NEW ANTI-REFLUX PROCEDURES
MYTH: SLIDING HIATAL HERNIA = GERD?
• 70% over 70 y
• GERD = 4% of total pop
• Crural repair alone – no effect, fails >50% after LF
• HH = -ve pressure gradient: HH + bad LES = GERD severity
Normal LEHPZ = NO GERD
ASSESSING SUCCESS
• Acid exposure tests?
No single parameter
Sensitivity High
Specificity low
Diagnosis NOT outcome
• Clinical improvement!
GERD-HRQL most validated
PPI use ±
GERD RX BY INVASIVENESS
• Life style changes
• Lifelong PPI
% Incomplete responders high
Long term risks
• Trans-oral operations
• Laparoscopic / open operations
FUNDOPLICATION
• LES not repaired
• Wrap = new HPZ
Fundus pressure
• Centers of excellence
• Community
US: 100k ops/y > 8,000,000 suffer
WHY SO FEW?
• Non experts = poor results
• Large scale studies - > 60% PPI
• Redo LF - Hard
• 360º = 30 - 10% dysphagia
GI do not refer
ANGELCHIK RING 1977
• >100k implanted
• Dysphagia, erosion
• LINX same idea
LINX: NEW AND IMPROVED
• Magnetic Beads
• Expands on swallowing
• No dysphagia, erosions
• Safe and effective
• Easy = more surgeons
WILL LINX INCREASE REFERRALS?
• Laparoscopic
• Patients don’t like scar
• LINX ≠ solution
Surgeons ≠ Referrals
TRANS-ORAL OPERATIONS
• Many dead and gone
• On the market
Stretta
Esophyx
MUSE™ ~ 150 pts
• All CE marked, FDA cleared
• Selected Patients: Safety & Efficacy ≈ LF (QoL + PPI use)
STRETTA
• Low power radiofrequency
• Outpatient ~ 40 min
MODE OF OPERATION
• Affects LES directly
• How?
Blunts sensory nerves??
Scarring – some increased collagen
No strictures or dysphagia > 8y
Increase muscle bulk
Animal models
STRETTA - DISADVANTAGES
• HH < 2 cm
• ~ 3 months to relief
• PPI Rx
• Can be repeated
ESOPHYX
• Inkwell
Betsey mark IV
• Multiple fasteners
6-20
• Many iterations
• Unique fasteners
ESOPHYX DISADVANTAGES
• Two Operators
• HH < 2 cm
• Not available outside US
• Conversion to LF difficult
MUSE™
• Single patient use flexible endostapler
• Single Operator
• Computer Controlled
ANTERIOR FUNDOPLICATION (DOR-THAL) MUSE™ STYLE
• Fundus stapled to esophagus
• Video/US guided
• 4.8mm (Green) “B” stales
• 2-4 staggered quintuplets
MUSE™ REQUIREMENTS
• Skill in advanced endoscopic procedure
• Anti-emetics ASA class 3
2 drugs
• Full muscle relaxation
• PEEP of 7 cmH2O on induction
• SHH - PEEP up to 15 or until HH reduces
NEW OPTIONS FOR GERD