Reflux and Motility Symposium Highlights

This co-sponsored event (EGS and Medtronic) provided a clinical update on the management of reflux disease from diagnosis to therapy and was led by experts who discussed optimal methods and best practices for patient care. Below are two highlighted segments.

1. Minimally Invasive Fundoplication for Chronic Acid Reflux

Barham Abu Dayyeh, MD, MPH, FASGE, Director of Advanced Endoscopy, Consultant, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN

Dr. Abu Dayyeh provides a thorough overview of transoral incisionless fundoplication (TIF) as a safe and effective treatment option for many patients suffering from gastroesophageal reflux disease (GERD), outlining how this increasingly popular procedure fits in the patient’s spectrum of care. He emphasizes that GERD is not a hyper secretory disorder, resulting from parietal cells making too much acid, and that about 10-40% of patients with GERD fail to respond symptomatically, either partially or completely, to standard-dose PPIs. This is because GERD is an anatomical breakdown resulting in a movement of the esophagus both axially and longitudinally creating a gap at the opening of the hiatus, which needs to be addressed with various treatment options depending primarily on size of the opening, or Hill Grade.

If PPIs are not working, or the patient wants to discontinue PPIs, a patient accurately assessed as having a Hill grade 2 is a good candidate for a minimally invasive procedure such as transoral incisionless fundoplication. TIF can also be effective for Hill Grade 3 patients, but patients with a Hill Grade 4 would most likely require a hiatal hernia repair, which can be applied concomitantly with a TIF. Dr. Abu Dayyeh outlines the evolution of treatments leading up to the current version of TIF 2.0 using the latest Esophyx Z device, with detailed demonstrations and highlights of the procedure, and a caveat that some of the literature still has not caught up to the current version of TIF. He provides success rates for TIF, where two thirds of patients stayed off PPIs for at least five years during the span of the supporting data. Dr. Abu Dayyeh concludes by noting that for about 22,000 cases of TIF, the serious adverse event rate (SAE) was 0.4%, which is on par or better than the safety profile of a colonoscopy.

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View the complete slide deck for Dr. Abu Dayyeh’s presentation including:

2. Clinical Dilemmas in GERD Discussion–Panel Members:

• Anish Sheth, MD, Chief of Gastroenterology, Director, Digestive Health Center, Penn Medicine, Princeton Health, Plainsboro, NJ
• Abraham Khan, MD, Director, Center for Esophageal Disease, Assistant Professor of Medicine, NYU Langone Health, New York, NY
• Amir Masoud, MD, Associate Program Director, Gastroenterology Fellowship Program Director, Temple Endoscopy Center, Yale School of Medicine, New Haven, CT
• Barham Abu Dayyeh, MD, MPH, FASGE, Director of Advanced Endoscopy, Consultant, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN

This panel of leading experts in the field of gastroenterology examined three cases of moderate to severe gastroesophageal reflux disease (GERD) with various symptoms and desired outcomes. The first patient is a 48-year-old male with heartburn who got better with PPIs and had no dysphagia regurgitation, but wanted surgery because he didn’t want to take PPIs long term. The endoscopy showed a 3cm hernia, no esophagitis. EndoFLIP, performed with the endoscopy showed RACs and normal EGJ distensibility. The panel focused on the components of an EndoFlip exam and “the million-dollar question,” regarding the efficacy of forgoing a preoperative manometry in patients with a normal EndoFLIP exam.

The second patient is a 63-year-old female with longstanding heartburn regurgitation. Pre-op-eval has regurgitation, 40-hour pH monitoring shows a 2cm hernia, pH testing, upright supine reflux and good symptom correlation. For this case, the panel explored the nuances associated with ineffective esophageal motility, using the DCI failed swallows and impedance to advise surgeons about what they should do in such cases. The Panel also explored ways to mitigate post-operative dysphagia, questions about additional pre-operative motility workup, and the usage of TIF and LINX devices vs. partial fundoplication.

The final case is a 65-year-old male patient with Barrett’s, having high grade dysplasia, longstanding GERD, AGD 5cm hernia, C4 M5, and some esophagitis. The panel explored various views on how best to manage the patient’s GERD and Barrett’s esophagus, as well as questions about whether he should undergo anti-reflux surgery prior to radio frequency ablation (RFA). These case discussions invoked input from a well-informed audience with an emphasis on effective, yet minimally invasive treatments, such as transoral incisionless fundoplication gearing as much as possible toward 0% complications for the patients, and highlighting the need for more personalized treatment as inter-observable agreement in many such cases can prove to be difficult.