ASGE Masterclass: Barrett’s Esophagus, GERD and Esophageal Adenocarcinoma (On Demand) | February 2022 OLMASFEB1222-PPIs not working

PPIs not working

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The document discusses the use of endoscopic and surgical minimally invasive therapies for gastroesophageal reflux disease (GERD) when proton pump inhibitors (PPIs) are not effective. Refractory GERD, which occurs in 10-54% of patients despite PPI therapy, can have symptoms that may or may not be GERD-related or persistent symptoms related to ongoing reflux. It can also be characterized by persistent esophagitis, even with adequate PPI use.<br /><br />Surgical therapies such as fundoplication (complete or partial), Roux-en-Y gastric bypass (RYGB) for obese patients, and magnetic sphincter augmentation (LINX) can be considered for refractory GERD. A randomized controlled trial comparing laparoscopic anti-reflux surgery (LARS) with PPI therapy showed that LARS provided better remission of symptoms, including heartburn, regurgitation, dysphagia, bloating, and flatulence.<br /><br />The use of fundoplication is recommended for long-term treatment of patients with objective evidence of GERD, especially those with severe reflux esophagitis, large hiatal hernias, and persistent troublesome symptoms. Magnetic sphincter augmentation (MSA) has also been shown to be effective, with patients reporting significant reduction in PPI use, improvement in symptoms, and high satisfaction rates.<br /><br />Endoscopic therapies, such as Stretta, transoral incisionless fundoplication (TIF), anti-reflux mucosectomy (ARMS), and anti-reflux mucosal ablation (ARMA), are also options for GERD treatment. Stretta has shown improvement in subjective and objective measurements of GERD symptoms, and TIF has demonstrated improvement in regurgitation and reduction in PPI use. ARMS and ARMA have also shown promising results in improving symptoms.<br /><br />However, not all patients are suitable candidates for endoscopic or surgical therapies. Patients with grade C or D esophagitis, hiatal hernia larger than 2 cm, Barrett's esophagus, esophageal dysmotility, or Hill Grade IV are not ideal candidates. Before considering these therapies, it is important to optimize PPI therapy, confirm GERD diagnosis, assess anatomy and function through various tests, such as endoscopy, esophageal high-resolution manometry, pH testing, and potentially solid phase gastric emptying scintigraphy.<br /><br />Overall, when PPIs are not effective in treating GERD, endoscopic and surgical minimally invasive therapies can provide alternative options for symptom relief and improvement in quality of life.

Keywords

endoscopic therapies

surgical minimally invasive therapies

gastroesophageal reflux disease

proton pump inhibitors

refractory GERD

fundoplication

magnetic sphincter augmentation

laparoscopic anti-reflux surgery

Stretta

GERD treatment