Relief of Reflux Symptoms after Endoscopic Gastroplication May Be Associated with Reduced Esophageal Acid Sensitivity: A Pilot Study

Background and Study Aims: Although the new endoscopic techniques for the treatment of gastroesophageal reflux disease (GERD) lead to marked clinical benefit, the underlying mechanism of this is unknown.
Materials and Methods: In this prospective study, the effect of endoscopic gastroplication was investigated in six patients with GERD, who were assessed before and 4 weeks after treatment. The effect on reflux symptoms, quality of life, proton pump inhibitor (PPI) consumption, reflux esophagitis, acid exposure, esophageal motility, lower esophageal sphincter pressure (LESP), and gastric emptying was measured. Esophageal acid sensitivity before and after treatment was investigated using a standardized acid provocation test, and compared with that of six age- and sex-matched healthy controls.
Results: Significant clinical benefit and discontinuation of PPI consumption after gastroplication was seen. Among the objectively measured parameters, only acid exposure was significantly reduced and gastric emptying significantly delayed. However, acid exposure remained pathologically high. Esophageal acid sensitivity was significantly reduced. The induction of heartburn and/or pain was abolished in four patients after gastroplication. In two patients the intensity of heartburn/pain was significantly reduced by 40 % or 60 %, and the time to provoke heartburn/pain significantly prolonged by 40 % or 100 %.
Conclusion: These preliminary data suggest that the decrease of esophageal sensitivity to acid after endoscopic gastroplication is part of the mechanism responsible for the reduction of reflux symptoms.

References

• 1 Kadirkamanathan S S, Yazaki E, Evans D F. et al . An ambulant porcine model of acid reflux used to evaluate endoscopic gastroplasty.  Gut. 1999;  44 782-788
• 2 Martinez-Serna T, Davis R E, Mason R. et al . Endoscopic valvuloplasty for GERD.  Gastrointest Endosc. 2000;  52 663-670
• 3 Utley D S, Kim M, Vierra M A, 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 81-86
• 4 Kim M S, Holloway R H, Dent J, Utley D S. Radiofrequency energy delivery to the gastric cardia inhibits triggering of transient lower esophageal sphincter relaxation and gastroesophageal reflux in dogs.  Gastrointest Endosc. 2003;  57 17-22
• 5 Mason R J, Hughes M, Lehman G A. et al . Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model.  Surg Endosc. 2002;  16 386-391
• 6 Triadafilopoulos G, Utley D S. Temperature-controlled radiofrequency energy delivery for gastroesophageal reflux disease: the Stretta procedure.  J Laparoendosc Adv Surg Tech A. 2001;  11 333-339
• 7 Triadafilopoulos G, Dibaise J K, Nostrant T T. et al . Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD.  Gastrointest Endosc. 2001;  53 407-415
• 8 Triadafilopoulos G, DiBaise J K, Nostrant T T. 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;  55 149-156
• 9 DiBaise J K, Brand R E, Quigley E M. Endoluminal delivery of radiofrequency energy to the gastroesophageal junction in uncomplicated GERD: efficacy and potential mechanism of action.  Am J Gastroenterol. 2002;  97 833-842
• 10 Corley D A, Katz P, Wo J M. et al . Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial.  Gastroenterology. 2003;  125 668-676
• 11 Filipi C J, Lehman G A, Rothstein R I. et al . Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.  Gastrointest Endosc. 2001;  53 416-422
• 12 Mahmood Z, McMahon B P, Arfin Q. et al . Endocinch therapy for gastro-oesophageal reflux disease: a one year prospective follow up.  Gut. 2003;  52 34-39
• 13 Feretis C, Benakis P, Dimopoulos C. et al . Endoscopic implantation of Plexiglas (PMMA) microspheres for the treatment of GERD.  Gastrointest Endosc. 2001;  53 423-426
• 14 Deviere J, Pastorelli A, Louis H. et al . Endoscopic implantation of a biopolymer in the lower esophageal sphincter for gastroesophageal reflux: a pilot study.  Gastrointest Endosc. 2002;  55 335-341
• 15 Johnson D A, Ganz R, Aisenberg J. et al . Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial.  Am J Gastroenterol. 2003;  98 1921-1930
• 16 Fockens P, Costamagna G, Gabriella A. Endoscopic augmentation of the lower esophageal sphincter (LES) for the treatment of GERD: multicenter study of the gatekeeper reflux repair system.  Gastrointest Endosc. 2002;  55 AB 90
• 17 Dutsch M, Eichhorn U, Worl J. et al . Vagal and spinal afferent innervation of the rat esophagus: a combined retrograde tracing and immunocytochemical study with special emphasis on calcium-binding proteins.  J Comp Neurol. 1998;  398 289-307
• 18 Berthoud H R, Neuhuber W L. Functional and chemical anatomy of the afferent vagal system.  Auton Neurosci. 2000;  85 1-17
• 19 Kulich K R, Malfertheiner P, Madisch A. et al . Psychometric validation of the German translation of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in patients with reflux disease.  Health Qual Life Outcomes. 2003;  1 62
• 20 Ghoos Y F, Maes B D, Geypens B J. et al . Measurement of gastric emptying rate of solids by means of a carbon-labeled octanoic acid breath test.  Gastroenterology. 1993;  104 1640-1647
• 21 Corley D A, Katz P, Wo J M. et al . Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial.  Gastroenterology. 2003;  125 668-676
• 22 Sontag S J, Kogut D G, Fleischmann R. et al . Lansoprazole prevents recurrence of erosive reflux esophagitis previously resistant to H2-RA therapy. The Lansoprazole Maintenance Study Group.  Am J Gastroenterol. 1996;  91 1758-1765
• 23 Lauritsen K, Deviere J, Bigard M A. et al . Esomeprazole 20 mg and lansoprazole 15 mg in maintaining healed reflux oesophagitis: Metropole study results.  Aliment Pharmacol Ther. 2003;  17 333-41
• 24 Lundell L, Backmann L, Ekstrom P. et al . Prevention of relapse of reflux esophagitis after endoscopic healing: the efficacy and safety of omeprazole compared with ranitidine.  Scand J Gastroenterol. 1991;  26 248-56
• 25 Arts J, Van Olmen A, D’Haens G. et al . Radiofrequency delivery at the gastroesophageal junction in GERD improves acid exposure and symptoms and decreases esophageal sensitivity to acid.  Gastroenterology. 2003;  124 A148