Heartburn, GERD, PPIs, Endoscopic Treatment, or Surgery

Is endoscopic therapy, rather than surgical therapy, a treatment option for gastroesophageal reflux disease (GERD)?

As more and more patients are interested in stopping chronic medical therapy with proton pump inhibitors (PPIs)—endoscopic therapy for the treatment of gastroesophageal reflux disease (GERD) is evolving.

Patients are also looking for alternatives to traditional antireflux surgery.

Both of the above are based on concerns raised about side effects and complications of the long-term use of PPIs, or surgery itself in the short and long-term. For more, you can read a past post on the Safety of Proton Pump Inhibitors (PPIs).

What is the goal of endoscopic therapy for GERD?

The goal of endoscopic therapy or surgical treatment of GERD is to strengthen the barrier to acid reflux. That "barrier" is the lower esophageal sphincter (LES). When not working normally, it allows gastroesophageal reflux to occur. Reflux is the stomach acid that goes back up into the esophagus. That is what causes the symptom if heartburn.

The goal of endoscopic therapy or surgical treatment of GERD is to strengthen the barrier to acid reflux.

Who is a good candidate for endoscopic therapy for GERD?

Someone who has:

• Typical symptoms of GERD (heartburn and regurgitation)

• Low-grade erosive esophagitis (Los Angeles Grades A and B)

• A negative upper endoscopy (EGD) with an abnormal esophageal acid (pH) test

• A hiatal hernia (if present) that is smaller than 3 cm

• A partial response to PPI treatment at a minimum

Who should be considered for endoscopic therapy for GERD?

Patients with:

• Poor compliance with medical therapy

• Desire to discontinue medical therapy

• Preference for a nonmedical, nonsurgical therapy

• No interest in antireflux surgery

Is there a role of endoscopic therapy for GERD in patients with atypical or extraesophageal presentations of GERD, such as cough or asthma?

There are not enough studies or information about the value of endoscopic therapy in these patients at this time.

There are not enough studies or information about the value of endoscopic therapy in patients at this time with atypical or extraesophageal presentations of GERD, such as cough or asthma

What endoscopic therapy options are available for GERD?

• Endoscopic radiofrequency ablation procedure (Stretta)

• Transoral incisionless fundoplication (TIF) procedure uses the EsophyX device

• Medigus Ultrasonic Surgical Endostapler (MUSE) procedure

What is the difference between the endoscopic therapy options available for GERD?

Again, the goal of endoscopic therapy or surgical treatment is to strengthen the barrier to acid reflux. That "barrier" is the lower esophageal sphincter (LES).

Endoscopic therapy options use either heat or fundoplication.

Fundoplication is where the upper portion of the stomach is wrapped around the lower end of the esophagus) with a suture or staple

• The Stretta procedure uses low-power, temperature-controlled, radiofrequency energy

• The TIF procedure (EsophyX) uses fundoplication

• The MUSE procedure uses fundoplication

Does it work compared with the use of PPIs or traditional surgical therapy?

The problem is that there are not many studies comparing the efficacy of endoscopic procedures to PPIs or the traditional surgical (Nissen) fundoplication.

One study demonstrated "61% of patients returned to PPIs"

Some takeaways points from the small studies that have been done.

• "Similar improvement in esophageal acid exposure in the short term (6 months)"

• "61% of patients returned to PPIs" (TIF)

• "Fewer reported improvement in GERD health-related quality of life at 6 months postprocedure than laparoscopic fundoplication"

• "Similar control of GERD symptoms and reduction in PPI use" (Stretta)

• "Less effect on improving the typical GERD"

Another study demostrated "Similar control of GERD symptoms and reduction in PPI use"

What are the main benefits of endoscopic therapy for GERD at this time?

It provides a therapeutic option, besides surgical intervention, to patients who cannot, or do not wish to take chronic PPI medications for GERD.

Also, endoscopic therapy is:

• An outpatient procedure

• Less expensive than surgical intervention

• Relatively safe

• Effective at controlling GERD symptoms

• Can improve health-related quality of life

What are the downsides of endoscopic therapy for GERD?

Endoscopic therapy should be performed by experts in therapeutic endoscopy who routinely perform these procedures. Bariatric surgeons typically fall in this category. They can also perform surgery as a backup

Endoscopic therapy should be performed by experts in therapeutic endoscopy who routinely perform these procedures.

Some downsides are the following.

• The long-term efficacy (i.e. the need for PPI therapy in addition)

• Esophageal acid exposure does not change or normalize in most patients

• There is a limited effect on healing erosive esophagitis (which can lead to Barrett's esophagus — a precancerous condition)

Reimbursement and insurance coverage for endoscopic therapy is also a limiting factor in clinical practice and is still viewed as "experimental/investigational" by many plans.

What are the risks associated with endoscopic therapy for GERD?

Major complications are uncommon, but may include:

• Bleeding

• Perforation

• Pneumothorax

• Mediastinal abscess

• Mucosal tear

Post-procedure symptoms can include:

• Dysphagia

• Chest pain

• Sore throat

• Bloating

Are there contraindications to endoscopic therapy for GERD?

Endoscopic therapy should be avoided in:

• Morbid obesity

• Scleroderma

• Past esophageal or gastric surgery

• Major esophageal motility (motor) disorders (i.e. achalasia, jackhammer esophagus, absent contractility, distal esophageal spasm, and esophagogastric junction outflow obstruction)

• Esophageal stricture

• Barrett's esophagus

• Esophageal or gastric varices

• Pregnant or lactating women

The bottom line of endoscopic therapy for GERD?

It works for some people who wish not to be on long-term PPI therapy, although even with the procedure, you may still need to be on medication for symptom control. Choose your doctor wisely, make sure they are experienced performing the procedure, make sure you are a good candidate, and ask questions.