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Bomman S, Malashanka S, Ghafoor A, Sanders DJ, Irani S, Kozarek RA, Ross A, Hubka M, Krishnamoorthi R. Safe implementation of transoral incisionless fundoplication as a new technique in a tertiary care center. Clin Endosc 2022; 55:630-636. [PMID: 35974471 PMCID: PMC9539295 DOI: 10.5946/ce.2022.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/17/2022] [Indexed: 11/24/2022] Open
Abstract
Background/Aims Transoral incisionless fundoplication (TIF) is an accepted anatomic treatment for gastroesophageal reflux disease in selected patients. In this report, we analyze our institution’s programmatic allocation of resources during the safe implementation of TIF as a new procedure.
Methods A retrospective analysis of all patients who underwent TIF from January 2020 to February 2021 at our institution was performed. The process of initially allocating the operating room (OR) with overnight admission and postoperative esophagram for added safety, and subsequently transitioning TIF to the endoscopy suite (ES) as an outpatient procedure was described. Patient safety and outcomes were evaluated during transition.
Results Thirty patients who underwent TIF were identified. The mean age was 51.2±16.0 years. TIF was performed in an OR in nine patients (30%) and 21 (70%) in the ES. All the OR patients were admitted overnight and had routine esophagogram. In contrast, four (19%) from the ES group required clinically-indicated admission and three (14.2%) required esophagram. The mean procedure duration was significantly lower in the ES group (65.7 min vs. 84 min, p=0.02).
Conclusions A stepwise, resource-efficient process was described that allowed safe initiation of TIF as a new technique and its effective transition to a fully outpatient procedure.
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Affiliation(s)
- Shivanand Bomman
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Sofya Malashanka
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Adil Ghafoor
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - David J Sanders
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Shayan Irani
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Richard A Kozarek
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Andrew Ross
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Michal Hubka
- Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
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2
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Ihde GM. The evolution of TIF: transoral incisionless fundoplication. Therap Adv Gastroenterol 2020; 13:1756284820924206. [PMID: 32499834 PMCID: PMC7243382 DOI: 10.1177/1756284820924206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/15/2020] [Indexed: 02/04/2023] Open
Abstract
Transoral incisionless fundoplication (TIF) was introduced in 2006 as a concerted effort to produce a natural orifice procedure for reflux. Since that time, the device, as well as the procedure technique, has evolved. Significant research has been published during each stage of the evolution, and this has led to considerable confusion and a co-mingling of outcomes, which obscures the results of the current device and procedure. This report is intended to review the identified stages and literature associated with each stage to date and to review the current state of treatment outcomes.
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Jung Y. Role of Endoscopic Gastroplasty Techniques in the Management of Obesity. Clin Endosc 2017; 50:21-25. [PMID: 28147478 PMCID: PMC5299983 DOI: 10.5946/ce.2016.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/04/2016] [Accepted: 12/13/2016] [Indexed: 12/12/2022] Open
Abstract
Health and wellness represent a major global concern. Trends such as a lack of exercise and excessive consumption of calories are major causes of the rapid increase in obesity worldwide. Obesity should be controlled because it can result in other illnesses, such as diabetes, high blood pressure, high cholesterol, coronary artery disease, stroke, breathing disorders, or cancer. However, many people have difficulty in managing obesity through exercise, dietary control, behavioral modifications, and drug therapy. Bariatric surgery is not commonly used due to a variety of complications, even though it has been demonstrated to produce reliable results with respect to adequate weight loss when performed using an open or a laparoscopic approach. Endoscopic bariatric procedures are emerging techniques that are less invasive and safer compared with current surgical approaches. However, the evaluation of endoluminal procedures is limited by the small number of studies and their short-term follow-up.
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Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Cheonan, Korea
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4
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Witteman BPL, Conchillo JM, Rinsma NF, Betzel B, Peeters A, Koek GH, Stassen LPS, Bouvy ND. Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease. Am J Gastroenterol 2015; 110:531-42. [PMID: 25823768 DOI: 10.1038/ajg.2015.28] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 12/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence. METHODS Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months. RESULTS A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. CONCLUSION Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.
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Affiliation(s)
- Bart P L Witteman
- 1] Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands [2] Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jose M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Nicolaas F Rinsma
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Bark Betzel
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Andrea Peeters
- Department of Clinical Epidemiolgy and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Ger H Koek
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
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5
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Reavis KM, Perry KA. Transoral incisionless fundoplication for the treatment of gastroesophageal reflux disease. Expert Rev Med Devices 2015; 11:341-50. [PMID: 24918903 DOI: 10.1586/17434440.2014.925394] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common and costly chronic medical condition affecting millions of patients. It is associated with substantial morbidity and negatively impacts quality of life. Reflux of gastric contents into the esophagus damages the esophageal mucosa and is associated with conditions including esophagitis and esophageal stricture. While GERD is most commonly seen in Western populations, changes in dietary patterns and the global increase in obesity have led to a pronounced increase in its prevalence worldwide. Medical and surgical GERD therapies are costly and pose considerable side effects, leading many to pursue effective endoscopic treatment options. Transoral incisionless fundoplication is an endoluminal procedure that offers patients a minimally invasive treatment option with the potential to eliminate the need for medical acid suppression with a low risk of side effects.
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Affiliation(s)
- Kevin M Reavis
- Esophageal and Foregut Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, 4805 NE Glisan Street, Ste 6N60, Portland, OR 97213, USA
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Kim D, Velanovich V. Surgical treatment of GERD: where have we been and where are we going? Gastroenterol Clin North Am 2014; 43:135-45. [PMID: 24503364 DOI: 10.1016/j.gtc.2013.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.
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Affiliation(s)
- David Kim
- Division of General Surgery, University of South Florida, One Tampa General Circle, Tampa, FL 33606, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, One Tampa General Circle, Tampa, FL 33606, USA.
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7
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Bonavina L, Siboni S, Saino GI, Cavadas D, Braghetto I, Csendes A, Korn O, Figueredo EJ, Swanstrom LL, Wassenaar E. Outcomes of esophageal surgery, especially of the lower esophageal sphincter. Ann N Y Acad Sci 2013; 1300:29-42. [PMID: 24117632 DOI: 10.1111/nyas.12232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.
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Affiliation(s)
- Luigi Bonavina
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Stefano Siboni
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Greta I Saino
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Demetrio Cavadas
- Department of Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Italo Braghetto
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Attila Csendes
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Owen Korn
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Edgar J Figueredo
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Eelco Wassenaar
- Department of Surgery, University of Washington, Seattle, Washington
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8
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Triadafilopoulos G. Stretta for refractory GERD: now more than ever. Am J Gastroenterol 2013; 108:1655-6. [PMID: 24091509 DOI: 10.1038/ajg.2013.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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9
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LeBedis CA, Penn DR, Uyeda JW, Murakami AM, Soto JA, Gupta A. The Diagnostic and Therapeutic Role of Imaging in Postoperative Complications of Esophageal Surgery. Semin Ultrasound CT MR 2013; 34:288-98. [DOI: 10.1053/j.sult.2013.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Antireflux endoluminal therapies: past and present. Gastroenterol Res Pract 2013; 2013:481417. [PMID: 23935608 PMCID: PMC3723090 DOI: 10.1155/2013/481417] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 06/13/2013] [Indexed: 12/14/2022] Open
Abstract
The basic principle of antireflux procedures employing endoscopic intervention aims to create a mechanical barrier to prevent primary pathophysiology in gastroesophageal reflux disease (GERD). We review, highlight, and discuss the past and present status of endoluminal therapy. Currently, there are 3 commonly employed anti-reflux endoluminal procedures: fundoplication or suturing techniques (EndoCinch, NDO, and EsophyX), intramural injection or implant techniques (enhancing lower esophageal sphincter (LES) volume and/or strengthening compliance of the LES-Enteryx and Gatekeeper), and radiofrequency ablation of LES and cardia. EndoCinch plication requires further study and modification of technique before it can be recommended because of durability issues. Esophynx, the transoral incisionless fundoplication, may reduce hiatal hernias and increase LES length. Preliminary studies have shown promising reduction in symptoms and medication use but evidence concerning safety and long-term durability is still pending. The safety issue with injection technique is the main concern as evident from the incidences of implant withdrawals after reported major adverse events. Future research with cautious monitoring is required before any new implant material can be recommended for commercial application. Radiofrequency ablation therapy is regaining popularity in treating refractory symptoms despite PPI use due to improved efficacy, durability, and safety after years of refinement of protocol.
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11
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Kim WH, Park PW, Hahm KB, Hong SP. Endoscopic treatment of refractory gastroesohageal reflux disease. Clin Endosc 2013; 46:230-4. [PMID: 23767031 PMCID: PMC3678058 DOI: 10.5946/ce.2013.46.3.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 03/28/2013] [Indexed: 12/27/2022] Open
Abstract
Though efficient acid suppression with proton pump inhibitors (PPIs) remains the mainstay of treatment of gastroesophageal reflux disease (GERD), some of the patients showed refractory response to PPIs, necessitating further intervention. After increasing dose of PPIs and other kinds of pharmacological intervention adopting prokinetics or others, variable endoscopic treatments are introduced for the treatment of these refractory cases. The detailed introduction regarding endoscopic treatment for GERD is forwarded in this review article. Implantation of reabsorbable or synthetic materials in the distal esophagus was tried in vain and is expelled from the market due to limited efficacy and serious complication. Radiofrequency energy delivery (Stretta) and transoral incisionless fundoplication (EsophyX) are actively tried currently.
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Affiliation(s)
- Won Hee Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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12
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Zerbib F, Simon M. Novel therapeutics for gastro-esophageal reflux symptoms. Expert Rev Clin Pharmacol 2013; 5:533-41. [PMID: 23121276 DOI: 10.1586/ecp.12.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Approximately 20-30% of patients with gastro-esophageal reflux symptoms report inadequate symptom relief while on proton-pump inhibitor therapy. The mechanisms involved are failure of the antireflux barrier (transient lower esophageal sphincter relaxations), high proximal extent of the refluxate, esophageal hypersensitivity and impaired mucosal integrity. Persisting acid or nonacid reflux can be demonstrated in 40-50% of cases, suggesting that there is room for antireflux therapy in these patients. New antireflux compounds have been shown to decrease the occurrence of transient lower esophageal sphincter relaxations. The most promising classes of compounds are GABA type B agonists and metabotropic glutamate receptor 5 antagonists, which can reduce both reflux episodes and symptoms, but the development of these compounds has been abandoned for either safety issues or lack of efficacy. Esophageal hypersensitivity and impaired mucosal integrity may prove to be relevant therapeutic targets in the future.
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Affiliation(s)
- Frank Zerbib
- CHU Bordeaux, Saint André Hospital, Gastroenterology Department, Bordeaux, F-33075, France.
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Légner A, Tsuboi K, Stadlhuber R, Yano F, Halvax P, Hunt B, Penka W, Filipi CJ. Mucosal excision and suturing for obesity and GERD. Surg Innov 2013; 20:586-93. [PMID: 23423723 DOI: 10.1177/1553350613475881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Suture and staple-based endoluminal devices for gastroesophageal reflux disease (GERD) and obesity have failed to demonstrate long-term efficacy. OBJECTIVE To demonstrate the feasibility of mucosal excision and full-thickness suture apposition of the excision beds to create sufficient scar tissue formation at the gastroesophageal junction for the intraluminal treatment of GERD or obesity. DESIGN Survival animal experiments. PATIENTS Seven mongrel dogs. Interventions. Under general endotracheal anesthesia, a Barostat test was performed on 4 dogs. A mucosal excision device was introduced through the esophagus into the proximal stomach. Two to 4 mucosal excisions were performed on all dogs at or just below the gastroesophageal junction and the mucosal pieces were removed. After hemostasis, an intraluminal suturing instrument was introduced and either 2 or 4 sutures were placed through the excision beds to bring them into apposition. These were tied and the suture strands cut. All dogs were survived for 2 months. End-term endoscopies were performed, and a repeat Barostat procedure was performed on the animals undergoing an antireflux procedure. After euthanasia the stomachs were explanted, examined, photographed, and sectioned for histologic examination. RESULTS All dogs survived without complication. In the 4 GERD dogs, the Barostat studies demonstrated a significant decrease in gastroesophageal junction compliance. In the 3 dogs undergoing the obesity procedure, the gastric outlet apposition to a 6-mm endoscope was satisfactory with full insufflation and the desired scarring was seen on histologic examination. CONCLUSION It is possible to create adequate gastroesophageal junction scarring for the treatment of GERD and obesity. A clinical pilot study will be initiated.
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Affiliation(s)
- András Légner
- 1Creighton University School of Medicine, Omaha, NE, USA
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Topuz U, Umutoglu T, Bakan M, Ozturk E. Anesthetic management of the SRS TM endoscopic stapling system for gastro-esophageal reflux disease. World J Gastroenterol 2013; 19:319-320. [PMID: 23345959 PMCID: PMC3547558 DOI: 10.3748/wjg.v19.i2.319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 10/30/2012] [Accepted: 12/18/2012] [Indexed: 02/06/2023] Open
Abstract
The SRSTM Endoscopic Stapling System (Medigus, Tel Aviv, Israel) is a new tool capable of creating a totally endoscopic fundoplication, combined with an endoscope, endoscopic ultrasound and a surgical stapler. SRSTM endoscopic stapling for gastro-esophageal reflux disease is a minimally invasive, outpatient procedure, which requires general anesthesia with positive-pressure ventilation. Keeping the patient on positive end-expiratory pressure (PEEP) may minimize the pressure gradient between the esophagus and the mediastinum, as well as help to prevent air from leaking around the screws and causing pneumomediastinum. In addition, in patients with hiatal hernia, higher PEEP levels may be required to increase intra-thoracic pressure and to force the stomach to slide into the abdomen for ease of endoscopy. We advise smoother emergence from anesthesia, taking precautions for retching, postoperative nausea and vomiting (PONV), while coughing and gagging during extubation and PONV may affect the success of the procedure. Total intravenous anesthesia with propofol and remifentanil seems to be a good choice for these reasons.
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15
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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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16
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Rodríguez L, Rodríguez P, Neto MG, Ayala JC, Saba J, Berel D, Conklin J, Soffer E. Short-term electrical stimulation of the lower esophageal sphincter increases sphincter pressure in patients with gastroesophageal reflux disease. Neurogastroenterol Motil 2012; 24:446-50, e213. [PMID: 22292889 DOI: 10.1111/j.1365-2982.2012.01878.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Electrical stimulation (ES) of the lower esophageal sphincter (LES) increases resting LES pressure (LESP) in animal models. Our aims were to evaluate the safety of such stimulation in humans, and test the hypothesis that ES increases resting LESP in patients with gastroesophageal reflux disease (GERD). METHODS A total of 10 subjects (nine female patients, mean age 52.6 years), with symptoms of GERD responsive to PPIs, low resting LES pressure, and abnormal 24-h intraesophageal pH test were enrolled. Those with hiatal hernia >2 cm and/or esophagitis >Los Angeles Grade B were excluded. Bipolar stitch electrodes were placed longitudinally in the LES during an elective laparoscopic cholecystectomy, secured by a clip and exteriorized through the abdominal wall. Following recovery, an external pulse generator delivered two types of stimulation for periods of 30 min: (i) low energy stimulation; pulse width of 200 μs, frequency of 20 Hz and current of 5-15 mA (current was increased up to 15 mA if LESP was less than 15 mmHg), and (ii) high energy stimulation; pulse width of 375 ms, frequency of 6 cpm, and current 5 mA. Resting LESP, amplitude of esophageal contractions and residual LESP in response to swallows were assessed before and after stimulation. Symptoms of chest pain, abdominal pain, and dysphagia were recorded before, during, and after stimulation and 7-days after stimulation. Continuous cardiac monitoring was performed during and after stimulation. KEY RESULTS All patients were successfully implanted nine subjects received high frequency, low energy, and four subjects received low frequency, high energy stimulation. Both types of stimulation significantly increased resting LESP: from 8.6 mmHg (95% CI 4.1-13.1) to 16.6 mmHg (95% CI 10.8-19.2), P < 0.001 with low energy stimulation and from 9.2 mmHg (95% CI 2.0-16.3) to 16.5 mmHg (95% CI 2.7-30.1), P = 0.03 with high energy stimulation. Neither type of stimulation affected the amplitude of esophageal peristalsis or residual LESP. No subject complained of dysphagia. One subject had retrosternal discomfort with stimulation at 15 mA that was not experienced with stimulation at 13 mA. There were no adverse events or any cardiac rhythm abnormalities with either type of stimulation. CONCLUSIONS & INFERENCES Short-term stimulation of the LES in patients with GERD significantly increases resting LESP without affecting esophageal peristalsis or LES relaxation. Electrical stimulation of the LES may offer a novel therapy for patients with GERD.
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Affiliation(s)
- L Rodríguez
- Departments of Gastroenterology and General Surgery, Indisa Hospital, Providencia Santiago, Chile
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17
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Familiari P, Boškoski I, Marchese M, Perri V, Costamagna G. Endoscopic treatment of obesity. Expert Rev Gastroenterol Hepatol 2011; 5:689-701. [PMID: 22017697 DOI: 10.1586/egh.11.77] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Obesity is a worldwide epidemic, complex metabolic disease associated with a variety of severe comorbidities. Bariatric surgery provides the patients with the benefits of sustained weight loss and improves obesity-related comorbidities, but can result in potentially life-threatening complications. Gastrointestinal endoscopy has recently been proposed as a scarless and noninvasive approach to obesity. Most of the current endoluminal devices and techniques are comparable to restrictive surgery. A variety of medical devices and procedures have been evaluated in recent years; however, with the exception of the intragastric balloon, evaluation of all the other endoluminal procedures is limited by the numbers of patients treated, the short follow-up and especially by the study design. Today, only a few devices have been evaluated in randomized controlled trials. The preliminary results of the first studies are extremely promising, but definitive statements cannot be drawn yet.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Roma, Italy
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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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Bell RCW, Freeman KD. Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease. Surg Endosc 2011; 25:1975-84. [PMID: 21140170 PMCID: PMC3098375 DOI: 10.1007/s00464-010-1497-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 10/24/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transoral treatment of gastroesophageal reflux disease (GERD) using the EsophyX device enables creation of an esophagogastric fundoplication with potential for better control of reflux than gastrogastric techniques. Efficacy and safety of a rotational/longitudinal esophagogastric transoral incisionless fundoplication (TIF) was evaluated retrospectively using subjective and objective outcomes. METHODS Thirty-seven consecutive patients on antisecretory medication and with proven gastroesophageal reflux and limited hiatal hernia underwent TIF for persistent GERD symptoms. Five patients were reoperations for failed laparoscopic fundoplication. RESULTS Of the 37 treated patients, 57% were female. The median age was 58 (range=20-81) years and BMI was 25.5 (range=15.9-36.1) kg/m2. Sixty-eight percent indicated GERD-associated cough, asthma, or aspiration as a primary complaint and 32% complained of heartburn or regurgitation. The TIF procedures created tight wraps of 230°-330° extending 3-4 cm above the Z-line. Two complications occurred: one mediastinal abscess treated laparoscopically and one postoperative bleeding requiring transfusion. At 6 (range=3-14) months median follow-up TIF resulted in a significant improvement of both atypical and typical symptoms in 64% and 70-80% of patients, respectively, as indicated by the corresponding GERD health-related quality of life (HRQL) and reflux symptom index (RSI) score reduction by 50% or more compared to baseline on proton pump inhibitors (PPIs). No patient reported problems with dysphagia, bloating, or excess flatulence, and 82% were not taking any PPIs. Reflux characteristics were significantly improved and normalized in 61, 89, and 56% of patients in terms of acid exposure, number of refluxates, and DeMeester scores, respectively. TIF was effective in treating GERD in 75% of patients among whom 54% were in a complete "remission" and 21% were "improved." The remaining 25% were considered failures, and five (13.5%) patients underwent revision. CONCLUSION Rotational/longitudinal esophagogastric fundoplication using the EsophyX device significantly improved symptomatic and objective outcomes in over 70% of patients at median 6-month follow-up. Post-fundoplication side effects were not reported after TIF.
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Affiliation(s)
- Reginald C W Bell
- Swedish Medical Center & SurgOne, P.C., 401 W. Hampden Place, Suite 230, Englewood, CO 80110, USA.
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Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
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Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
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St. Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg 2011; 46:163-8. [PMID: 21238659 PMCID: PMC3097032 DOI: 10.1016/j.jpedsurg.2010.09.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. METHODS After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. RESULTS One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) CONCLUSIONS Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
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Affiliation(s)
- Shawn D. St. Peter
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA,Corresponding author. Department of Surgery, Center for Prospective Clinical Trials, Children’s Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. S.D. St. Peter
| | | | | | - KuoJen Tsao
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | | | - Susan W. Sharp
- The Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Donna Bartle
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
| | - Tracey Morgan
- University of Alabama in Birmingham, Birmingham, AL 35233, USA
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Watson DI, Immanuel A. Endoscopic and laparoscopic treatment of gastroesophageal reflux. Expert Rev Gastroenterol Hepatol 2010; 4:235-43. [PMID: 20350269 DOI: 10.1586/egh.10.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.
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Affiliation(s)
- David I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.
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