GERD: the potential for endoscopic intervention

The laparoscopic nissen fundoplication eliminates obstructive sleep apnea syndrome due to gastroesophageal reflux disease

Gastroesophageal reflux disease may produce esophageal syndromes, such as heartburn and regurgitation. It is a common clinical presentation with extraesophageal manifestations, such as asthma, arrhythmia, snoring, and sleep disturbance, which could make identifying it more difficult than the usual esophageal symptoms. The aim of this study is to characterize the extraesophageal manifestations in patients with gastroesophageal reflux disease and investigate the effect of laparoscopic Nissen fundoplication. We describe the case of a 38-year-old male patient with a history of sleep disturbance attributable to gastroesophageal reflux disease, which resolved on successful laparoscopic Nissen fundoplication treatment. The long-standing sleep apnea obviously improved after laparoscopic Nissen fundoplication treatment. To our knowledge, this is a rare case of successful laparoscopic Nissen fundoplication treatment of a patient with extraesophageal manifestations induced by gastroesophageal reflux disease. The results indicate an underlying mechanism for extraesophageal manifestations and the success of laparoscopic Nissen fundoplication treatment.

The Stretta procedure eliminates arrhythmia due to gastroesophageal reflux disease

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.

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.

Endotherapy and surgery for GERD

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.

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

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.

Sustained improvement in symptoms of GERD and antisecretory drug use: 4-year follow-up of the Stretta procedure

BACKGROUND

Approximately 20% of patients with GERD do not respond to medical therapy. The Stretta radiofrequency antireflux procedure represents an alternative to failed drug therapy for GERD.

OBJECTIVE

The aim of this study was to assess symptom and medication changes after the Stretta procedure during a 4-year follow-up period.

DESIGN

Prospective case series on intent-to-treat basis.

SETTING

Community practice.

PATIENTS

Patients with GERD with persistent symptoms despite twice-daily proton pump inhibitor (PPI) medications.

INTERVENTIONS

The Stretta procedure was performed in drug-refractory patients with GERD diagnosed by the presence of endoscopically evidenced esophagitis or abnormal esophageal pH testing. Symptom assessment was performed with a validated health-related quality-of-life questionnaire (with and without medication) at baseline and 6, 12, 24, 36, and 48 months after treatment. Complications of the procedure and medication usage were analyzed.

MAIN OUTCOME MEASUREMENTS

Significant changes in symptom scores, GERD quality-of-life parameters, and medication usage on the basis of clinical outcomes.

RESULTS

We report on a series of 109 consecutive patients treated with the Stretta procedure who have reached 4-year follow-up. Complete long-term follow-up assessment was available in matched data for 109 patients at 12 months, 108 patients at 24 months, 102 patients at 36 months, and 96 patients at 48 months. A second procedure was performed in 13 patients. Heartburn scores decreased from 3.6 to 1.18 (P < .001), total heartburn score (GERD health-related quality-of-life questionnaire) decreased from 27.8 to 7.1 (P < .001), and patient satisfaction improved from 1.4 to 3.8 (P < .001) (see ). Medication usage decreased significantly from 100% of patients on twice-daily PPI therapy at baseline to 75% of patients showing elimination of medications or only as-needed use of antacids/over-the-counter PPIs at 48 months (P < 0.005). There were no serious complications of the procedure.

LIMITATIONS

This is an uncontrolled, nonrandomized case series in consecutive patients that does not include long-term pH or motility studies.

CONCLUSIONS

This study in drug-refractory patients with GERD found the Stretta procedure to be a safe, effective, and durable treatment that produced significant improvements in heartburn and quality of life and decreased medication usage during a 4-year period of follow-up.

Not asthma, but GERD: case report

Asthma is a disorder of the lungs characterized by increased responsiveness of the airways, as manifested by episodes of wheezing and increased resistance to expiratory airflow because of varying degrees of smooth muscle contraction, edema of the mucosa, and mucus in the lumen of the bronchi and bronchioles. The stimuli vary widely and include antigens, infection, air pollutants, respiratory tract irrtants, exercise, and emotional factors. This condition is completely different from distress breathing because of laryngotracheal spasm. One of its causes is the gastric content reflux through the pharynx to the larynx because of gastroesophageal reflux disease (GERD), in addition to the typical human avian flu that may cause immediate suffocation by laryngospasm owing to acute larygotrachitis. A patient suffered from GERD without esophageal symptoms, which was diagnosed and treated as bronchial asthma during his five emergency admissions. The admissions were because of episodic attacks of severe air hunger owing to an extreme throat tightening. The patient was being treated for as long as two years. After the correct diagnosis was made and treatment of laporascopic fundaplication was performed, the longstanding "bronchial asthma", after all, completely disappeared. The concept of "not asthma, but GERD" seems undervalued, unappreciated, even misunderstood among patients with intractable asthma. Therefore, such a case is reported in detail, similar cases are mentioned briefly as well, and a mechanism responsible for GERD-originated larryngo-or laryngotracho-spasm is proposed.