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When PPIs fail

Dr Stuart Bloom and Dr George Webster review what is on offer when maximum doses of medical treatment no longer relieve GORD symptoms

Dr Stuart Bloom and Dr George Webster review what is on offer when maximum doses of medical treatment no longer relieve GORD symptoms

Endoscopic approach

Endoscopic gastroplication was developed in the 1990s by Swain. Currently there is only one commercial application (Endocinch, BARD), although other suturing devices are under development.

Radiofrequency-induced collagen remodelling has been commercialised in the Stretta procedure. Using a dedicated catheter a balloon is inflated up to 3cm and four needle electrodes are deployed into the muscular layer of the oesophagus. Each needle produces a lesion through a controlled rise in temperature up to 85°C. By rotating the catheter, a total of 50-60 lesions can be created in the areas around the gastro-

oesophageal junction.

Endoscopic submucosal injection into the cardia is best developed in the Enteryx procedure, using a non-biodegradable polymer which is injected into the muscle of the cardia. This transformed on contact with water into a foamy particle. Repeated injections result in circumferentially distributed patches of injected material. A similar principle is followed by the Gatekeeper system, developed by Medtronic.

Surgical approach

The procedure is performed laparoscopically or as an open operation, and involves mobilisation of the lower oesophagus, reduction of hiatus hernia and wrapping of the gastric fundus around the lower oesophagus either totally (such as with Nissan 360° fundoplication) or partially (as with Toupet 270° fundoplication). This re-establishes the competence of the anti-reflux barrier and increases the resting lower oesophageal sphincter pressure.

Patient selection

Patient selection is difficult, as there are no direct comparisons of medical therapy versus anti-reflux surgery, but indications may include:

• failed medical therapy, with persistent symptomatic oesophagitis

• young healthy patient who responds to medical therapy, but is unable or unwilling to take long-term medication

• recurrent reflux complications such as aryngitis, asthma and pneumonia.

Complications of surgery include dysphagia and air trapping, which may require reoperation, and have been reported in >10% following laparoscopic fundoplication.

Mortality rate is 0.2%, which is significant in a condition that runs a benign course in the great majority. There is no good evidence that surgical fundoplication reduces the risk of oesophageal tumours.

Outcome

Clinical outcome after endoscopic procedures is currently dependent on open label studies, except for one sham controlled randomised trial for the Stretta procedure. Available outcome data suggests a significant reduction in both symptoms and oesophageal acid exposure for the Endocinch, Enteryx and Stretta procedures, but controlled data is needed. The incidence of adverse events is falling with increasing operator experience: the current serious complication rate is estimated at 0.25%.

Long-term outcome results are awaited: the role of endoscopic anti-reflux procedures relative to maintenance medical therapy and surgical anti-reflux approaches remain to be defined.

Dr Stuart Bloom is consultant gastroenterologist at University College Hospital, London, and Dr George Webster is consultant gastroenterologist/hepatologist at University College Hospital London.

This article is an extract from the Oxford Handbook of Gastroenterology and Hepatology by Stuart Bloom and George Webster published by Oxford University Press, price £29.95. To order go to www.oup.co.uk/search and enter the ISBN (0-19-856652-2).

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