Endoscopic treatment of acid reflux – GERDX- (endoscopic plication)
Professor Sauid Ishaq, Professor of medicine Birmingham City University and Consultant Gastroenterologist at Russells Hall Hospital in Dudley introduced this treatment in the UK in 2018.
Gastro-oesophageal reflux disease or acid reflux is a common problem and 10 to 20 per cent of adults suffer from reflux symptoms at least once a week, mainly heartburn or regurgitation.
When we swallow, a circular band of muscle around the bottom of the oesophagus, known as the lower oesophageal sphincter, relaxes to allow food and liquid to flow into the stomach, and then closes again to seal it in.
If the sphincter relaxes abnormally or weakens, stomach acid can flow back up into the oesophagus and over time it irritates the lining, often causing it to become inflamed. If left untreated, a persistent state of acid reflux can lead to Barrett’s oesophagus, a pre-cancerous condition which can turn into oesophageal cancer.
The consequences of reflux can be painful and can severely affect the quality of life of those affected. Common symptoms include a burning sensation in the chest - heartburn - chest pain, difficulty swallowing, regurgitation of food, and a sensation of a lump in the throat. It also affects quality of life and disrupts sleep.
Lifestyle advice, such as not eating later at night, has limited impact, and the condition is mainly treated with strong acid suppressants called proton pump inhibitors (PPIs) that work by stopping cells in the lining of the stomach producing too much acid, and which patients need to take for long time..
If taken over some years, PPI can cause side-effects, such as diarrhoea, fatigue, osteoporosis, vitamin deficiency and kidney disease. PPI side effect may be related to inhibition of acid production in stomach that lead to poor absorption of vitamins such as Vit B and D. Acid in stomach help kill microorganism, hence low level of acid also makes patient vulnerable to infection such C difficile infection.
A third of PPI users are not satisfied with the results of the medication or cannot tolerate the side effects. There patients can be offered surgery known as laparoscopic fundoplication, in which the upper part of the stomach is wrapped around the lower end of oesophagus and stitched in place.
This creates tightness of lower oesophageal sphincter to stop reflux of acid. It is a surgical invasive procedure, and more than 30 per cent of operated patients despite surgery end up having to use PPI long term after a few years. Too lose wrap can lead to relapse of acid reflux symptoms and too tight wrap frequent cause bloating and inability to burp and belch that can lead to uncontrolled flatulence.
Risk of side effects: scars, dysphagia/and uncontrolled flatulence, vagus nerve injury, gas bloat syndrome are reported with surgical fundoplication.
However, since 2018 Professor S Ishaq has been using endoscopic fundoplication to cut these risks. Rather than making an incision in the tummy as with the traditional route, we go through the mouth to reach the stomach. With the development of this GERDX kit it is now possible to use natural orifice endoscopic surgery (NOTES)
We plicate in the upper part of stomach very close to oesophageal sphincter with permeant suture placed inside the stomach. Patients can return home as day case following this procedure.
As with traditional surgery, the aim is to tighten the junction between the oesophagus and the stomach, to make a mechanical barrier, using sutures reinforced with pledges, two pieces of teflon-like material that are implanted with the sutures to keep the tissue stitched together.
Under deep sedation or general anaesthetic, an endoscope, a narrow tube-like device that carries a tiny camera, is inserted through the mouth and down through the oesophagus and to the junction with the stomach. A wire is then inserted along the same route. Then the new GERDX is inserted over the wire into the stomach. (SEE PICTURES A&B BELOW)
GERDX plicator- a) hydraulic platform (Handle)- highlighting scope channel, b) shaft of the plicator including hydraulic tip that act as two arms, when opened a retractor pushed out between the arms to retract stomach wall into the plicator.
Once the GERDX device tip is in the stomach a small endoscope is passed through scope channel on the handle. Endoscope then provides detailed views of tip of the device, and the device is then positioned close to junction of stomach and oesophagus.
At this stage the two plicator arms are opened and special retractor is advanced deeply into the gastric wall and then drawn back to gather tissue between the open arms of the plicator.
The arms are then closed to sandwich the tissue and the pledges are sutured in place. A second suture is applied in the same way to get a tight closure of the junction between stomach and oesophagus. This creates a mechanical barrier to prevent acid reflux.
This gathering up of the tissue, like a pleat in a skirt, has the effects of tightening the tissue and reducing the size of the gastro-oesophageal junction, reducing the possibility of reflux. Where the sphincter is particularly wide or if there is small hiatus hernia the second fold helps to achieve the much needed reduction.
Once the procedure is completed, the instruments and the retractor are removed but the implant remains to hold the tissue in place permanently.
After the procedure the patient will be monitored in the recovery area and either discharged as a day case procedure or be kept for overnight observation if necessary.
Temporary sore throat, abdominal pain, chest pain may be expected usually treated with simple analgesics.
Serious complications such as bleeding and perforation are rare.
Likely advantages are, this is incisionless short and patient friendly procedure with long-term effectiveness
It has proved to be life-changing for patients such as Yvonne who is no longer being sick on a daily basis.
As this is new technique hence accessories used to carry this out are expensive and each procedure can cost the NHS up to £4000. This poses stumbling block to its use. Thus in patient led NHS there need to be a major shift how we embrace innovation that look costly but actually more cost effective to overall NHS health economy because of saved bed days and precious theatre slots.
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