Endotherapy and surgery for GERD

Esophgeal Perforation and Bilateral Empyema Following Endoscopic EsophyX Transoral Incisionless Fundoplication

Transoral incisionless fundoplication (TIF) has been used for endoscopic treatment of gastroesophageal reflux disease (GERD). TIF using the EsophyX device system (EndoGastric Solutions) was designed to create a full-thickness valve at the gastroesophageal junction through the insertion of multiple fasteners; it improves GERD, reduces proton pump inhibitor use, and improves quality of life. Although TIF is effective in select patients, a significant subset of patients undergoing TIF develop persistent or recurrent GERD symptoms and may need antireflux surgery to control the GERD symptoms. We now report a 48-year-old man with chronic GERD unresponsive to medical management. He underwent TIF complicated by esophageal perforation and developed mediastinitis, left pneumothorax, bilateral pleural effusions, and acute respiratory failure. He required chest tube placement and bilateral decortication for treatment of nonresolving empyemas. Additional postmarketing studies are required to assess the safety, efficacy, and clinical outcomes of this novel procedure, and patients undergoing this procedure need close postprocedural follow-up.

Transoral incisionless fundoplication (TIF 2.0) with EsophyX for gastroesophageal reflux disease: long-term results and findings affecting outcome

INTRODUCTION

Transoral incisionless fundoplication (TIF) with the EsophyX(™) device is reported to be effective for creating a continent gastroesophageal valve and for good functional results, as measured by pH impedance in patients with gastroesophageal reflux disease (GERD). The aim of this study is to assess the long-term effect of TIF in patients with symptomatic GERD.

PATIENTS AND METHODS

TIF 2.0 fundoplication was done in 42 consecutive patients. All were studied with GERD-HRQL and GERD-QUAL questionnaires, upper gastrointestinal (GI) endoscopy, esophageal manometry, and 24 h pH impedance before and at 6, 12, and 24 months after TIF.

RESULTS

In all, 35 patients completed 6-month follow-up; 21 (60.0%) completely stopped proton pump inhibitor (PPI) therapy, 6 (17.1%) more than halved it, and 8 (22.9%) continued with the same dose as before the procedure. There were 26 patients with complete 24-month follow-up; 11 (42.3%) completely stopped PPI therapy, 7 (26.9%) more than halved it, and 8 (30.8%) were taking the same dose as before the procedure. Hiatal hernia and ineffective esophageal motility seemed to raise the risk of recurrence of symptoms (p = 0.02 and p < 0.001, respectively). The number of fasteners deployed during TIF was the only factor predictive of successful outcome (p = 0.018).

CONCLUSIONS

TIF using the EsophyX device allowed withdrawal or reduction of PPI in about 77% of patients at 6-month follow-up and about 69% at 24 months. Larger number of fasteners deployed during TIF was predictive of positive outcome; pre-TIF ineffective esophageal motility and hiatal hernia raised the risk of recurrence of GERD symptoms, but were not significant from a prospective point of view.

Improvement in reflux gastroesophagitis in a patient with spinal muscular atrophy after surgical correction of kyphoscoliosis: a case report

BACKGROUND

Scoliosis, a three-dimensional deformity, has secondary effects on the gastrointestinal system. Reflux gastroesophagitis with hiatus hernia in patients with scoliosis is difficult to manage. We present a patient in whom primary correction of a spinal deformity was associated with resolution of symptoms of reflux.

CASE DESCRIPTION

A 15-year-old girl with severe thoracolumbar kyphoscoliosis visited our scoliosis research institute complaining of back pain, positional imbalance, intermittent respiratory tract infections, and gastrointestinal discomfort such as pain, dysphagia, and heartburn for several years. On preoperative CT, her abdominal organs were in a deviant position, and esophagogastroduodenoscopy revealed severe reflux gastroesophagitis, Los Angeles classification (LA) Grade D, and a sliding hiatus hernia. After kyphoscoliosis correction, the patient's truncal balance and pain improved. Postoperatively, the patient reported abdominal pain and dysphagia that gradually subsided after 3 weeks. At 1 year, the patient had no abdominal complaints secondary to reflux gastroesophagitis, and episodes of recurrent respiratory tract infections were substantially reduced. Postoperative evaluation showed the reflux gastroesophagitis had improved to LA Grade A. Postoperative CT showed the abdominal cavity had expanded and the abdominal organs were more centered.

LITERATURE REVIEW

The association between scoliosis and reflux gastroesophagitis is well documented. However, the secondary effects of scoliosis correction on gastrointestinal symptoms caused by reflux gastroesophagitis have not been investigated in detail.

PURPOSE AND CLINICAL RELEVANCE

This patient illustrates the relationship between spinal deformity and gastrointestinal symptoms. Postural balance correction resulted in the alleviation of reflux gastroesophagitis symptoms secondary to hiatus hernia.

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

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

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population

BACKGROUND

EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device.

METHODS

Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant.

RESULTS

The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure.

CONCLUSION

This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population

BACKGROUND

EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device.

METHODS

Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant.

RESULTS

The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure.

CONCLUSION

This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Effect of transoral incisionless fundoplication on symptoms, PPI use, and ph-impedance refluxes of GERD patients

BACKGROUND

Three previous studies from the same institution have reported that transoral incisionless fundoplication (TIF) with the EsophyX device is effective for creating a continent gastroesophageal valve and for good functional results as measured only by pH-metry in patients with gastroesophageal reflux disease (GERD). The objective of the present study was to evaluate the effect of TIF on symptoms, use of proton pump inhibitors (PPI), esophageal motility, and pH-impedance in patients with symptomatic GERD.

METHODS

Twenty consecutive patients were enrolled to complete the GERD-HRQL and GERD-QUAL questionnaires while on and off PPI. They were also examined by upper gastrointestinal (GI) endoscopy to determine Hill grade and Jobe length of the gastroesophageal valve, and to check for hiatal hernia and esophagitis, esophageal manometry, and pH-impedance before and 6 months after TIF.

RESULTS

Six months after TIF, the GERD-HRLQ and GERD-QUAL scores off-PPI therapy and the number of total and acid pH-impedance refluxes were significantly reduced (p < 0.05). The PPI had been completely stopped in 55% of the patient and was reduced in 22% of the patients.

CONCLUSIONS

At 6-month follow-up, TIF performed using the EsophyX device reduces symptoms and pH-impedance refluxes, allowing interruption or reduction of PPI use in 78% of patients with GERD.

Imaging of subsquamous Barrett's epithelium with ultrahigh-resolution optical coherence tomography: a histologic correlation study

BACKGROUND

Optical coherence tomography (OCT) is being developed as a potentially valuable method for high-resolution cross-sectional imaging of the esophageal mucosal and submucosal layers. One potential application of OCT imaging is to identify subsquamous Barrett's epithelium in patients who have undergone ablative therapy, which is not visible on standard endoscopic examination. However, histologic correlation confirming the ability of OCT to image subsquamous Barrett's epithelium has yet to be performed.

DESIGN

Histologic correlation study.

OBJECTIVE

To perform histologic correlation of ultrahigh-resolution optical coherence tomography (UHR-OCT) imaging for identification of subsquamous Barrett's epithelium.

SETTING

Academic Medical Center (University of Washington, Seattle, WA).

PATIENTS

Fourteen patients with pathologic biopsy specimens, proven to be high-grade dysplasia or adenocarcinoma underwent esophagectomy.

INTERVENTIONS

UHR-OCT imaging was performed on ex vivo esophagectomy specimens immediately after resection.

MAIN OUTCOME MEASUREMENTS

Correlation of UHR-OCT images with histologic images.

RESULTS

Subsquamous Barrett's epithelium was clearly identified by using UHR-OCT images and was confirmed by corresponding histology.

LIMITATIONS

Difficulty distinguishing some subsquamous Barrett's glands from blood vessels in ex vivo tissue (because of the lack of blood flow) in some cases. Imaging was performed with a bench-top system.

CONCLUSIONS

Results from this study demonstrate that UHR-OCT imaging is capable of identifying subsquamous Barrett's epithelium.

Medical management of gastroesophageal reflux disease

Antisecretory therapies that raise intragastric pH provide the best healing of the esophageal mucosal damage that occurs in gastroesophageal reflux disease. Continuous maintenance therapy is also effective to reduce the likelihood of recurrence of esophagitis and control symptoms in the long term. Proton pump inhibitor (PPI) therapy is an effective approach for healing esophagitis and controlling symptoms. Endoscopic and surgical treatments may provide an option for patients who are refractory to PPIs in whom reflux has been clearly demonstrated. Long-term antireflux medication is often needed after surgical treatment because of persisting or recurrent pathologic reflux and symptoms. An alternative approach to controlling transient lower esophageal sphincter relaxations, such as the GABA-B agonists, deserves further study.

Endoscopic full-thickness plication for the treatment of GERD by application of multiple Plicator implants: a multicenter study (with video)

BACKGROUND

The full-thickness Plicator allows transmural suturing at the gastroesophageal (GE) junction to restructure the antireflux barrier. Studies of the Plicator procedure to date have been limited to placement of a single transmural suture to create the endoscopic gastroplication.

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of placing multiple transmural sutures for the treatment of GERD.

DESIGN

Open-label, prospective, multicenter study.

SETTING

Four tertiary-referral centers.

PATIENTS

Subjects with symptomatic GERD who require daily maintenance proton pump inhibitor (PPI) therapy. Study exclusions were hiatal hernia >3 cm, grades III and IV esophagitis, Barrett's epithelium, and esophageal dysmotility.

INTERVENTIONS

Forty-one patients received two or more transmural sutures placed linearly in the anterior gastric cardia approximately 1 cm below the GE junction.

MAIN OUTCOME MEASUREMENTS

Six months after the procedure, median GERD-health-related quality of life (HRQL) improved 76% compared with off-medication baseline (6.0 vs 25.0, P < .001), with 75% of patients (32/40) achieving >50% improvement in their baseline GERD-HRQL score. Six months after the procedure, daily PPI therapy was eliminated in 70% of patients (28/40). Heartburn symptoms improved 80% compared with off-medication baseline (16.0 vs 84.0, P < .001). Median esophagitis grade improved 75% compared with baseline (0.0 vs 1.0, P = .005). Esophageal pH assessed as median distal esophageal-acid exposure (percentage time pH < 4.0) improved 38% compared with baseline (9.0 vs 11.0, P < .020; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data) and manometric outcomes were also improved compared with baseline (median lower esophageal sphincter resting pressure improved 25% [10.0 vs 6.0, P < .017; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data]) and median amplitude of contraction improved 11% (70.0 vs 62.0, P < .037; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data).

LIMITATIONS

Small sample size. No randomized comparison with a single implant group.

CONCLUSIONS

Endoscopic full-thickness plication with multiple serially placed implants was safe and effective in reducing GERD symptoms, medication use, esophageal-acid exposure, and esophagitis.

Endoscopic therapy for GERD: does it have a future?

Approximately 20% of patients with gastroesophageal reflux disease (GERD) have symptoms refractory to long-term proton pump inhibitor (PPI) therapy. Furthermore, PPI therapy is expensive. Fundoplication is considered the gold standard of GERD therapy in terms of normalization of esophageal acid exposure and symptom control; however, this exposes the patient to the risks of surgery and anesthesia. Therefore, an endoscopic approach to treating GERD that obviates the need for PPIs and avoids surgical morbidity is desirable. Several endoscopic methods have been used, including radiofrequency ablation, implantation of foreign substances as bulking agents, and various tissue apposition strategies. The emerging field of GERD endotherapy is promising, but more rigorous, sham-controlled, long-term studies are required to elucidate its exact role in clinical practice. This review discusses the evolution of these concepts, describes specific endoscopic devices that have been developed, and explores the future of endotherapies as viable treatment alternatives for GERD.