Endoscopic Treatment Of Gastroesophageal Reflux Disease Research Articles

Endoscopic Management Options for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a prevalent condition that affects a significant portion of the Western population. Despite its benign pathophysiology, it has the potential to cause serious complications over time, ranging from conditions that are benign, premalignant, and/or malignant. Traditional treatment options include lifestyle measures, anti-secretory medications (e.g., proton pump inhibitor (PPI)), and surgical options (e.g., Nissen and Toupet fundoplication). However, recent studies have revealed long-term side effects of anti-secretory medications. Moreover, surgical options, though effective, are considered invasive and associated with potential complications. In the current age of ongoing research in minimally invasive options, endoscopic treatment of GERD has become popular. As a result, procedures such as radiofrequency treatment and transoralincisionlessfundoplication (TIF) have gained FDA approval and are currently being covered by most insurance. In this review article, we will discuss pre-procedural workup, appropriate patient selection, advantages, disadvantages, procedure techniques, and follow-up of patients who undergo various endoscopic treatments for GERD.In addition, we will review the short and long-term success of these techniques in improving quality of life, use of PPI, and improvement in symptoms considering published data in high-quality peer-reviewed journals.

A Case of Refractory Gastroesophageal Reflux Disease Successfully Treated with Endoscopic Anti-gastroesophageal Reflux Mucosal Resection by the ESD-G Method (with video).

A 70-year-old man who had undergone treatment for gastroesophageal reflux disease (GERD) by a family doctor presented to our hospital with severe heartburn and dysphagia despite taking vonoprazan (20 mg) for 3 months. A diagnosis of vonoprazan-refractory nonerosive reflux disease was made based on esophagogastroduodenoscopy and esophageal function examinations. The patient elected to undergo endoscopic treatment for GERD. Therefore, we performed endoscopic treatment using the endoscopic submucosal dissection (ESD-G) technique developed at our institution. After endoscopic treatment, his GERD symptoms disappeared and he no longer required GERD-related medications. An examination of his esophageal function revealed the improvement of items related to GERD.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. Systematic literature reviews were conducted for 4 key questions regarding thesurgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, analgorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitorsalone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Endoscopic Treatment of GERD in Patients With Obesity

Gastroesophageal reflux disease (GERD) is one of the most common obesity-associated comorbidities. The increasing prevalence of obesity worldwide is expected to cause a concomitant increase in the prevalence of GERD. While laparoscopic Nissen fundoplication (LNF) remains the gold standard for the treatment of GERD, its efficacy in the setting of obesity is limited by a relatively high rate of post-procedural reflux recurrence. Currently, Roux-en-Y gastric bypass (RYGB) is the gold standard treatment for GERD in patients with obesity. However, despite its proven efficacy, it remains underutilized due to its cost, safety concerns, and patient acceptance. During the past 2 decades, endoscopic therapies have emerged as minimally invasive and safe alternatives for the management of GERD. While most studies assessed their outcomes in patients without obesity, recently published case reports offered a potential framework for their use in patients with obesity. In this article, we review the available endoscopic anti-reflux therapies (EART) and endoscopic bariatric therapies (EBT), with emphasis on their potential role in the management of GERD in patients with obesity.

Endoscopic treatments for GERD.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Tu1168 MUCOSAL ABLATION AND SUTURING AT THE ESOPHAGOGASTRIC JUNCTION (MASE): A NOVEL PROCEDURE FOR THE MANAGEMENT OF PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE

Many patients with gastroesophageal reflux disease (GERD) either have symptoms refractory to proton-pump inhibitor (PPI) therapy or are worried about long-term risks of PPI. Not all patients are candidates for fundoplication. There is a need for novel endoscopic treatments for reflux, especially for those with altered anatomy who may not be candidates for fundoplication. To evaluate the safety and efficacy of a novel mucosal ablation and endoscopic suturing procedure for the management of patients with GERD. We performed a single-center prospective observational study on all patients who underwent this novel procedure. The standardized procedure involved APC ablation below the GE junction to improve tissue apposition prior to suturing. Next, in the forward viewing position, three sutures were placed along the lesser curvature of the cardia immediately below the esophagogastric junction to create a tightening and tissue bulge to prevent stomach contents from refluxing into the esophagus. Patients were discharged home after the procedure and followed up in clinic or by phone to assess treatment response. The primary outcome evaluated was reduction or cessation of medications used for treatment of GERD. The secondary outcomes evaluated were procedure tolerance and safety. 27 patients with a mean age of 67 years (range, 44-84) underwent the MASE procedure with typical procedural length of 25 minutes. Mean follow-up time was 124 days (range, 34-338). The indications for the procedure included either poorly controlled symptoms (48%) or a desire to discontinue their medication (52%). 7 patients (26%) had altered anatomy from prior surgery: Fundoplication (N=4), Billroth II (N=1), Roux-en-Y (N=1), and Sleeve gastrectomy (N=1). Pre-procedure, 22 patients (82%) were on once or twice daily PPI therapy and 5 patients were on H2-receptor antagonists/topical antacids. Of the 22 patients on daily PPI, 13 patients (59%) were able to discontinue their medication, and 3 patients (14%) were able to reduce their dose (see Figure). Of the 7 patients with altered anatomy, 4 patients (57%) were able to discontinue or reduce their PPI after the procedure. With regards to tolerance, the most common side effect was self-limited epigastric pain post-procedure (22%). One patient required an overnight stay in hospital for intravenous pain control. There were no other early or late complications. The MASE procedure represents a novel endoscopic treatment for GERD. This procedure may serve especially useful in managing complex patients with GERD, including those with altered anatomy who may not be candidates for surgical or endoscopic fundoplication.

Update on novel endoscopic therapies to treat gastroesophageal reflux disease: A review.

Endoscopic treatments for gastroesophageal reflux disease (GERD) have become increasingly popular in recent years. While surgical intervention with the Laparoscopic Nissen Fundoplication remains the gold standard, two endoscopic interventions, specifically, are gaining traction in clinical use (EsophyX and Stretta). The EsophyX (EndoGastric Solutions, Inc., Redmond, WA, United States) was developed as a method of restoring the valve at the GE junction through an endoluminal fundoplication (ELF) technique. Long-term data suggests that transoral incisional fundoplication (TIF) with EsophyX may be effective for symptom control and proton pump inhibitor reduction or cessation for up to 2-6 years. There is no evidence that EsophyX is more effective than surgical intervention. TIF may be most effective for patients with HH < 2 cm and Hill Grade I/II valves. Stretta (Mederi Therapeutics, Greenwich, CT, United States) was approved by the Food and Drug Administration in 2000. It delivers radiofrequency energy to the lower esophageal sphincter and gastric cardia. Published reviews of the literature are conflicted in their recommendations of Stretta in the management of GERD. The literature suggests that the Stretta procedure has an acceptable safety profile and may be effective in reducing symptom burden and quality of life scores up to 8 years post-intervention. However, there does not appear to be any sustained improvement in objective outcomes and there is no evidence that Stretta results in improved outcomes as compared to surgical intervention. Treatment modalities for GERD, as a field, suffer from a lack of standardization in primary and secondary outcomes. Although many studies have looked at health related quality of life, the tools used to do so are markedly heterogeneous. Future directions for the endoscopic treatment of GERD include novel techniques like endoscopic submucosal dissection.

The Mexican consensus on gastroesophageal reflux disease. Part II

AimsTo update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002. MethodsPart I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher. ResultsTwenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%. ConclusionsCurrently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

Endoscopic Treatment of Refractory Gastroesohageal Reflux Disease

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.

Noncardiac Chest Pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.

Asia‐Pacific consensus on the management of gastroesophageal reflux disease: Update

Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed. A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials. Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.

Suture Location Impacts Clinical Outcome for Endoscopic Treatment of Gastroesophageal Reflux Disease

Purpose: Endoscopic treatments for gastroesophageal reflux disease (GERD) have variable long-term success rates, however the reason for such variability in response rates is unclear. The aim of this study was to determine the effects of location and number of sutures on clinical outcome in patients undergoing endoscopic treatment for GERD. Methods: Patients with persistent GERD symptoms despite medical therapy and undergoing endoscopic anti-reflux treatment with more than one year follow up were included. Endoscopic suturing of the gastroesophageal junction (GEJ) was done using commercially available endoscopic suturing devices. Sutures were placed within 2 cm distal to the squamo-columnar junction in a circumferential fashion. The number of sutures was recorded and the locations of the sutures were documented according to the face clock position at the GEJ. Greater curve sutures were at the 6 o'clock position and lesser curve sutures were at the 12 o'clock position. Complete symptom resolution was defined as absence of heartburn and regurgitation symptoms at the longest available follow up. The association between number of sutures, suture location (combination of lesser and greater curve, or lesser curvature or greater curvature) and symptom resolution was examined using Fisher's exact test. Results: Forty-two patients (26F/16M) with a mean follow up of 20 months were included in the analysis. Thirteen patients (31%) achieved complete symptom resolution. Sixteen patients had placement of three sutures, 24 patients had placement of two sutures, and 2 patients had placement of one suture. The number of sutures did not correlate with clinical outcome. Patients with a combination of greater and lesser curve sutures achieved the best clinical outcome (p = 0.014) during follow up. Conclusions: A combination of greater and lesser curve sutures at the gastroesophageal junction was associated with the best long-term clinical outcome of endoscopic treatment for gastroesophageal reflux disease. Future larger studies will be needed to confirm this finding and to determine the optimal suture placement configuration.

Functional heartburn

Functional heartburn (FH) is a common disorder that accounts for 30% to 50% of the patients with nonerosive reflux disease. FH is composed from a heterogeneous group of patients. They primarily include the hypersensitive and the nonacid sensitive esophagus. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach of FH remain to be fully elucidated. Symptom response rate to potent antireflux treatment is significantly lower in FH patients as compared with any other gastroesophageal reflux disease (GERD) group, suggesting that in proton pump inhibitor (PPI) non-responders mechanisms other than acid reflux are likely the cause of symptoms. Patients with FH should be approached therapeutically as patients with GERD and should initially receive antireflux medications. Due to the need for profound acid suppression in this group of patients, PPIs should be considered relatively early in their care. Failure to respond to standard dosage of PPI is common and will require doubling the dose. If patients continue to report heartburn symptoms while receiving PPI twice daily, adding or switching to pain modulators/visceral analgesics is an appropriate therapeutic approach. Data about the usage of other therapeutic modalities in FH such as antireflux surgery, endoscopic treatment for GERD, and psychotherapy are still unavailable. Emerging treatment will likely include novel pain modulators and more effective antireflux medications.

Antibiotic Prophylaxis for Enteryx™ Procedure: Preliminary Results

Introduction: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorder. EnteryxTM (Boston Scientific Corporation, Natick, Massachussets, USA) is a recently FDA-approved procedure for endoscopic treatment of GERD. About 12% of patients treated by EnteryxTM, experience fever of unknown origin within 24h post byopolimer implantation. No data are available about antibiotic prophylaxis in these patients. The aim of this preliminary study is to investigate the prevalence of bacteremia after Enteryx injection. Methods: A cohort study, including all consecutive patients, admitted at our institute to perform EnteryxTM injection, was started on June 2004. For each patients we collected age, sex, white blood cells count, risk factors for bloodstream infections, co-morbidity and previous antibiotic therapy. All patients underwent two blood-cultures after EnteryxTM procedure when they became febrile. No antibiotics prophylaxis were given. Results: Six patients (4 males and 2 females, 42.6 median age, range 26-55), with PPIs-dependent GERD symptoms were enrolled. At admission no patients had signs or symptoms of infection in any site and none received antibiotic prophylaxis. One patient had a history of Helicobacter pylori gastritis eradicated one year before the study. Five patients (83%) became febrile (body temperature >99.5 F) within 24 hours of EnteryxTM injection. All blood-cultures were negative and none had leucocytosis. After one month of follow-up no patients were no sign or symptoms of infection. Conclusions: These preliminary data show that the development of fever after EnteryxTM injection is probably associated to the procedure itself and not to bacteremia. Further results are needed to confirm that antibiotic prophylaxis is not necessary for this procedure.

Medical, surgical, and endoscopic treatment of gastroesophageal reflux disease and Barrett's esophagus.

Over the past decade, medical and surgical approaches to the patient with gastroesophageal reflux disease (GERD) have improved dramatically. Proton pump inhibitors have become the dominant medical therapy because of their high efficacy and safety. Laparoscopic surgical approaches have improved concomitantly with the advances in medical therapy, resulting in the perception that either continuous medical therapy or surgery are appropriate options for long-term maintenance of this chronic disorder. Recent approval of new endoscopic treatments for GERD has generated considerable interest, but acceptance of these techniques should be limited by the small number of patients studied to date, the lack of placebo controls, and the short duration of follow-up.