Clinical experience with the Stretta procedure.
The benchmarks in GERD therapy comprise the commonly prescribed anti-secretory drugs (H2RAs and PPIs) and anti-reflux surgery. Although drugs are typically safe, cost and patient compliance are challenges to long-term management. Furthermore, while heartburn may be controlled with aggressive medical therapy, other symptoms such as regurgitation may persist, reducing patient satisfaction and adversely affecting quality of life. Surgical anti-reflux procedures, most commonly laparoscopic Nissen fundoplication, improve GERD symptoms and normalize esophageal acid exposure in most patients. Patient perception of the potential risk of abdominal surgery and general anesthesia may limit willingness to undergo surgery resulting in only a small portion of GERD sufferers that actually undergo anti-reflux surgery each year. Overall, the Stretta procedure is well tolerated, with an acceptably low incidence of complications and obviates the need for anti-secretory drug therapy for most patients at the 6- and 12-month follow-up. GERD symptom scores, heartburn, satisfaction, and SF-36 scores significantly improve over the baseline and this effect lasts at least 12 months. The symptomatic improvement after Stretta at 12 months in one trial (GERD score, 27 to 9) is similar to that reported by Velanovich after fundoplication (GERD score, 27 to 3). Furthermore, the significant reduction in median esophageal acid exposure time (distal 10.6% to 6.2%, proximal 1.9% to 0.9%), provides objective evidence of an anti-reflux effect. Although the reported studies have been non-randomized, the objective improvement observed in esophageal acid exposure and the persistence of GERD symptom score improvement with repeated measure analysis over a course of 12 months make a significant placebo effect unlikely. Stretta is a promising new technology for the treatment of GERD that should be considered for patients who wish to discontinue a lifelong anti-secretory medication regimen or who have incomplete GERD symptom control on drugs, but are not yet accepting anti-reflux surgery.
Triadafilopoulos
George
G
Gastroenterology Section, VA Palo Alto Health Care System, (111-G1), 3801 Miranda Avenue, Palo Alto, CA 94304, USA. vagt@stanford.edu
D017115:Catheter Ablation / Q000379:methods*; D002986:Clinical Trials as Topic; D019723:Endoscopes; D004943:Esophagogastric Junction / Q000528:radiation effects / Q000601:surgery; D005753:Gastric Mucosa / Q000473:pathology / Q000528:radiation effects / Q000601:surgery; D005764:Gastroesophageal Reflux / Q000601:surgery*; D015391:Gastroplasty / Q000379:methods*; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D006979:Hyperthermia, Induced / Q000295:instrumentation*; D011183:Postoperative Complications; D011840:Radiation, Nonionizing; D016896:Treatment Outcome