SAN FRANCISCO – It is now reasonable to conclude that many of the endoscopic devices and procedures developed for the treatment of gastroesophageal reflux disease (GERD) offer good short-term efficacy, leaving only the task to understand how these fit with competing options to improve quality of life long term, according to a state-of-the-art summary at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.
“The quality of the data for many of these devices has improved substantially, putting us in a much better place than we were in 4 or 5 years ago in considering their role,” reported Michael F. Vaezi, MD, PhD, professor of medicine, Vanderbilt University, Nashville, Tenn.
Over the past 15 years, an array of endoscopic approaches to treatment of GERD has received FDA approval. Examples of the very different techniques include plication devices that can suture, staple, or otherwise prevent reflux at the gastroesophageal junction (GEJ), and interventions aimed at the lower esophageal sphincter (LES), where placement of magnets or radiofrequency ablation has been employed to achieve a tighter defense against transient reflux episodes.
Despite FDA approval, the supportive evidence for many of these endoscopic interventions was criticized. In some cases, the number of patients evaluated in pivotal studies was considered too small. In others, there were objections to methodology, particularly to the choice of control arm. In all cases, there has been concern that follow-up was insufficient to confirm persistent benefit. Many of these criticisms are dissipating under the weight of more data.
“For most of the currently available, FDA-approved devices, there is now a substantial body of at least short-term data showing efficacy and safety,” reported Dr. Vaezi, who is a coauthor of an expert review now being prepared for publication. “This includes evidence that they improve quality of life, reduce the need for acid-suppressing therapy, and reduce esophageal acid exposure.”
Additional follow-up represents the final hurdle for understanding how these endoscopic interventions fit for extended symptom control. The long-term efficacy of the current standards of chronic proton pump inhibitor (PPI) therapy and surgical fundoplication has been established. Among these options, the choice is indefinite pharmacologic therapy or a surgical procedure. Endoscopic devices add additional options, but not with clear conclusions to be drawn on persistence of benefit.
Patient selection is an important consideration. Dr. Vaezi outlined three groups of patients: Patients who have responded to once-daily PPIs and are doing well, but would prefer not to take them indefinitely; PPI non-responders; and patients with improved heartburn but no improvement in regurgitation. Responders are reasonable candidates for endoscopic interventions, but non-responders are not, according to Dr. Vaezi. “You’re exposing the patient to the risk without the benefit, because they don’t have reflux. It’s something else,” he said.
Patients with improved heartburn but no change in regurgitation may be a candidate for endoscopic devices, as long as the clinician rules out non-reflux causes such as achalasia or gastroparesis.
“In patients being considered for alternative nonmedical therapy, it is essential to show that their symptoms are acid related. Those who do not respond to a PPI have traditionally not been good surgical candidates because the lack of a response suggests that acid reflux is not the source of their complaints. For patients being considered for an endoscopic treatment, we must apply the same time proven strategy. At this point, what is uncertain about the device therapies is the long-term durability for reflux control,” Dr. Vaezi said.
PPIs are effective for acid control, so the reason to consider an invasive treatment strategy is to avoid chronic PPI treatment. This is an increasingly attractive goal for many patients as a result of well-publicized case-control studies associating PPI use with a variety of increased risks, such as osteoporosis, chronic kidney disease, and gastrointestinal infections, but many gastroenterologists have been slow to recommend endoscopic interventions due to enduring concerns about safety and efficacy.
From his survey of the evidence, Dr. Vaezi characterized himself as “cautiously optimistic” that many of the endoscopic interventions will be included among standard options for durable GERD treatment.
