Endoscopic treatment of gastroesophageal reflux disease

"Gastroesophageal reflux disease is a chronic illness with a wide spectrum of symptoms that can significantly affect people's quality of life and increase the risk of complications, including cancer. Gastroesophageal reflux disease has been primarily treated with anti-secretory medications and, when needed, surgery. However, caveats to this approach include long-term medications, side effects, drug-interaction, cost, and the morbidity and mortality associated with surgery. Endoscopic management of gastroesophageal reflux disease offers a safe, effective and less invasive alternative to medications and surgery. There are different endoscopic therapies that include suturing, application of radiofrequency, injection of polymer, and placement of prostheses. The available data on these therapies is here discussed".     

Endoscopic therapies for gastroesophageal reflux disease

Although medical and surgical treatments are available for gastroesophageal reflux disease, endoscopic therapies for this condition are relatively new. This review describes the principles behind such treatments as well as the individual procedures themselves, focusing on mechanisms of action, safety and tolerability, and efficacy in animal and human clinical trials. Future trends in endoscopic therapy are discussed.     

Endoscopic therapy for gastroesophageal reflux disease

Many new and developing endoscopic techniques for treatment of gastroesophageal reflux disease (GERD) are now or will soon be available for clinical use. These new therapies are directed to the gastroesophageal junction and include three basic techniques, which are outlined in this review: thermal remodeling and neurolysis of the lower esophageal sphincter (LES) zone; bulking or reinforcing of the LES; and plicating gastric folds at the gastric cardia. Only two of these treatments, radiofrequency ablation and fundic fold plication, have been approved by the US Food and Drug Administration (FDA). Published clinical research on endoscopic treatment is reviewed, although it is mostly comprised of open-label trials and anecdotal clinical reports. Complications of endoscopic GERD treatments are described as well as real and potential pitfalls of these techniques. Problems caused by premature introduction of endoscopic GERD treatments into the marketplace are also discussed, along with the rationale for FDA approval of similar devices.     

Endoscopic therapies for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) accounts for a substantial degree of medical resource utilization and is a common indication for outpatient physician visits. The primary therapy for GERD has been proton pump inhibitors (PPIs). Equally effective and reasonably safe for GERD is surgical therapy, specifically, laparoscopic Nissen fundoplication. Medical therapy is used initially, with surgery reserved for patients with refractory symptoms despite optimal medical management, to avoid the added risks of abdominal surgery. As such, there has been considerable investigation into minimally invasive, endoscopic therapies for patients who respond to PPI, but would prefer to avoid long-term medication use. Here, we discuss the anatomical and physiological barriers that must be overcome by such devices. We further review the data on currently available endoscopic devices. Despite considerable interest and resources in developing an effective endoscopic therapy for GERD, none of the currently available technologies have demonstrated an ability to overcome the pathophysiological hurdles present in most patients with GERD. Furthermore, well-designed trials have not demonstrated adequate clinical efficacy for these endoscopic devices. As such, despite a growing need for an intermediate therapy between PPI and fundoplication, at present there is not adequate evidence to recommend endoscopic therapy for patients with GERD.     

Endoscopic therapy for gastroesophageal reflux disease

Endoscopic therapies aimed to reduce gastroesophageal reflux have gained an enormous enthusiasm during the last 5 years when several of them were approved by the regulatory agencies and released on the market. These novel therapies comprise 3 types of techniques: injection/bulking, plicating/suturing and radiofrequency thermal injury. Open-labelled trials performed on proton pump inhibitors-responding patients with typical gastroesophageal reflux disease (GERD) symptoms have shown an improvement in reflux symptoms during short term follow-up. Longer-term data are now available and show disappointing results with partial-thickness plications of the cardia. Randomized sham-controlled trials, which are essential to proof the efficacy of GERD endotherapy because of a known high placebo effect in the management of GERD patients, have been conducted, one with radiofrequency and one with polymer injection, and have confirmed the clinical efficacy of both techniques, although the clinical benefit was less impressive than suggested in open-labelled trials. While mechanistic studies have suggested that the compliance of the gastroesophageal junction might be altered by GERD endotherapy, objective assessment of acid reflux with ambulatory pH-metry has shown, however, minimal or no modification by the treatment. Concerns about the safety of these new techniques have raised when complications were reported as the number of treated cases increased. Currently, no definite indication is established for each technique, but numerous potential indications exist and should be addressed in the setting of carefully designed clinical trials. Physicians should be patient and wait for proof of efficacy and safety of these techniques before using them in their clinical practice. Specific and extensive warning should be obtained before starting clinical application. The present review aims to provide a comprehensive and critical view of endoscopic therapy in GERD management.     

Endoscopic anti-reflux therapy for gastroesophageal reflux disease

Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide. A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects. Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication. The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia. Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials. Band-assisted ligation techniques, anti-reflux mucosectomy, anti-reflux mucosal ablation, and new plication devices have yielded promising results in recent noncontrolled studies. Nonetheless, the role of endoscopic procedures remains controversial due to limited long-term and comparative data, and no consensus exists in current clinical guidelines. This review provides an updated summary focused on the patient selection, technical details, clinical success, and safety of current and future endoscopic anti-reflux techniques.     

胃食管反流病的食管外表现及其临床进展

胃食管反流病(GERD)的食管外表现是指除反酸、烧心等典型症状外,同时伴有呼吸系统、耳鼻喉、口腔等部位的症状,如支气管哮喘、慢性咳嗽、阻塞型睡眠呼吸暂停综合征、特发性肺纤维化、咽炎、喉炎、牙侵蚀症等.因其表现特殊、临床容易误诊,本文特对其发病机制及临床表现作一综述.     

Oral manifestations of gastroesophageal reflux disease

Numerous case-control and other studies involving confirmation of gastroesophageal reflux disease (GERD) by esophageal pH-metry and the assessment of dental erosions have shown significant associations between the two conditions in both adults and children. By contrast, when asked to vote on whether GERD may cause dental erosions, only 42% of physicians strongly agreed that such an association existed in adults, and just 12.5% strongly agreed for children, respectively in two global consensus reports. Part of this divergence between the perceptions of physicians and the findings of research publications may reflect a general lack of oral health education during medical training, and cursory oral examinations being made under less-than-ideal conditions. Adequate salivary secretions are essential for the protection of the teeth and the oropharyngeal and esophageal mucosa. The quantity and quality of the saliva require monitoring as many drugs, including several of the proton pump inhibitors (PPIs), can cause hyposalivation. In addition, PPIs do not always result in adequate acid suppression. Therefore, collaboration between physicians and dentists is strongly advocated to prevent or ameliorate possible adverse oral effects from both endogenous and exogenous acids, and to promote adequate saliva production in patients with GERD.     

Laryngeal manifestations of gastroesophageal reflux disease

Chronic laryngeal signs and symptoms associated with gastroesophageal reflux disease (GERD) are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to otolaryngology offices are because of manifestations of LPR. Damage to laryngeal mucosa may be the result of reflux of gastroduodenal contents, whether chronic or a single incident. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs, including laryngeal edema and erythema. The current recommendation for managing these patients is empiric therapy with twice-daily proton pump inhibitors for 1 to 2 months. Other causes of laryngeal irritation are considered in most of those who are unresponsive to such therapy. Surgical fundoplication is most effective in those who are responsive to acid-suppressive therapy.     

Endoscopic therapies of gastroesophageal reflux disease

The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease (GERD). The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.     

胃食管反流病的内镜治疗现状

胃食管反流病(gastroesophageal reflux disease．GERD)是指胃或十二指肠内容物反流入食管，引起并发症或明显地损害了病人的生活质量。主要表现为烧心、反酸或食物反流，可引起食管糜烂、溃疡、出血、狭窄等。GERD非常常见，西方国家约10％的人患有此病，老年人约1／4患有GERD。我国该病的发病率具体不详，京沪二地调查约6％的人患有GERD。GERD的     

Extraesophageal manifestations in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition that affects about 20-30% of the adult population, presenting with a broad spectrum of symptoms and varying degrees of severity and frequency. Other manifestations are being increasingly recognized: the so-called 'extraesophageal' manifestations, such as laryngitis, hoarseness, chronic cough, asthma, or non-cardiac chest pain. Epidemiological studies consistently demonstrate significant associations between pulmonary manifestations and GERD. Up to 50% of patients with an endoscopically proven esophagitis suffer from symptoms other than heartburn or acid regurgitation. However, the published estimates of extraesophageal disorders in patients with GERD vary widely, which may be a result of referral bias. The most effective initial approach in suspected reflux-related extraesophageal symptoms is empiric proton pump inhibitor (PPI) therapy. However, studies demonstrated that the advantage of long-term PPI treatment over placebo could have been overestimated.     

Supraesophageal manifestations of gastroesophageal reflux disease.

An increasing amount of evidence indicates that gastroesophageal reflux disease (GERD) is a contributing factor to hoarseness, throat clearing, throat discomfort, chronic cough, and shortness of breath. The association between GERD and these supraesophageal symptoms may be elusive. Heartburn and regurgitation are absent in more than 50% of patients. Acid reflux should be considered if signs of GERD are present, symptoms are unexplained, or symptoms are refractory to therapy. The diagnosis of GERD may be unclear, despite a careful history and initial evaluation. A high index of suspicion is required to make the diagnosis. An empiric trial of antireflux therapy is appropriate when GERD is suspected. Multiprobe ambulatory pH monitoring is currently the diagnostic test of choice, but the level of sensitivity and specificity for supraesophageal manifestations of GERD is uncertain. Response to antireflux therapy is less predictable than typical GERD. More intensive acid suppression and longer treatment duration are usually required.     

Pediatric otolaryngologic manifestations of gastroesophageal reflux disease

In adults, an estimated 4% to 10% of chronic, nonspecific laryngeal disease seen in otolaryngologic clinics is associated with gastroesophageal reflux disease (GERD). Although no such estimates exist in children, many investigators have reported extraesophageal manifestations of GERD, of which the most common is the association of GERD with asthma and chronic cough. A variety of signs and symptoms of otolaryngologic disease also have been attributed to GERD, including hoarseness, laryngitis, chronic rhinitis, sinusitis, globus pharyngeus, recurrent croup, laryngomalacia, stridor, subglottic stenosis, otalgia, vocal cord granulomas, and oropharyngeal dysphagia. However, proof of the association between these manifestations of otolaryngologic disease and GERD is sparse. Furthermore, the manifestations of otolaryngologic disease often occur in the absence of such classic systems of GERD as heartburn or chest pain. This review explores the role of GERD in otolaryngologic disease in children.