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Desai M, Ruan W, Thosani NC, Amaris M, Scott JS, Saeed A, Abu Dayyeh B, Canto MI, Abidi W, Alipour O, Amateau SK, Cosgrove N, Elhanafi SE, Forbes N, Kohli DR, Kwon RS, Fujii-Lau LL, Machicado JD, Marya NB, Ngamruengphong S, Pawa S, Sheth SG, Thiruvengadam NR, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: summary and recommendations. Gastrointest Endosc 2025; 101:267-284. [PMID: 39692638 DOI: 10.1016/j.gie.2024.10.008] [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] [Received: 10/02/2024] [Accepted: 10/05/2024] [Indexed: 12/19/2024]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations Assessment, Development, and Evaluation framework and serves as an update to the 2014 ASGE guideline on the role of endoscopy in the management of GERD. This updated guideline addresses the indications for endoscopy in patients with GERD as well as in the emerging population of patients who develop GERD after sleeve gastrectomy or peroral endoscopic myotomy. It also discusses how to endoscopically evaluate gastroesophageal junctional integrity in a comprehensive and uniform manner. Importantly, this guideline also discusses management strategies for GERD including the role of lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy (including transoral incisionless fundoplication [TIF], radiofrequency energy, and combined hiatal hernia repair and TIF [cTIF]) in the management of GERD. The ASGE suggests upper endoscopy for the evaluation of GERD in patients with alarm symptoms, with multiple risk factors for Barrett's esophagus, and with a history of sleeve gastrectomy. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings with attention to gastroesophageal junction landmarks and integrity in patients who undergo upper endoscopy to improve care. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration possible while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernias (≤2 cm) and Hill grade I or II who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to chronic medical management. In patients with persistent GERD with large hiatal hernias (> 2cm) and Hill grade III or IV, the ASGE suggests either cTIF or surgical therapy based on multidisciplinary review. This document summarizes the methods, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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Affiliation(s)
- Madhav Desai
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Manuel Amaris
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - J Stephen Scott
- Bariatric & Metabolic Specialists, Overland Park, Kansas, USA
| | - Ahmed Saeed
- Advanced Gastroenterology Associates, Overland Park, Kansas, USA
| | - Barham Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Wasif Abidi
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Omeed Alipour
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Medical Center, Elon Floyd School of Medicine, Washington State University, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Desai M, Ruan W, Thosani NC, Amaris M, Scott JS, Saeed A, Abu Dayyeh B, Canto MI, Abidi W, Alipour O, Amateau SK, Cosgrove N, Elhanafi SE, Forbes N, Kohli DR, Kwon RS, Fujii-Lau LL, Machicado JD, Marya NB, Ngamruengphong S, Pawa S, Sheth SG, Thiruvengadam NR, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: methodology and review of evidence. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2025; 10:81-137. [PMID: 40012897 PMCID: PMC11852708 DOI: 10.1016/j.vgie.2024.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and serves as an update to the prior ASGE guideline on the role of endoscopy in the management of GERD (2014). The updated guideline addresses the indications for endoscopy in patients with GERD, including patients who have undergone sleeve gastrectomy (SG) and peroral endoscopic myotomy (POEM). It also discusses endoscopic evaluation of gastroesophageal junctional integrity comprehensively and uniformly. Important, this guideline discusses management strategies for GERD including lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy including transoral incisionless fundoplication (TIF), radiofrequency energy, and TIF combined with hiatal hernia repair (cTIF). The ASGE recommends upper endoscopy for the evaluation of GERD in patients with alarm symptoms. The ASGE suggests upper endoscopy for symptomatic patients with a history of SG and POEM. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings and gastroesophageal junction landmarks and integrity to improve patient care and outcomes. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernia (≤2 cm) and Hill grade I or II flap valve who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to long-term medical management. In patients with confirmed GERD with a large hiatal hernia (>2 cm) and Hill grade 3 or 4 flap valve, the ASGE suggests evaluation for combined endoscopic-surgical TIF (cTIF) in a multidisciplinary review. This document clearly outlines the methodology, analysis, and decision used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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Affiliation(s)
- Madhav Desai
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Manuel Amaris
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - J Stephen Scott
- Bariatric & Metabolic Specialists, Overland Park, Kansas, USA
| | - Ahmed Saeed
- Advanced Gastroenterology Associates, Overland Park, Kansas, USA
| | - Barham Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Wasif Abidi
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Omeed Alipour
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Medical Center, Elon Floyd School of Medicine, Washington State University, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Tanvir F, Nijjar GS, Aulakh SK, Kaur Y, Singh S, Singh K, Singla A, Sandhu APS, Luthra S, Antaal H. Gastroesophageal Reflux Disease: New Insights and Treatment Approaches. Cureus 2024; 16:e67654. [PMID: 39314570 PMCID: PMC11417972 DOI: 10.7759/cureus.67654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2024] [Indexed: 09/25/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) remains a significant global health concern, with increasing prevalence and a substantial impact on quality of life. This narrative review explores recent advances in our understanding of GERD pathophysiology, diagnosis, and management. The complex interplay of factors contributing to GERD, including lower esophageal sphincter dysfunction, transient sphincter relaxations, and esophageal motility disorders, is discussed. Emerging diagnostic techniques, such as high-resolution manometry and impedance-pH monitoring, have enhanced our ability to accurately identify and characterize GERD. The review highlights the evolving landscape of GERD treatment, from conventional approaches like lifestyle modifications and proton pump inhibitors to novel strategies including potassium-competitive acid blockers, endoscopic therapies, and minimally invasive surgical techniques. The potential role of the microbiome in GERD pathogenesis and as a therapeutic target is examined. The concept of personalized medicine in GERD management is explored, considering genetic factors, biomarkers, and individual patient profiles. Complications of GERD, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma, are reviewed, emphasizing the importance of early detection and appropriate management. The economic burden and impact on the quality of due to GERD are also addressed. This comprehensive review underscores the multifaceted nature of GERD and the need for a personalized, multidisciplinary approach to its management. It highlights ongoing research efforts and emerging therapies that promise to improve outcomes for GERD patients, while also identifying areas requiring further investigation to optimize diagnosis and treatment strategies.
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Affiliation(s)
- Fnu Tanvir
- Internal Medicine, Government Medical College Amritsar, Amritsar, IND
| | | | - Smriti Kaur Aulakh
- Internal Medicine, Sri Guru Ram Das University of Health Sciences and Research, Amritsar, IND
| | - Yasmeen Kaur
- Internal Medicine, Government Medical College Amritsar, Amritsar, IND
| | - Sumerjit Singh
- Radiology, Government Medical College Amritsar, Amritsar, IND
| | | | - Abhinandan Singla
- Internal Medicine, Government Medical College Amritsar, Amritsar, IND
| | - Ajay Pal Singh Sandhu
- Internal Medicine, Sri Guru Ram Das University of Health Sciences and Research, Amritsar, IND
| | - Shivansh Luthra
- Internal Medicine, Government Medical College Amritsar, Amritsar, IND
| | - Harman Antaal
- Internal Medicine, Government Medical College Patiala, Patiala, IND
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Loganathan P, Gajendran M, Perisetti A, Goyal H, Mann R, Wright R, Saligram S, Thosani N, Umapathy C. Endoscopic Advances in the Diagnosis and Management of Gastroesophageal Reflux Disease. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1120. [PMID: 39064549 PMCID: PMC11278532 DOI: 10.3390/medicina60071120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/01/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.
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Affiliation(s)
- Priyadarshini Loganathan
- Division of Gastroenterology & Nutrition, The University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA; (P.L.); (M.G.); (R.W.)
| | - Mahesh Gajendran
- Division of Gastroenterology & Nutrition, The University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA; (P.L.); (M.G.); (R.W.)
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO 64128, USA;
| | - Hemant Goyal
- Department of Gastroenterology, Borland Groover, Baptist Medical Center-Downtown, Jacksonville, FL 32207, USA
| | - Rupinder Mann
- Department of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Randy Wright
- Division of Gastroenterology & Nutrition, The University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA; (P.L.); (M.G.); (R.W.)
| | - Shreyas Saligram
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ 08901, USA;
| | - Nirav Thosani
- Department of Surgery, McGovern Medical School at UT Health, Houston, TX 77030, USA;
| | - Chandraprakash Umapathy
- Division of Gastroenterology & Nutrition, Audie L. Murphy VA Hospital, San Antonio, TX 78229, USA;
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Onana Ndong P, Gonzalez JM, Beyrne A, Barthet M, Vitton V. Does the presence of an esophageal motor disorder influence the response to anti-reflux mucosectomy (ARMS) for refractory GERD? Scand J Gastroenterol 2024; 59:639-646. [PMID: 38497142 DOI: 10.1080/00365521.2024.2331554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION The prevalence of esophageal motor disorders (EMD) in PPI-refractory gastroesophageal reflux disease (GERD) is substantial. However, limited data exist on their impact on the efficacy of endoscopic treatments like anti-reflux mucosectomy (ARMS). This study aimed to evaluate the influence of EMD on ARMS efficacy in patients with PPI-refractory GERD. METHOD This single-center retrospective study enrolled patients with refractory GERD treated with ARMS-b (anti-reflux mucosectomy band-ligation). High-resolution esophageal manometry (HREM) was conducted before the procedure to identify EMD presence. The primary endpoint was treatment efficacy, defined as >50% improvement in GERD-HRQL score at 1 year. Secondary endpoints included PPI intake, symptom control, ARMS complications, and overall patient satisfaction at 12 months. RESULTS The study included 65 patients, with 41 (63.1%) showing EMD on HREM. Treatment efficacy was achieved by 33.8% (22) of patients, with 8 without EMD, 11 having isolated LES hypotonia, and 3 with both LES hypotonia and esophageal body motor disorder. No significant differences were observed between patients with and without EMD regarding the primary endpoint, PPI use, symptom control, or complications. Dysphagia developed in 52.3% (34) within 6 months, leading to esophageal dilatation in 15.3% (10). Two patients experienced acute hemorrhage, and one had perforation. CONCLUSION The presence of esophageal motor disorders does not seem to impact ARMS response, suggesting the technique's consideration in this population. Larger studies are essential for confirming these results and exploring treatment response and post-operative predictors.
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Affiliation(s)
- Philippe Onana Ndong
- Service de Gastroentérologie, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Jean-Michel Gonzalez
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Ana Beyrne
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Marc Barthet
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Veronique Vitton
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique Hôpitaux de Marseille, Marseille, France
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Kasugai K, Ogasawara N. Gastroesophageal Reflux Disease: Pathophysiology and New Treatment Trends. Intern Med 2024; 63:1-10. [PMID: 36927966 PMCID: PMC10824640 DOI: 10.2169/internalmedicine.1551-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/02/2023] [Indexed: 03/15/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is caused by the reflux of gastric contents into the esophagus due to a decline in esophageal clearance and anti-reflux barrier mechanisms. Mucosal injury is caused by a combination of gastric juice directly damaging the esophageal mucosa and the immune and inflammatory mechanism in which inflammatory cytokines released from the esophageal mucosal epithelium cause neutrophil migration, triggering inflammation. Gastric secretion inhibitors are the first-line treatment for GERD, but they can be combined with prokinetic agents and Chinese herbal remedies. However, pharmacotherapy cannot improve anatomical problems or prevent physical causes of GERD, such as reflux of non-acidic contents. Therefore, surgery can be warranted, depending on the pathology. Intraluminal endoscopic therapy, which is both less invasive and more effective than surgery, was recently developed and applied in Europe and the United States. In Japan, intraluminal endoscopic therapies, such as anti-reflux mucosectomy, anti-reflux mucosal ablation, and endoscopic submucosal dissection, for GERD have been independently developed.
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Affiliation(s)
- Kunio Kasugai
- Department of Internal Medicine, Division of Gastroenterology, Aichi Medical University, Japan
| | - Naotaka Ogasawara
- Department of Internal Medicine, Division of Gastroenterology, Aichi Medical University, Japan
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Simadibrata DM, Lesmana E, Fass R. Role of endoscopy in gastroesophageal reflux disease. Clin Endosc 2023; 56:681-692. [PMID: 37822063 PMCID: PMC10665616 DOI: 10.5946/ce.2023.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 10/13/2023] Open
Abstract
In general, gastroesophageal reflux disease (GERD) is diagnosed clinically based on typical symptoms and/or response to proton pump inhibitor treatment. Upper gastrointestinal endoscopy is reserved for patients presenting with alarm symptoms, such as dysphagia, odynophagia, significant weight loss, gastrointestinal bleeding, or anorexia; those who meet the criteria for Barrett's esophagus screening; those who report a lack or partial response to proton pump inhibitor treatment; and those with prior endoscopic or surgical anti-reflux interventions. Newer endoscopic techniques are primarily used to increase diagnostic yield and provide an alternative to medical or surgical treatment for GERD. The available endoscopic modalities for the diagnosis of GERD include conventional endoscopy with white-light imaging, high-resolution and high-magnification endoscopy, chromoendoscopy, image-enhanced endoscopy (narrow-band imaging, I- SCAN, flexible spectral imaging color enhancement, blue laser imaging, and linked color imaging), and confocal laser endomicroscopy. Endoscopic techniques for treating GERD include esophageal radiofrequency energy delivery/Stretta procedure, transoral incisionless fundoplication, and endoscopic full-thickness plication. Other novel techniques include anti-reflux mucosectomy, peroral endoscopic cardiac constriction, endoscopic submucosal dissection, and endoscopic band ligation. Currently, many of the new endoscopic techniques are not widely available, and their use is limited to centers of excellence.
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Affiliation(s)
- Daniel Martin Simadibrata
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elvira Lesmana
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Truong VG, Kim H, Lee BI, Cha B, Jeong S, Oh SJ, Kang HW. Development of Novel Balloon-Integrated Optical Catheter for Endoscopic and Circumferential Laser Application. Ann Biomed Eng 2023; 51:2021-2034. [PMID: 37191825 DOI: 10.1007/s10439-023-03228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/29/2023] [Indexed: 05/17/2023]
Abstract
The current study aims to demonstrate the feasibility of a novel balloon-integrated optical catheter (BIOC) to achieve endoscopic laser application for circumferential coagulation of a tubular tissue structure. Both optical and thermal numerical simulations were developed to predict the propagation of laser light and a spatio-temporal distribution of temperature in tissue. Ex vivo esophagus tissue was tested with 980 nm laser light at 30 W for 90 s for quantitative evaluations. In vivo porcine models were used to validate the performance of BIOC for circumferential and endoscopic laser coagulation of esophagus in terms of acute tissue responses post-irradiation. Optical simulations confirmed that a diffusing applicator was able to generate a circumferential light distribution in a tubular tissue structure. Both numerical and experimental results presented that the maximum temperature elevation occurred at 3-5 mm (muscle layer) below the mucosa surface after 90 s irradiation. In vivo tests confirmed the circumferential delivery of laser light to a deep muscle layer as well as no evidence of thermal damage to the esophageal mucosa. The proposed BIOC can be a feasible optical device to provide circumferential laser irradiation as well as endoscopic coagulation of tubular esophagus tissue for clinical applications.
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Affiliation(s)
- Van Gia Truong
- Industry 4.0 Convergence Bionics Engineering and Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea
- TeCure, Inc., Busan, Republic of Korea
| | - Hyejin Kim
- Industry 4.0 Convergence Bionics Engineering and Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea
- TeCure, Inc., Busan, Republic of Korea
| | - Byeong-Il Lee
- Division of Smart Healthcare, College of Information Technology and Convergence, Pukyong National University, Busan, Republic of Korea
| | - Boram Cha
- Department of Internal Medicine, Inha University School of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Sun-Ju Oh
- Department of Pathology, Kosin University College of Medicine, Busan, Republic of Korea
| | - Hyun Wook Kang
- Industry 4.0 Convergence Bionics Engineering and Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea.
- TeCure, Inc., Busan, Republic of Korea.
- Division of Smart Healthcare, College of Information Technology and Convergence, Pukyong National University, Busan, Republic of Korea.
- Marine-Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, Republic of Korea.
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Ota K, Takeuchi T, Higuchi K, Sasaki S, Mori Y, Tanaka H, Hakoda A, Sugawara N, Iwatsubo T, Nishikawa H. Frontiers in Endoscopic Treatment for Gastroesophageal Reflux Disease. Digestion 2023; 105:5-10. [PMID: 37591209 DOI: 10.1159/000533200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The 3rd edition of the evidence-based clinical practice guidelines for gastroesophageal reflux disease (GERD) 2021 from the Japanese Society of Gastroenterology states that the treatment strategy for potassium-competitive acid blocker (PCAB)-refractory GERD remains unclear. Furthermore, even if GERD improves with the administration of an acid secretion inhibitor, it is feared that GERD may flare up after discontinuation of the drug, resulting in some cases in which patients are forced to take vonoprazan semipermanently (the so-called PCAB-dependent cases). From a global perspective, PCAB is not yet used in all countries and regions, and measures that can be taken now for cases in which a conventional proton pump inhibitor (PPI) is inadequately effective need to be devised. SUMMARY Endoscopic treatment for GERD may be effective in cases where conventional proton pump inhibitors are ineffective; however, there are insufficient long-term studies to corroborate this, and its cost effectiveness is unknown. Other treatment options for PCAB or PPI-refractory GERD include surgical procedures (Nissen and Toupet operations), which have a longer history than endoscopic treatment for GERD. However, their long-term results are not as good as those of acid secretion inhibitors, and they are not cost effective. Endoscopic treatment for GERD may fill gaps in inadequate surgical treatment. In April 2022, endoscopic anti-reflux mucosal resections (ARMS [anti-reflux mucosectomy] and ESD-G [endoscopic submucosal dissection for GERD]) were approved for reimbursement, making endoscopic treatment of GERD possible throughout Japan. KEY MESSAGES It is important to identify the background factors in cases in which endoscopic treatments are effective.
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Affiliation(s)
- Kazuhiro Ota
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Toshihisa Takeuchi
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Shun Sasaki
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yosuke Mori
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Hironori Tanaka
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Akitoshi Hakoda
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Noriaki Sugawara
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Taro Iwatsubo
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Hiroki Nishikawa
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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10
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Shen S, Yu G, Guo X, Zong G, Wang C, Bao J, Chen J, Cheng Z, Xiao W, Shen J, Jiang W, Wan R. The long-term efficacy of transoral incisionless fundoplication with Medigus Ultrasonic Surgical Endostapler (MUSE) for gastroesophageal reflux disease. Esophagus 2023; 20:581-586. [PMID: 36877412 PMCID: PMC10234897 DOI: 10.1007/s10388-023-00992-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/14/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND To evaluate the long-term efficacy of transoral incisionless fundoplication (TIF) with Medigus Ultrasonic Surgical Endostapler (MUSE) for gastroesophageal reflux disease (GERD). METHODS A total of 16 patients with proton pump inhibitor-dependent gastroesophageal reflux disease had undergone TIF by MUSE in Shanghai General Hospital （Shanghai, China）from March 2017 to December 2018. Patients were followed up at 6 months, and the GERD-health-related quality of life (GERD-HRQL) questionnaire score, the GERD questionnaire (GERD-Q) score, high-resolution esophageal manometry (HREM) and 24 h esophageal pH parameters, the Hill grade of the gastroesophageal flap valve (GEFV) and daily Proton pump inhibitor (PPI) consumption before and after procedure were compared. Patients also were followed up at 3 years and 5 years using a structured questionnaire via phone which evaluated symptoms of reflux, dose of PPI medication and side effects. RESULTS Follow-up data were collected from 13 patients, ranging from 38 to 63 months, 53 months on average. 10/13 patients reported symptomatic improvement and daily PPI consumption was stopped or halved in 11/13. After procedure, the mean scores of GERD-HRQL and GERD-Q were significantly increased. The mean DeMeester score, the mean acid exposure time percentage and the mean number of acid reflux episodes were significantly lower. The mean rest pressure at lower esophageal sphincter (LES) had no significant difference. CONCLUSION TIF by MUSE has significant efficacy in the treatment of PPI-dependent GERD, which can improve symptoms and life quality of patients, and reduce the acid exposure time for long-term. Chictr.org.cn. TRIAL REGISTRATION ChiCTR2000034350.
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Affiliation(s)
- Shien Shen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Ge Yu
- Shanghai General Hospital of Nanjing Medical University, Nanjing, China
| | - Xingya Guo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Guanzhao Zong
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Chuanyang Wang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Jingpiao Bao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Jiahui Chen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Zhiyuan Cheng
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Wenqin Xiao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Jie Shen
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Weiliang Jiang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
| | - Rong Wan
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 85 Wujin Road, Shanghai, 200080 China
- Shanghai General Hospital of Nanjing Medical University, Nanjing, China
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11
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Lopes SO, Gonçalves AR, Macedo G, Santos-Antunes J. Endoscopic treatment of gastroesophageal reflux: a narrative review. Porto Biomed J 2023; 8:e226. [PMID: 37547707 PMCID: PMC10400068 DOI: 10.1097/j.pbj.0000000000000226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 08/08/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common chronic disease that affects one-third of the population worldwide. In recent years, there have been significant advances for diagnostic workup, which leads to better identification of reflux-related complications. Classically, the mainstay of therapy has been proton pump inhibitor and lifestyle and dietary modifications. For refractory GERD the gold-standard therapies are surgical antireflux procedures. Recently, endoscopic procedures have emerged as safe and efficient alternatives to surgery. These could represent a less invasive approach, with scarce morbidity and with a well-tolerated profile. Each of the existing endoscopic techniques for the treatment of GERD are addressed in this report, highlighting their potential advantages, aiming at helping decide the best management of these patients. Future studies, with larger numbers of patients, may allow a definitive role for these techniques in the management of GERD to be established.
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Affiliation(s)
| | - Ana Raquel Gonçalves
- Faculty of Medicine, University of Porto, Porto, Portugal
- Gastroenterology Department, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Guilherme Macedo
- Faculty of Medicine, University of Porto, Porto, Portugal
- Gastroenterology Department, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - João Santos-Antunes
- Faculty of Medicine, University of Porto, Porto, Portugal
- Gastroenterology Department, Centro Hospitalar Universitário S. João, Porto, Portugal
- Ipatimup/i3S (Instituto de Investigação e Inovação em Saúde da Universidade do Porto), Porto, Portugal
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12
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Cha B, Kim H, Truong VG, Oh SJ, Jeong S, Kang HW. Feasibility Study on Endoscopic Balloon-Assisted Laser Treatment (EBLT) of Gastroesophageal Reflux Disease (GERD) in In Vivo Porcine Model. Biomedicines 2023; 11:1656. [PMID: 37371751 DOI: 10.3390/biomedicines11061656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) has been growing globally, with an increasing burden on the healthcare system due to multiple factors, such as aging and obesity. The current study evaluated the feasibility of endoscopic balloon-assisted laser treatment (EBLT) in a porcine model. GERD was initially developed in three animals via botulinum toxin injection into lower esophageal sphincter (LES). A week after the injection, the EBLT was performed on the GERD-developed models (control = 1 vs. treated = 2). A dose of 30 W of 980 nm laser light was endoscopically applied for 90 s to the LES. Both endoscopic ultrasound and manometry were performed before and after the EBLT. After 12 weeks, esophageal tissues were extracted and prepared for histological analysis. The maximum mucosa temperature was below 50 °C during the EBLT. Compared to control, the treated group yielded thicker and shorter LES muscle layers and maintained LES pressure. Through histology, the EBLT reinforced the muscularis layer with preserved mucosa and mild remodeling of the intermuscular collagen in the LES. The current study demonstrated the feasibility of EBLT as a new endoscopic approach for GERD. Further studies will examine the EBLT in a larger number of animals to warrant efficacy and safety for clinical translations.
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Affiliation(s)
- Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Hyejin Kim
- TeCure, Inc., Busan 48548, Republic of Korea
| | | | - Sun-Ju Oh
- Department of Pathology, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Hyun Wook Kang
- TeCure, Inc., Busan 48548, Republic of Korea
- Department of Biomedical Engineering and MarineIntegrated Biomedical Technology Center, Pukyong National University, Busan 48513, Republic of Korea
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13
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Peng L, Wan R, Chen S, Wu J, Yang J, Wang X, Yan B, Zhao H, Pan F, Shi Y, Wang W, Ai J, Yang Y. Efficacy of endoscopic anterior fundoplication with a novel ultrasonic surgical endostapler for gastroesophageal reflux disease: Six-month results from a multicenter prospective trial. Endosc Ultrasound 2023; 12:128-134. [PMID: 36861512 PMCID: PMC10134931 DOI: 10.4103/eus-d-21-00244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Abstract
Background and Objectives Endoscopic therapy is an option for the treatment of refractory gastroesophageal reflux disease (GERD). We aimed to evaluate the efficacy and safety of transoral incisionless fundoplication with the Medigus ultrasonic surgical endostapler (MUSE™) for refractory GERD. Materials and Methods Patients with 2 years of documented GERD symptoms and at least 6 months of proton-pump inhibitors (PPIs) therapy were enrolled in four medical centers from March 2017 to March 2019. The GERD health-related quality of life (HRQL) score, GERD questionnaire score, total acid exposure on esophageal pH probe monitoring, the gastroesophageal flap valve (GEFV), esophageal manometry, and PPIs dosage were compared between the pre- and post-MUSE procedure. All of the side effects were recorded. Results A reduction of at least 50% in the GERD-HRQL score was observed in 77.8% (42/54) patients. Most patients 74.1% (40/54) discontinued PPIs and 11.1% (6/54) reported a ≥50% dose reduction. The percentage of patients who had normalized acid exposure time after the procedure was 46.9% (23/49). The existence of hiatal hernia at baseline was negatively correlated with the curative effect. Mild pain was common and resolved within 48 h postprocedure. Serious complications were pneumoperitoneum (one case), mediastinal emphysema combined with pleural effusion (two cases). Conclusions Endoscopic anterior fundoplication with MUSE was an effective treatment for refractory GERD, but still needs refinement and improvement in safety aspect. Esophageal hiatal hernia may affect the efficacy of MUSE. (www.chictr.org.cn, ChiCTR2000034350).
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Affiliation(s)
- Lihua Peng
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rong Wan
- Department of Gastroenterology, Shanghai First People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shengliang Chen
- Department of Gastroenterology, Renji Hospital of Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jimin Wu
- Department of Gastroesophageal Reflux Disease, Chinese PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Jing Yang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaoxiao Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Bin Yan
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Huijun Zhao
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Fei Pan
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yichao Shi
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Weifeng Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Ai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yunsheng Yang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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14
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Aslam N, Telese A, Sehgal V, Sweis R, Lovat LB, Haidry R. Minimally invasive endoscopic therapies for gastro-oesophageal reflux disease. Frontline Gastroenterol 2023; 14:249-257. [PMID: 37056318 PMCID: PMC10086720 DOI: 10.1136/flgastro-2022-102343] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/02/2023] [Indexed: 04/15/2023] Open
Abstract
The prevalence of the gastro-oesophageal reflux disease (GORD) in the western world is increasing. Uncontrolled GORD can lead to harmful long-term sequela such as oesophagitis, stricture formation, Barrett's oesophagus and oesophageal adenocarcinoma. Moreover, GORD has been shown to negatively impact quality of life. The current treatment paradigm for GORD consists of lifestyle modification, pharmacological control of gastric acid secretion or antireflux surgery. In recent years, several minimally invasive antireflux endoscopic therapies (ARET) have been developed which may play a role in bridging the unmet therapeutic gap between the medical and surgical treatment options. To ensure optimal patient outcomes following ARET, considered patient selection is crucial, which requires a mechanistic understanding of individual ARET options. Here, we will discuss the differences between ARETs along with an overview of the current evidence base. We also outline future research priorities that will help refine the future role of ARET.
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Affiliation(s)
- Nasar Aslam
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Andrea Telese
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Vinay Sehgal
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rami Sweis
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Laurence B Lovat
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rehan Haidry
- Department of Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- Division of Gastroenterology, Cleveland Clinic, London, UK
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15
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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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16
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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: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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17
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Shibli F, Sandhu DS, Fass R. The Discrepancy Between Subjective and Objective Clinical Endpoints in Gastroesophageal Reflux Disease. J Clin Gastroenterol 2022; 56:375-383. [PMID: 35324484 DOI: 10.1097/mcg.0000000000001687] [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
Therapeutic outcome in gastroesophageal reflux disease (GERD) is commonly determined by both subjective and objective clinical endpoints. Clinicians frequently use symptom improvement as a key benchmark of clinical success, in conjunction with normalization of objective parameters such as esophageal acid exposure and inflammation. However, GERD therapeutic trials have demonstrated that a substantial number of patients rendered asymptomatic, whether through medical, surgical, or endoscopic intervention, continue to have persistent abnormal esophageal acid exposure and erosive esophagitis. The opposite has also been demonstrated in therapeutic trials, where patients remained symptomatic despite normalization of esophageal acid exposure and complete resolution of esophageal inflammation. Moreover, there is no substantive evidence that symptomatic response to antireflux treatment requires complete esophageal mucosal healing or normalization of esophageal acid exposure. Thus, it appears that a certain level of improvement in objective parameters is needed to translate into meaningful changes in symptoms and health-related quality of life of GERD patients. This supports the need to reconsider the commonly used "hard" clinical endpoints to evaluate therapeutic trials in GERD.
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Affiliation(s)
- Fahmi Shibli
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH
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18
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Yeh JH, Lee CT, Hsu MH, Lin CW, Hsiao PJ, Chen CL, Wang WL. Antireflux mucosal intervention (ARMI) procedures for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Therap Adv Gastroenterol 2022; 15:17562848221094959. [PMID: 35509424 PMCID: PMC9058334 DOI: 10.1177/17562848221094959] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic treatments are increasingly being offered for refractory gastroesophageal reflux disease (GERD). Three procedures have similar concepts and techniques: antireflux mucosectomy (ARMS), antireflux mucosal ablation (ARMA), and antireflux band ligation (ARBL); we have collectively termed them antireflux mucosal intervention (ARMI). Here, we systematically reviewed the clinical outcomes and technical aspects. METHODS The PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. The primary outcome was the clinical success rate. The secondary outcomes were acid exposure time, DeMeester score, need for proton pump inhibitors (PPIs), endoscopic findings, and adverse events. RESULTS Fifteen studies were included. The pooled clinical success rate was 73.8% (95% confidence interval (CI) = 69%-78%) overall, 68.6% (95% CI = 62.2%-74.4%) with ARMS, 86.7% (95% CI = 78.7%-91.9%) with ARMA, and 76.5% (95% CI = 65%-85.1%) with ARBL. ARMI resulted in significantly improved acid exposure time, DeMeester score, and degree of hiatal hernia. Furthermore, 10% of patients had dysphagia requiring endoscopic dilatation after ARMS or ARMA, and ARMS was associated with a 2.2% perforation rate. By contrast, no bleeding, perforation, or severe dysphagia was noted with ARBL. Severe hiatal hernia (Hill grade III) may predict treatment failure with ARMA. CONCLUSIONS The three ARMI procedures were efficacious and safe for PPI-refractory GERD. ARMA and ARBL may be preferred over ARMS because of fewer adverse events and similar efficacy. Further studies are necessary to determine the optimal technique and patient selection.
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Affiliation(s)
- Jen-Hao Yeh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Hospital, KaohsiungDepartment of Medical Technology, College of Medicine, I-Shou University, KaohsiungDivision of Gastroenterology and Hepatology Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung
| | - Ching-Tai Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Hospital, Kaohsiung
| | - Min-Hung Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Hospital, Kaohsiung
| | - Chi-Wen Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Hospital, KaohsiungDivision of Gastroenterology and Hepatology Department of Internal Medicine, E-DA Dachang Hospital, KaohsiungSchool of Medicine, College of Medicine, I-Shou University, Kaohsiung
| | - Po-Jen Hsiao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, HualienInstitute of Medical Sciences, Tzu Chi University, HualienSchool of Medicine, Tzu Chi University, HualienDivision of Gastroenterology, Department of Internal Medicine, HualienTzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien
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19
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Kuribayashi S, Hosaka H, Nakamura F, Nakata K, Sato K, Itoi Y, Hashimoto Y, Kasuga K, Tanaka H, Uraoka T. The role of endoscopy in the management of gastroesophageal reflux disease. DEN OPEN 2022; 2:e86. [PMID: 35310713 PMCID: PMC8828240 DOI: 10.1002/deo2.86] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/14/2021] [Accepted: 11/27/2021] [Indexed: 11/05/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disease that may cause a huge economic burden. Endoscopy is performed not only to rule out other organic diseases but also to diagnose reflux esophagitis or Barrett's esophagus. Non‐erosive GERD (non‐erosive reflux disease [NERD]) is called endoscopy‐negative GERD; however, GERD‐related findings could be obtained through histological assessment, image‐enhanced endoscopy, and new endoscopic modalities in patients with NERD. Moreover, endoscopy is useful to stratify the risk for the development of GERD. In addition, endoscopic treatments have been developed. These techniques could significantly improve patients’ quality of life as well as symptoms.
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Affiliation(s)
- Shiko Kuribayashi
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Hiroko Hosaka
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Fumihiko Nakamura
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Ko Nakata
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Keigo Sato
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Yuki Itoi
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Yu Hashimoto
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Kengo Kasuga
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Hirohito Tanaka
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Gunma Japan
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20
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Mann R, Gajendran M, Perisetti A, Goyal H, Saligram S, Umapathy C. Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions. Front Med (Lausanne) 2021; 8:728696. [PMID: 34912815 PMCID: PMC8666712 DOI: 10.3389/fmed.2021.728696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Gastroenterology and Advanced Endoscopy, Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Rettura F, Bronzini F, Campigotto M, Lambiase C, Pancetti A, Berti G, Marchi S, de Bortoli N, Zerbib F, Savarino E, Bellini M. Refractory Gastroesophageal Reflux Disease: A Management Update. Front Med (Lausanne) 2021; 8:765061. [PMID: 34790683 PMCID: PMC8591082 DOI: 10.3389/fmed.2021.765061] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
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Affiliation(s)
- Francesco Rettura
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Bronzini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michele Campigotto
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christian Lambiase
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Pancetti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ginevra Berti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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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: 17] [Impact Index Per Article: 4.3] [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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Chen S, Du F, Zhong C, Liu C, Wang X, Chen Y, Wang G, Gao X, Zhang L, Li L, Wu W. Gastroesophageal reflux disease: recent innovations in endoscopic assessment and treatment. Gastroenterol Rep (Oxf) 2021; 9:383-391. [PMID: 34733523 PMCID: PMC8560030 DOI: 10.1093/gastro/goab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/19/2022] Open
Abstract
Innovations in endoscopy have brought about some impressive improvements in diagnosing and treating gastroesophageal reflux disease (GERD). GERD, as one of the most prevalent gastrointestinal disorders in the world, has always been on the cutting edge of endoscopic interventions. A primary diagnosis of GERD is based on symptoms and an initial trial of proton-pump inhibitor (PPI) therapy, which is devoid of adequately instructive value for therapeutic strategies. Endoscopy and optional biopsies can be used to directly observe and determine the abnormal structural and pathophysiological damage in the esophagus. The emergence of minimally invasive endoscopic therapy fills the gap between patients who are reluctant or insensitive to PPIs and candidates who are not indicated for surgical anti-reflux fundoplication. In this review, we discuss the utility of endoscopy and biopsy in patients with persistent GERD-related manifestations after proper medical anti-reflux treatment. Moreover, we portray a landscape of four current endoscopic GERD therapies and clarify the merits and disadvantages of each technique. Future research needs to concentrate on stratifying GERD patients based on personal conditions and elucidating the primary pathophysiology of GERD.
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Affiliation(s)
- Sheng Chen
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Feng Du
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Internal Medicine, The Hospital of the People's Liberation Army 63650 Corps, Malan, Xinjiang, P. R. China
| | - Changqing Zhong
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Caifang Liu
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Medical University, Xi’an, Shaanxi, P. R. China
| | - Xiaoying Wang
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Yan Chen
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Gang Wang
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Otorhinolaryngology Head and Neck Surgery, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Xiaopei Gao
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Lu Zhang
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Lianyong Li
- Department of Gastroenterology, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
| | - Wei Wu
- State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
- Department of Otorhinolaryngology Head and Neck Surgery, PLA Strategic Support Force Characteristic Medical Center, Beijing, P. R. China
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24
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Walsh PR, Lamba M, Benias P, Lafta A, Hopkins G. Feasibility of resection and plication "RAP" technique for management of medically refractory GERD in patients with altered gastric anatomy. Endosc Int Open 2021; 9:E1549-E1555. [PMID: 34540549 PMCID: PMC8445683 DOI: 10.1055/a-1535-1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/16/2021] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Gastroesophageal reflux disease (GERD) is common, especially in patients after gastric surgery. Medical management of GERD is ineffective in up to 30 % patients and revisional gastric surgery for management of GERD is associated with higher morbidity. We aimed to assess the safety, feasibility, and efficacy of a novel endoscopic resection and plication (RAP) anti-reflux procedure for management of medically refractory GERD in patients with altered gastric anatomy. Patients and methods The RAP procedure involves endoscopic mucosal resection and full-thickness plication over the right posterior-medial axis extending 15 mm above and 20 to 30 mm below the squamocolumnar junction. Adverse events, technical feasibility, GERD health-related quality-of-life (GERD-HRQL) scores, and medication use were prospectively recorded. Results Twenty consecutive patients with previous gastric surgery underwent RAP between September 2018 and August 2020 with a median follow-up of 5.7 months. The median procedure duration was 66 minutes (IQR 53.8-89.5). RAP was technically successful in 19 patients. One patient developed gastric hemorrhage from suture dehiscence, which was managed endoscopically, and four patients developed esophageal stricture requiring endoscopic dilation. Following the RAP procedure, significant improvement in GERD-HRQL score was observed (mean 26.9, 95 %CI 23.36-30.55, P < 0.01). Fourteen of 19 patients reported > 50 % improvement in GERD-HRQL scores. Sixteen of 18 patients reported reduction in requirement for or cessation of antacid therapy. Conclusions Patients with refractory GERD after gastric surgery have limited therapeutic options. We have demonstrated that the RAP procedure is feasible, safe, and clinically effective at short-term follow-up. It provides a potential alternative to revisional surgery in patients with altered gastric anatomy.
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Affiliation(s)
- Patrick R. Walsh
- St. Vincent’s Private Hospital Northside, Chermside, Australia,Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - Mehul Lamba
- Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - Petros Benias
- Division of Gastroenterology, North Shore-Long Island Jewish Medical Center, Zucker school of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, United States
| | - Abdulnasser Lafta
- Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - George Hopkins
- St. Vincent’s Private Hospital Northside, Chermside, Australia,Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
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25
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Tschoner A. [Update on Endoscopic Therapies for the Treatment of GERD: GERDX, MUSE, EsophyX]. Zentralbl Chir 2021; 146:188-193. [PMID: 33851381 DOI: 10.1055/a-1333-3751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Gastroesophageal reflux disease (GERD) has been a problem for patients throughout in recent decades worldwide and its prevalence is increasing. Until 20 years ago, the established treatments were the proton pump inhibitors (PPI) and varieties of laparoscopic fundoplication (LF). Increasing experience with endoscopy and knowledge of the oesophagogastric junction (EGJ) has led to new options in the treatment of GERD. However, promising short term effects have been found with radiofrequency ablation (RFA, Stretta device), endoscopic mucosal resection (ARMS) for induction of scar tissue at the lower oesophageal sphincter (LES) and endoscopic suture devices like GERDX, MUSE and EsophyX to reconstruct the flap valve at the EGJ. Long-term follow-up data and randomised controlled studies in comparison to LF are still rare.
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Affiliation(s)
- Andreas Tschoner
- Abteilung für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Ordensklinikum Linz, Barmherzige Schwestern Hospital, Österreich
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26
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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: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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: 26] [Impact Index Per Article: 5.2] [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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Monino L, Gonzalez JM, Vitton V, Barthet M. Antireflux mucosectomy band in treatment of refractory gastroesophageal reflux disease: a pilot study for safety, feasibility and symptom control. Endosc Int Open 2020; 8:E147-E154. [PMID: 32010747 PMCID: PMC6976317 DOI: 10.1055/a-1038-4012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Antireflux mucosectomy band ligation (ARM-b) is an endoscopic procedure that mimics a fundoplication for managing gastroesophoageal reflux disease (GERD). The aim of this study was to assess safety and feasibility of ARM-b. Patients and methods This was a single-center study on consecutive patients operated between June 2017 and January 2019 with refractory GERD, confirmed with pH-metry and without motility disorder at high-resolution manometry. A piecemeal mucosectomy of three quarters of circumference of esophagogastric junction was performed using a band ligation system and a hexagonal snare. The primary objective was to assess procedural safety and feasibility. The secondary objective was to document the clinical improvement at 3 and 6 months based on patient satisfaction, proton pump inhibitor (PPI) intake, symptoms, and quality of life scores. Results Twenty-onepatients (11 men) with mean age 56.9 ± 14.4 years were analyzed. The technical success rate was 100 % (mean duration 35 ± 11 min). Four patients (19 %) had mild adverse events: one delayed bleeding at Day 1 managed conservatively, and three dysphagia endoscopically managed. Mean follow-up was 10 ± 5 months. Decrease/discontinuation of PPI intake was 76 % at 3 months and 72 % at 6 months. Improvement in mean symptoms and quality of life scores (GERD-Q and GERD-HQL) were statistically significant. One patient required laparoscopic fundoplication after ARM-b failure without complication. Conclusion ARM-b is safe, feasible, and symptom-effective for treating refractory GERD, and it can be performed in the ambulatory setting. Further prospective studies are required to confirm these promising outcomes.
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Affiliation(s)
- Laurent Monino
- Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium,Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France,Corresponding author Laurent Monino, MD Department of HepatogastroenterologyAP-HM, Aix-Marseille UniversitéHôpital NordChemin des Bourrely13015 MarseilleFrance+33-4-91968737
| | - Jean-Michel Gonzalez
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
| | - Véronique Vitton
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
| | - Marc Barthet
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
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Nabi Z, Reddy DN. Update on Endoscopic Approaches for the Management of Gastroesophageal Reflux Disease. Gastroenterol Hepatol (N Y) 2019; 15:369-376. [PMID: 31391807 PMCID: PMC6676348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered gastrointestinal diseases in outpatient clinics. Proton pump inhibitors (PPIs) are the cornerstone of the treatment of GERD. However, approximately one-third of patients have suboptimal response to PPIs. The management options in such cases include antireflux surgery or endoscopic antireflux treatments. Antireflux surgery is not popular due to its invasive nature and potential for adverse events. Therefore, minimally invasive endoscopic antireflux therapies are gaining popularity for the management of PPI-dependent and PPI-refractory GERD. These endoscopic therapies include radiofrequency application, endoscopic fundoplication modalities, and mucosal resection techniques. In appropriately selected patients, the response to these endoscopic modalities is encouraging. Unlike surgical fundoplication, endoscopic antireflux therapies are less likely to be associated with complications such as dysphagia and gas-bloat syndrome. On the other hand, antireflux surgery remains the ideal treatment in patients with a large hiatal hernia (laparoscopic Nissen fundoplication), morbid obesity (gastric bypass), and severe reflux esophagitis. Endoscopic treatment modalities bear the potential to narrow the treatment gap between PPIs and antireflux surgery. Long-term follow-up studies and randomized comparison with antireflux surgery are required to provide a clear understanding of the current role of endoscopic modalities in patients with PPI-refractory and PPI-dependent GERD.
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Affiliation(s)
- Zaheer Nabi
- Dr Nabi is a consultant gastroenterologist and Dr Reddy is chairman and chief gastroenterologist at the Asian Institute of Gastroenterology in Hyderabad, India
| | - D Nageshwar Reddy
- Dr Nabi is a consultant gastroenterologist and Dr Reddy is chairman and chief gastroenterologist at the Asian Institute of Gastroenterology in Hyderabad, India
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A Prospective Randomized Trial to Assess the Antireflux Effect of Antireflux Mucosectomy in the Porcine Model. Gastroenterol Res Pract 2019; 2019:3286738. [PMID: 30944560 PMCID: PMC6421794 DOI: 10.1155/2019/3286738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/30/2018] [Accepted: 12/30/2018] [Indexed: 12/13/2022] Open
Abstract
Background Both long-term proton pump inhibitor use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). Our aim was to investigate the potential efficacy of antireflux mucosectomy (ARMS) in porcine and determine the optimal circumference of resection in relation to gastroesophageal junction (GEJ). Methods Nine pigs were allocated into the following 3 groups by computerized randomization: group A: control, group B: 1/3 circumference of the esophagus, and group C: 2/3 circumference of the esophagus. We performed mucosectomy with a crescentic mucosal resection at 3 cm above the GEJ and 1 cm below the GEJ. The animals were kept on a liquid diet for 24 h prior to endoscopy. At 6 weeks, animals underwent esophagoscopy, barium radiography, gastric yield pressure (GYP), and gastric yield volume (GYV) determination. Results The weight of swines has no significant difference, and all pigs had maintained their weight after the procedure. We both found scar formation at the GEJ in group B and C. Compared with group A and B, group C produced significantly higher GYP (24.23 ± 3.42 mmHg, p = 0.004) and significantly smaller GYV (2200.0 ± 238.96 mL, p = 0.028) after 6 weeks. Barium radiography showed that the width of the cardia was narrower (13.73 ± 1.19 mm, p = 0.032) in group C after 6-week postprocedure. Conclusion Our study demonstrated the potential antireflux effect of ARMS. We also recommend the 2/3 circumference resection of mucosa at 3 cm distance from the GEJ.
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Mayor MA, Fernando HC. Endoluminal Approaches to Gastroesophageal Reflux Disease. Thorac Surg Clin 2018; 28:527-532. [DOI: 10.1016/j.thorsurg.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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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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Zadeh J, Andreoni A, Treitl D, Ben-David K. Spotlight on the Linx™ Reflux Management System for the treatment of gastroesophageal reflux disease: evidence and research. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:291-300. [PMID: 30214323 PMCID: PMC6124788 DOI: 10.2147/mder.s113679] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device. METHODS A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review. CONCLUSION After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed.
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Affiliation(s)
- Jonathan Zadeh
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Anthony Andreoni
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Daniela Treitl
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
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Coronel MA, Bernardo WM, Moura DTHD, Moura ETHD, Ribeiro IB, Moura EGHD. THE EFFICACY OF THE DIFFERENT ENDOSCOPIC TREATMENTS VERSUS SHAM, PHARMACOLOGIC OR SURGICAL METHODS FOR CHRONIC GASTROESOPHAGEAL REFLUX DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:296-305. [PMID: 30540095 DOI: 10.1590/s0004-2803.201800000-65] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/14/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic antireflux treatments for gastroesophageal reflux disease (GERD) are still evolving, and most of the published studies address symptom relief in the short-term. Objective - We aimed to perform a systematic review and meta-analysis focused on evaluating the efficacy of the different endoscopic procedures. METHODS Search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane, SciELO, and EMBASE for patients with chronic GERD (>6 months), over 18 years old and available follow up of at least 3 months. The main outcome was to evaluate the efficacy of the different endoscopic treatments compared to sham, pharmacological or surgical treatment. Efficacy was measured by different subjective and objective outcomes. RESULTS We analyzed data from 16 RCT, totaling 1085 patients. The efficacy of endoscopic treatments compared to sham and proton pump inhibitors (PPIs) treatment showed a significant difference up to 6 months in favor of endoscopy with no heterogeneity (P<0.00001) (I2: 0%). The subgroup analysis showed a statistically significant difference up to 6 months in favor of endoscopy: endoscopy vs PPI (P<0.00001) (I2: 39%). Endoscopy vs sham (P<0.00001) (I2: 0%). Most subjective and objective outcomes were statistically significant in favor of endoscopy up to 6 and 12 months follow up. CONCLUSION This systematic review and meta-analysis shows a good short-term efficacy in favor of endoscopic procedures when comparing them to a sham and pharmacological or surgical treatment. Data on long-term follow up is lacking and this should be explored in future studies.
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Affiliation(s)
- Martin Andrés Coronel
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
| | - Eduardo Turiani Hourneaux de Moura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
| | - Igor Braga Ribeiro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
| | - Eduardo Guimarães Hourneaux de Moura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Endoscopia Avançada Gastrointestinal, São Paulo, SP, Brasil
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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: 1.9] [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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Akiyama J, Kuribayashi S, Baeg MK, Bortoli N, Valitova E, Savarino EV, Kusano M, Triadafilopoulos G. Current and future perspectives in the management of gastroesophageal reflux disease. Ann N Y Acad Sci 2018; 1434:70-83. [PMID: 29766521 DOI: 10.1111/nyas.13850] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/28/2018] [Accepted: 04/06/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Junichi Akiyama
- Division of Gastroenterology and HepatologyNational Center for Global Health and Medicine Tokyo Japan
| | - Shiko Kuribayashi
- Division of Gastroenterology and Hepatology, Integrative Center of Internal MedicineGunma University Hospital Maebashi Japan
| | - Myong Ki Baeg
- Division of Gastroenterology, Department of Internal MedicineCatholic Kwandong University College of Medicine, International St. Mary's Hospital Incheon South Korea
| | - Nicola Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of Pisa Pisa Italy
| | - Elen Valitova
- Department of Upper Gastrointestinal Tract DisordersClinical Scientific Centre Moscow Russia
| | - Edoardo V. Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and GastroenterologyUniversity of Padua Padua Italy
| | - Motoyasu Kusano
- Division of Gastroenterology and Hepatology, Integrative Center of Internal MedicineGunma University Hospital Maebashi Japan
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Richter JE, Kumar A, Lipka S, Miladinovic B, Velanovich V. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology 2018; 154:1298-1308.e7. [PMID: 29305934 DOI: 10.1053/j.gastro.2017.12.021] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The effects of transoral incisionless fundoplication (TIF) and laparoscopic Nissen fundoplication (LNF) have been compared with those of proton pump inhibitors (PPIs) or a sham procedure in patients with gastroesophageal reflux disease (GERD), but there has been no direct comparison of TIF vs LNF. We performed a systematic review and network meta-analysis of randomized controlled trials to compare the relative efficacies of TIF vs LNF in patients with GERD. METHODS We searched publication databases and conference abstracts through May 10, 2017 for randomized controlled trials that compared the efficacy of TIF or LNF with that of a sham procedure or PPIs in patients with GERD. We performed a network meta-analysis using Bayesian methods under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve. RESULTS Our search identified 7 trials comprising 1128 patients. Surface under the cumulative ranking curve ranking indicated TIF had highest probability of increasing patients' health-related quality of life (0.96), followed by LNF (0.66), a sham procedure (0.35), and PPIs (0.042). LNF had the highest probability of increasing percent time at pH <4 (0.99), followed by PPIs (0.64), TIF (0.32), and the sham procedure (0.05). LNF also had the highest probability of increasing LES pressure (0.78), followed by TIF (0.72) and PPIs (0.01). Patients who underwent the sham procedure had the highest probability for persistent esophagitis (0.74), followed by those receiving TIF (0.69), LNF (0.38), and PPIs (0.19). Meta-regression showed a shorter follow-up time as a significant confounder for the outcome of health-related quality of life in studies of TIF. CONCLUSIONS In a systematic review and network meta-analysis of trials of patients with GERD, we found LNF to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4. Although TIF produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, we do not recommend it as a long-term alternative to PPI or LNF treatment of GERD.
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Affiliation(s)
- Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Morsani College of Medicine, Tampa, Florida.
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Branko Miladinovic
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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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: 25] [Impact Index Per Article: 3.6] [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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Mermelstein J, Chait Mermelstein A, Chait MM. Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions. Clin Exp Gastroenterol 2018; 11:119-134. [PMID: 29606884 PMCID: PMC5868737 DOI: 10.2147/ceg.s121056] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.
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Affiliation(s)
- Joseph Mermelstein
- Gasteroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alanna Chait Mermelstein
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maxwell M Chait
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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40
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Labenz J, Gross M. [Gastroesophageal reflux disease beyond PPI]. MMW Fortschr Med 2018; 160:40-44. [PMID: 29417512 DOI: 10.1007/s15006-018-0149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Joachim Labenz
- Diakonie Klinikum, Jung-Stilling Krankenhaus, Wichernstr. 40, D-57074, Siegen, Deutschland.
| | - Manfred Gross
- Internistisches Klinikum München Süd, München, Deutschland
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41
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Rouphael C, Padival R, Sanaka MR, Thota PN. Endoscopic Treatments of GERD. ACTA ACUST UNITED AC 2018; 16:58-71. [DOI: 10.1007/s11938-018-0170-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Nikonov EL. [Surgical treatment of the diaphragmatic hernia and the possibility of new endoscopic procedures]. Khirurgiia (Mosk) 2018:96-105. [PMID: 29798999 DOI: 10.17116/hirurgia2018596-105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- E L Nikonov
- N.I. Pirogov Russian National Research Medical University, Moscow, Russia
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43
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Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:302-318. [PMID: 28827081 DOI: 10.1053/j.gastro.2017.07.049] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 02/06/2023]
Abstract
Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio.
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44
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Triadafilopoulos G. Novel Endoscopic Antireflux Procedures: Do They Have a Role in Patients with Hiatus Hernia? HIATAL HERNIA SURGERY 2018:105-122. [DOI: 10.1007/978-3-319-64003-7_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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45
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Thosani N, Goodman A, Manfredi M, Navaneethan U, Parsi MA, Smith ZL, Sullivan SA, Banerjee S, Maple JT. Endoscopic anti-reflux devices (with videos). Gastrointest Endosc 2017; 86:931-948. [PMID: 29054276 DOI: 10.1016/j.gie.2017.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
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Abstract
OPINION STATEMENT Dysphagia is a common problem in the elderly population with an especially high prevalence in hospitalized and institutionalized patients. If inadequately addressed, dysphagia leads to significant morbidity and contributes to decreased quality of life. Dysphagia can be categorized as emanating from either an oropharyngeal or esophageal process. A disproportionate number of elderly patients suffer from oropharyngeal dysphagia with a multifactorial etiology. Historically, treatment options have been limited and included mostly supportive care with a focus on dietary modification, food avoidance, and swallow rehabilitation. Nascent technologies such as the functional luminal imaging probe (FLIP) and advances in esophageal manometry are improving our understanding of the pathophysiology of oropharyngeal dysphagia. Recent developments in the treatment of specific causes of oropharyngeal dysphagia, including endoscopic balloon dilations for upper esophageal sphincter (UES) dysfunction, show promise and are expected to enhance with further research. Esophageal dysphagia is also common in the elderly and more commonly due to an identifiable cause. The full breadth of treatment options is frequently unavailable to elderly patients due to comorbidities and overall functional status. However, the increasing availability of less invasive solutions to specific esophageal pathologies has augmented the number of treatment options available to this population, where an individualized approach to patient care is paramount. This review focuses on the evaluation and management of dysphagia in the elderly and delineates how standard and novel therapeutics are contributing to more nuanced and personalized management.
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Affiliation(s)
- Scott M Smukalla
- Department of Gastroenterology, Center for Esophageal Disease, NYU School of Medicine, 240 East 38th St., 23rd Floor, New York, NY, 10016, USA
| | - Irina Dimitrova
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | | | - Abraham Khan
- Department of Gastroenterology, Center for Esophageal Disease, NYU School of Medicine, 240 East 38th St., 23rd Floor, New York, NY, 10016, USA.
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Interim Report of a Prospective Trial on the Clinical Efficiency of a New Full-thickness Endoscopic Plication Device for Patients With GERD: Impact of Changed Suture Material. Surg Laparosc Endosc Percutan Tech 2017; 27:163-169. [DOI: 10.1097/sle.0000000000000396] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Asche KU, Kaindlstorfer A, Pointner R. [Surgical and interventional procedures for reflux therapy : Endoscopic or laparoscopic?]. Chirurg 2017; 88:188-195. [PMID: 28180974 DOI: 10.1007/s00104-017-0369-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
An optimal functioning of the gastroesophageal antireflux barrier depends on an anatomical overlapping of the lower esophageal sphincter and the crural diaphragm. Restoration of this situation is currently only possible by antireflux interventions combined with hiatoplasty and necessitates a laparoscopic approach. Newer alternative techniques to the generally accepted fundoplication are laparoscopic implantation of the LINX® device or the EndoStim® system and various endoscopic antireflux procedures, such as radiofrequency energy treatment, plication and implantation techniques aimed at augmentation of the gastroesophageal valve. Endoscopic techniques are becoming established more and more between pharmaceutical and surgical therapy instead of replacing them.
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Affiliation(s)
- K U Asche
- Allgemein- und Viszeralchirurgie, A.ö. Tauernklinikum GmbH Standort Zell am See, Paracelsusstr. 8, 5700, Zell am See, Österreich.
| | - A Kaindlstorfer
- Allgemein- und Viszeralchirurgie, A.ö. Tauernklinikum GmbH Standort Zell am See, Paracelsusstr. 8, 5700, Zell am See, Österreich
| | - R Pointner
- Allgemein- und Viszeralchirurgie, A.ö. Tauernklinikum GmbH Standort Zell am See, Paracelsusstr. 8, 5700, Zell am See, Österreich
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Triadafilopoulos G. Endoscopic Options for Gastroesophageal Reflux: Where Are We Now and What Does the Future Hold? Curr Gastroenterol Rep 2017; 18:47. [PMID: 27424219 DOI: 10.1007/s11894-016-0521-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Early in the twenty-first century, novel endoscopic techniques were introduced for the management of gastroesophageal reflux disease, providing minimally invasive ways to eliminate pharmacologic acid inhibition and avoid the need for anti-reflux surgery. These techniques do not significantly alter the anatomy of the gastroesophageal junction, minimizing short- and long-term adverse effects, such as dysphagia and bloating. After extensive clinical testing, many endoscopic therapies were abandoned due to either lack of durable efficacy or unfavorable safety profile. Today, only four such therapies remain clinically available, each with variable levels of clinical validation and market penetration. This review will provide an assessment of these endoscopic therapies, highlighting their respective strengths and weaknesses and their present and future applicability to patients with gastroesophageal reflux disease.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M-211, Stanford, CA, 94306, USA.
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50
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Brar TS, Draganov PV, Yang D. Endoluminal Therapy for Gastroesophageal Reflux Disease: In Between the Pill and the Knife? Dig Dis Sci 2017; 62:16-25. [PMID: 27796767 DOI: 10.1007/s10620-016-4355-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/17/2016] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a chronic disease characterized by symptoms of heartburn and acid regurgitation. Uncontrolled GERD can significantly impact quality of life, can lead to complications, and increases the risk of esophageal cancer. Over the past few decades, there has been an increasing prevalence of GERD among adults in Western populations. The use of proton pump inhibitors (PPI) in conjunction with lifestyle modifications remains the mainstay therapy. However, the efficacy of this intervention is often hampered by adherence, costs, and the risks of long-term PPI use. Anti-reflux surgery is an option for patients with refractory symptoms or in those in whom medical therapy is contraindicated or not desirable. While conventional surgery has an acceptable safety profile, there has been an increasing interest in alternate treatments that may potentially offer similar results and be associated with a faster recovery. Recent advances in interventional endoluminal techniques have introduced novel incisionless anti-reflux procedures. While the current data are promising, further larger prospective studies are needed in order to assess the long-term efficacy of endoluminal therapies and its place among the treatment options for GERD.
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Affiliation(s)
- Tony S Brar
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5251, Gainesville, FL, 32608, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5251, Gainesville, FL, 32608, USA.
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