Gastroesophageal reflux disease (GERD) is a clinical condition that can lead to esophagitis, esophageal strictures, aspiration, pneumonia, vocal cord inflammation, pulmonary dysfunction, Barrett esophagus, and esophageal cancer among others. Forty-four percent of the general population has some reflux and up to 10% of the population has daily reflux symptoms.1,2 Several factors have been known to contribute to GERD including LES function, hiatal hernias, esophageal dysmotility, and gastric delayed emptying. Surgical correction of reflux disease has demonstrated improvement in patient symptoms, correction of some pulmonary dysfunction, and may have a role in reducing the incidence of esophageal cancer.3 The most common surgical approach today is the laparoscopic Nissen fundoplication (Chapter 39), although other approaches such as the Toupet (Chapter 40) and the transthoracic Belsey (Chapter 38) procedures also have been utilized. Endoscopic treatment for reflux, however, has lagged both in terms of efficacy and durability. We review the attempted endoscopic approaches and the future outlook of endoscopic antireflux surgery.
Most endoscopic therapies have focused on trying to increase the resistance at the gastroesophageal (GE) junction.
The Stretta system uses radiofrequency ablation of the GE junction. This method utilizes a flexible catheter with a balloon. Four electrodes are placed into the surrounding tissue at the level of the LES. The probes reach the level of the submucosa and radiofrequency energy is applied, elevating the submucosal temperature to 85°C whereas a cold water infusion in the balloon keeps the mucosal temperature at 50°C. The procedure is repeated. The energy creates thermal lesions in the submucosa which cause scarring and tightening around the LES. In essence, a stricture is created at the LES, increasing resistance at the GE junction. Unfortunately, a randomized sham trial did not demonstrate any difference in any objective measure of reflux in these patients, although some did report a reduction in heartburn symptoms.4
Additional studies, to date, all have been characterized by short-term follow-ups of 6 to 12 months, small numbers of patients, and variable improvements in objective symptoms.5 Aziz et al.6 in 2010 reported on 30 patients with improvement in health-related quality-of-life (HRQL) scores, LES pressure, and pH scores of those patients off medication, although some patients experienced some delayed gastric emptying. Coron et al.7 in 2008 demonstrated that 18 of 20 patients were able to stop proton pump inhibitor (PPI) use, although there was no change in esophageal acid exposure.
One prospective nonrandomized comparison of the Stretta system with laparoscopic fundoplication demonstrated a superior outcome with the laparoscopic procedure. Patients in both groups had improvement of their quality of life and symptoms, but only 58% of patients in the Stretta group were able to discontinue medication compared to 97% of patients following the laparoscopic procedure, despite the fact that the Stretta group patients had less severe disease.8