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Endoscopic Management of Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is defined by the reflux of gastric fluid into the esophagus causing troublesome symptoms and/or complications, such as mucosal inflammation and metaplasia. Functional disturbances of the lower esophageal sphincter (LES), along with anatomic abnormalities of the esophagogastric junction (EGJ) such as hiatal hernia, allow the reflux of gastric fluid up into the esophagus. Treatment of GERD is focused on providing relief of symptoms and reducing reflux-related mucosal injury. The choice of treatment modality is based on symptom severity, the degree of esophageal injury, the presence and severity of hiatal hernia, and the degree of esophageal dysmotility.
The mainstay of therapy is medical with gastric acid suppression through the use of proton pump inhibitors (PPIs). PPIs are recommended as first-line therapy based on their rapid impact on symptoms and efficient control of esophageal inflammation. PPIs have a well-known safety profile that allows for long-term use. Such additional measures as weight loss, head-of-bed elevation, and elimination of food triggers are also used but are less effective. Because none of the medical therapies address the incompetent LES, their efficacy is somewhat limited.
Surgical therapy is the preferred treatment in patients with recalcitrant symptoms, especially those with esophagitis, Barrett esophagus, or extraesophageal pathology. Surgical repair includes two fundamental principles: restoration of the gastroesophageal flap valve ( Fig. 21.1 ) with reinforcement of the LES and placement of the EGJ below the diaphragm. Laparoscopic fundoplication with correction of the hiatal hernia, if indicated, is the gold standard, with well-established efficacy. Postoperative dysphagia and gas-bloat syndrome continue to be troublesome side effects for surgical fundoplication despite modifications to the original procedure. Over the past 10 to 15 years a number of endoscopic approaches have been developed to treat GERD and will be described in this review.
Endoscopic appraisal of the gastroesophageal flap valve.
(Redrawn from Jobe BA, Kahrilas PJ, Vernon AH, et al. Endoscopic appraisal of the gastroesophageal valve after antireflux surgery. Am J Gastroenterol. 2004;99:233.).
Indications for Endoscopic Therapy of Gastroesophageal Reflux Disease
Endoscopic antireflux (EAR) procedures aim to reinforce the mechanical antireflux barrier, thereby reducing symptoms and preventing pathologic progression of esophagitis. Indications for EAR intervention are similar to those for surgical intervention, namely relapsing or recalcitrant symptoms despite adequate medical therapy, PPI intolerance, desire to stop chronic drug therapy, and progressive esophagitis. In addition, there are patients who want to avoid surgical fundoplication and the associated side effects, such as dysphagia, bloating, or meteorism, and who will seek an EAR approach. Endoscopic therapy also provides a less invasive option for patients who are not good candidates for laparoscopic interventions due to previous laparotomies, or are not candidates for open repair due to medical comorbidities. In addition, there may be situations when patients with recurrent reflux after an operative fundoplication may find benefit from EAR therapy.
Due to the limitations of endoscopic manipulation, patients with hiatal hernias larger than 2 cm and GERD are not candidates for endoscopic therapy and are best managed with a standard laparoscopic repair. Patients with moderate to severe mucosal inflammation (Los Angeles endoscopic classification grade C and D), as well as patients with Barrett esophagitis, have been excluded from most studies evaluating EAR therapies. Although these characteristics are not an absolute contraindication to an EAR approach, the efficacy for these patients is not yet known.
Techniques
The primary endoscopic therapies for GERD can be classified into three major categories: (1) endoscopic suturing or plication (full or partial thickness), (2) thermal remodeling and neurolysis of the LES zone by radiofrequency energy delivery, and (3) bulking or reinforcement of the LES zone by injection of inert material. These methods, along with a recently described technique using endoscopic mucosal resection (EMR), will be examined next.
Endoscopic Plication
Endoscopic suturing techniques were first described in the 1980s when Swain and colleagues developed a miniature sewing machine that attached to the end of a standard upper gastrointestinal endoscope. The first US Food and Drug Administration (FDA)-approved method for treating GERD was an endoscopic suturing method introduced by Bard (Murray Hill, New Jersey) under the name EndoCinch. This method was the commercial version of the miniature sewing machine as developed by Swain and Mills in London. This technique involved a partial-thickness plication on the gastric side of the EGJ. Clinical outcomes with the EndoCinch have generally been marginal. As a result, the EndoCinch, like many endoscopic therapies, has been withdrawn from clinical use.
Currently there are two endoscopic plication systems that are FDA approved for patients with reflux. These are the Medigus Ultrasonic Endostapling system (MUSE; Medigus, Omer, Israel) and the EsophyX device (Endogastric Solutions, Redmond, Washington). Each is described later.
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