a 6-h formal EBM workshop is effective in enhancing the critical appraisal skills of medical trainees.

Short-term and long-term outcome of endoluminal gastroplication for the treatment of GERD: the first multicenter trial in Japan

PURPOSE

Endoluminal gastroplication (ELGP) was the first endoscopic therapy for gastroesophageal reflux disease (GERD). Data on the long-term outcomes, including the plication status and data from Asian populations, are limited. The aim of this study was to evaluate the short-term and long-term effectiveness and safety of ELGP for GERD in the Japanese population.

METHODS

This was an open-label, prospective, multicenter trial of ELGP. Forty-eight patients with GERD were enrolled. The procedure involved placing circumferential plications 1-2 cm below the GE junction using the EndoCinch system. Outcome measurements were improvement of heartburn, medication use, endoscopic Los Angeles grade, durability of plications, 24-h esophageal acid exposure, esophageal manometry, and frequency of adverse events.

RESULTS

During the 24-month follow-up, the rate of complete resolution of heartburn ranged from 54 to 66%, the rate of discontinuation or reduction of PPI/H2RA use ranged from 65 to 76%, and the rate of endoscopic classification to grade O ranged from 66 to 81%. The status with more than one plication remaining was associated with higher rates of improvement of heartburn, PPI/H2RA use, and endoscopic findings as compared with those associated with the loss of all plications. A modest decrease of the esophageal acid exposure level, but no change of the manometric parameters, was observed after ELGP. No serious adverse events were observed.

CONCLUSIONS

In this 24-month follow-up study conducted in Japanese subjects, ELGP was found to be effective in about 60% of patients with GERD, and the procedure was safe.

Proton pump inhibitor failure--what are the therapeutic options?

Proton pump inhibitor (PPI) failure is very common and may affect up to one-third of the PPI consumers. Identifying the underlying mechanisms for PPI failure in each individual patient is essential for treatment success. For residual acid reflux, increasing the PPI dose to twice daily; switching to another PPI, or adding an histamine 2 receptor antagonist could be a successful therapeutic strategy. In patients with duodenogastroesophageal reflux, weak acidic/alkaline reflux and hypersensitivity to acid reflux, therapeutic modalities that reduce transient lower esophageal sphincter relaxation or visceral pain could be entertained. Treatment of PPI failure due to delayed gastric emptying should be focused on improving gastric motor activity. Psychological management may supplement any medical or surgical approach toward PPI failure.

Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients

BACKGROUND

Radiofrequency (RF) energy delivery is an endoscopic procedure developed for the treatment of gastro-oesophageal reflux disease.

AIM

To compare RF and a proton pump inhibitor strategy (PPI) in PPI-dependent patients by carrying out a prospective, randomized trial.

METHODS

Patients with PPI-dependent typical reflux symptoms were randomly allocated to either RF or PPI regimen alone. The primary endpoint, evaluated at 6-month, was defined as the possibility for the patient to stop or to decrease PPI use to <50% of the effective dose required at baseline.

RESULTS

In the RF group, 18/20 patients stopped (n = 3) or decreased (n = 15) PPI use as compared to eight of 16 in the PPI group (P = 0.01). None of the control patients could stop PPI. Health-related quality of life scores were not different between groups. No significant change in oesophageal acid exposure (OAE) was noted between baseline and 6-months after RF. No severe complication was reported.

CONCLUSIONS

Radiofrequency energy delivery is a safe and effective therapeutic option, allowing reduction in or discontinuation of PPI therapy in patients with PPI-dependent symptoms, without loss of quality of life. However, in a majority of patients, PPI therapy cannot be completely stopped. The efficacy of RF does not seem to be related to a decrease in OAE.

Use of endoluminal antireflux therapies for obese patients with GERD

BACKGROUND

Obese patients with gastroesophageal reflux disease (GERD) refractory to medical therapy are a challenging patient population as obesity is a preoperative predictor of failure after antireflux surgery. We therefore sought to evaluate outcomes using one of two commercially available endoluminal therapies in this population.

METHODS

Consecutive obese patients (body mass index (BMI)>30) with GERD (DeMeester>14.5) undergoing either Plicator (NDO) or Stretta (Curon) were identified in our single-institution prospective database. Outcomes assessed were: (1) failure rate (absolutely no symptomatic improvement after procedure and/or need for subsequent antireflux surgery), (2) postoperative vs. preoperative symptom (heartburn, chest pain, regurgitation, dysphagia, cough, hoarseness, and asthma) scores, and (3) proton-pump inhibitor (PPI) medication use.

RESULTS

Twenty-two patients each underwent an endoluminal therapy (ten Plicator patients and 12 Stretta patients) with mean follow-up of 1.5 years. There were no treatment-associated complications. Mean BMI was not different between Plicator and Stretta groups (39.6 vs. 38.6, respectively, p=0.33). The failure rate for the entire cohort was 28% (10% Plicator vs. 42% Stretta, p=0.11). The proportion of patients reporting moderate/severe symptoms postop was significantly less than preop: chest pain 9% vs. 13% (p=0.04), cough 22% vs. 36% preop (p=0.025), voice changes 9% vs. 36% preop (p=0.012), and dysphagia 9% vs. 32% preop (p=0.04). The proportion of patients on PPI medications postop was also less than preop (45% vs. 81%, p=0.1)

CONCLUSION

Endoluminal treatment can provide a safe means of improving GERD symptoms for some obese patients, though many will continue to require medication therapy also. Further work aimed at understanding optimal candidates for endoluminal therapy in this patient population is warranted.

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) does not provide long-term symptom control

The Stretta procedure (radiofrequency energy application to the lower esophageal sphincter) is a unique endoluminal technique for the management of gastroesophageal reflux. This article reports on the long-term effectiveness of the Stretta procedure in patients with significant gastroesophageal reflux disease (GERD) referred to a surgical practice. Patients who underwent Stretta with a minimum of 36 months follow-up were included. Thirty-two patients with an average follow-up of 53 months were included; 19 proceeded to anti-reflux surgery. Those not undergoing surgery showed a significant improvement in their GERD satisfaction from 3.14 to 1.46 (P = .0006) but had significantly lower preprocedure heartburn scores (2.43) than those who proceeded to surgery (3.66, P = .0401). The Stretta procedure was effective in reducing symptoms in 40% of patients. Responders had less severe preoperative heartburn. Radiofrequency energy delivery to the lower esophageal sphincter may be effective in selected patients for the treatment of gastroesophageal reflux.

Gastroparesis associated with gastroesophageal reflux disease and corresponding reflux symptoms may be corrected by radiofrequency ablation of the cardia and esophagogastric junction

BACKGROUND

Reflux is a common medical condition with symptoms ordinarily controlled using drug/medical therapy. However, 20% of patients experience unmanageable symptoms despite twice-daily (BID) proton pump inhibitor (PPI) therapy. Growing clinical evidence shows that delayed gastric emptying (gastroparesis) may be a factor associated with severe reflux, dyspepsia, or both. Gastroparesis, concomitant in 25% of patients with gastroesophageal reflux disease (GERD), has been shown to improve after Nissen fundoplication. Radiofrequency treatment for GERD potentially corrects GERD-associated gastroparesis and resultant PPI BID reflux failures.

METHODS

From July 2000 until July 2004, 227 patients undergoing Stretta for GERD were screened for gastric anomalies. Patients with gastroparesis, documented on a standardized nuclear gastric emptying scans, and patients with heartburn and regurgitation uncontrolled by PPI BID medications underwent radiofrequency ablation of the cardia and esophagogastric junction via the Stretta procedure. The patients had esophagogastroduodenoscopy and/or pH studies, manometry, solid-phase gastric emptying, and electrogastrography and completed standardized heartburn and health-related quality-of-life surveys before treatment, then 6 months afterward. Patients with pyloric obstruction and those taking motility agents were excluded from the study. Gastric emptying scans were repeated 6 months after Stretta. The nuclear radiologist was blinded to the study design.

RESULTS

At baseline, 31 patients were classified as abnormal. At 6 months after the procedure, emptying scores had improved significantly, with the percentage of solid food emptied at 90 min improved from 41% to 66% (p < 0.0001) and at 120 minutes from 55% to 84%. Significant improvements were seen at all intervals. Overall, 23 patients (74%) experienced normalization of gastric emptying, and 4 patients were improved but remained abnormal. Four patients showed no improvement on their gastric emptying scans, with one patient electing to undergo a Nissen procedure. All the patients had a 1-year symptom follow-up assessment, which showed significant improvements in GERD health-related quality of life, dyspepsia, and heartburn scores.

CONCLUSIONS

Radiofrequency treatment has been demonstrated to correct gastroparesis. Patients' symptoms improved significantly. The mechanism of action is unknown but may be related to reduction in transient lower esophageal sphincter relaxations (TLESRs), increased esophagogastric junction barrier, decreased esophageal venting, alteration of the gastric pacemaker function in the region of radiofrequency therapy administration, removal of medications for symptoms, or a combination of all these.