New GERD Procedure

June 7, 2006 Gastroesophageal Reflux When we eat, foods and liquids pass from the mouth through the esophagus and into the stomach. At the lower end of the esophagus there is a ring of muscle, called the lower esophageal sphincter (LES). Normally, the LES acts like a one-way valve, allowing foods to pass into the stomach and preventing the stomach contents from leaking back. In patients with gastroesophageal reflux disease (GERD), the LES doesnt always close as tightly as it should. Partially digested food and stomach acids can leak back into the esophagus, causing a burning sensation in the throat or chest (heartburn). Patients may also complain of a sensation of choking, food being caught in the throat, cough or bad breath. Heartburn is a common problem. The American College of Gastroenterology estimates about 60 million Americans experience the symptoms at least once a month. As many as 15 million may experience daily symptoms. GERD is generally defined as heartburn that occurs at least twice a week. The exact cause of GERD isnt known. People with a hiatal hernia (a protrusion of the upper part of the stomach above the diaphragm) may be at higher risk for the condition. Pregnancy, consumption of alcohol, smoking and being overweight may also increase the risk of GERD. In addition, some types of food, like tomatoes, chocolate, and citrus fruits, are associated with reflux. Long-term exposure of the esophagus to stomach acids and digestive enzymes can damage the tissue lining the esophagus. Patients may experience esophageal stricture (narrowing of the esophagus caused by scar formation), swallowing difficulty and bleeding. In serious cases, the cells lining the esophagus are replaced with those that normally line the intestine. This is a precancerous condition called Barretts esophagus. People who have Barretts esophagus are 30 times more likely to develop esophageal cancer. Treating GERD Initially, doctors may recommend lifestyle modifications for people with GERD - stop smoking, avoid alcohol or foods that are associated with reflux, lose weight, eat smaller meals and wear loose-fitting clothing. Patients are generally advised not to eat anything for at least two hours before going to bed. It sometimes helps to raise the head of the bed or elevate the head to reduce the risk of backflow of stomach acids. Over-the-counter medications may also be recommended. Mild symptoms can often be relieved with antacids. If antacids arent helpful, drugs called H2 blockers may be used. These medications suppress acid production, decreasing the flow of stomach acid into the esophagus. H2 blockers are available in over-the-counter and prescription strengths. They reduce or eliminate symptoms in about half of patients. The strongest medications are the proton pump inhibitors. These medications relieve symptoms for most patients and are effective in promoting healing of the esophagus. When lifestyle changes and medications dont provide adequate relief, doctors may recommend surgery. The standard surgical treatment for GERD is Nissen fundoplication. Traditionally, doctors make a large incision into the chest or abdomen to access the LES. The upper part of the stomach is wrapped around the LES to provide more support and strength for the muscle, hopefully preventing stomach acids from backing up into the esophagus. More recently, doctors have been performing the surgery laparoscopically. The Plicator™ Procedure In 2003, the FDA approved a new device for treatment of GERD, called the Plicator™. The device treats the problem from inside the esophagus and stomach - eliminating the need for incisions. The Plicator is inserted into the throat and passed through the end of the esophagus to the top of the stomach. An endoscope, or viewing tube is then passed through the Plicator to allow the surgeon to see inside the esophagus and upper area of the stomach. Next, a tiny arm on each side of the Plicator opens to grasp tissue where the stomach meets the esophagus. When the arms close, they pinch the tissue together into a fold around the LES. Then, a suture is deployed into the tissue, permanently securing the fold. The folded tissue creates a tighter barrier between the esophagus and stomach, restoring the ability of the LES to prevent backflow of stomach acids. The Plicator procedure is done in about 20 to 25 minutes using conscious sedation. Most patients are able to go home the same day. Gastroenterologist, Daniel DeMarco, M.D. of Baylor University Medical Center in Dallas, Texas, says he is seeing about an 80 percent success rate with the Plicator procedure. AUDIENCE INQUIRY For information on GERD: American College of Gastroenterology, http://www.acg.gi.org National Institute of Diabetes and Digestive and Kidney Diseases, http://www.niddk.nih.gov For information about the Plicator™ Procedure: NDO Surgical, http://www.ndosurgical.com/patient_portal/plicator_procedure.htm BIBLIOGRAPHY Chuttani, R., et al., "A Novel Endoscopic Full-Thickness Plicator for Treatment of GERD," Gastrointestinal Endoscopy, July 2002, Vol. 56, No. 1, pp. 116-122. Hassall, E., "Outcomes of Fundoplication," Archives of Disease in Children, October 2005, Vol. 90, No. 10, pp. 1047-1052. "Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)," Bethesda: National Institute of Diabetes and Digestive and Kidney Diseases, downloaded from website (http://www.niddk.nih.gov), May 3, 2006. "Information You Can Stomach," Bethesda: American College of Gastroenterology, downloaded from website (http://www.acg.gi.org), May 3, 2006. Limpert, Patricia, M.D., and Keith Naunheim, M.D., "Partial Versus Complete Fundoplication," Surgical Clinics of North America, June 2005, Vol. 85, No. 3, pp. 453-463. Ozawa, S., et al., "New Endoscopic Treatments for Gastroesophageal Reflux Disease," Annals of Thoracic and Cardiovascular Surgery, June 2005, Vol. 11, No. 3, pp. 146-153. Rakita, Steven, M.D., et al., "Laparoscopic Nissen Fundoplication Offers High Patient Satisfaction with Relief of Extraesophageal Symptoms of Gastroesophageal Reflux Disease," The American Surgeon, March 2006, Vol. 72, No. 3, pp. 207-212. Rothstein, Richard, M.D., and Andrew Dukowicz, M.D., "Endoscopic Therapy for Gastroesophageal Reflux Disease," Surgical Clinics of North America, October 2005, Vol. 85, No. 5, pp. 949-965. Shah, Anoop, M.D., et al., "Gastroesophageal Reflux Disease and Obesity," Gastroesophageal Clinics of North America, March 2005, Vol. 34, No. 1, pp. 35-43. Sollano, J., "Non-pharmacological Treatment Strategies in Gastroesophageal Reflux Disease," Journal of Gastroenterology and Hepatology, September 2004, Vol. 19, No. 3, Suppl., pp. S44-S48. "The Word on GERD," Bethesda: American College of Gastroenterology, downloaded from website (http://www.acg.gi.org), May 3, 2006. Research compiled and edited by Barbara J. Fister