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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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Kalapala R, Singla N, Reddy DN. Endoscopic management of gastroesophageal reflux disease: Panacea for proton pump inhibitors dependent/refractory patients. Dig Endosc 2022; 34:687-699. [PMID: 34651353 DOI: 10.1111/den.14169] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 02/08/2023]
Abstract
Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti-reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy and anti-reflux mucosal ablation have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.
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Affiliation(s)
| | - Neeraj Singla
- Asian Institute of Gastroenterology, Hyderabad, India
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Rodríguez de Santiago E, Albéniz E, Estremera-Arevalo F, Teruel Sanchez-Vegazo C, Lorenzo-Zúñiga V. Endoscopic anti-reflux therapy for gastroesophageal reflux disease. World J Gastroenterol 2021; 27:6601-6614. [PMID: 34754155 PMCID: PMC8554403 DOI: 10.3748/wjg.v27.i39.6601] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide. A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects. Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication. The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia. Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials. Band-assisted ligation techniques, anti-reflux mucosectomy, anti-reflux mucosal ablation, and new plication devices have yielded promising results in recent noncontrolled studies. Nonetheless, the role of endoscopic procedures remains controversial due to limited long-term and comparative data, and no consensus exists in current clinical guidelines. This review provides an updated summary focused on the patient selection, technical details, clinical success, and safety of current and future endoscopic anti-reflux techniques.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Fermin Estremera-Arevalo
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Carlos Teruel Sanchez-Vegazo
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia 46026, Spain
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Vaezi MF, Shaheen NJ, Muthusamy VR. State of Evidence in Minimally Invasive Management of Gastroesophageal Reflux: Findings of a Scoping Review. Gastroenterology 2020; 159:1504-1525. [PMID: 32621903 DOI: 10.1053/j.gastro.2020.05.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/30/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUNDS & AIMS Endoscopic management of gastroesophageal reflux disease (GERD) is being employed increasingly. The aim of this scoping review was to assess the volume of available evidence on the benefits of endoscopic and minimally invasive surgical therapies for GERD. METHODS criteria were used to perform an extensive literature search of data regarding the reported benefit of endoscopic therapies in GERD. Randomized controlled studies were utilized when available; however, data from observational studies were also reviewed. RESULTS A formal review of evidence was performed in 22 studies. Inclusion and exclusion criteria and study duration were noted and tabulated. Assessment of outcomes was based on symptoms and objective criteria reported by investigators. Reported outcomes for the interventions were tabulated under the heading of subjective (symptom scores, quality of life metrics, and change in proton pump inhibitor use) and objective metrics (pH parameters, endoscopic signs, and lower esophageal sphincter pressure changes). Adverse events were noted and tabulated. The majority of studies showed symptomatic and objective improvement of GERD with the device therapies. Adverse events were minimal. However, normalization of acid exposure occurred in about 50% of patients and, for some modalities, long-term durability is uncertain. CONCLUSIONS This scoping review revealed that the endoluminal and minimally invasive surgical devices for GERD therapy are a promising alternative to proton pump inhibitor therapy. Their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially durability of effect, are better understood.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Nicholas J Shaheen
- Division of Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
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Shibli F, Kitayama Y, Fass R. Novel Therapies for Gastroesophageal Reflux Disease: Beyond Proton Pump Inhibitors. Curr Gastroenterol Rep 2020; 22:16. [PMID: 32185589 DOI: 10.1007/s11894-020-0753-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Despite the many areas of unmet needs in gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) remain the cornerstone of medical therapy. However, since their introduction, the therapeutic limitations of PPIs in GERD management have been increasingly recognized. RECENT FINDINGS In this review we discuss the new medical, endoscopic, and surgical therapeutic modalities that have been developed over the last decade. They include the potassium-competitive acid blockers (P-CABs) which provide a rapid onset, prolonged, and profound acid suppression, mucosal protectants which promote the physiological protective barrier of the esophageal mucosa, new prokinetics and neuromodulators. There are growing numbers of novel therapeutic endoscopic techniques that are under investigation or were recently introduced into the market, further expanding our therapeutic armamentarium for GERD. The development of diverse therapeutic modalities for GERD, despite the availability of PPIs, suggests that there are many areas of unmet need in GERD that will continue and drive future exploration for novel therapies.
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Affiliation(s)
- Fahmi Shibli
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - Yoshitaka Kitayama
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
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Brewer Gutierrez OI, Akshintala VS, Ichkhanian Y, Brewer GG, Hanada Y, Truskey MP, Agarwal A, Hajiyeva G, Kumbhari V, Kalloo AN, Khashab MA, Ngamruengphong S. Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis. Endosc Int Open 2020; 8:E313-E325. [PMID: 32118105 PMCID: PMC7035039 DOI: 10.1055/a-1073-7593] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Endoscopic full-thickness resection (EFTR) allows for treatment of epithelial and sub-epithelial lesions (SELs) unsuitable to conventional resection techniques. This meta-analysis aimed to assess the efficacy and safety of clip-assisted method for non-exposed EFTR using FTRD or over-the-scope clip of gastrointestinal tumors. Methods A comprehensive literature search was performed. The primary outcome of interest was the rate of histologic complete resection (R0). Secondary outcomes of interest were the rate of enbloc resection, FTR, adverse events, and post-EFTR surgery. Random-effects model was used to calculate pooled estimates and generate forest plots. Results Eighteen studies with 730 patients and 733 lesions were included in the analyses. Indications for EFTR were difficult/residual colorectal adenoma, adenoma at a diverticulum or appendiceal orifice and early cancer (n = 634), colorectal SELs (n = 42), and upper gastrointestinal lesions (n = 51), other colonic lesions (n = 6). Median size of lesions was 13.5 mm. There were 22 failed EFTR attempts. Pooled overall R0 resection rate was 82 % (95 % CI: 75, 89). The pooled overall FTR rate was 83 % (95 % CI: 77, 89). The pooled overall enbloc resection rate was 95 (95 % CI: 92, 96). The pooled estimates for perforation and bleeding were < 0.1 % and 2 %, respectively. Following EFTR, a total of 110 patients underwent surgery for any reason [pooled rate 7 % (95 % 2, 14). The pooled rates for post-EFTR surgery due to invasive cancer, for non-curative endoscopic resection and for adverse events were 4 %, < 0.1 % and < 0.1 %, respectively. No mortality related to EFTR was noted. Conclusions EFTR appears to be safe and effective for gastrointestinal lesions that are not amenable to conventional endoscopic resection. This technique should be considered as an alternative to surgery in selected cases.
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Affiliation(s)
- Olaya I. Brewer Gutierrez
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Venkata S. Akshintala
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Gala G. Brewer
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yuri Hanada
- Department of Internal Medicine, Johns Hopkins Hospital Baltimore, Maryland, United States
| | - Maria P. Truskey
- William H. Welch Medical Library, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Amol Agarwal
- Department of Internal Medicine, Johns Hopkins Hospital Baltimore, Maryland, United States
| | - Gulara Hajiyeva
- Department of Internal Medicine, Johns Hopkins Hospital Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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Abstract
PURPOSE OF REVIEW Nearly, a third of patients with medically refractory gastroesophageal reflux disease (GERD) will desire an additional nonsurgical treatment option. Recently, endoscopic therapy has been reintroduced as a minimally invasive antireflux barrier treatment, after addressing prior efficacy and safety concerns. Over the last two decades, additional experience and new technologies have resulted in devices and protocols with favorable short-term outcomes and safety profiles. The current literature in endoscopic antireflux therapies covers new devices, long-term follow-up data and further safety experience. This review discusses the endoscopic antireflux devices on the market and most recent studies in this area. RECENT FINDINGS Quality of life and reflux symptom score improvement is observed in 73-90% of patients through a 36-48 month follow-up period, with 41-77% remaining off all reflux medicines. Composite data from several thousand cases indicate a low rate (0.93-2.4%) of serious complications and no late adverse effects, including gas-bloat syndrome. SUMMARY In this review, we describe the four endoscopic antireflux devices on market and summarize the current data in the literature. The short and long-term data demonstrate durable symptom improvement and favorable safety profile. Endoscopic antireflux treatment should be considered in the management of GERD.
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Rieder E, Riegler M, Simić AP, Skrobić OM, Bonavina L, Gurski R, Paireder M, Castell DO, Schoppmann SF. Alternative therapies for GERD: a way to personalized antireflux surgery. Ann N Y Acad Sci 2018; 1434:360-369. [PMID: 29774563 DOI: 10.1111/nyas.13851] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder, known to affect about 20% of the Western population. Although conventional medical or surgical treatment has proven effective, there is certainly room for improvements. As only 10% of GERD patients are finally treated by antireflux surgery, a large therapeutic window exists. This treatment gap consists of patients who are not effectively treated with proton pump inhibitor but do not want to run the potential risks of conventional surgery. During the last two decades, several novel and intriguing options for the surgical treatment of GERD have been introduced and found their way into clinical use. The following summary will give an update of certain alternative therapeutic options to treat GERD or its pathological consequences.
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Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Aleksandar P Simić
- University Hospital for Digestive Surgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Ognjan M Skrobić
- University Hospital for Digestive Surgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milano School of Medicine, IRCCS Policlinico San Donato, Milano, Italy
| | - Richard Gurski
- Department of Surgery, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Matthias Paireder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Donald O Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Weitzendorfer M, Spaun GO, Antoniou SA, Witzel K, Emmanuel K, Koch OO. Clinical feasibility of a new full-thickness endoscopic plication device (GERDx™) for patients with GERD: results of a prospective trial. Surg Endosc 2018; 32:2541-2549. [PMID: 29602998 PMCID: PMC5897467 DOI: 10.1007/s00464-018-6153-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/21/2018] [Indexed: 01/08/2023]
Abstract
Background Previous studies suggest clinical effectiveness of endoscopic full-thickness plication in selected patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess the clinical safety and efficiency of the GERDx™ device by evaluating clinical parameters, reflux symptom scores, and quality of life (QoL). Methods Prospective one-arm trial evaluating the outcome of forty patients with GERD subjected to endoscopic plication with the GERDx™ device. We included patients with at least one typical reflux symptom despite treatment with a PPI for > 6 months, pathologic esophageal acid exposure, hiatal hernia of size < 2 cm, and endoscopic Hill grade II–III. Evaluation of Gastrointestinal Quality of Life Index (GIQLI), symptom scores, esophageal manometry, and impedance-pH-monitoring were performed at baseline and at 3 months after surgery. (Trial Registration: ClinicalTrials.gov NCT 01798212.) Results There were no intraoperative complications. Four out of forty patients experienced postoperative complications requiring intervention. Seven of forty patients were subjected to laparoscopic fundoplication 3 months after endoscopic plication due to persistent symptoms and were lost to further follow-up. Thirty out of forty patients were available at 3-month follow-up. There was an improvement of the GIQLI score, from a mean of 92.45 ± 18.47 to 112.03 ± 13.11 (p < 0.001). The general reflux-specific score increased from a mean of 49.84 ± 24.83 to 23.93 ± 15.63 (p < 0.001), and the DeMeester score from a mean of 46.48 ± 30.83 to 20.03 ± 23.62 (p < 0.001). There was no significant change in manometric data after intervention. Three of thirty patients continued daily antireflux medication. Conclusions Endoscopic plication with the GERDx™ device reduced distal acid exposure of the esophagus, reflux-related symptoms, and improved GIQLI scores with minimal side effects in a selected cohort of patients and may be a safe alternative in the treatment of GERD.
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Affiliation(s)
| | - Georg O Spaun
- Department of Surgery, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | | | - Kai Witzel
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria.,Minimal Invasiv Center, Hersfelder Strasse 1, 36088, Huenfeld, Germany
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria
| | - Oliver O Koch
- Department of Surgery, Paracelsus Medical University, 5020, Salzburg, Austria
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