Dr. Biswajit Deka presented on endoluminal treatments for GERD. He discussed the pathophysiology of GERD and how endoluminal procedures aim to increase LES tone and length to prevent reflux. The main endoluminal procedures covered were EsophyX which creates an incisionless fundoplication, Stretta which uses RF to remodel the LES, MUSE which creates a partial fundoplication with staples, and injections or mucosal excision techniques. Complications were generally minor but include bleeding, perforation, and pain. Endoluminal GERD treatments are promising but still developing compared to anti-reflux

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 …