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Joel A, Konjengbam A, Viswanath Y, Kourounis G, Hammond E, Frank H, Kuttuva S, Mbarushimana S, Hidayat H, Thulasiraman S. Endoscopic radiofrequency Stretta therapy reduces proton pump inhibitor dependency and the need for anti-reflux surgery for refractory gastroesophageal reflux disease. Clin Endosc 2024; 57:58-64. [PMID: 37157958 PMCID: PMC10834287 DOI: 10.5946/ce.2023.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 05/10/2023] Open
Abstract
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.
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Affiliation(s)
- Abraham Joel
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Alakh Konjengbam
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Yirupaiahgari Viswanath
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Georgios Kourounis
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Emily Hammond
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Helen Frank
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Shivani Kuttuva
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Simon Mbarushimana
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Hena Hidayat
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
| | - Srivishnu Thulasiraman
- Department of General and Upper Gastrointestinal Surgery, James Cook University Hospital, Cleveland, UK
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Cha B, Kim H, Truong VG, Oh SJ, Jeong S, Kang HW. Feasibility Study on Endoscopic Balloon-Assisted Laser Treatment (EBLT) of Gastroesophageal Reflux Disease (GERD) in In Vivo Porcine Model. Biomedicines 2023; 11:1656. [PMID: 37371751 DOI: 10.3390/biomedicines11061656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) has been growing globally, with an increasing burden on the healthcare system due to multiple factors, such as aging and obesity. The current study evaluated the feasibility of endoscopic balloon-assisted laser treatment (EBLT) in a porcine model. GERD was initially developed in three animals via botulinum toxin injection into lower esophageal sphincter (LES). A week after the injection, the EBLT was performed on the GERD-developed models (control = 1 vs. treated = 2). A dose of 30 W of 980 nm laser light was endoscopically applied for 90 s to the LES. Both endoscopic ultrasound and manometry were performed before and after the EBLT. After 12 weeks, esophageal tissues were extracted and prepared for histological analysis. The maximum mucosa temperature was below 50 °C during the EBLT. Compared to control, the treated group yielded thicker and shorter LES muscle layers and maintained LES pressure. Through histology, the EBLT reinforced the muscularis layer with preserved mucosa and mild remodeling of the intermuscular collagen in the LES. The current study demonstrated the feasibility of EBLT as a new endoscopic approach for GERD. Further studies will examine the EBLT in a larger number of animals to warrant efficacy and safety for clinical translations.
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Affiliation(s)
- Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Hyejin Kim
- TeCure, Inc., Busan 48548, Republic of Korea
| | | | - Sun-Ju Oh
- Department of Pathology, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Hyun Wook Kang
- TeCure, Inc., Busan 48548, Republic of Korea
- Department of Biomedical Engineering and MarineIntegrated Biomedical Technology Center, Pukyong National University, Busan 48513, Republic of Korea
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Duarte Chavez R, Marino D, Kahaleh M, Tyberg A. Endoscopic Treatment of Reflux: A Comprehensive Review. J Clin Gastroenterol 2022; 56:831-843. [PMID: 36040930 DOI: 10.1097/mcg.0000000000001757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The last decade has seen the rise of multiple novel endoscopic techniques to treat gastroesophageal reflux disease, many of which are efficacious when compared with traditional surgical options and allow relief from long-term dependence on antacid medications. This review will explore the latest endoscopic treatment options for gastroesophageal reflux disease including a description of the technique, review of efficacy and safety, and future directions.
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Affiliation(s)
- Rodrigo Duarte Chavez
- Department of Gastroenterology, Robert Wood Johnson Medical Center, New Brunswick, NJ
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Richardson WS, Gorham JK, Neal N, Fanelli RD. Endoscopic Treatment of Gastroesophageal Reflux Disease. Adv Surg 2022; 56:205-227. [PMID: 36096568 DOI: 10.1016/j.yasu.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.
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Affiliation(s)
- William S Richardson
- Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121, USA; University of Queensland, Brisbane, Australia.
| | | | - Nicole Neal
- Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Robert D Fanelli
- Department of Surgery, The Guthrie Clinic, One Guthrie Square, Sayre, PA 18840, USA; Geisinger Commonwealth School of Medicine, Sayre, PA, USA
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5
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Sui X, Gao X, Zhang L, Zhang B, Zhong C, Chen Y, Wang X, Li D, Wu W, Li L. Clinical efficacy of endoscopic antireflux mucosectomy vs. Stretta radiofrequency in the treatment of gastroesophageal reflux disease: a retrospective, single-center cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:660. [PMID: 35845516 PMCID: PMC9279761 DOI: 10.21037/atm-22-2071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022]
Abstract
Background Currently, antireflux mucosectomy (ARMS) and Stretta radiofrequency (SRF) are the most commonly used minimally invasive antireflux therapies. To date, there have not been any reports comparing ARMS and SRF. Our aim was to compare the clinical efficacies of these two therapeutic methods. Methods We analyzed data from gastroesophageal reflux disease (GERD) patients, including 39 who received ARMS treatment and 30 who received SRF treatment between January 2020 and May 2021. Symptom control, gastroesophageal reflux disease questionnaire (GERDQ) score, gastroesophageal reflux disease health-related quality of life (GERD-HRQL) score, proton pump inhibitor (PPI) withdrawal, and PPI reduction were analyzed and compared. Results After 6 months of follow-up, the results showed that both therapies were effective in improving symptoms and quality of life. No difference was found between the ARMS group and SRF group in GERDQ score, GERD-HRQL score, PPI withdrawal rate, or PPI reduction rate (P>0.05). There was no significant difference in the PPI withdrawal rate between the two therapies among patients with gastroesophageal flap valve (GEFV) grade II and grade III (P>0.05), but the PPI withdrawal rate in the ARMS group was significantly higher than that in the SRF group among patients with GEFV grade IV (P<0.05). Conclusions The clinical efficacies of ARMS and SRF 6 months postoperation were equivalent. The results showed that both ARMS and SRF treatment were acceptable for patients with GEFV grades II and III, while ARMS should be selected for patients with GEFV grade IV.
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Affiliation(s)
- Xinke Sui
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Xiaopei Gao
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Lu Zhang
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Bin Zhang
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Changqing Zhong
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Yan Chen
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Xiaoying Wang
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Dou Li
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
| | - Wei Wu
- Department of Otorhinolaryngology Head and Neck Surgery, Strategic Support Force Medical Center, Beijing, China
| | - Lianyong Li
- Department of Gastroenterology, Strategic Support Force Medical Center, Beijing, China
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6
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Abstract
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.
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Affiliation(s)
- David P. Lee
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX USA
| | - Kenneth J. Chang
- Digestive Health Institute, University of California Irvine, Irvine, CA USA ,Gastroenterology, Department of Medicine, UC Irvine School of Medicine, 333 City Blvd. West, Suite 400, Orange, CA 92868 USA
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Mann R, Gajendran M, Perisetti A, Goyal H, Saligram S, Umapathy C. Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions. Front Med (Lausanne) 2021; 8:728696. [PMID: 34912815 PMCID: PMC8666712 DOI: 10.3389/fmed.2021.728696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Gastroenterology and Advanced Endoscopy, Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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8
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Sowa P, Samarasena JB. Nonablative Radiofrequency Treatment for Gastroesophageal Reflux Disease (STRETTA). Gastrointest Endosc Clin N Am 2020; 30:253-265. [PMID: 32146945 DOI: 10.1016/j.giec.2019.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Piotr Sowa
- University of California - Irvine, Orange, CA, USA
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9
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A Prospective Randomized Trial to Assess the Antireflux Effect of Antireflux Mucosectomy in the Porcine Model. Gastroenterol Res Pract 2019; 2019:3286738. [PMID: 30944560 PMCID: PMC6421794 DOI: 10.1155/2019/3286738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/30/2018] [Accepted: 12/30/2018] [Indexed: 12/13/2022] Open
Abstract
Background Both long-term proton pump inhibitor use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). Our aim was to investigate the potential efficacy of antireflux mucosectomy (ARMS) in porcine and determine the optimal circumference of resection in relation to gastroesophageal junction (GEJ). Methods Nine pigs were allocated into the following 3 groups by computerized randomization: group A: control, group B: 1/3 circumference of the esophagus, and group C: 2/3 circumference of the esophagus. We performed mucosectomy with a crescentic mucosal resection at 3 cm above the GEJ and 1 cm below the GEJ. The animals were kept on a liquid diet for 24 h prior to endoscopy. At 6 weeks, animals underwent esophagoscopy, barium radiography, gastric yield pressure (GYP), and gastric yield volume (GYV) determination. Results The weight of swines has no significant difference, and all pigs had maintained their weight after the procedure. We both found scar formation at the GEJ in group B and C. Compared with group A and B, group C produced significantly higher GYP (24.23 ± 3.42 mmHg, p = 0.004) and significantly smaller GYV (2200.0 ± 238.96 mL, p = 0.028) after 6 weeks. Barium radiography showed that the width of the cardia was narrower (13.73 ± 1.19 mm, p = 0.032) in group C after 6-week postprocedure. Conclusion Our study demonstrated the potential antireflux effect of ARMS. We also recommend the 2/3 circumference resection of mucosa at 3 cm distance from the GEJ.
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Roark R, Sydor M, Chatila AT, Umar S, Guerra RDL, Bilal M, Guturu P. Management of gastroesophageal reflux disease. Dis Mon 2019; 66:100849. [PMID: 30798984 DOI: 10.1016/j.disamonth.2019.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) continues to be one of the most prevalent gastrointestinal tract disorders. Management of GERD is individualized for each patient depending on severity of symptoms, complications of GERD and patient/physician preference. The different management options include life style modification, pharmacological therapy, minimally invasive procedures and surgery. The final decision regarding management should be made based on an individualized patient centered approach on a case-by-case basis in consultation with a multidisciplinary team including primary care physician, gastroenterologist and surgeon. We provide a comprehensive review for the management of GERD.
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Affiliation(s)
- Russell Roark
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Michael Sydor
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Ahmed T Chatila
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Shifa Umar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, PA, United States
| | - Ramiro De La Guerra
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555, USA.
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555, USA
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11
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Nikonov EL. [Surgical treatment of the diaphragmatic hernia and the possibility of new endoscopic procedures]. Khirurgiia (Mosk) 2018:96-105. [PMID: 29798999 DOI: 10.17116/hirurgia2018596-105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- E L Nikonov
- N.I. Pirogov Russian National Research Medical University, Moscow, Russia
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12
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Abstract
Over the past 2 decades, a number of new endoscopic techniques have been developed for management of gastroesophageal (GE) reflux disease symptoms as alternatives to medical management and surgical fundoplication. These devices include application of radiofrequency treatment (Stretta), endoscopic plication (EndoCinch, Plicator, Esophyx, MUSE), and injection of bulking agents (Enteryx, Gatekeeper, Plexiglas, Duragel). Their goal was symptom relief through reduction of tissue compliance and enhancement of anatomic resistance at the GE junction. In this review, we critically assess the research behind the efficacy, safety, and durability of these treatments to better understand their roles in contemporary GE reflux disease management.
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Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015; 13:1058-67.e1. [PMID: 25459556 DOI: 10.1016/j.cgh.2014.10.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/26/2014] [Accepted: 10/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A radiofrequency ablation technique known as Stretta was recommended by the Society of American Gastrointestinal and Endoscopic Surgeons as an alternative treatment for gastroesophageal reflux disease (GERD). However, randomized controlled trials of the efficacy of Stretta have produced conflicting findings, and those from previous systematic reviews were compromised as a result of deficiencies in study conduct and reporting of findings. We performed a systematic review to evaluate all evidence on the efficacy of Stretta for the management of GERD. METHODS We searched MEDLINE and the Cochrane Central Register of Controlled Trials (The Cochrane Library) from inception until February 28, 2014, along with other databases, for randomized controlled trials of Stretta in patients with GERD. Primary outcomes were physiologic parameters of GERD, including normalization of esophageal pH values and augmentation of lower esophageal sphincter pressure (LESP). Secondary outcomes were health-related quality of life (HRQOL) and ability to stop the use of proton pump inhibitors (PPIs). For quality assurance purposes, 2 investigators were involved throughout the study. Data were pooled under a random-effects model. The systematic review was performed as per the standards of the Cochrane collaboration. RESULTS We collected data from 4 trials and a total of 165 patients (153 patients were analyzed). Three trials compared Stretta vs sham, and 1 trial compared Stretta with PPI therapy. The overall quality of evidence was very low. The pooled results showed no difference between Stretta and sham or management with PPI in patients with GERD for the outcomes of mean (%) time the pH was less than 4 over a 24-hour time course, LESP, ability to stop PPIs, or HRQOL. CONCLUSIONS In a meta-analysis of trials, we found that Stretta for patients with GERD does not produce significant changes, compared with sham therapy, in physiologic parameters, including time spent at a pH less than 4, LESP, ability to stop PPIs, or HRQOL.
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Affiliation(s)
- Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida.
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Affiliation(s)
- John E Pandolfino
- Feinberg School of Medicine, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Kumar Krishnan
- Feinberg School of Medicine, Department of Medicine, Northwestern University, Chicago, Illinois
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15
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Pandolfino JE, Krishnan K. Do endoscopic antireflux procedures fit in the current treatment paradigm of gastroesophageal reflux disease? Clin Gastroenterol Hepatol 2014; 12:544-54. [PMID: 23811248 PMCID: PMC3880639 DOI: 10.1016/j.cgh.2013.06.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/06/2013] [Accepted: 06/08/2013] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common condition requiring considerable medical resources. The mainstay of therapy is proton pump inhibitors (PPIs), which are effective at reducing acid reflux. In patients who have refractory acid reflux and esophagitis despite high-dose PPI, or are intolerant of the side effects of PPI therapy, surgical fundoplication is the primary therapy. The risk and cost gap between medical therapy and surgery has resulted in substantial interest in less-invasive endoscopic therapies. In this review, we discuss the underlying physiology of GERD along with the anatomic hurdles that must be overcome to develop an effective antireflux procedure. We also review the current published literature and assess the clinical efficacy of the devices that have been studied or currently are being investigated. Despite promising early studies, many of the devices fall short in high-quality randomized controlled trials. Furthermore, the physiologic aberration resulting in GERD oftentimes is addressed inadequately. Although there is certainly a need for less-invasive, safe, and effective therapy for reflux, therapy will need to withstand the established clinical efficacy of both PPI and surgical fundoplication. At present, we have the luxury of time to wait for such a device to become available.
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Affiliation(s)
- John E Pandolfino
- Department of Medicine, Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Kumar Krishnan
- Department of Medicine, Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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16
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Noar M, Squires P, Noar E, Lee M. Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later. Surg Endosc 2014; 28:2323-33. [PMID: 24562599 DOI: 10.1007/s00464-014-3461-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 01/21/2014] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Mark Noar
- Heartburn & Reflux Study Center, Endoscopic Microsurgery Associates PA, 7402 York Road 100, Towson, MD, 21204, USA,
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18
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Duarte MES, Freitag CPF, Fornari F, Kruel CRP, Sanches PRS, Thomé PRO, Callegari-Jacques SM, Möllerke RO, Vicente YAMVA, Goldani HAS, Barros SGS. Gastric yield pressure and gastric yield volume to assess anti-reflux barrier in a porcine model. J INVEST SURG 2013; 26:80-4. [PMID: 23273175 DOI: 10.3109/08941939.2012.695429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Anti-reflux barrier (ARB) resistance may be useful to test new treatments for gastroesophageal reflux (GER). The ARB has been estimated by increasing gastric yield pressure (GYP) and gastric yield volume (GYV) in animal models but has not been validated. This study aimed to develop an experimental model suitable for assessing the ARB resistance to increasing intragastric pressure and volume and its reproducibility in a seven-day interval. Ten two-month-old female Large-White swine were studied. Intragastric pressure and volume were recorded using a digital system connected to a Foley catheter inserted through gastrostomy into the stomach. GYP and GYV were defined as the gastric pressure and volume able to yield gastric contents into the esophagus detected by esophageal pH. A sudden pH drop below 3 sustained during 5 min was considered diagnostic for gastric yield. Animals were studied again after seven days. On days 0 and 7, there were no significant differences for GYP (mean ± SD = 7.66 ± 3.02 mmHg vs. 7.07 ± 3.54 mmHg, p = .686) and GYV (636.70 ± 216.74 ml vs. 608.30 ± 276.66 ml; p = .299), respectively. Concordance correlation coefficient (ρc) was significant for GYP (ρc = 0.634, 95% CI = 0.141-0.829, p = .006), but not for GYV (ρc = 0.291, 95% CI = -0.118 to 0.774, p = .196). This study demonstrated an experimental model, assessing the ARB resistance. GYP seems to be a more reliable parameter than GYV for assessment of ARB resistance.
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Affiliation(s)
- Marcos E S Duarte
- Programa de Pós-graduação Ciências em Gastroenterologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul UFRGS, Porto Alegre, Brazil
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Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:283-8. [PMID: 22874675 DOI: 10.1097/sle.0b013e3182582e92] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Arts J, Bisschops R, Blondeau K, Farré R, Vos R, Holvoet L, Caenepeel P, Lerut A, Tack J. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol 2012; 107:222-30. [PMID: 22108449 DOI: 10.1038/ajg.2011.395] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several studies have reported symptom relief in gastro-esophageal reflux disease (GERD) patients treated with radiofrequency delivery (Stretta procedure) at the gastro-esophageal junction (GEJ), but the mechanism underlying this improvement is unclear. The objective of this study was to test the hypothesis that Stretta alters GEJ resistance. METHODS We conducted a double-blind randomized cross-over study of Stretta and sham treatment. Consecutive GERD patients were included in the study. The study was conducted in a tertiary care center. Patients underwent two upper gastrointestinal endoscopies with 3 months interval, during which active or sham Stretta treatment was performed in a randomized double-blind manner. Symptom assessment, endoscopy, manometry, 24-h esophageal pH monitoring, and a distensibility test of the GEJ were done before the start of the study and after 3 months. RESULTS Barostat distensibility test of the GEJ before and after administration of sildenafil was the main outcome measure. In all, 22 GERD patients (17 females, mean age 47±12 years) participated in the study; 11 in each group. Initial sham treatment did not affect any of the parameters studied. Three months after initial Stretta procedure, no changes were observed in esophageal acid exposure and lower esophageal sphincter (LES) pressure. In contrast, symptom score was significantly improved and GEJ compliance was significantly decreased. Administration of sildenafil, an esophageal smooth muscle relaxant, normalized GEJ compliance again to pre-Stretta level, arguing against GEJ fibrosis as the underlying mechanism. CONCLUSIONS The limitation of this study was reflux evaluation did not include impedance monitoring. In this sham-controlled study, Stretta improved GERD symptoms and decreased GEJ compliance. Decreased GEJ compliance, which reflects altered LES neuromuscular function, may contribute to symptomatic benefit by decreasing refluxate volume.
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Affiliation(s)
- J Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Long-Term Results of Radiofrequency Energy Delivery for the Treatment of GERD: Results of a Prospective 48-Month Study. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2011; 2011:507157. [PMID: 22110288 PMCID: PMC3202130 DOI: 10.1155/2011/507157] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 06/18/2011] [Accepted: 08/17/2011] [Indexed: 12/17/2022]
Abstract
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.
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Liu HF, Zhang JG, Li J, Chen XG, Wang WA. Improvement of clinical parameters in patients with gastroesophageal reflux disease after radiofrequency energy delivery. World J Gastroenterol 2011; 17:4429-33. [PMID: 22110270 PMCID: PMC3218158 DOI: 10.3748/wjg.v17.i39.4429] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 08/11/2011] [Accepted: 08/18/2011] [Indexed: 02/06/2023] Open
Abstract
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.
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Abstract
A significant percentage of patients with gastroesophageal reflux disease may experience extraesophageal manifestations, such as chest pain or asthma. These symptoms are more difficult to diagnose than the usual esophageal symptoms. The aim of this article is to characterize the extraesophageal manifestations in patients with gastroesophageal reflux disease and report the effects of the Stretta procedure. We report a case of a 59-year-old female patient with a history of arrhythmia. She was referred for the Stretta procedure in the gastroesophageal junction after her symptoms were documented by pH monitoring and proton-pump inhibitors treatment to be associated with acid reflux. The long-standing arrhythmia improved after the Stretta procedure. To our knowledge, this is a rare case of successful Stretta procedure treatment of a patient with cardiovascular manifestations induced by gastroesophageal reflux disease. The results indicate an underlying mechanism for extraesophageal manifestations and the success of the Stretta procedure.
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Parker M, Smith CD. Comparing the effectiveness of endoscopic full-thickness plication and endoscopic radiofrequency treatments for patients with GERD. Expert Rev Gastroenterol Hepatol 2010; 4:387-90. [PMID: 20678010 DOI: 10.1586/egh.10.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Chaillou E, Tillet Y, Malbert CH. Organisation of the catecholaminergic system in the vagal motor nuclei of pigs: A retrograde fluorogold tract tracing study combined with immunohistochemistry of catecholaminergic synthesizing enzymes. J Chem Neuroanat 2009; 38:257-65. [DOI: 10.1016/j.jchemneu.2009.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 07/07/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
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Endoscopic augmentation of the esophagogastric junction with polymethylmethacrylate: durability, safety, and efficacy after 6 months in mini-pigs. Surg Endosc 2009; 23:2430-7. [DOI: 10.1007/s00464-009-0376-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 12/18/2008] [Accepted: 01/12/2009] [Indexed: 01/11/2023]
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Smith CD. Surgical therapy for gastroesophageal reflux disease: indications, evaluation, and procedures. Gastrointest Endosc Clin N Am 2009; 19:35-48, v-vi. [PMID: 19232279 DOI: 10.1016/j.giec.2008.12.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux is a very common condition, and surgery remains a reasonable options in select patients. Successful surgical care for GERD depends on proper patient selection, workup and operative technique. This manuscript reviews surgical care for GERD.
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Affiliation(s)
- C Daniel Smith
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Wachowiak R, Krauss A, Donaubauer B, Muensterer OJ. Cardia Yield Pressure Measurement in an Infant Porcine Model: A Novel Technique to Evaluate the Quality of Laparoscopic Fundoplication. J Laparoendosc Adv Surg Tech A 2008; 18:887-90. [DOI: 10.1089/lap.2008.0001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Robin Wachowiak
- Department of Pediatric Surgery, Children's University Hospital of Leipzig, Leipzig, Germany
| | - Alexandra Krauss
- Department of Pediatric Surgery, Children's University Hospital of Leipzig, Leipzig, Germany
| | - Bernd Donaubauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Oliver J. Muensterer
- Department of Pediatric Surgery, Children's University Hospital of Leipzig, Leipzig, Germany
- Department of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
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Coron E, Sebille V, Cadiot G, Zerbib F, Ducrotte P, Ducrot F, Pouderoux P, Arts J, Le Rhun M, Piche T, Bruley des Varannes S, Galmiche JP. Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients. Aliment Pharmacol Ther 2008; 28:1147-58. [PMID: 18616516 DOI: 10.1111/j.1365-2036.2008.03790.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- E Coron
- Institut des Maladies de l'Appareil Digestif, CHU Hôtel-Dieu, Nantes
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Endoscopic implantation of polymethylmethacrylate augments the gastroesophageal antireflux barrier: a short-term study in a porcine model. Surg Endosc 2008; 23:1272-8. [DOI: 10.1007/s00464-008-0145-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 06/26/2008] [Accepted: 07/24/2008] [Indexed: 12/26/2022]
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Transoral endoscopic fundoplication in the treatment of gastroesophageal reflux disease: the anatomic and physiologic basis for reconstruction of the esophagogastric junction using a novel device. Ann Surg 2008; 248:69-76. [PMID: 18580209 DOI: 10.1097/sla.0b013e31817c9630] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the safety, mechanism of action, immediate postprocedural anatomic impact on the esophagogastric junction, and short-term efficacy of the first entirely endolumenal antireflux procedure. BACKGROUND A safe and effective endoscopic antireflux procedure remains elusive. Transoral endolumenal surgery has enormous potential for the treatment of gastroesophageal reflux disease (GERD) and other esophagogastric diseases. A canine model was used to study a novel endoscopic device, which allows for creation of an endoluminal fundoplication. METHODS The transoral incisionless fundoplication (TIF) was performed in 21 canines in a phase I feasibility and safety study, and in 21 canines in a phase II study that included a detailed objective assessment of the effects of 2 variants of the TIF procedure (TIF 1.0 and TIF 2.0) versus sham on esophageal physiology and esophagogastric junction (EGJ) anatomy. RESULTS In phase I, TIF provided a safe and feasible endolumenal therapy for GERD, with histologic data that demonstrated serosal fusion of approximated full-thickness tissue plications and durability of the fundoplication. TIF procedures effectively reduced cardia circumference and improved Hill classification grade. In phase II, the TIF 2.0 procedure achieved normalization of distal esophageal acid exposure and increased lower esophageal sphincter (LES) pressure and length based on objective testing over a 2-week period. TIF 2.0 demonstrated superior results to TIF 1.0, and valve appearance and location exhibited similarity to the Nissen fundoplication by vector volume analysis. CONCLUSIONS The TIF procedure is safe and results in a durable and functional fundoplication as well as a platform for further development and modification of the procedure, which can be use to impact outcome. This work provides the foundation for human translation and assessment of long-term outcomes.
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Sidhu AS, Triadafilopoulos G. Neuro-regulation of lower esophageal sphincter function as treatment for gastroesophageal reflux disease. World J Gastroenterol 2008; 14:985-90. [PMID: 18286675 PMCID: PMC2689423 DOI: 10.3748/wjg.14.985] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The junction between the esophagus and the stomach is a specialized region, composed of lower esophageal sphincter (LES) and its adjacent anatomical structures, the gastric sling and crural diaphragm. Together these structures work in a coordinated manner to allow ingested food into the stomach while preventing reflux of gastric contents across the esophago-gastric junction (EGJ) into the esophagus. The same zone also permits retrograde passage of air and gastric contents into esophagus during belching and vomiting. The precise coordination required to execute such a complicated task is achieved by a finely-regulated high-pressure zone. This zone keeps the junction between esophagus and stomach continuously closed, but is still able to relax briefly via input from inhibitory neurons that are responsible for its innervation. Alterations of the structure and function of the EGJ and the LES may predispose to gastroesophageal reflux disease (GERD).
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Ganz RA, Gostout CJ, Grudem J, Swanson W, Berg T, DeMeester TR. Use of a magnetic sphincter for the treatment of GERD: a feasibility study. Gastrointest Endosc 2008; 67:287-94. [PMID: 18226691 DOI: 10.1016/j.gie.2007.07.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 07/02/2007] [Indexed: 12/27/2022]
Abstract
BACKGROUND The success of fundoplication surgery varies widely; furthermore, complications after fundoplication can be common. We introduced a new device to treat GERD: biomechanical augmentation of the lower esophageal sphincter (LES) by use of a magnetic reinforcing appliance. OBJECTIVES The aim was to determine whether a magnetic appliance could safely increase LES pressure, maintain a closed sphincter except during swallowing and belching, and increase the gastric yield pressure in a porcine model. DESIGN Ex vivo work-assessed design variables that would augment the reflux barrier yet still preserve swallow function. Porcine acute and chronic (44 weeks) postimplant studies were also performed. A single animal underwent planned device removal. MAIN OUTCOME MEASUREMENTS Gastric yield pressure, animal behavior, endoscopy, barium studies, balloon expansion studies, esophageal manometry, and histology. RESULTS Gastric yield pressure correlated with increasing magnetic forces (R(2)=0.5608, P< .001). The sphincter augmentation device was safe in all animals, with no observed effect on eating behavior and normal weight gain. The mucosa of the esophagus appeared normal at all intervals, and there was no device migration or significant tissue inflammation. The average LES pressure rose after implantation (P< .005). Balloon and barium studies demonstrated a closed sphincter with normal opening of the gastroesophageal junction during swallowing. CONCLUSIONS Magnetic sphincter augmentation is a novel approach for the treatment of GERD. This study demonstrates the safety and feasibility of such a device in a porcine model. Further investigation of this device for the treatment of GERD in humans seems warranted.
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Affiliation(s)
- Robert A Ganz
- Minnesota Gastroenterology, Plymouth, Minnesota 55446, USA
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Sari YS, Koc O, Tunali V, Erkan E, Uzum G, Sayilgan C, Koksal G, Ugurlu S. Endolaparoscopic approach in the management of gastroesophageal reflux disease: an experimental study in pigs. J Laparoendosc Adv Surg Tech A 2008; 17:639-44. [PMID: 17907978 DOI: 10.1089/lap.2006.0204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Yavuz Selim Sari
- Department of General Surgery, SB Istanbul Egitim ve Arastirma Hastanesi, Istanbul, Turkey.
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Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Systematic review: endoluminal therapy for gastro-oesophageal reflux disease: evidence from clinical trials. Eur J Gastroenterol Hepatol 2007; 19:1125-39. [PMID: 17998840 DOI: 10.1097/meg.0b013e3282f16a21] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
During the last few decades many endoscopic interventions have been developed as an alternative for the treatment of gastro-oesophageal reflux disease (GORD). In many countries, these interventions are thus being performed in the general clinical setting. The aim of this study is to systematically review the evidence on the effect of endoscopic therapies for GORD. A systematic search of the literature on this subject in English, indexed in MEDLINE (1966 to May 2007) and in the Cochrane Library, was carried out. For the study selection, retrospective and prospective open-label and randomized, sham-controlled trials were taken into account. The exclusion criteria included the following: case series that included fewer than 10 patients, abstracts, studies involving children or those with a follow-up shorter than 3 months. For data extraction, two reviewers, using standardized forms, independently abstracted data on study design and methods, population, sample size, function studies (e.g. pH-metry), type of endoscopic treatment, follow-up, health-related and quality of life scores, outcomes and complications. Data synthesis involved the following: 43 studies, including four randomized, sham-controlled trials that met the inclusion criteria, out of 4182 citations. The primary end point in most studies was the reduction of the use of proton pump inhibitors (PPIs) by more than 50%. In view of these findings, the majority of studies suggested the efficacy of endoluminal therapies for the control of symptoms in GORD. In the sham-controlled studies, the effect of placebo was, nevertheless, as high as 50%. Most studies were small feasibility studies, with follow-ups of less than 1 year. No study comparing endoscopic techniques with other established treatment options such as PPIs existed. All endoscopic therapies were associated with a small but important percentage of mild to severe complications, which included perforation, abscess and death. In conclusion, the data from most of the short-term follow-up and the few sham-controlled studies demonstrate that subgroups of patients experienced improvement or resolution of typical GORD symptoms and decreased PPI usage. Currently, however, there are not enough scientific and clinical data on safety, efficacy and durability to support the use of endoluminal therapies for GORD in routine clinical practice.
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Arts J, Sifrim D, Rutgeerts P, Lerut A, Janssens J, Tack J. Influence of radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) on symptoms, acid exposure, and esophageal sensitivity to acid perfusion in gastroesophagal reflux disease. Dig Dis Sci 2007; 52:2170-7. [PMID: 17436101 DOI: 10.1007/s10620-006-9695-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2006] [Accepted: 11/26/2006] [Indexed: 12/16/2022]
Abstract
Several studies have demonstrated that radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) induces symptom relief in gastroesophageal reflux disease (GERD), although improvement of acid exposure on pH monitoring was usually limited. A role for decreased esophageal sensitivity has been suggested. Our aim was to evaluate the influence of Stretta on symptoms, acid exposure, and sensitivity to esophageal acid perfusion in GERD. Thirteen patients with established proton pump inhibitor (PPI)-dependent GERD (three males; mean age, 51+/-10 years) participated in the study. Before and 6 months after the procedure symptom score, pH monitoring and Bernstein acid perfusion test were performed. The latter was done by infusing HCl (pH 0.1) at a rate of 6 ml/min 15 cm proximal to the gastroesophageal junction for a maximum of 30 min or until the patients experienced heartburn. Results were compared by Student's t-test. Stretta procedure time was 51+/-4 min and no complications occurred. After 6 months, the symptom score was significantly improved (12.5+/-2.0 to 7.5+/-2.1; P<0.05), seven patients no longer needed daily PPI, and acid exposure was significantly decreased (11.6%+/-1.6% to 8.5%+/-1.8% of time pH<4; P<0.05). The time needed to induce heartburn during acid perfusion decreased from 9.5+/-2.3 to 18.1+/-3.4 min (P=0.01), and five patients became insensitive to 30-min acid perfusion, versus none at baseline (P=0.04). In conclusion, the Stretta procedure induces subjective improvement of GERD symptoms and decreases esophageal acid exposure. In addition, esophageal acid sensitivity is decreased 6 months after the Stretta procedure. The mechanism underlying this finding and its relevance to symptom control require further studies.
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Affiliation(s)
- J Arts
- Department of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Liu JJ. Endoscopic treatment for gastroesophageal reflux disease: should you learn the techniques? CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:213-5. [PMID: 17431508 PMCID: PMC2657692 DOI: 10.1155/2007/812967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Julia J Liu
- University of Alberta Hospital, Edmonton, Albert, Canada.
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Abstract
Today, there are several modalities to treat gastroesophageal reflux disease (GERD) (medications, endoscopic therapies, surgery) and such therapies can be used either singly, or in tandem, or in combination with the others, aiming at "normalization" of the patient's GERD-related quality of life and, if possible, esophageal acid exposure. Several intermediate end points or clinically significant outcomes have not been reached by some therapeutic modalities and no single modality is or can be perfect. Statistically significant improvements in these intermediate end points have been shown in "some" but not all studies. Although healing of esophagitis can be accomplished with either medical or surgical therapy, there is inadequate data with endotherapies, because most patients treated with endotherapies have had prior trials of proton pump inhibitors (PPIs) and hence healed their esophagitis. Effective prevention of complications, such as esophageal adenocarcinoma, remains challenging for all modalities. Patients who have not normalized their GERD-related quality of life with once or twice daily PPI therapy should undergo functional esophageal evaluation with pH testing and esophageal motility study and they should be evaluated by both an endoscopist and a surgeon. The decision on how to proceed should be made on the basis of the criteria for endotherapy and surgery, availability of local endoscopic and surgical expertise and patients' preference. Such multimodality therapy model is in many ways similar to the long-term management of coronary artery disease where pharmacotherapy, angioplasty, and bypass surgery are frequently used in tandem or in combination. Multimodality therapy aiming at normalization of GERD-related quality of life is an option today, and should be available to all patients in need of therapy. The target population for GERD endotherapy currently consists of PPI-dependent GERD patients, who have a small (<2-cm-long) or no sliding hiatal hernia, and without severe esophagitis or Barrett esophagus. Thus far, only Stretta and the NDO plicator have been studied in sham-controlled trials. Registries of complications suggest that these techniques are relatively safe, but serious morbidity, including rare mortality have been reported (for a continuous update on complications related to endoscopic therapies see: http://www.fda.gov/cdrh/maude.html). All can be performed on an outpatient basis, under intravenous sedation and local pharyngeal anesthesia. Future comparative studies with predetermined clinically significant end points, validated outcome measures, prolonged follow-up, and complete complication registries will eventually determine the precise role of endoscopic procedures for the patients with GERD.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305-5187, USA.
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Higuchi K, Fujiwara Y, Okazaki H, Tabuchi M, Kameda N, Kadouchi K, Machida H, Tanigawa T, Shiba M, Watanabe T, Tominaga K, Oshitani N, Arakawa T. Feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with gastroesophageal reflux disease: first report from Asia. J Gastroenterol 2007; 42:205-10. [PMID: 17380278 DOI: 10.1007/s00535-006-1944-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 12/14/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND In recent years, various endoscopic treatments have become available to treat gastroesophageal reflux disease (GERD) in Western countries. The Stretta procedure, which uses radiofrequency energy, is one type of safe and effective endoluminal treatment for GERD. However, the feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with GERD, who differ from Western peoples in their physiological characteristics, are not known. In 2006, we imported a Stretta system from the United States and investigated important clinical aspects of the system in Japanese patients with GERD. METHODS This study was an open-label trial that enrolled patients with GERD who desired to undergo the Stretta procedure. Heartburn scores, medication use, overall satisfaction with the procedure, and adverse events were evaluated. RESULTS Nine patients received the Stretta treatment between February and September 2006. Esophagogastroduodenoscopy just after treatment revealed a remarkable reduction in the expansion of the gastric cardia and small erosions in all patients. At 3 or 6 months after treatment, heartburn scores were significantly improved compared with pretreatment scores (5.0 +/- 1.7 pretreatment vs. 0.7 +/- 1.4 posttreatment, P=0.007). In six of nine patients (66.7%), treatment significantly (P=0.009) decreased medication use. There were no major adverse events. All patients were satisfied with this treatment. CONCLUSIONS The Stretta procedure safely reduced GERD symptoms and decreased medication use in Japanese patients with GERD. This treatment may thus be very useful for such patients, and it is hoped that a nationwide trial will be undertaken in Japan to obtain more extensive data.
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Affiliation(s)
- Kazuhide Higuchi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Reymunde A, Santiago N. Long-term results of radiofrequency energy delivery for the treatment of GERD: sustained improvements in symptoms, quality of life, and drug use at 4-year follow-up. Gastrointest Endosc 2007; 65:361-6. [PMID: 17321231 DOI: 10.1016/j.gie.2006.06.036] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Accepted: 06/05/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Stretta endoscopic antireflux procedure has effectively controlled symptoms of patients with GERD refractory to proton pump inhibitor (PPI) medication up to 1 year. OBJECTIVE The aim of this study was to evaluate the efficacy of the Stretta procedure for patients with GERD based on symptom control, quality of life (QOL), and medication use. DESIGN Prospective single-center case series. SETTING Academic endoscopy referral center. PATIENTS Adults with GERD symptoms and partial response to daily antisecretory medication. INTERVENTION We have used the Stretta procedure for patients with GERD diagnosed by endoscopic or pH testing since 2000. Our primary assessment was a validated health-related QOL score for heartburn and regurgitation and GERD symptoms index performed at baseline, 12, 36, and 48 months after treatment. A secondary outcome measure was the dose and the frequency of antisecretory pharmaceutical use. RESULTS We performed the Stretta procedure in 83 consecutive patients with persistent GERD symptoms. Complete matched data for follow-up evaluations are reported at 12, 36, and 48 months. The mean GERD QOL score was 2.4 (baseline), 4.6 (36 months), and 4.3 (48 months, P < .001). The mean GERD symptom score was 2.7 (baseline), 0.3 (36 months), and 0.6 (48 months P < .001). Daily medication usage was 100% (baseline) and 13.6% (48 months, P < .001). LIMITATIONS Nonrandomized study design, lack of control arm, and lack of 24-hour pH. CONCLUSIONS For these GERD patients followed to 4 years, the Stretta procedure was a safe, effective, and durable treatment, with significant and sustained improvements in GERD symptoms, QOL, and PPI elimination.
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Affiliation(s)
- Alvaro Reymunde
- Gastroenterology Section, Ponce Gastroenterology Research, Damas Hospital, Ponce, Puerto Rico 00731, USA
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Smith CD. Stretta: ahead of its time or has its time passed? Gastrointest Endosc 2007; 65:373-4. [PMID: 17321233 DOI: 10.1016/j.gie.2007.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Accepted: 01/04/2007] [Indexed: 12/10/2022]
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McClusky DA, Khaitan L, Gonzalez R, Baghai M, Van Sickle KR, Smith CD. A comparison between fluoroscopically guided radiofrequency energy delivery and conventional technique in an animal model of fundoplication failure. Surg Endosc 2007; 21:1332-7. [PMID: 17332957 DOI: 10.1007/s00464-007-9204-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The use of radiofrequency energy (RFe) treatment at the gastroesophageal junction (GEJ) has been considered an alternative to surgery after fundoplication disruption. It is unknown whether the recommended delivery technique for primary gastroesophageal reflux disease applies to an anatomically altered GEJ following fundoplication. The aim of this study was to determine whether modifications to the standard technique using fluoroscopic guidance more accurately localizes ablation zones compared with standard technique alone. METHODS Ten pigs were randomized to either conventional or fluoroscopically guided RFe ablation. All pigs had a laparoscopic Nissen fundoplication that was subsequently disrupted by severing all but the most cranial fundoplication stitch. Conventional RFe delivery included usage of markers located on the Stretta catheter. After labeling the z-line via submucosal contrast injection, fluoroscopic guidance involved using fluoroscopic markers to guide RFe ablation. Ablations were acutely marked, measured, and agreed upon by a panel of three researchers analyzing harvested tissue. Distances from the target zone for each ablation line (e.g., 1 cm was the target zone for line 1) were calculated and analyzed using Mann-Whitney and Fischer's tests. RESULTS Fluoroscopic guidance was significantly more accurate than the conventional technique (0.2 +/- 0.2 cm vs. 1.8 +/- 0.8 cm, p < 0.0001). Analyzing the individual distances for each of the six ablation lines revealed that all within Group B were closer than Group A (p < 0.01 for all except lines 1 and 2). Overall, the total ablation treatment length for conventionally treated animals was 4.48 +/- 0.7 cm and for those who underwent fluoroscopic guidance it was 2.92 +/- 0.5 cm (p < 0.001). CONCLUSION In a porcine model of fundoplication disruption, fluoroscopic guidance improved RFe accuracy.
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Affiliation(s)
- David A McClusky
- Emory Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Morgenthal CB, Richards WO, Dunkin BJ, Forde KA, Vitale G, Lin E. The role of the surgeon in the evolution of flexible endoscopy. Surg Endosc 2006; 21:838-53. [PMID: 17180263 DOI: 10.1007/s00464-006-9109-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 09/22/2006] [Indexed: 12/15/2022]
Abstract
Several cultures, including the Egyptians, Greeks, Romans, and Arabs, made attempts to view accessible human body cavities using a variety of instruments such as spatulas and specula. The first endoscope was created in 1806 when Phillip Bozzini, a German-born urologist, constructed the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880 Mikulicz made the first gastroscope using a system similar to Nitze's cystoscope. Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Over the ensuing 50 years endoscopy revolutionized many aspects of the surgeon's practice. Endoscopy can now be used to diagnose and often treat gastrointestinal cancer, hemorrhage, obstruction, and inflammatory conditions. This review was initiated by the SAGES Flexible Endoscopy Committee to chronicle the role of the surgeon in the development and introduction of flexible endoscopy into clinical practice, historically and in contemporary surgery. Flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges. There have been many recent technological advances that facilitate endoluminal therapies, and flexible endoscopy is now traversing new ground. Surgeons have been major contributors in the development of all aspects of endoscopy. There is a continually expanding list of therapeutic options available to patients. The difficult questions of which procedure, on which patient, and when can be answered best by the surgeon versed in endoscopic, laparoscopic, and open surgical techniques.
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Affiliation(s)
- C B Morgenthal
- Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Falk GW, Fennerty MB, Rothstein RI. AGA Institute technical review on the use of endoscopic therapy for gastroesophageal reflux disease. Gastroenterology 2006; 131:1315-36. [PMID: 17030199 DOI: 10.1053/j.gastro.2006.08.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Gary W Falk
- Department of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic, Cleveland, OH, USA
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Bunch TJ, Nelson J, Foley T, Allison S, Crandall BG, Osborn JS, Weiss JP, Anderson JL, Nielsen P, Anderson L, Lappe DL, Day JD. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2006; 17:435-9. [PMID: 16643370 DOI: 10.1111/j.1540-8167.2006.00464.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. CASE A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. CONCLUSION Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.
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Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Hüttl TP, Hüttl TK, Lang RA, Meyer G, Wichmann MW. Laparoscopic partial myectomy. Surg Endosc 2006; 20:665-72. [PMID: 16432650 DOI: 10.1007/s00464-005-0401-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Accepted: 11/21/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND A number of different surgical procedures have been described for the treatment of gastroesophageal reflux disease. Moreover, modifications and completely new techniques are being introduced on a regular basis. Nonetheless, in most cases of novel laparoscopic techniques profound experimental data have not been collected prior to their clinical introduction. Due to the lack of an animal model of inadequate esophageal sphincter function, most experimental studies on antireflux procedures were done on normally functioning esophageal sphincters. METHODS It is well-known that myotomy alone cannot induce sphincter insufficiency in animal models. In addition, complete myectomy is associated with severe mortality and, therefore, is not useful as an experimental model. This study introduces a new model of laparoscopic partial in vivo myectomy. The procedure described here forms a myectomy of the esophagus using scissors and a sponge on the side of the greater gastric curvature. The size of the myectomy is approximately 6 x 1.5 cm and was successfully performed in a consecutive series of eight experimental animals (male German house pigs). RESULTS Following an intensive team training on dead animals, the procedure was performed with success via the laparoscope in all study animals (n = 8). The sphincter pressure as determined by manometry was significantly reduced from 7.7 mmHg (range, 4.5-9.1; preoperative values) to 2.2 mmHg (range, 0-6.8; early postoperative values) and 2.3 mmHg (range, 0-3.7) at 8 weeks after surgery (p < 0.001). In addition, the length of the lower esophageal sphincter as well as the sphincter pressure vector volume were significantly reduced early as well as at 8 weeks after laparoscopic myectomy. Furthermore, endoscopy and reflux testing were pathologic compared with control animals. CONCLUSIONS Laparoscopic partial myectomy results in complete sphincter insufficiency with only little procedure-related morbidity. This procedure allows for the experimental evaluation of surgical procedures on the gastroesophageal junction. Future modifications of surgical antireflux procedures can therefore be evaluated in an experimental setting prior to their clinical introduction.
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Affiliation(s)
- T P Hüttl
- Department of Surgery, Klinikum Grosshadern, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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Abstract
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.
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Affiliation(s)
- Richard I Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Watson TJ, Peters JH. Lower esophageal sphincter injections for the treatment of gastroesophageal reflux disease. Thorac Surg Clin 2005; 15:405-15. [PMID: 16104131 DOI: 10.1016/j.thorsurg.2005.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic therapies for the control of GERD offer the potential for significant symptomatic improvement while obviating many of the potential drawbacks associated with long-term medical therapy with acid suppressive or neutralizing medications and traditional antireflux surgery. Such endoluminal therapies are intended to be safe with a brief learning curve, easily administered in an outpatient setting without the need for general anesthesia, reproducible, and durable. LES injection therapies share the common theoretic method of action of bulking at the GEJ, leading to loss of sphincter compliance and distensibility. In the case of Enteryx, this sustained effect has been demonstrated to be secondary to chronic inflammation, fibrosis, and encapsulation resulting from a foreign body response to the injectate. Available data suggest that a majority of patients respond to LES injection therapies, as demonstrated by a decreasing usage of PPIs after implantation, the ability of many patients to terminate PPI use completely, and improved GERD-HRQOL scores. Responses seem reasonably durable in follow-up assessment up to 24 months post treatment. Although there may be some placebo effect associated with treatment, patients injected with Enteryx respond better than a control group of sham-treated subjects. Individuals treated with LES injections, however, represent a select subgroup of the overall population of refluxers. Study subjects, by and large, have had uncomplicated GERD with typical reflux symptoms of heartburn or regurgitation that have responded to PPIs. Patients who have severe anatomic derangements, such as esophageal strictures, persistent esophagitis, Barrett's esophagus, or sizeable hiatal hernias, are excluded from clinical trials, as are patients who have severe motility disorders or significant comorbid conditions. Similarly, patients who have responded poorly to PPIs and those who have primarily extraesophageal manifestations of GERD have not been studied. Outcomes to date have been assessed over the short to medium term; long-term outcome studies are lacking. The durability of response, therefore, remains largely unknown, as does the incidence of any long-term complications or side effects. A postmarket study to assess the long-term safety and durability of Enteryx therapy up to 36 months is under way, as required by the FDA, with a target enrollment of 300 patients. Detailed cost analyses have yet to be reported. Such data are important not only for comparing the various endoluminal therapies but also for comparison to standard medical therapy and antireflux surgery. At present, no randomized trials are completed that compare injection therapies to other accepted treatments of GERD. The ability to perform fundoplication safely and effectively after failed LES injection therapy is not well known, in that the number of subsequent surgical cases is small and the results largely anecdotal to date. Likewise, the ability to use LES injection as salvage therapy after failed fundoplication has not been tested. The data regarding endoluminal injection therapies are similar to those after endoscopic plication and radiofrequency application to the LES, in that a definite symptomatic response is observed, but the objective documentation of diminished esophageal acid exposure lags behind. Esophageal acid exposure is normalized in a minority of treated subjects and improved in an additional subgroup, whereas the rate of symptomatic response exceeds these objective improvements. The reasons for this disconnect are the subject of much speculation and controversy. A placebo effect has been discussed, but clearly more factors are at play. Perhaps a study effect also is important, in that patients enrolled in clinical trials for GERD control may be more likely to modify their dietary and lifestyle habits in an effort to bring about symptom relief. Maybe the understanding of the perception of reflux events is lacking, and these endoluminal therapies work mainly by altering the perception of reflux more than the amount of reflux itself. A recent technologic review of injection therapies for GERD concludes that the "data for Enteryx are as compelling as those of any other open-label evaluation of an endoluminal therapy for GERD". There is much to be learned about all endoluminal techniques. For now, LES injections are promising therapies lacking supportive evidence of long-term safety and efficacy. The available data justify their use only in patients who have GERD symptoms responsive to PPIs and who do not have significant comorbidities or complications associated with GERD. Whether or not the role of LES injection techniques will be expanded to include more complicated cases, patients who are partially responsive to PPIs, combination therapy with other endoluminal techniques, or salvage therapy after failed fundoplication awaits further study.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
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