Endoluminal therapy in Gastro oesophageal reflux disease (GERD)

1. Seminar on
Endoluminal treatment in GERD
Presenter
Dr. Biswajit Deka
PGT
Deptt of surgery , SMCH

2. Introduction
• Gastroesophageal reflux disease (GERD) is due to the failure of the
gastroesophageal barrier.
• The disease has dramatically increased in the last 2 decades.
• The optimal treatment of GERD continues to be debated.

3. • The rising number of patients having daily reflux-related
symptoms and their impact on quality of life has lead to a better
understanding of the pathophysiology of this condition and its
appropriate management.
• New anti-secretory medications, laparoscopic techniques, and
novel endoluminal devices have been introduced ; the outcomes
are encouraging, but the cost is a matter of concern.

4. Anatomical & physiological background
• The LES and the geometric profile of the cardia prevent GERD
and are the targets of surgical and endoluminal GERD
procedures.
• The LES is characterized by its length, relative position to the
diaphragm, and pressure.
• A decrease in pressure, overall or intra-abdominal length
predisposes to reflux.

5. • In severe GERD, the “high-pressure zone” (LES) is virtually non-
existent or greatly reduced, and reflux in this instance is understandable.
• However, the cause of reflux in milder disease with a normal lower
oesophageal sphincter resting pressure (LESP) is under considerable
debate.
• It is believed that transient LES relaxations (tLESR), ie, intermittent
spontaneous decreases in LESP, are responsible for reflux events.

6. • Recent electrophysiological data suggest that the relevant vagal
afferent fibres terminate with specialized intra-ganglionic laminar
endings (IGLEs).
• These deformity-sensitive transducers are lined in series with
muscle fibres at the cardia and fundus and are believed to mediate
both fundic receptive relaxation and elicitation of tLESRs.

8. • In light of the above-described pathophysiologic factors,
endoscopic therapies should prevent reflux in one or more of the
following ways:
(1) alter the compliance of the cardia and prevent tLES shortening or
relaxation.
(2) increase baseline LES tone.
(3) increase baseline LES length.

9. Indications & contra-indication
• Refractory symptoms despite maximized medical treatment
• Contra-indication to medication therapy.
• Conscious sedation- (No GA) - target large population
• Contra-indication: anatomical ( hiatal hernia longer than 2cm
& wider than 3cm )

10. Pre-op preparation
• Complete esophageal work up –
UGI endoscopy
Esophageal manometry
 Evaluate for other disorder with GERD like symptoms
 Extent of esophagitis
 Barrett’s esophagus
Anatomical abnormality

11. Types
1. EsophyX – create incisionless fundoplication, FDA- 2007
2. Stretta – utilizes RF to remodel the LES by contracting
collagen and creating a barrier to gastric pressure.
3. Medigus ultrasonic Surgical Endostapler – creates an anterior
partial wrap
4. Injection / implantation – inert substance
5. Mucosal excision

12. 1. EsophyX : Transoral Incisionless Fundoplication
• Deployed in the stomach with an endoscope
• Creates a full thickness plication of GEJ using H-shaped polypropylene
fasteners.
• Several revisions : TIF-1 : produce a gastric wrap at the level of GEJ.
• TIF-2 : place the fasteners above GEJ to create a gastroesophageal flap
valve that replicates laparoscopic fundoplication ; TIF 2.0 – current
technique

13. EsophyX

14. EsophyX

15. Procedure
• Patient under GA , left lateral position
• Endoscopy - rule out hiatal hernia
• 2 physicians reqd ; Device introduced with CO2 insufflation.
• Device retroflexed- greater & lesser curvatures identified.
• Helical screw deployed at GEJ to retract the tissue.

16. • A paddle- shaped tissue mold is then used to deploy
polypropylene fasteners to create a ‘crimp’.
• The tech. performed circumferentially to create a 270 degree
fundoplication. (TIF-1: 2000-2500 fundoplication)
• Device removed- endoscopy done – to assess plication ,
bleeding or perforation

17. Fig: A) A bad valve B) Fastener delivery C) Repair with Helical Retractor D)
Repaired tissue E) Repaired tissue (with wrap) F) Repaired valve with fasteners

18. Post-op care
• Kept under observation
• Can be discharged the following day
• Omeprazole 40mg x 14 days : to promote mucosal healing
• Liquid diet x 2 weeks
• Soft food x 3-7 weeks
• Normal diet after 2 months

19. Complications and their management
• Very few
• Bleeding – Self limiting
BT occasionally
• Perforation – laparoscopic transabdominal drainage
partial fundoplication over damaged esophagus

20. 2. STRETTA
• An inflatable balloon catheter system with 4 electrode needle
sheaths
• Radiofrequency delivered to electrodes – heat the adjacent cells
• Target temp- 65o to 85oC x 1 min cycles.
• RF- induce fibrosis of LES- reduce tissue compliance and transient
LES relaxation.

21. Radiofrequency device

22. Technique
• Deep sedation & endoscopy
• Hiatal hernia >2cm & severe esophagitis – excluded
• Using a guidewire exchange tech- STRATTA catheter introduced
• Placed 2cm proximal to Z-line
• Balloon inflated, electrode needles deployed into esophageal wall

23. • RF energy delivered x 1min
• Needle retracted – balloon deflated- catheter rotated 45 degree
• Tech repeated , cover a length 2cm above &1.5cm below Z-line
• Mucosa- cooled with water irrigation

24. Post-op period
• Day care procedure
• Minor bleeding
• Pain
• Perforation , deaths – not reported yet

25. 3. Medigus ultrasonic Surgical Endostapler ( MUSE)

26. • It’s a stand alone unit – operated by a single user
• Designed in a shape of an endoscope, with a video camera, light
source, ultrasonic transducer and a stapling mechanism at the tip.
• Device is advanced down the esophagus through a endoscopic over
tube with 17mm internal diameter

27. • Retroflexed- to identify the site to place staplers
• Fundic tissue compressed against esophagus and USG transducer
measure tissue thickness – once it reaches 1.4-1.6mm, stapler is
fired.
• Procedure repeated to mimic a partial anterior fundoplication

28. MUSE

29. MUSE

30. Post-op period.
• Observation for 72 hrs.
• UGI endoscopy on POD-1 to evaluate for leaks
• Complication – insufficient data: Bleeding
Esophageal perforation
Pneumomediastinum
Pneumothorax
Chest pain , sore throat

31. 4. Injection/Implantation Techniques
• The goal: to deliver a biologically inert, injectable substance into
different depths of the LES region.
• Submucosal injections increase the volume of the LES, and
injection into the muscularis propria results in granulation and
fibrous capsule formation.
• From the mid 1980s, several biopolymers were tested in animals
and obtained FDA approval

32. 1. Enteryx : an ethylene vinyl alcohol copolymer with tantalum
dissolved in dimethyl sulfide, not in use
2. Gatekeeper Reflux Repair System was a dehydrated hydrogel
prosthesis implanted into the submucosa of the cardia/LES ,
removed from the market because of lack of efficacy.
3. Durasphere : a new sterile, biocompatible injectable bulking
agent composed of pyrolytic carbon-coated graphite beads
containing zirconium oxide, suspended in a water-based, absorbable
polysaccharide carrier gel.

33. 5. ANTI-REFLUX MUCOSECTOMY (ARMS)
• Based on the principle that after mucosal resection, the mucosal healing
results in scar formation.
• Shrinkage and remodelling of gastric cardia flap valve; thereby, reducing
reflux events.
• It involves resection of gastric (about 2 cm) & oesophageal mucosa (about 1
cm) in crescentic fashion; field marked by electrocautery .
• Next , mucosal resection is performed along the lesser curvature

34. • Subsequently, a solution of saline mixed with indigo-carmine
dye is injected submucosally to raise a wheal.
• A gap equal to twice the scope diameter is left along the greater
curvature side.
• Circumferential resection of the mucosa is avoided to prevent
stricture formation as was noted in initial few cases of this series.
• Any bleeding during the procedure is controlled by coagrasper

35. (A) Submucosal injection of saline
with indigo-carmine at gastric cardia.
(B) Application of snare over the
mucosa with cap-endoscopic mucosal
resection technique.
(C) Completion of near
circumferential (2/3) resection of
gastric mucosa.
(D) Actively bleeding spurter during
mucosectomy procedure.
(E) Effective control of bleeding
vessel with coagrasper

36. • The advantages of ARMS: no requirement of any propriety
devices and no end-prostheses are left in situ.
• However, no randomized studies ; durability of response is
unknown.
• The amount of mucosa to be resected for optimal results is not
known and needs further evaluation.
• Patients with large hiatal hernia are not suitable candidates

37. • Anti-reflux surgery is recommended for patients with refractory or
complicated GERD and provides excellent symptom control in 85% to 90% of
cases
• These anti-reflux procedures can be categorised into ablation, injection or
implantation, fixation and mucosal excision.
• Endoluminal intervention for GERD is relatively new and still immature but is
a promising option for GERD patients. Morbidities and mortality should be
reduced, and repeat procedures may be easier to perform.
Conclusion

38. THANK YOU …