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

New anti-reflux procedures