GERD May Be Helped by Radiofrequency and Endoluminal Full-Thickness Plication

Laurie Barclay, MD

January 23, 2009

January 23, 2009 — For patients with gastroesophageal reflux disease (GERD), radiofrequency (RF) treatment and endoluminal full-thickness plication (FTP) were both associated with decreased use of proton pump inhibitors (PPIs) and decreased scores for voice symptoms and dysphagia, according to the results of a study reported in the January issue of Archives of Surgery.

"Endoluminal therapies have emerged as adjuncts for the treatment of [GERD] in select patients," write Louis O. Jeansonne IV, MD, from Emory University School of Medicine in Atlanta, Georgia, and colleagues." These therapies have been offered to patients who are averse to the long-term sequela of prolonged acid suppression therapy, who are partial responders to medical treatment and are seeking an alternative to surgery, or who have failed an earlier fundoplication."

The goal of this study was to compare the effectiveness of endoscopic FTP of the gastric cardia and endoscopic RF treatments of the esophagogastric junction in patients with GERD. During a 4-year period, 126 patients were included (68 received RF treatments and 58 received FTP).

The primary study endpoints were comparison of medication use, symptom scores, and pH values at baseline and follow-up. Mean duration of follow-up was 6 months, and follow-up data were available for 51% of patients.

In the RF group, there were decreases in the percentage of patients with moderate to severe heartburn (from 55% to 22%; P < .01), in PPI use (from 84% to 50%; P = .01); and in dysphagia, voice symptoms, and cough. However, there was no change in the percentage of time the pH was less than 4.

In the FTP group, there were decreases in the percentage of patients with moderate to severe heartburn (from 53% to 43%; P = .3), in PPI use (from 95% to 43%; P = .01), in percentage of time the pH was less than 4 (from 10.0% to 6.1%; P = .05), and in regurgitation, voice symptoms, and dysphagia. Neither group had a change in scores for chest pain or asthma.

"For patients with GERD, RF and FTP both resulted in a decrease in both PPI use and in scores for voice symptoms and dysphagia," the study authors write. "In addition, RF resulted in decreased heartburn and cough, while FTP resulted in the most dramatic reduction in regurgitation."

Limitations of this study include its relatively small sample size, possibly resulting in type 2 error, that the study was not randomized or sham-controlled, the use of inherently subjective symptom scores, and the short duration of the follow-up.

"Our experience indicates that both procedures are effective, providing symptomatic relief and reduction in PPI use," the study authors conclude. "For patients whose chief complaint is regurgitation, FTP may be the preferred procedure.... Further study is needed to determine the long-term effectiveness of endoluminal treatments."

In an invited critique, Jon Gould, MD, from the University of Wisconsin Medical School in Madison, notes that some endoluminal GERD devices have been withdrawn from the market because of safety concerns, and others have shown a lack of long-term effectiveness.

"What this study and others fail to definitively demonstrate is the kind of consistent symptom improvement and durability of therapy related to laparoscopic fundoplication in the hands of an experienced surgeon," Dr. Gould writes. "In this era of limited health care dollars, especially considering the prevalence of severe GERD in our society, we have a responsibility to ensure that these endoluminal therapies effect durable and consistent results on par with our time-tested treatments. In my opinion, we still have a long way to go before a clear alternative to laparoscopic antireflux surgery emerges for those with medically refractory GERD symptoms."

The study authors and Dr. Gould have disclosedno relevant financial relationships.

Arch Surg. 2009;144:19–24.

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