Radiofrequency therapy of the lower esophageal sphincter for treatment of GERD.

Abstract

Recent years have witnessed the introduction of a multitude of novel therapies for GERD. Prominent among these is the Stretta procedure, an endoluminal therapy in which radiofrequency energy is delivered to the esophagogastric junction (EGJ). At first glance that may seem a strange way to treat what is generally thought to be either an oversensitive or overstimulated distal esophagus. However, in other organ systems radiofrequency energy has been shown capable of ablating aberrant nerve pathways as in Wolf-Parkinson-White syndrome,1 tightening lax tissue as in damaged joints,2 shrinking the prostate in benign prostatic hypertrophy,3 shrinking liver tumors,4 and volumetric reduction of the palate in snoring and sleep apnea.5 In each case, the mechanism of action targets the underlying pathophysiology of the disease process, be it neurolysis or tissue necrosis with subsequent scarring. Thus, the underlying hypothesis of the Stretta procedure is that one or both of these potential effects will prove beneficial in the treatment of GERD. If there is one true cliche of GERD it is that it is a heterogeneous clinical entity with a multitude of potential causative factors that has consistently defied all attempts at a simple definition. Consider for example the definition of GERD recently labored over by the Genval workshop, “...all individuals who are exposed to the risk of physical complications from gastrooesophageal reflux, or who experience clinically significant impairment of health related well being (quality of life) due to reflux related symptoms, after adequate assurance of the benign nature of their symptoms.”6 This definition was carefully crafted so as to encompass the multitude of GERD syndromes including the following: (1) esophagitis and its complications with or without corresponding esophageal symptoms, (2) esophageal symptoms without corresponding esophagitis or complications of esophagitis, or (3) extraesophageal reflux-related symptoms with or without accompanying esophageal manifestations. Clearly, if it is so difficult to define an entity, one can anticipate equal difficulty in finding a uniformly effective therapy. A corollary of that is that a multitude of potential therapies can be anticipated. One need spend little time on the Internet to appreciate that this prediction has been realized. It is from this perspective that the Stretta procedure will be analyzed. First, what is actually known about the physiologic effects of this intervention? Second, what are the resultant effects of this intervention on each potential manifestation of GERD?