In Which Situation is Endoscopic Radiofrequency Anti-Reflux Therapy (Stretta) Effective for Controlling Gastroesophageal Reflux Symptoms?

Abstract

451 Endoscopic radiofrequency anti-reflux therapy (Stretta) is a minimally invasive mechanical therapy for gastroesophageal reflux disease (GERD) and it targets the intrinsic components of the gastroesophageal junction (GEJ). The components of GEJ are the lower esophageal sphincter (LES, intrinsic sphincter) and the surrounding structures, including the crural diaphragm, esophagophrenic ligaments, and connective tissues, which form the extrinsic sphincter. Moderate heat, ranging from 80–90C, denatures muscle fibers at the tip of the catheter, and enables injured muscle fibers to regenerate through the remodeling process. The remodeling process induces hypertrophic changes in the muscle fibers and results in the augmentation of barrier function. Stretta therapy increases LES pressure and decreases LES compliance, resulting in decreased reflux, which enhances the quality of life. Because the extrinsic barrier function of GEJ is lost in larger hiatal hernias measuring >2 cm, the effect of Stretta would be limited in cases of hiatal hernia. The diagnosis of hiatal hernia is crucial for the selection of appropriate candidates. If a hiatal hernia is found on high-resolution manometry, the patient will not be a candidate for Stretta. Diagnosing hiatal hernia on the basis of endoscopic findings is difficult since endoscopic features change consistently in the early phase. Hill classification for gastroesophageal flap valve (GEFV) can be used to evaluate the presence of angle of His. GEFV grade IV, i.e. blunting of angle of His, may be representative of hiatal hernia, even though hiatal hernia may not be apparent on endoscopy. Some patients show hernial sac formation only after burping of excessive air. This transient loss of GEFV could affect the efficacy of the Stretta treatment. The first indication of Stretta is refractory GERD without definite hiatal hernia or GEFV grade IV. Stretta procedure can be applied for the management of GERD after upper gastrointestinal surgery, including anti-reflux surgery. Fundoplication restores the extrinsic barrier of GEJ; however, some patients continue to complain of reflux. Recurrent reflux symptoms after fundoplication may be amenable to Stretta, which strengthens the intrinsic sphincter. In this issue of Clinical endoscopy, Nevin et al. reported that reflux symptoms of almost all the patients (6/7) improved after Stretta. Stretta was also effective for the patients who had undergone other surgeries such as fundal gastrointestinal stromal tumor resection and vagotomy with pyloroplasty. Because these surgeries do not affect the GEJ anatomy, GERD symptoms were successfully controlled with Stretta. However, Stretta could not improve reflux symptoms in cases of revision COMMENTARY