Enteryx implant for gastroesophageal reflux disease

Opinion statement Although pharmacologic therapy is safe and effective for gastroesophageal reflux disease (GERD), patients requiring chronic drug treatment often seek alternatives. Surgical alternatives to chronic drug treatment are associated with increased morbidity and long-term failure rates in more than 50% of surgically treated patients. Newer endoluminal therapies using modifications of standard endoscopy techniques are under evaluation as alternatives to chronic drug treatment or surgical intervention for GERD. Appropriate patient selection is KEY. Patients considered for any endoluminal therapy should have well documented GERD and demonstrated appropriate and successful response to medical therapy with a proton pump inhibitor (PPI). The Enteryx implant is an injectable biocompatible polymer approved by the US Food and Drug Administration for the management of GERD symptoms. Clinical trial data indicate that the Enteryx procedure is a safe and effective GERD treatment that manages symptoms of GERD and addresses the underlying anatomic and functional aspects of the disorder. Multicenter clinical trials have shown that the Enteryx procedure safely and effectively eliminates or significantly reduces PPI use in approximately 84% of patients at 1 year and 72% of patients at two years. The risk-benefit profile of this procedure and alternative treatment options should be carefully evaluated for each patient considered a candidate for Enteryx and all endoluminal therapies. Randomized-controlled studies comparing the Enteryx procedure to placebo and cost-effective analyses comparing treatment options will further define the use of the Enteryx implant in patients with GERD.     

Esophageal abscess complicating endoscopic treatment of refractory gastroesophageal reflux disease by Enteryx injection: a first case report

Enteryx (Boston Scientific) is an injectable solution containing 8% ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide that has been approved for the treatment of gastroesophageal reflux disease (GERD). The technique consists of injecting Enteryx into the lower esophageal sphincter where it solidifies into a sponge-like permanent implant and prevents or reduces gastric acid reflux into the esophagus. The procedure appears to be generally safe, even if minor or moderate adverse events have been observed. We present the case of a 52-yr-old female treated by Enteryx injection for GERD who developed subsequently an esophageal parietal abscess.     

Short-term treatment of gastroesophageal reflux disease

OBJECTIVE: To investigate the efficacy of acid suppressant drugs in the empirical treatment of gastroesophageal reflux disease (GERD) and in the treatment of endoscopy-negative reflux disease (ENRD). DESIGN: medline, embase, and the Cochrane Controlled Trials Register were searched. Bibliographies were reviewed. SETTING: Studies were eligible that compared the short-term use of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) with each other or with placebo in adults with GERD who were enrolled irrespective of endoscopic findings (empirical cases) or in whom endoscopy showed no signs of esophagitis (endoscopy-negative cases). MEASUREMENTS: Of 1,408 studies, only 13 could be included for meta-analysis. Data on 3,433 patients empirically treated for GERD and 2,520 patients treated for ENRD were extracted. The primary endpoint was relief of heartburn. MAIN RESULTS: In the empirical treatment of GERD, the summary relative risk (sRR) for symptom relief from H2RAs versus placebo was 0.77 (95% confidence interval [95% CI], 0.60 to 0.99). RR in the only placebo-controlled PPI trial was 0.35 (95% CI, 0.26 to 0.46). The sRR for standard dose PPIs versus H2RAs was 0.55 (95% CI, 0.44 to 0.68). In treatment of ENRD, both PPIs (sRR, 0.64; 95% CI, 0.52 to 0.79) and H2RAs (sRR, 0.78; 95% CI, 0.62 to 0.97) were superior to placebo, and PPIs were superior to H2RAs (sRR, 0.81; 95% CI, 0.70 to 0.95). CONCLUSIONS: Acid suppressant therapy (with a PPI or an H2RA) is more effective than placebo for short-term relief of heartburn in patients with persistent symptoms who are treated empirically for GERD and in those in whom esophagitis was excluded after endoscopy. The benefit of PPIs compared with H2RAs is more pronounced in patients treated empirically.     

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".     

胃食管反流病的非酸反流和治疗

胃食管反流病(GERD)的发生与酸反流和非酸反流有关。此文从非酸反流的定义、成分、非酸反流损伤机制、非酸反流与正常人、非酸反流与GERD症状、非酸反流与食管外症状、非酸反流治疗和治疗后非酸反流的频率变化方面进行阐述。     

New pharmacological agents for the treatment of gastroesophageal reflux disease

Proton pump inhibitors (PPIs) are currently the most effective and most widely used agents for gastroesophageal reflux disease (GERD). Despite the efficacy of these agents in healing and symptom relief, a substantial proportion of patients require twice-daily therapy with PPIs, and break-through symptoms cause others to use over-the-counter antacids and histamine 2-receptor antagonists to supplement their PPI therapy. Major strategies that are being pursued include the development of agents that have a faster onset of action for on-demand therapy; have better control of acid secretion, resulting in improved healing in advanced grades of esophagitis and better symptom control; and agents that decrease transient lower esophageal sphincter relaxations (TLESRs), thereby reducing distal acid exposure and weakly acidic refluxate. A number of new pharmaceutical agents are currently undergoing clinical evaluation for the treatment of GERD. These include agents that reduce TLESRs, serotonergic agents/ prokinetics, long-acting PPIs, mucosal protectants, and antigastrin agents. One or more of these agents may be the future of GERD therapy.     

胃食管反流病的治疗进展

胃食管反流病是常见的上消化道动力障碍性疾病,发病率呈现逐年上升趋势,目前胃食管反流病的治疗主要有改变生活方式、应用质子泵抑制剂以及中药治疗。对于药物治疗无效的胃食管反流病,内镜治疗如内镜下射频消融、注射治疗以及抗反流手术及外科手术治疗均可改善患者症状,减少胃食管反流病的并发症发生,对于胃食管反流病患者的治疗,应根据具体情况,选择恰当的治疗方法。     

Detection and treatment of gastroesophageal reflux disease

The diagnosis of GERD requires the thoughtful evaluation of a patient's symptoms and clinical course. In young patients with classical reflux symptoms in the absence of untoward complications such as structure, bleeding or pulmonary aspiration, antireflux treatment can be instituted without the need for diagnostic testing. A large number of patients will demonstrate a good clinical response to medical therapy. The diagnostic challenge arises when symptoms of reflux masquerade as cardiac and pulmonary disease or do not respond to simple medical treatment. The use of diagnostic testing to determine the presence and quantity of reflux is helpful in establishing the diagnosis in atypical settings. Prolonged pH monitoring offers the opportunity to monitor symptoms in a physiologic setting over a prolonged period and to provide a correlation of symptoms with the presence of reflux. Endoscopic evaluation is most important in evaluating patients with complications such as peptic strictures, hemorrhagic esophagitis, or Barrett's metaplasia. In these situations, important diagnostic and prognostic information as well as therapeutic intervention can be gained through endoscopy. In patients with peptic strictures, palliation can be achieved by endoscopic dilatation. The number of options available for the medical management of reflux disease has increased significantly in recent years. The introduction of effective agents to block acid secretion has provided a significant advance in the medical treatment of gastroesophageal reflux. Prokinetic agents offer an attractive alternative either alone or in combination with acid inhibition. Early results using parietal cell proton-pump blocking agents suggest that they may be effective in the treatment of severe esophagitis previously resistant to medical therapy. Despite significant advances in the medical treatment of GERD, a number of patients (5 to 10 per cent) may require antireflux surgery. The Nissen fundoplication has been shown to be an effective means of attaining mucosal healing usually accompanied by symptomatic relief. The use of a "loose wrap" performed over a large bore dilator avoids the postoperative problems of dysphagia or gas bloat. Despite improvements in our diagnostic and therapeutic armamentarium, a number of patients continue to pose a challenge for the clinician. There remains a clear need for more well-designed, well-controlled studies to assist in the effective treatment of this ubiquitous and often debilitating disease.     

Endoscopic treatment for atypical manifestations of gastroesophageal reflux disease

OBJECTIVES: Atypical manifestations are common in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the response of atypical manifestations of GERD to endoscopic antireflux treatment. METHODS: Patients with atypical manifestations of GERD including hoarseness, cough, wheezing, and non-cardiac chest pain were studied. Endoscopic antireflux treatment consisted of placement of sutures below the squamo-columnar junction. Clinical response was defined as complete resolution of the atypical symptom. Patients were followed clinically for up to 3 yr after the procedure. Short-term response was evaluated within 6 months of the procedure, and long-term follow-up was determined 1-3 yr after the procedure. RESULTS: Forty-three patients met the inclusion criteria; four patients underwent repeat procedures during the study period and were excluded from the analysis. Long-term follow-up was available in all 39 patients. Short-term response counts were: hoarseness, 12 of 19 patients, cough, 17 of 19; wheezing, 8 of 9; and chest pain, 13 of 18. Long-term follow-up of patients (mean of 18 months) for these symptoms was not significantly different compared to short-term response. CONCLUSIONS: Endoscopic suturing of the gastroesophageal junction appears to be a possible treatment option for atypical manifestations of GERD and future studies are needed to determine its role in management.     

Diagnostic and treatment of gastroesophageal reflux disease

We propose a diagnostic algorithm based on the evaluation of GERD symptoms, the test results with a single dose of alginate with heartburn and EGD--esophagogastroduodenoscopy data. The diagnosis of GERD with reflux esophagitis based on the endoscopic detection of characteristic changes of esophagus. Diagnostic criteria endoscopically negative forms of GERD are the presence of symptoms of concern to the patient, the absence of damage to the esophagus during EGD and rapid relief of heartburn, a single dose of alginate (alginate positive test). Drug of choice for reflux esophagitis is an PPI. Specify the role of Helicobacter pylori diagnosis, indications for eradication in patients with GERD.     

Diagnosis and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease(GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical,atypi-cal and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms,these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations,further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis,peptic stricture,Barrett's esophagus,esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification,medical therapy and surgical therapy. Life-style modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids,histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy,others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gas-troesophageal reflux disease.     

Non-pharmacologic treatment strategies in gastroesophageal reflux disease

Abstract   In the West, gastroesophageal reflux disease (GERD) is a common and well-recognized disease. Lately, it has been described as an emerging problem in the East as well. While it is not a rapidly fatal illness, it causes a myriad of disturbing symptoms that remarkably reduce the patients' quality of life (QOL). The economic impact that results from multiple consultations, diagnostic investigations, and administration of a variety of treatment regimens, including surgery, is enormous.
The operative management for GERD is fundoplication, for example Toupet (270 degree wrap of the distal esophagus) and Nissen (360 degree wrap of the distal esophagus). These surgical procedures are aimed at permanently controlling acid reflux by reconstructing the gastroesophageal junction. Currently, the ease, aesthetic advantages, and the comparable outcomes achieved by minimally invasive laparoscopic fundoplication have rekindled interest in the operative alternatives of GERD management. Fundoplication controls or diminishes considerably the severity of the symptoms associated with GERD. However, appearance of new symptoms i.e. dysphagia, 'gas–bloat syndrome', etc. as postoperative events have been reported.
Recently, several innovative endoluminal treatment modalities have been introduced, namely; endoscopic plicator/suturing devices, bulking injections, and radiofrequency treatment. They are focused on enhancing the performance of a malfunctioning lower esophageal sphincter. While results of several case series reflect substantial improvements in GERD-HRQL scores, lack of long-term durability data is a major concern when recommending these novel, relatively simple, peroral techniques to a long suffering patient. It is clear that these therapies are still evolving and long-term outcomes of properly designed comparative efficacy trials are awaited.     

难治性胃食管反流病的诊疗策略

胃食管反流病（GERD）是临床常见疾病,约30%~50%的患者症状在质子泵抑制剂（PPI）治疗后不能得到完全缓 解,其中难治性GERD占较大比例。pH阻抗监测、高分辨率食管测压、内镜及活检等有助于分析导致难治性GERD 发生的原因。其中,pH阻抗对分析导致难治性GERD成因非常重要。反流后吞咽诱发蠕动波指数（PSPWI）和夜间平 均基线阻抗（MNBI）这两个新指标有助于提高诊断率。难治性GERD的治疗手段包括更换PPI种类、加用H2受体阻 滞剂、辅以促动力药物、外科手术、内镜下治疗等。个体化治疗策略的制定有赖于难治性GERD的具体成因。