Antireflux operations at flexible endoscopy using endoluminal stitching techniques: an experimental study

Bariatric endoscopy: current state of the art, emerging technologies, and challenges

INTRODUCTION

Over the last few decades obesity has become a major health issue worldwide. Although dietary and lifestyle changes are the cornerstone of obesity management, it still poses a huge challenge for the majority of patients to permanently change their eating habits. Bariatric endoscopy represents an evolving filed of minimally invasive techniques and procedures for weight loss trying to respond to these challenges by developing new methods with the increasing role of endoscopists in the management of obesity. Areas covered: The aim of this article is to review the role and the advantages of bariatric endoscopy in the management of obesity by providing a comprehensive reference source and evaluating the currently available and emerging endoscopic devices and techniques for weight loss. Expert commentary: Endoscopic methods for weight loss represent a useful armamentarium in the management of obesity by providing improved effectiveness compared with medications, with a lower risk profile than traditional bariatric surgery. Although preliminary results of recently introduced methods are encouraging, many questions remain regarding the safety and efficacy of such interventions. Combining scientific background with advancements in technology is the key strategy for the further development of bariatric endoscopy.

Recent Trends in Endoscopic Management of Obesity

Obesity remains a tremendous public health, clinical, and scientific challenge globally. Conventional approaches in the management of obesity offer limited potential for sustained weight loss. Bariatric surgery, although it represents the most effective weight loss treatment, has its own risks and is associated with substantial costs and limited patient applicability. Endoscopic weight loss procedures are considered as the major breakthrough in the management of obesity. Endoluminal interventions performed entirely through the gastrointestinal tract have evolved as a result of an attempt to replicate some of the anatomical features and the physiological effects of the traditional weight loss surgery while being reversible, less invasive, and more cost-effective. Restrictive procedures act to decrease gastric volume by space-occupying devices and/or by suturing or stapling techniques that alter gastric anatomy, whereas malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. Other procedures act by influencing gastric function (gastric botulinum injections, gastric pacing, and vagal nerve blocking) or by gastric aspiration. It is important to underline that the majority of endoscopic weight loss procedures are still being evaluated and are not yet available routinely. Even though some of the techniques and devices that have recently emerged have demonstrated promising short-term results, evidence on their safety and long-term efficacy from well-designed and well-conducted research should be given before they can become an inherent part of everyday clinical practice. Given the rapid development of endoscopic weight loss procedures, this review considers the current state and recent trends in endoscopic management of obesity.

ENDOSCOPIC SLEEVE GASTROPLASTY - MINIMALLY INVASIVE THERAPY FOR PRIMARY OBESITY TREATMENT

Background

Less invasive and complex procedures have been developed to treat obesity. The successful use of Endoscopic Sleeve Gastroplasty using OverStitch(r) (Apollo Endosurgery, Austin, Texas, USA) has been reported in the literature.

Aim

Present technical details of the procedure and its surgical/ endoscopic preliminary outcome.

Method

The device was used to perform plications along the greater curvature of the stomach, creating a tubulization similar to a sleeve gastrectomy.

Result

A male patient with a BMI of 35.17 kg/m2 underwent the procedure, with successful achievement of four plications, and preservation of gastric fundus. The procedure was successfully performed in 50 minutes, time without bleeding or other complications. The patient presented mild abdominal pain and good acceptance of liquid diet.

Conclusions

The endoscopic gastroplasty procedure was safe, with acceptable technical viability, short in duration and without early complications.

Development of minimally invasive techniques for management of medically-complicated obesity

The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal interventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.

Efficacy of endoluminal gastroplication in Japanese patients with proton pump inhibitor-resistant, non-erosive esophagitis

AIM: To evaluate the efficacy, safety, and long-term outcomes of endoluminal gastroplication (ELGP) in patients with proton pump inhibitor (PPI)-resistant, non-erosive reflux disease (NERD).

METHODS: The subjects were NERD patients, diagnosed by upper endoscopy before PPI use, who had symptoms such as heartburn or reflux sensations two or more times a week even after 8 wk of full-dose PPI treatment. Prior to ELGP, while continuing full-dose PPI medication, patients’ symptoms and quality of life (QOL) were assessed using the questionnaire for the diagnosis of reflux disease, the frequency scale for symptoms of gastro-esophageal reflux disease (FSSG), gastrointestinal symptoms rating scale, a 36-item short-form. In addition, 24-h esophageal pH monitoring or 24-h intraesophageal pH/impedance (MII-pH) monitoring was performed. The Bard EndoCinch^TM was used for ELGP, and 2 or 3 plications were made. After ELGP, all acid reducers were temporarily discontinued, and medication was resumed depending on the development and severity of symptoms. Three mo after ELGP, symptoms, QOL, pH or MII-pH monitoring, number of plications, and PPI medication were evaluated. Further, symptoms, number of plications, and PPI medication were evaluated 12 mo after ELGP to investigate long-term effects.

RESULTS: The mean FSSG score decreased significantly from before ELGP to 3 and 12 mo after ELGP (19.1 ± 10.5 to 10.3 ± 7.4 and 9.3 ± 9.9, P < 0.05, respectively). The total number of plications decreased gradually at 3 and 12 mo after ELGP (2.4 ± 0.8 to 1.2 ± 0.8 and 0.8 ± 1.0, P < 0.05, respectively). The FSSG scores in cases with no remaining plications and in cases with one or more remaining plications were 4.4 and 2.7, respectively, after 3 mo, and 2.0 and 2.8, respectively, after 12 mo, showing no correlation to plication loss. On pH monitoring, there was no difference in the percent time pH < 4 from before ELGP to 3 mo after. Impedance monitoring revealed no changes in the number of reflux episodes or the symptom index for reflux events from before ELGP to 3 mo after, but the symptom sensitivity index decreased significantly 3 mo after ELGP (16.1 ± 12.9 to 3.9 ± 8.3, P < 0.01). At 3 mo after ELGP, 6 patients (31.6%) had reduced their PPI medication by 50% or more, and 11 patients (57.9%) were able to discontinue PPI medication altogether. After 12 mo, 3 patients (16.7%) were able to reduce the amount of PPI medication by 50% or more, and 12 patients (66.7%) were able to discontinue PPI medication altogether. A high percentage of cases with remaining plications had discontinued PPIs medication after 3 mo, but there was no difference after 12 mo. No serious complications were observed in this study.

CONCLUSION: ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term in patients with PPI-refractory NERD.

Endoscopic approaches to obesity

Given the emerging role of endoscopic procedures in the treatment of obesity and rapid changes in endoscopic technologies and techniques, this review considers the current state of endoscopic management of obesity. Endoluminal interventions performed entirely through the GI tract by using flexible endoscopy offer the potential for an ambulatory weight loss procedure that may be safer and more cost- effective compared with current surgical approaches. Endoscopic techniques attempt to mimic the anatomic features of bariatric surgery. Accordingly, there are two main endoscopic weight loss modalities - restrictive and malabsorptive. Restrictive procedures act to decrease gastric volume by space-occupying prosthesis and/or by suturing or stapling devices, while malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. The former include intragastric balloon treatment, endoluminal vertical gastroplasty, transoral gastroplasty and transoral endoscopic restrictive implant system, while the latter include duodenojejunal bypass sleeve. Gastroduodenojejunal bypass sleeve is a combination of both procedures. Except for intragastric balloon, all mentioned procedures are rather new, tested on a small number of human subjects, with a high rate of success, but with limited knowledge on safety and long-term efficacy. The role of gastric electrical stimulation and intragastric injections of botulinum toxin in obesity treatment is also considered as is the role of minimally invasive bariatric endoscopic interventions.

Recent advances in endoscopic therapy for diagnostic and therapeutic endoscopy-associated perforations of the digestive tract

As diagnostic and therapeutic endoscopy is more widely applied in clinical practice, endoscopy-associated perforations of the digestive tract have become more and more common. Among patients with endoscopy-associated perforations, few can be cured by conservative therapy, and the majority need to undergo laparoscopic or surgical operations to avoid serious consequences. However, the development of new medical instruments makes it possible to effectively and promptly manage endoscopy-related perforations via endoscopic suturing and closure.

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.

Endoluminal fundoplication – the Hill procedure

Endoluminal operations for reflux are currently limited by the inability to visualise and manipulate structures outside the wall of the gut. This may be possible using endoscopic ultrasound (EUS). The aim of this study was to define EUS-anatomy of structures outside the gut which influence reflux; to place stitches in the median arcuate ligament (MAL); to perform posterior gastropexy (Hill procedure) and test the feasibility of crural repair under EUS control in pigs. In survival experiments in 14 pigs, using linear array echo-endoscopes the MAL and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used allowing stitches to be placed through a 2.8 mm accessory channel to any predetermined depth. New methods allowed knot-tying and thread-cutting through the 2.8 mm channel of the echo-endoscope. Stitches were placed through the gastric wall into the MAL and one just beyond the wall of the lower esophageal sphincter (LES). They were tied together and locked against the gastric wall. Preoperative manometry showed a median LES pressure of 11 mm/Hg and 21 mm/Hg after stitch placement (p = 0.0028). The length of the LES increased from median 2.8 cm pre-procedure to 3.5 cm post-procedure. At post mortem, the force to pull the tags out of the MAL was 2.8 kg median. This study shows that transgastric gastro-esophageal reflux surgery using stitching under EUS control can significantly increase the lower oesophageal sphincter pressure in pigs.

N.O.T.E.S.: the progression of a novel and emerging technique

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the latest and perhaps most significant innovation in surgery since Phillipe Mouret of France performed the first laparoscopic cholecystectomy in 1987. This new "minimum-invasive" concept that promises scar-free surgery is steadily gathering momentum. It is another milestone in our quest to eliminate surgical trauma, speed patient recovery time and decrease surgical wound-related complications. On 22 July 2005, the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) published a white paper highlighting the barriers to NOTES development, which included the need for appropriate selection of access points, effective closure of the enterotomy site, innovative tools, stable platforms and improved endoscopic orientation. These are just some of the many issues that need to be resolved before the NOTES concept and technique could become a common feature of modern surgery. The publication of the white paper ushered in the beginning of multiple research projects using animal models to test the application of NOTES and its newly developed instruments. The success in animal models was followed by several highly selected successful human trials. National and international surgical innovation departments should now be created where medical industry personnel including inventors, designers and engineers can work together with the medical and surgical providers to address all the limitations affecting NOTES progress.

Endoscopic therapy of gastroesophageal reflux disease: outcomes of the randomized-controlled trials done to date

Endoscopic therapies to treat gastroesophageal reflux disease have been developed as another option for patients with reflux symptoms who do not want to continue medications indefinitely or are unwilling to undergo surgical intervention. The endoscopic treatments can be divided into those that pleat or plicate the upper stomach, deliver thermal energy into the lower esophageal sphincter, or inject or implant biopolymers into the gastroesophageal junction. Although capable to improve reflux symptoms for the majority of treated patients for a short while, durability has been variable among the various treatments, and there have been safety issues with some of the therapies. Although symptom improvement has been universally shown in short-term follow-up, there has been variable outcome for reduced need of antisecretory medications and pH studies show normalization of the distal esophageal acid exposure for only the minority of treated patients. Patients with significant reflux esophagitis or Barrett esophagus are not typically candidates for this antireflux intervention. Except for the NDO Plicator, in sham-controlled studies, there have been no significant differences between treated and sham-treated individuals for ability to discontinue medications or normalize pH. One issue in interpreting the results of these preliminary studies is the influence of the learning curve of a new technology. Another is that the devices and techniques have not been optimized. Currently, only the Davol/Bard EndoCinch and the NDO Plicator are available for commercial use. There are several newer devices under study or in development, and further testing and experience will demonstrate their capabilities in the treatment of gastroesophageal reflux disease.

Early clinical experience with a new flexible endoscopic suturing method for natural orifice transluminal endoscopic surgery and intraluminal endosurgery (with videos)

BACKGROUND

To perform advanced endoscopic treatments, one has to be able to close defects and perforations. Many devices have been constructed to perform endoscopic suturing, but all are rather complicated, expensive, and difficult to use.

OBJECTIVE

To develop and use a new simple stitching technique at intraluminal flexible endoscopy.

DESIGN

A flexible 19-gauge needle, loaded with a metal tag attached to a 3-0 polypropylene thread is passed down the working channel of a conventional endoscope. Two tags are placed into the stomach or the intestinal wall, 1 on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is possible. Multiple stitches can be placed quickly, without removal of the endoscope.

SETTING

Surgical department at Sahlgrenska University Hospital in Göteborg, Sweden.

PATIENTS

Three patients in whom other conventional treatments had failed.

INTERVENTIONS

Initially, survival studies in pigs were performed, and full-thickness resections, pyloroplasty, and gastrojejunostomies could be completed. The technique was subsequently used in patients when surgery was not feasible and when other endoscopic interventions had failed.

MAIN OUTCOME MEASUREMENTS

Clinical evaluation; successful sealing of defects, leaks, or a bleeding vessel.

RESULTS

We present 3 human cases and describe endoluminal closure of a perforated duodenal ulcer, a leaking gastroenteroanastomosis after gastroplasty, and successful treatment of upper-GI bleeding by oversewing a bleeding vessel.

CONCLUSIONS

This stitching technique is easy to use and makes endoscopic suturing possible for closure of perforations and tissue approximation almost anywhere in the GI tract that can be reached by a flexible endoscope.

Review article: endoscopic antireflux procedures - an unfulfilled promise?

BACKGROUND

Most published reviews concerning the endoscopic treatment of gastro-oesophageal reflux disease date back to 2005.

AIM

To provide an updated review that includes all papers published up to 2007.

METHODS

A Medline search from January 2005 to June 2007 was performed regarding endoscopic procedures aiming at treating gastro-oesophageal reflux disease. In addition, we retrieved the abstracts presented at Digestive Disease Week during the last 3 years. We included in the review both 'mechanistic' studies - that is, papers exploring the potential mechanism of action of the procedure/device - and studies trying to assess its clinical efficacy.

RESULTS

During the last 3 years, the number of published papers has declined, and some devices are not available any more. The alleged mechanism(s) of action of the various devices or procedures is (are) still not completely elucidated; however, some concerns have arisen as far as durability and potential detrimental effects. Moreover, all the aspects of endoscopic therapy, except for its safety, are either insufficiently explored or not investigated at all, or assessed only in particularly selected patient subgroups.

CONCLUSIONS

None of the proposed antireflux therapies has fulfilled the criteria of efficacy, safety, cost, durability and, possibly, of reversibility. There is at present no definite indication for endoscopic therapy of gastro-oesophageal reflux disease. We suggest a list of recommendations to be followed when a new endoscopic therapeutic procedure is to be assessed for use in clinical practice.

Endolaparoscopic approach in the management of gastroesophageal reflux disease: an experimental study in pigs

INTRODUCTION

Chronic reflux of gastric content to the esophagus causes retrosternal burning, pain, and regurgitation, and results in histopathologic changes that may culminate in adenocarcinoma. Insufficiency of the lower esophageal sphincter and hiatal hernia are the two principal causative factors. In this paper, we present the early results of a new antireflux operation in pigs.

MATERIALS AND METHODS

The status of physiologic reflux was determined in 5 pigs (approximately 40-45 kg) with 24-hour pH monitorization. Under endoscopic guidance, a trocar was inserted into the stomach (similar to the percutaneous endoscopic gastrostomy technique). The endoscope was put into the retroflexed position; a mucomuscular pursestring suture was placed around the endoscope at the cardia and tied. Ten days later, pH monitorization was repeated to evaluate the effectiveness of the method. Late postoperative results have been reevaluated by 24-hour pH monitorization in the sixth month.

RESULTS

The procedure achieved statistically significant improvements in total reflux time, number of reflux periods, number of long reflux periods, the longest reflux period, and the DeMeester score. The preoperative and postoperative DeMeester scores of the individual animals were 179.24-0.94, 11.48-0.98, 68.4-3.74, 132.2-46.49, and 38.72-5.86, respectively. Even though there appeared to be a slight increase in the pH monitorization levels after 6 months, these results did not reach significant degrees, and compared to the physiological reflux, the results were remarkable.

CONCLUSIONS

The results obtained showed considerable decreases in physiologic reflux in all animals. We believe that this endoluminal, laparoendoscopic operation can be used in the treatment of gastroesophageal reflux disease as a minimally invasive method.

Long-term outcome of endoluminal gastroplication in the treatment of gastro-oesophageal reflux disease: effect of a second procedure

OBJECTIVE

Endoluminal gastroplication has been used with limited success for the treatment of gastro-oesophageal reflux disease (GORD). This method was used in 119 patients with GORD, and the results from short-term and long-term followup of symptoms and the use of acid suppression medication are reported. The purpose of this study was also to report on the effect of a second procedure on selected patients.

MATERIAL AND METHODS

The Bard EndoCinch endosuturing system was used for all procedures. Data were recorded at 3 and 12 months, and symptoms and medication use were registered by means of a telephone survey after an average of 41 months (range 27-55 months). A second procedure was carried out in 20 of the initial patients, and mean follow-up time was 39 months (range 15-51 months).

RESULTS

There were very few complications of the procedure. Heartburn severity score was reduced from an initial 21.4 to 12.4 (p < 0.01) and 13.4 (p < 0.01) at 3 and 12 months, respectively, corresponding to a reduction in the use of acid suppression from 8.7 doses per week (DD/w) to 4.0 (p < 0.01) and 5.6 DD/w (p < 0.01). At long-term follow-up there was a return towards baseline values for acid suppression use (6.4 DD/w, p = 0.06), whereas the heartburn severity score remained low (8.5, p < 0.01). Loss of sutures was significant, from an average of 2.51 applied sutures to 1.87 (p < 0.01) and 1.81 (p < 0.01) remaining sutures at 3 and 12 months, respectively. After the second procedure, the heartburn severity score fell from an initial 22.5 to 12.7 (p < 0.01) after 3 months and remained low at long-term follow-up (6.6, p < 0.01). The corresponding data for acid suppression use were 11.7, 3.6 (p < 0.01) and 5.2 (p < 0.01) DD/w. Number of sutures increased from an average of 2.15 sutures placed initially, with 2.65 sutures added at the second procedure, to an average of 2.80 remaining sutures (p < 0.01) at 3 months.

CONCLUSIONS

Endoluminal gastroplication has a significant, yet transient effect on symptom score and the use of acid suppressants in GORD patients. A selection of patients for a subsequent procedure may be of value.

Endoscopic suturing: now and incoming

There is a particular need for inexpensive, simple multipurpose suturing methods that can be used for most applications. Such devices are in advanced stages of development and early clinical use. Complex procedure-specific devices that fix large-volume procedures such as reflux or obesity may well be needed but will need to prove their value in clinical studies.

Smooth muscle remodeling of the gastroesophageal junction after endoluminal gastroplication

BACKGROUND

Endoluminal gastroplication has been shown to reduce symptoms of gastroesophageal reflux disease and to induce focal hypertrophy of the gastroesophageal junction (GEJ) muscularis propria. Despite suture loss, some patients have persistent symptomatic resolution.

OBJECTIVE

This study was designed to examine the durability of smooth muscle hypertrophy after suture removal.

DESIGN

Seven pigs underwent upper endoscopy with endoscopic ultrasonography (EGD/EUS) at baseline to evaluate GEJ muscularis propria layer. Endoluminal gastroplication was performed at week 1 with placement of 2 sutures at the GEJ. Repeat EGD/EUS was performed at week 3 and week 5. Three of the 7 pigs were killed for histologic analysis. The remaining 4 pigs had sutures removed and survived for 9, 11, and 13 weeks; serial weekly EGD/EUS was performed until the animal was killed.

RESULTS

The GEJ muscularis propria thickness by EUS was 1.1+/-0.1 mm at baseline, 4.7+/-1.9 mm at week 3, and 4.4+/-1.1 mm at week 5. The muscularis propria thickness by histologic examination in the 3 animals with sutures intact were 6.2+/-0.3 mm near the suture site and 4.7+/-0.5 mm at the opposing wall to the suture site. For the 4 animals with sutures removed, the measurements were 6.9+/-0.2 mm (suture site) and 4.7+/-0.5 mm (opposing wall), respectively.

CONCLUSIONS

The GEJ smooth muscle cell hypertrophy induced by endoluminal gastroplication persisted after removal of mucosal sutures. These changes may be responsible for persistent symptomatic response despite suture loss in patients.

Endoluminal fundoplication

In GERD patients in whom pharmacological therapies are ineffective and anti-reflux surgery is not indicated, a viable option could be proposed. To date, several endoscopic antireflux procedures, involving sewing, injection and/or implant, and radiofrequency are available. The sewing techniques demonstrated good clinical results, with reduction in proton pump inhibitors consumption; despite significant changes in esophageal manometry and/or acid exposure time reduction and healing of esophagitis were noted only in few patients.

The lower esophageal sphincter strength in patients with gastroesophageal reflux before and after laparoscopic Nissen fundoplication

Lower esophageal sphincter pressure (LESP) and sphincter strength (LESS) were measured before and after short and floppy laparoscopic Nissen fundoplication (LNF) in 38 patients with severe gastro-esophageal reflux disease (GERD). These patients were compared with a control group of 23 healthy volunteers. GERD was assessed by stationary manometry, 24-h pH recordings and endoscopy. LESS was verified by motorized pull-back of an air-filled balloon catheter from the stomach into the esophagus. The catheter assembly was well tolerated by all study participants. LESP increased significantly after operation from 8 mmHg to 14 mmHg (75% of normal values; P < 0.0001), but compared to the control group, LESP (22 mmHg) decreased significantly (P < 0.002). In the control group and in patients with GERD, LESP and LESS showed excellent correlation (r = 0.97, r = 0.94, respectively). After LNF, LESS increased significantly from 0.6 to 1.6 N (P < 0.0001), about 166%. We conclude that the measurement of LESS is able to explain the discrepancy between satisfactory NF operation and the distinct increase of postoperative LESP. The evaluation of LESS is a helpful tool in assessing functional understanding of laparoscopic Nissen fundoplication with a short and floppy wrap.

New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery

Endoluminal and transgastric procedures are evolving concepts that combine the skills and techniques of flexible endoscopy with minimally invasive surgery. Precisely how this technology and skill set will be applied in the field of general surgery is not yet known, but the treatment of obesity with an endoluminal or transgastric procedure holds great promise. As the demand for bariatric surgery increases, efforts will be directed toward developing less morbid and less costly treatment options that can provide substantial weight loss and resolution of comorbid conditions. Natural orifice bariatric procedures may include short-term weight loss in preparation for a definitive laparoscopic procedure, revisional procedures to reduce stoma or pouch size or repair fistulas, or primary therapy that provides durable weight loss. The latter application will undoubtedly appeal to patients and referring physicians if it can be performed as an outpatient procedure with significantly less morbidity than a laparoscopic procedure. Early preclinical and clinical work has been published in this area, but many technical obstacles must be overcome before a primary endoluminal or transgastric bariatric procedure can be offered. This article reviews the endoluminal and transgastric technology currently available, the endoluminal procedures currently performed, and the future of these technologies with respect to bariatric surgery.

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity. However, many patients regain weight over time. The mechanisms for this are unclear, and several factors may contribute, including dilation of the gastrojejunal anastomosis. This study aimed to assess the feasibility of endoscopic gastrojejunal anastomotic tightening and to determine the effect of tightening on body weight.

METHODS

Eight patients with significant weight regain and dilated gastrojejunal anastomosis after RYGB were included in this pilot study. Sutures were placed endoscopically at the rim of the anastomosis. When tightened, the sutures formed tissue placations, reducing the size of the anastomotic aperture.

RESULTS

The average preprocedure body mass index (BMI) was 40.5, and the patients had regained a mean of 24 kg from their post-RYGB nadir. The average pouch length was 5.7 cm, and the average anastomotic diameter was 25 mm. The average postreduction diameter was 10.0 mm (68% reduction). Six of the eight patients showed weight loss (mean, 10 kg) at 4 months. Repeat procedures were performed for three patients who had lost 4, 5, and 9 kg, respectively with the initial procedure. After the second anastomotic reduction, the final diameters were, respectively, 14, 5, and 5 mm. The first patient did not have further weight loss. The remaining two patients showed a total weight loss of 19 and 20 kg, respectively, at 5 months. All 11 reductions were accomplished without significant complication. The average postreduction BMI was 37.7, and the percentage of excess weight loss was 23.4%.

CONCLUSION

Peroral endoscopic suturing to tighten dilated gastrojejunal anastomoses appears technically feasible and safe. This procedure is associated with variable but significant weight loss, and preliminary results suggest that it may offer a new treatment option for postbypass weight regain in selected patients.

Animal models for endoscopic simulation

Animal models for GI endoscopy are a safe, reliable, and reproducible method for teaching diagnostic and therapeutic procedures and for developing techniques that have the potential to advance GI endoscopy. Although these methods never can replace human endoscopy as a modality for endoscopic training, animal models may serve as an adjunct to standard endoscopic training and safely enhance the hands-on experience.

Endoscopic therapies of gastroesophageal reflux disease

The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease (GERD). The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.

Endoscopic Therapy for Gastroesophageal Reflux Disease

Within the last 15 years, novel endoscopic therapies have been developed as options for patients who have gastroesophageal reflux disease (GERD). These approaches can provide long-term relief of GERD, or can be used to "bridge" patients to future therapy, because undergoing treatment does not preclude one from future medical or surgical therapy. These therapies continue to bean active source of research and investigation. Although they are undergoing rapid development, there are only a few peer-reviewed articles detailing original studies with short-term follow-up. Future success in this arena will depend on sham-controlled trials, long-term outcome studies, and cost-effectiveness analyses. This article describes available endoscopic therapies, discusses their effectiveness and duration of response, and reviews their failures and complications.

Endoscopic Therapies For Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a chronic condition affect-ing over 7% of the US population. The primary objective of therapy is symptom relief, with secondary goals to heal esophagitis, prevent reflux-related complications, and maintain remission. There are several new endoscopic therapies (ETs) for treatment of GERD, generating considerable interest. An outpatient procedure, performed without an incision and general anesthesia, is attractive to patients and these therapies are being rapidly introduced, despite lack of long-term follow-up and randomized trials. In this article, the authors review endoscopic procedures, including technical aspects, mechanisms of action, safety, efficacy, and tolerability. Patient selection and relevant human studies are reviewed to clarify advantages and disadvantages of ET compared with conventional procedures.

A current assessment of endoluminal approaches to the treatment of gastroesophageal reflux disease

Over the past decade, a number of endoscopic techniques have been developed as alternatives to medical and surgical treatment of gastroesophageal reflux disease (GERD). The driving force was to provide an outpatient transoral, endoscopic procedure effective in controlling reflux in a portion of patients with GERD. Three major technologies emerged, although each use different approaches to augment the barrier function of the lower esophageal sphincter, mechanisms may be similar. These include Endocinch which tightens the gastroesophageal junction via a set of suture plications around the lower esophageal sphincter, Stretta, which delivers radiofrequency energy at the cardia, and Enteryx, which is an inert polymer injected into the muscle layer of the gastroesophageal junction. To date, the underlying mechanism of action of these procedures has not been completely elucidated, although each alters the compliance of the GEJ and thus its ability to respond to a "refluxogenic stress". The target population currently consists of proton pump inhibitor-dependent GERD patients, with little or no hiatal hernia and without severe esophagitis or Barrett's. The Stretta procedure is the only procedure to date to be subjected to a sham-controlled trial. Registries of complications suggest that these techniques are relatively safe, but serious morbidity including rare mortality have been reported. All can be performed on an outpatient basis. Future comparative studies with predetermined end points, validated outcome measures, prolonged follow-up, and complete complication registries are needed to determine the role of endoscopic procedures in the clinical practice of patients with GERD. Evolution of the current technologies will almost certainly occur, and a commonly performed, efficacious endoscopic antireflux procedure is likely to emerge.

Long-term outcomes of endoluminal gastroplication: a U.S. multicenter trial

BACKGROUND

Endoluminal gastroplication has shown promise for the treatment of GERD in short-term studies. Until now, long-term outcome data have been lacking.

METHODS

A prospective, multicenter trial enrolled 85 patients with GERD to be treated with endoluminal gastroplication. Inclusion criteria were 3 or more heartburn or regurgitation episodes per week, >4.2% time in 24 hours with esophageal pH < 4, and dependency on antisecretory medications. Exclusion criteria were the presence of varices, achalasia, aperistalsis, or previous gastric resection. Patients underwent manometry, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patient diaries were used to assess medication use and to estimate annual medication cost.

RESULTS

At 1- and 2-year follow-up, patients had significant reductions in median heartburn symptom scores (72 at baseline [interquartile range (IQR) 90-48] vs. 4 at 12 months [IQR 43-0] and 16 at 24 months [IQR 53-3.5]; p < 0.0001 vs. baseline) and median regurgitation symptoms (2 at baseline [IQR 3-1] vs. 0 at 12 months (IQR 1-0) and 1 at 24 months [IQR 1-0]; p < 0.0001 vs. baseline). Of all patients, 59% and 52% showed heartburn symptom resolution at 12 and 24 months, respectively ( p < 0.0001 vs. baseline). Also, 83% and 77% had regurgitation symptom resolution at 12 and 24 months, respectively (p < 0.0001 vs. baseline). Proton pump inhibitor use also was significantly reduced at 12 and 24 months after the procedure. At 2-year follow-up, median annualized medication costs were reduced by 88% (1381 US dollars) (p < 0.0001). Endoluminal gastroplication significantly reduced the duration and the number of episodes of esophageal acid exposure (p < 0.0001 vs. baseline). Only 7 patients experienced adverse events.

CONCLUSIONS

Endoscopic gastroplication is safe and effective, and is associated with symptom reductions in patients with GERD for at least 24 months.

A one-year follow-up study of endoluminal gastroplication (Endocinch) in GERD patients refractory to proton pump inhibitor therapy

In a subset of patients with gastroesophageal reflux disease (GERD), symptoms persist in spite of proton pump inhibitor (PPI) therapy. Endoscopic gastroplication (EG) was reported to provide a novel therapeutic option in GERD. To evaluate symptomatic and objective outcome of EG in PPI refractory GERD, consecutive GERD patients with persisting reflux symptoms during at least 2 months double dose PPI were recruited for EG (Endocinch). Exclusion criteria were high-grade esophagitis, Barrett's esophagus, and hiatal hernia > 3 cm. Symptoms and PPI use were evaluated before and 1, 3, and 12 months after the EG; 24-hr pH monitoring off PPI was performed before and after 3 and 12 months. All data are given as mean +/- SD and were analyzed by Student's t test. Twenty patients (10 females; mean age, 45 +/- 11 years) were recruited. Under conscious sedation with midazolam (6 +/- 2 mg) and pethidine (53 +/- 5 mg), a mean of 2.0 +/- 0.2 sutures was applied during a procedure time of 33 +/- 6 min. Throat ache and mild epigastric pain for up to 3 days after the procedure were the only adverse events. At 3 and 12 months symptom score (11.6 +/- 6 vs. 6.4 +/- 3.7 [P < 0.01] and 7.1 +/- 4.5 [P < 0.05]) as well as pH monitoring (% time pH < 4: 17.0 +/- 11.1 vs. 8.1 +/- 5.7% [P < 0.01] and 9.8 +/- 4.1% [P < 0.01]) significantly improved. Ph monitoring was normalized (< 4% of time) in seven patients after 3 months. PPIs could be stopped in 13 patients, with 2 patients still using H2-blockers and 1 using cisapride after 3 months. After 12 months only six patients were free of PPI use and pH monitoring was normalized in six patients. We conclude that EG provides short- and medium-term symptomatic and objective relief to a subset of GERD patients refractory to high-dose PPI.

Future therapeutic indications for endoscopic ultrasound

Attempts to perform therapy guided by endoscopic ultrasound (EUS) are rare. Some new indications for interventional and therapeutic endoscopic procedures performed under EUS control have been developed in areas that have been purely surgical for many years. Indications, procedures, and related tools for EUS-guided endosurgery are described, all of which are experimental but may open a new corridor for endoscopists to enter a variety of transluminal procedures in real time without soiling the peritoneal or mediastinal cavity.

Gastroesophageal junction smooth muscle remodeling after endoluminal gastroplication

OBJECTIVES

Endoluminal gastroplication (ELGP) is an endoscopic mucosal suturing procedure for the treatment of gastroesophageal reflux disease. The antireflux mechanism of the mucosal suture remains poorly understood. The aim of this study is to investigate any morphologic changes in the smooth muscle layer induced by the mucosal sutures placed at the gastroesophageal junction.

METHODS

ELGPs were performed using endoscopic suturing devices with placement of two or three circumferential sutures within 2 cm of the squamocolumnar junction. Eight patients with subsequent symptom resolution underwent endoscopic ultrasound (EUS) to evaluate the muscularis propria layer at the gastroesophageal junction. A swine model was used for EUS and histopathologic correlation study. Six control and 15 ELGP pigs were evaluated with EUS and histological examination of the gastroesophageal junction smooth muscle layer.

RESULTS

Focal thickening of the muscularis propria layer near the suture region (2.3 +/- 0.4 mm vs 1.4 +/- 0.3 mm, p < 0.01) was found in eight patients with symptomatic resolution. In ELGP pigs, the smooth muscle layer thickness increased by 2.6 mm near the suture site by EUS. By histology, the total and circular smooth muscle layer thickness increased by 2.1 mm and 1.9 mm, respectively.

CONCLUSIONS

Focal thickening of smooth muscle layer occurs at the gastroesophageal junction after ELGP in patients with gastroesophageal reflux disease. This finding was reproduced in a swine model and localized hypertrophy was found to be entirely due to an increase in the circular smooth muscle layer.

[Endoscopic therapy methods for gastroesophageal reflux]

Gastroesophageal reflux disease (GERD) is prevalent in 10% of the population. In addition to the established therapy, endoscopic antireflux procedures have been developed to improve the gastroesophageal reflux barrier. This can achieved by endoscopically placed sutures, application of radio frequency energy, or injection of biocompatible materials. These new techniques might be effective in some patients with GERD. To date, there are limited data on the effectiveness and safety of these methods. During a follow-up of 1-2 years, subjective parameters improved in 70-75% of the test patients such that no antisecretory treatment was required. Further, randomized, placebo-controlled studies are needed for objective evaluation of these promising new methods.

Endoluminal gastroplication for treatment of patients with classic gastroesophageal reflux symptoms and borderline 24-h pH studies

BACKGROUND

Patients with classic gastroesophageal reflux disease (GERD) symptoms and borderline 24-h pH studies are not considered to be good candidates for surgical fundoplication. Endoluminal gastroplication (ELGP) is a new endoscopic treatment for patients with GERD. The aim of this study was to evaluate the efficacy of ELGP in these patients.

METHODS

Patients with heartburn, regurgitation symptoms and a DeMeester score of less than 30 were studied. ELGP involved placement of two or three plications within 2 cm of the gastroesophageal junction. Clinical outcomes measured were heartburn symptom score (HSS), regurgitation frequency score (RFS) and medication use.

RESULTS

Twenty-five patients (11 M, 14 F, mean age of 51 years) had a medication use of 11.5 doses of proton-pump inhibitors per week prior to ELGP. Average lower esophageal sphincter pressure measured 15 +/- 8 mmHg, and average DeMeester score was 18 +/- 8. Nine patients had hiatal hernias and 11 had esophagitis. Twenty-four patients were available for a mean follow-up of 12 months. HSS significantly decreased from 48 to 17 (P < 0.01) and RFS was reduced from 1.8 to 0.7 (P < 0.01). Proton-pump inhibitor use was 5.3 doses per week (P < 0.01) post-ELGP; 12 patients (50%) were off medications, 3 (13%) had a 50% reduction in medication use, and in 9 (37%) there was no change. Complications were bleeding in one patient and aspiration pneumonia in another patient.

CONCLUSIONS

Endoluminal gastroplication provides symptomatic relief for patients with classic GERD symptoms despite medical therapy and borderline 24-h pH studies.

Endoscopic suturing

We describe the development of endoscopic sewing machines and ancillary equipment for knot tying and thread cutting. We outline the experimental studies in dogs, pigs and baboons prior to the first studies in man. We consider the early results achieved by groups in Europe and the U.S.A., and present the available evidence from peer-reviewed studies and data from numerous abstracts on the use of endoscopic suturing in man for treating gastro-oesophageal reflux. We consider the limitations of the available studies, and outline the requirements for improvements in flexible endoscopic suturing methods.

Impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter function and gastroesophageal reflux in patients with reflux disease

OBJECTIVES

Plication of the gastroesophageal junction by endoscopic suturing has been reported to improve symptoms and reduce acid exposure in patients with gastroesophageal reflux disease (GERD). The mechanisms underlying these effects are not well defined. The aims of our study were to determine the impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter (LES) function in patients with GERD.

METHODS

In 15 patients (7 males) with GERD (heartburn, % time esophageal pH < 4 greater than 4%, +/- history of erosive esophagitis within 6 months), two plications were performed circumferentially 1 cm below the gastroesophageal junction. Endoscopy and combined postprandial esophageal manometry and pH monitoring were performed before and 6 months after treatment; 24-h ambulatory pH monitoring and symptom assessment were also performed before, and at 6 and 12 months after treatment.

RESULTS

Six months after treatment, the rate of transient LES relaxations (tLESRs) was decreased by 37% (p < 0.05) and basal LES pressure had increased from 4.3 +/- 2.2 mmHg to 6.2 +/- 2.1 mmHg (p < 0.05). The rate of postprandial reflux events and acid exposure time were not altered. Endoscopic suturing significantly reduced 24-h esophageal acid exposure from 9.6% (9.0-12.1) to 7.4% (3.9-10.1) at 6 months, due predominantly to a reduction in upright acid exposure. The reduction in total 24-h acid exposure was sustained to 12 months. At repeat endoscopy, only one plication was evident in 6 patients (40%) at 6 months. Seven patients (47%) remained off medications at 6 and 12 months follow-up.

CONCLUSIONS

In patients with GERD, endoscopic suturing of the gastroesophageal junction results in a reduction in the rate of tLESRs, and an increase in basal LES pressure. These changes in LES function result in only a modest reduction in gastroesophageal reflux.

Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model

BACKGROUND

Endoluminal operations for gastroesophageal reflux currently are limited by the inability to visualize and manipulate structures outside the wall of the gut. This may be possible by using EUS. The aims of this study were the following: to define the EUS anatomy of structures outside the gut that influence reflux, to place stitches in the median arcuate ligament, to perform posterior gastropexy, and to test the feasibility of crural repair under EUS control in pigs.

METHODS

In survival experiments in 22 pigs, by using a linear-array echoendoscope, the median arcuate ligament and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used, allowing stitches to be placed through a 2.8-mm accessory channel to any predetermined depth. New methods allowed knot tying and thread cutting through the 2.8-mm channel of the echoendoscope.

RESULTS

Stitches were placed through the gastric wall into the median arcuate ligament, and one stitch was placed just beyond the wall of the lower esophageal sphincter. The stitches were tied together and locked against the gastric wall. Median lower esophageal sphincter pressure, determined manometrically, was 11 mm Hg before surgery and 21 mm Hg after stitch placement (p=0.0002). The length of the lower esophageal sphincter increased from a median of 2.8 cm before the procedure to 3.5 cm after the procedure. At the postmortem, the median force required to pull the tags out of the median arcuate ligament was 2.8 kg.

CONCLUSIONS

This study demonstrates that transgastric gastroesophageal reflux surgery, by using stitching under EUS control, can significantly increase lower esophageal sphincter pressure in pigs.

Mucosal apposition in endoscopic suturing

BACKGROUND

The proliferation of minimally invasive surgery has led to the development of numerous entirely intracorporeal endoscopic suturing techniques. These techniques allow for simple apposition of the GI mucosa. It is yet to be determined whether this results in long-term mucosal apposition. This study was designed to determine whether the current techniques of endoscopic suturing necessitate preliminary mucosal manipulation.

METHODS

Seven dogs underwent laparotomy and gastrotomy to expose the proximal gastric mucosa. Three different suturing techniques were used to appose adjacent tissue folds: simple mucosal apposition, electrosurgical mucosal ablation before closure, and mucosal resection before closure. Apposition sites were scored histologically, based on tissue healing after 2 weeks.

RESULTS

Mucosal ablation before tissue apposition resulted in significantly greater healing compared with simple apposition and resulted in histologic scoring similar to that for mucosal resection. The mean histologic score after ablation was 1.5, vs. 1.25 after mucosal resection, and 0.9 for sites closed simply (p=0.02).

CONCLUSIONS

Endoscopic suturing techniques may one day offer an alternative to surgical treatment in the management of numerous GI conditions. As this modality evolves, the incorporation of target tissue ablation or mucosal resection before tissue apposition requires consideration. Human studies evaluating the safety and long-term efficacy of these modifications are necessary.

Endoscopic treatment of gastro-oesophageal reflux disease (GORD): a systematic review

Gastro-oesophageal reflux disease represents an extremely common disorder which has a substantial impact on patients' quality of life and use of health care resources. Gastro-oesophageal reflux disease is a chronic relapsing disease for which a lifelong solution is needed. Until now the two competing therapeutic modalities have been the medical and surgical therapies. Quite recently a third option has become available. A number of endoscopic anti-reflux procedures have been described, with the common goal of creating an anti-reflux barrier, thus obviating long-term proton pump inhibitors and the cost and potential risk of laparoscopic Nissen fundoplication. In this review the different techniques are thoroughly examined and the results are critically evaluated, giving special emphasis to efficacy, safety and durability of these new anti-reflux procedures. Available data show that these anti-reflux techniques produce significant improvement in gastro-oesophageal reflux disease symptomatology and quality of life as well as reduce the use of anti-reflux medication, without causing serious morbidity or mortality. However, the majority of these techniques have failed to adequately control oesophageal acid reflux. Endoscopic anti-reflux therapies therefore sound very attractive-being less invasive than surgery-and show a significant promise, but are still in the early stages of assessment. Large-scale randomized multi-centre trials comparing control groups with sham procedures are essential to confirm their efficacy. Further studies are also necessary to determine what modifications these techniques require in order to produce maximum clinical efficacy and durability. However, considering that current therapies (both medical and surgical) of gastro-oesophageal reflux disease are highly effective, the need for such new endoscopic modalities may be questionable. Moreover, appropriate trials in dedicated centres should be carried out to assure that the enthusiasm commonly associated with new technology is justified and can be generalized to open-access endoscopists.

Understanding endoluminal gastroplications: a histopathologic analysis of intraluminal suture plications

BACKGROUND

Endoluminal gastroplication is used to treat GERD, with modest results. Little is known of the histologic reaction to endosutures. Thus, the histologic response to intraluminal plications at different penetration depths within the gastric wall was studied in an animal model.

METHODS

Intraluminal gastroplications were performed through a laparotomy in 18 New Zealand rabbits. Three sets of everted plications were placed at different penetration depths in each stomach: submucosa (SMpl), muscularis propria (Mpl), and serosa (Spl). Animals were randomized to survival times of 3, 10, or 60 days (respectively, Groups I, II, and III). Plications were compared with a grade scale for each histologic healing phase and gross inspection.

RESULTS

Fusion between folds was absent in all groups. Serosa differed from muscularis propria with respect to the proportion of samples with microscopic ischemia (67% vs. 8%; p = 0.015), remaining sutures in Group III (33% vs. 3%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance), and remaining plications in Group II (96% vs. 54%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance). All of the total and partial histologic scores for the corresponding healing phase in each group escalated with penetration depth. Overall comparison of the histologic scores showed a significant difference among the plications in the proliferation (Group II, p = 0.004) and maturation (Group II, p = 0.009) phases. Total scores also differed among the plications in Groups II (p < 0.001) and III (p < 0.001). Plications were absent in all of Group III, with Spl resulting only in a flat scar.

CONCLUSION

Everted intraluminal gastroplications do not result in fusion between folds irrespective of suture-penetration depth. A flat scar is the final outcome and appears proportional to the amount of ischemia, foreign body reaction, and suture depth.

Endoluminal methods of treating gastroesophageal reflux disease

Several endoluminal methods of treating gastroesophageal reflux disease (GERD) have either been approved, or are under investigation and development. This review outlines the two approved methods (Bard's endoluminal sewing machine and Curon's Stretta radiofrequency treatment), and describes the available data on new methods under investigation. The various methods can be divided into three broad categories: methods that create a controlled stricture, methods that bulk the gastroesophageal junction, and methods that attempt to create a fundoplication. The pros and cons of each method are discussed. Unlike medical treatment, these methods attack the reflux itself, not just the symptoms. This is a promising approach. However, the controlled stricture and bulking methods do not approach the success rate of a standard fundoplication.

Bard EndoCinch: the device, the technique, and pre-clinical studies

There is, of course, room for improvement. More work is needed to make endoscopic suturing easier, quicker and more reliable. The single most important next goal is to construct a device, which can place multiple stitches without the need to remove the endoscope between each stitch. Devices, which can place two stitches in one go, would be a start. The development of double stitch and multiple stitch devices has been described earlier. The authors are pleased to see two alternative commercial endoscopic sewing devices appear at the last DDW which place two stitches without needing to withdraw the endoscopes--they use a double needle method.

Endoscopic suturing for gastroesophageal reflux disease: clinical outcome with the Bard EndoCinch

From a review of the single peer reviewed published report and the brief preliminary studies presented in abstract form, the BARD EndoCinch procedure seems safe and demonstrates an acceptable efficacy for symptom control during short-term follow-up. Most patients (about 2 out of 3) do well with improvement of GERD symptoms during the first post-procedural year. This benefit may wane over time. Objective benefit is lacking with the minority of treated individuals achieving normalization of 24-hour total acid exposure, and no significant effect has been seen in healing of esophagitis. This may focus the treatment towards that group of GERD patients with mild or non-erosive disease. The authors have no information that the endoscopic therapy could prevent reflux-related complications, and long-term data is awaited from accumulated clinical experience to establish the maintenance profile of this novel treatment. The outcomes from the sham trial, and long-term follow-up data will help to define the role of this anti-reflux therapy. The authors need additional studies to define the effect of endoluminal plication on the function of the lower esophageal sphincter to optimize its benefit for patients.