- Brian Dooreck, MD
Heartburn, GERD, PPIs, Endoscopic Treatment, or Surgery
Updated: 3 days ago
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
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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.
Personally
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