Patient selection is crucial for appropriate endoscopic management of GERD

David P. Lee, MD,
Methodist Digestive Institute,
Dallas Methodist Medical Center

Evidence suggests that many advances in the endoscopic management of GERD have made this approach viable for larger subgroups of patients with the disease in recent years. With a growing pool of treatment candidates and multiple endoscopic management options, careful patient selection is essential to ensure patients are matched with the most appropriate treatment, according to David P. Lee, MD, and Kenneth J. Chang , MD. For an article published in Digestive Diseases and Sciencesthey describe strategies that clinicians can use to identify the most appropriate endoscopic procedure for their patients.

“Endoscopic GERD treatments are now considered appropriate for patients on the early GERD spectrum, as well as those with altered anatomy, where standard laparoscopic surgical approaches are limited,” write Drs. Lee and Chang.

Kenneth J. Chang, MD

Kenneth J. Chang, MD,
Professor and Chef,
Gastroenterology Department,
Executive Director,
HH Chao Comprehensive Center for Digestive Diseases,
Medicine School,
University of California Irvine

They note that “a variety of endoscopic options have emerged to bridge the gap between medical and surgical management of GERD.” This is an important development, especially as an increasing number of risks have been associated with proton pump inhibitors (PPIs), which remain the mainstay of treatment for GERD; surgical procedures such as Nissen fundoplication have been associated with several uncomfortable adverse effects (AEs), including gas and bloating.

Drs. Lee and Chang explain that three endoscopic devices are currently FDA-approved to treat GERD:

–Stretta system, which was approved in 2000 and uses radiofrequency energy to improve reflux symptoms.

-Esophyx-Z, which received approval in 2007 and facilitates incisionless transoral fundoplication (TIF).

-OverStitch, which received approval in 2008 and allows endoscopic suture.

Energy treatment by radio frequency

Stretta is indicated for patients who are not candidates for medical treatment or who have concerns about long-term adverse effects associated with PPIs and who are not eligible or do not wish to undergo surgery. The approach is contraindicated in patients under the age of 18, pregnant women, poor surgical candidates, and patients with a hiatal hernia greater than 2 cm, demonstrated achalasia, or incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing, an American Society of Anesthesiology (ASA) IV, or without a diagnosis of GERD.

Drs. Lee and Chang note that patients with normal gastrointestinal anatomy are best suited for the Stretta procedure. “These patients have normal LES tone, no hiatal hernia, and a closed diaphragmatic hiatus (Hill Grade I),” they explain, noting that this finding is called dynamic failure, as no anatomical defects are evident and the primary mechanism of GERD in these patients is attributed to inappropriate transient relaxation of the lower esophageal sphincter. The success of the procedure is more likely in patients who have shown a response to antisecretory pharmacological treatment.

TIF

Drs. Lee and Chang note that patients being considered for FIT “must have a clear indication for an anti-reflux procedure.” Once the candidacy is established, clinicians must determine if their patient is best served with TIF alone or if concurrent laparoscopic hernia repair (cTIF) is warranted. “There are three components of anti-reflux anatomy to assess: (1) whether there is a hiatal hernia that needs to be reduced, (2) whether the right crura, which acts like a sling or noose around of the [gastroesophageal junction (GEJ)]needs to be tightened, and (3) whether the LES needs to have valve reconstruction,” they write.

The authors explain that hiatal hernia can be assessed via esophagus or upper endoscopy, but caution that either modality can miss sliding hernias. To assess the axial width of the crural opening, they recommend using Hill’s classification in retroflex view, adding that a full 60 seconds should be spent in retroflexion with active insufflation to improve accuracy, since in their experience an inaccurate assessment Hill grade is the most common reason for FIT failure.

“A Hill grade 1 or 2 is acceptable for TIF alone,” they write. “However, if the hiatus is open more than 2 cm (or diameter of 2 endoscopes, i.e. Hill 3), or if there is an axial hernia length of more than 2 cm (Hill 4) , the patient will most likely require crural repair, which cannot be accomplished with TIF alone. We call this the 2×2 rule.

Endoscopic suture

A variety of endoscopic suturing techniques have been explored in the literature, with some showing more benefit than others. Among the most promising, Drs. Lee and Chang include mucosal removal and suturing of the esophagogastric junction (MASE) and resection and plication (RAP).

MASE is a technique developed by the pair which consists of applying argon plasma coagulation to the gastric mucosa under the GEJ to improve tissue apposition before suturing. Then three sutures are placed along the lesser curvature of the cardia directly below the esophagogastric junction to prevent stomach contents from flowing back into the esophagus.

“The MASE procedure represents a novel endoscopic treatment for GERD that may be particularly useful in the management of complex patients with GERD, including those with altered anatomy who may not be candidates for surgical or endoscopic fundoplication. “, they write.

RAP replaces the mucosal ablation used in MASE with mucosal resection, combining semicircumferential mucosectomy with full-thickness plication of the LES and cardia; however, Drs. Lee and Chang also performed a variation of this technique, with the resection and plications performed further back and toward the lesser curve, with some patients also receiving a second reinforcing suture.

“We are primarily considering performing the RAP procedure in GERD patients with altered anatomy where options for other surgeries or anti-reflux procedures are limited,” they added. “In patients where mucosal resection is not feasible (prior resection, ablation, scarring), we will consider the MASE technique.”

Martin E. Berry