Recent Advances in Clinical Practice Endoscopic Antireflux Procedures

Correspondence to: Professor J P Galmiche, Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire de Nantes, Place Alexis Ricordeau, 44093 Nantes CEDEX 01, France; [email protected] _________________________ RATIONALE AND DEVELOPMENT OF ENDOLUMINAL THERAPY IN GORD Gastro-oesophageal reflux disease (GORD) is a common chronic disorder that has severe impact on quality of life. Moreover, GORD may also cause reflux oesophagitis and sometimes severe complications, such as ulceration, strictures, Barrett’s mucosa, and adenocarcinoma of the oesophagus. Surveys revealed that up to 15–20% of adults experience heartburn on a weekly basis and therefore the cost of drugs prescribed for the treatment of GORD represents a heavy economic burden for society. Although proton pump inhibitors (PPIs) are extremely effective in healing oesophagitis and improving typical reflux symptoms, they also have shortcomings and limitations. Firstly, they do not restore the normal antireflux barrier at the gastro-oesophageal junction and there is frequently a rebound acid hypersecretion after cessation of drug intake which both contribute to the high relapse rate observed after discontinuation of PPI therapy. Additionally, even though PPIs are usually extremely well tolerated drugs they can interact with Helicobacter pylori infection and occasionally be responsible for some rare side effects or drug interferences. In contrast with short term administration of H2 antagonists, PPIs are less potent in reducing nocturnal acid secretion. Finally, a challenging problem remains the treatment of the approximately 10–20% of patients with proven GORD who have only a partial or no response to high doses of PPIs. Laparoscopic fundoplication is often proposed as an alternative and more definitive option, especially in young patients, because it is intended to cure the disorder and the laparoscopic approach makes surgery more acceptable. 8 Despite the high success rate of surgery in resolving typical reflux symptoms, substantial morbidity and some mortality exist. Complications such as dysphagia, inability to belch, diarrhoea, and flatulence may develop in up to 30% of patients. Recent publications tempered the enthusiasm for antireflux surgery. Spechler et al reported that 62% of patients who underwent open antireflux surgery as part of a controlled study were still taking acid suppressive drug after 10 years. Similar data were reported in patients who underwent this procedure in routine clinical practice. Medical therapy was required for control of heartburn in approximately one third of patients after laparoscopic fundoplication and new onset of symptoms was common after surgery. Thus in spite of well established short term efficacy, surgery is not an ideal solution. During the past few years, a number of endoscopic procedures aimed at improvement of the barrier function of the lower oesophageal sphincter (LOS) have emerged. In general, these new endoscopic techniques use three different approaches to improve gastro-oesophageal barrier function: the gastro-oesophageal junction can be tightened by creation of plications, by delivery of radiofrequency energy at the cardia, or by injecting inert material into the muscle layer. Endoscopic gastroplication (Endocinch) was the first endoscopic antireflux procedure to become commercially available. It soon gained a level of acceptance. In a number of publications in the 1990s, the techniques of endoscopic suturing and of endoscopic knotting were developed and refined by Swain and colleagues. A device based on Swain’s studies was developed and commercialised by BARD, and approved for use by the Food and Drug Administration. Meanwhile, other types of suturing devices, at present still under evaluation, have been proposed by Wilson-Cook (Flexible Endoscopic Suturing Device) and by NDO (Full-Thickness Plicator). The second endoscopic procedure to obtain Food and Drug Administration approval was the Stretta procedure. Treatment by radiofrequency waves is traditionally used to obtain nerve ablation and collagen remodelling. Classical applications are ablation of accessory conductive bundles in patients with cardiac arrhythmias, remodelling of the palate in people who snore, or treatment of prostate hypertrophy. Application of radiofrequency energy to the LOS in a porcine model was found to augment lower oesophageal sphincter pressure and to increase the gastric yield pressure. Endoscopic submucosal injections at the level of the cardia, using bovine collagen or Teflon, have been attempted in the past, with encouraging but transient results in terms of symptoms 1207