Heartburn is a burning sensation behind the breast bone when stomach contents reflux backward into the esophagus (gastroesophageal reflux, GER). GER occurs in 10 percent to 48 percent of the U.S. population. Untreated GER has potentially severe complications including erosive esophagitis, ulcer disease, stricture and Barrett’s esophagus with its increased risk for the development of esophageal cancer.
Current GER treatments include gastric acid-blocking drugs and fundoplication surgery. Medications include H2 blockers that control GER symptoms in 60 percent of patients and esophagitis in 50 percent of patients. Proton pump inhibitors are more effective and control GER symptoms in 80 percent of patients and esophagitis in 90 percent of patients. Many patients are challenged, though, by a desire to discontinue these medications, difficulty with long-term medical compliance, a persistence of regurgitation symptoms or drug intolerance.
Fundoplication surgery is very effective in controlling acid reflux disease, esophagitis, and symptoms of regurgitation. This operation requires the use of general anesthesia and one to two days hospitalization. Post-operative complaints include swallowing difficulties in 4 percent to 31 percent of patients, bloating in 5 percent to 50 percent and excessive flatulence in up to 80 percent of patients.
The Stretta procedure is an approved technique for acid reflux disease.1 The Stretta procedure uses radiofrequency electrosurgery delivered to the lower esophageal sphincter and gastric cardia and represents a minimally invasive, endoscopic treatment alternative to drugs or fundoplication surgery. Radiofrequency energy is delivered to the tissue via a specially designed catheter used during outpatient endoscopy. The treatment produces vibrating water molecules and heat in the target tissue, which leads to tissue constriction and improved muscle wall thickness. The changes decrease the frequency of transient lower esophageal sphincter relaxations (tLESRs), which are major mechanisms underlying GER. In addition, the Stretta procedure has been demonstrated to increase lower esophageal sphincter pressure, decrease esophageal acid exposure time, decrease the need for acid blocking drugs, and controlling GER symptoms and esophagitis. Significant improvements in physical and mental quality-of-life scores of GER patients have been noted after the Stretta procedure.
At the Mayo Clinic in Jacksonville, Fla., the Stretta radiofrequency procedure has been used on selected GER patients since January 2001. Among these were 13 patients with documented acid reflux disease whose patient information and Stretta treatment parameters were subsequently reviewed, including patient age, weight, procedure time, medication requirement and recovery-room time. These patients had a median age of 64 (range: 34 to 75 years old) and a median weight of 83 kg (range: 68 kg to 108 kg). Five of the patients were women and eight were men. Procedure parameters and sedative medication requirements included a median midazolam dose of 10 mg (range: 7 mg to 12 mg) and median meperidine dose 250 mg (range: 150mg to 300 mg). The median length of the Stretta procedure was 51 minutes (range: 42 minutes to 75 minutes) and the median length of the patients’ recovery room stay was 115 minutes (range: 70 minutes to 175 minutes). Complications were limited to transient odynophagia and chest pain. We concluded the Stretta procedure can be safely performed in patients with a wide range of ages. The procedures, however, may be lengthy compared to a standard upper endoscopy. Conscious sedation for Stretta patients required higher doses of sedative medication and a longer stay in the recovery room. These factors have led us to schedule Stretta patients in the late morning to avoid disrupting the morning endoscopy schedule while permitting adequate recovery time. Our experience is similar to the results from controlled trials performed with the Stretta procedure. In these studies, post-Stretta adverse events were limited to transient fever, dysphagia, chest pain, superficial mucosal injury and anesthesia reactions. There were no new cases of swallowing problems, achalasia or decreased esophageal peristalsis (motility).
The Stretta procedure is not recommended for patients with severe GER, large hiatal hernias or a poorly functioning esophagus with dysphagia or stricture. Candidates for the Stretta procedure include patients with a desire to continue GER medications, patients who experience drug intolerance or patients with inadequate symptom response. These patients may consider endoscopic radiofrequency electrosurgery as an alternative to long-term drug therapy or fundoplication.