Radiofrequency treatment for gastroesophageal reflux disease
- George Triadafilopoulos, MD
George Triadafilopoulos, MD
- Clinical Professor of Medicine
- Stanford University School of Medicine
Standard therapy for gastroesophageal reflux disease (GERD) involves behavioral modifications and treatment with medications that reduce acid production or improve esophageal motility. Open or laparoscopic Nissen fundoplication may be chosen for those patients who do not wish to remain on an antisecretory medication, have an inadequate response to antisecretory medication, have a large hiatal hernia, or have persistence of esophagitis on medication. Esophagitis and GERD symptoms are improved or resolved after fundoplication in 76 to 98 percent of patients, while esophageal acid exposure time is normalized in approximately 90 percent of patients. (See "Surgical management of gastroesophageal reflux in adults".)
Minimally invasive alternatives to standard antireflux surgery have been developed, including the application of controlled radiofrequency (RF) energy to the lower esophageal sphincter region (Stretta procedure) . An advantage of RF treatment is that it can be used in patients with challenging anatomy . The Stretta system was approved by the US Food and Drug Administration in 2000.
This topic review will provide an overview of radiofrequency treatment for GERD. Medical and surgical treatments for GERD are discussed separately. (See "Medical management of gastroesophageal reflux disease in adults" and "Surgical management of gastroesophageal reflux in adults".)
Radiofrequency (RF) energy induces collagen contraction and has been shown to have therapeutic benefits in patients with cardiac arrhythmias, joint laxity, benign prostatic hyperplasia, and sleep-disordered breathing. Although the precise mechanisms of benefit in gastroesophageal reflux disease (GERD) are unclear, RF treatment appears to reduce postprandial transient lower esophageal sphincter relaxations and decrease compliance of the gastroesophageal junction, may decrease esophageal acid sensitivity by inducing healing of esophageal erosive disease, and may improve gastroparesis [2-4]. (See "Pathophysiology of reflux esophagitis", section on 'Transient lower esophageal sphincter relaxations'.)
One theory is that RF treatment improves symptoms of GERD through radiofrequency ablation of sensory neurons of the distal esophagus, leading to hyposensitization without an effect on pH. In a study of 13 patients undergoing pH monitoring and Bernstein acid perfusion testing, esophageal acid sensitivity was decreased six months after RF treatment . However, this hypothesis was not supported in a report of 118 patients examining the relationship between symptom improvement (GERD-health-related quality of life [HRQL] and heartburn scores, general satisfaction, daily proton pump inhibitor [PPI] use) and intraesophageal acid exposure (percent proximal and distal esophageal time with pH <4.0) six months after RF treatment . Responders to RF treatment had significant improvements in both proximal and distal acid exposure times. By contrast, non-responders had either no improvement or less improvement in proximal and distal acid exposure times. Changes in GERD-HRQL and heartburn severity positively correlated with changes in acid exposure.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Utley DS, Kim M, Vierra MA, Triadafilopoulos G. Augmentation of lower esophageal sphincter pressure and gastric yield pressure after radiofrequency energy delivery to the gastroesophageal junction: a porcine model. Gastrointest Endosc 2000; 52:81.
- Tam WC, Schoeman MN, Zhang Q, et al. Delivery of radiofrequency energy to the lower oesophageal sphincter and gastric cardia inhibits transient lower oesophageal sphincter relaxations and gastro-oesophageal reflux in patients with reflux disease. Gut 2003; 52:479.
- Arts J, Sifrim D, Rutgeerts P, et al. Influence of radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) on symptoms, acid exposure, and esophageal sensitivity to acid perfusion in gastroesophagal reflux disease. Dig Dis Sci 2007; 52:2170.
- Arts J, Bisschops R, Blondeau K, et al. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol 2012; 107:222.
- Triadafilopoulos G. Changes in GERD symptom scores correlate with improvement in esophageal acid exposure after the Stretta procedure. Surg Endosc 2004; 18:1038.
- Noar MD, Noar E. Gastroparesis associated with gastroesophageal reflux disease and corresponding reflux symptoms may be corrected by radiofrequency ablation of the cardia and esophagogastric junction. Surg Endosc 2008; 22:2440.
- https://www.sages.org/publications/guidelines/endoluminal-treatments-for-gastroesophageal-reflux-disease-gerd/ (Accessed on October 03, 2017).
- Triadafilopoulos G, DiBaise JK, Nostrant TT, et al. The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S. open label trial. Gastrointest Endosc 2002; 55:149.
- Richards WO, Houston HL, Torquati A, et al. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg 2003; 237:638.
- Wolfsen HC, Richards WO. The Stretta procedure for the treatment of GERD: a registry of 558 patients. J Laparoendosc Adv Surg Tech A 2002; 12:395.
- Torquati A, Houston HL, Kaiser J, et al. Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease. Surg Endosc 2004; 18:1475.
- White B, Jeansonne LO, Cook M, et al. Use of endoluminal antireflux therapies for obese patients with GERD. Obes Surg 2009; 19:783.
- Fass R, Cahn F, Scotti DJ, Gregory DA. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc 2017; 31:4865.
- Perry KA, Banerjee A, Melvin WS. Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:283.
- Dughera L, Rotondano G, De Cento M, et al. Durability of Stretta Radiofrequency Treatment for GERD: Results of an 8-Year Follow-Up. Gastroenterol Res Pract 2014; 2014:531907.
- Noar M, Squires P, Noar E, Lee M. Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later. Surg Endosc 2014; 28:2323.
- Liang WT, Wang ZG, Wang F, et al. Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study. BMC Gastroenterol 2014; 14:178.
- Noar M, Squires P, Khan S. Radiofrequency energy delivery to the lower esophageal sphincter improves gastroesophageal reflux patient-reported outcomes in failed laparoscopic Nissen fundoplication cohort. Surg Endosc 2017; 31:2854.
- Richards WO, Scholz S, Khaitan L, et al. Initial experience with the stretta procedure for the treatment of gastroesophageal reflux disease. J Laparoendosc Adv Surg Tech A 2001; 11:267.
- Houston H, Khaitan L, Holzman M, Richards WO. First year experience of patients undergoing the Stretta procedure. Surg Endosc 2003; 17:401.
- Dundon JM, Davis SS, Hazey JW, et al. Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) does not provide long-term symptom control. Surg Innov 2008; 15:297.
- Liang WT, Wu JN, Wang F, et al. Five-year follow-up of a prospective study comparing laparoscopic Nissen fundoplication with Stretta radiofrequency for gastroesophageal reflux disease. Minerva Chir 2014; 69:217.
- Perez AR, Moncure AC, Rattner DW. Obesity adversely affects the outcome of antireflux operations. Surg Endosc 2001; 15:986.
- Morgenthal CB, Lin E, Shane MD, et al. Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes. Surg Endosc 2007; 21:1978.
- Go MR, Dundon JM, Karlowicz DJ, et al. Delivery of radiofrequency energy to the lower esophageal sphincter improves symptoms of gastroesophageal reflux. Surgery 2004; 136:786.
- Gersin K, Fanelli R. The Stretta procedure: Review of catheter and technique evolution, efficacy and complications 2 years after introduction. Surg Endosc 2002; 16 (Suppl 1):PF199.
- Chen D, Barber C, McLoughlin P, et al. Systematic review of endoscopic treatments for gastro-oesophageal reflux disease. Br J Surg 2009; 96:128.
- Lutfi RE, Torquati A, Richards WO. Endoscopic treatment modalities for gastroesophageal reflux disease. Surg Endosc 2004; 18:1299.
- Comay D, Adam V, da Silveira EB, et al. The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: a cost-effectiveness analysis. Can J Gastroenterol 2008; 22:552.
- Funk LM, Zhang JY, Drosdeck JM, et al. Long-term cost-effectiveness of medical, endoscopic and surgical management of gastroesophageal reflux disease. Surgery 2015; 157:126.