ASGE Masterclass: Barrett’s Esophagus, GERD and Esophageal Adenocarcinoma (Virtual)

PPIs not working

Pdf Summary

The document discusses the use of endoscopic and surgical minimally invasive therapies for GERD (gastroesophageal reflux disease) when proton pump inhibitors (PPIs) are not effective. It highlights that a significant percentage of patients (10-54%) continue to experience symptoms despite PPI therapy. This includes both reflux-like symptoms that may not be GERD-related and persistent GERD symptoms with ongoing reflux. Additionally, it mentions that a significant percentage of patients (8-30%) still have evidence of esophagitis despite adequate PPI dosage.<br /><br />The document explores surgical therapies such as fundoplication (complete or partial), RYGB for obese patients, and magnetic sphincter augmentation (LINX). It presents the results of a study comparing laparoscopic antireflux surgery (LARS) to PPI therapy, showing better remission rates with LARS after 5 years of follow-up.<br /><br />The indications for fundoplication are discussed, including long-term treatment for patients with severe reflux esophagitis, large hiatal hernias, and persistent, troublesome GERD symptoms. Furthermore, the document provides criteria for inclusion in fundoplication surgery, such as abnormal pH-impedance study results or esophageal pH <4 for a significant portion of the 24-hour period.<br /><br />The use of magnetic sphincter augmentation (MSA) for GERD is also described, with studies showing reductions in PPI use, heartburn, regurgitation, and dysphagia, as well as high patient satisfaction rates.<br /><br />The document mentions endoscopic therapies such as Stretta, transoral incisionless fundoplication (TIF), anti-reflux mucosectomy (ARMS), and anti-reflux mucosal ablation (ARMA). Results of studies evaluating these procedures, including improvements in subjective and objective measurements of GERD symptoms, are presented.<br /><br />Finally, the document emphasizes the importance of optimizing PPI therapy, confirming the diagnosis of GERD, assessing the anatomy and function of the esophagus through various tests, and considering endoscopic or surgical therapies when necessary. However, it also notes that certain patients may not be suitable candidates for these procedures based on factors such as the severity of esophagitis, the size of hiatal hernia, and the presence of esophageal dysmotility.

Keywords

GERD

proton pump inhibitors

reflux-like symptoms

persistent GERD symptoms

esophagitis

laparoscopic antireflux surgery

magnetic sphincter augmentation

hiatal hernias

endoscopic therapies

surgical therapies