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Study on Plication

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  • Study on Plication

    From The American Journal of Gastroenterology

    Impact of Endoscopic Suturing of the Gastroesophageal Junction on Lower Esophageal Sphincter Function and Gastroesophageal Reflux in Patients with Reflux Disease
    Posted 03/08/2004

    William C.E. Tam, M.B.B.S., F.R.A.C.P.; Richard H. Holloway, M.D., F.R.A.C.P.; John Dent, M.B., B. Chir., Ph.D.; Rachael Rigda, B.Sc., F.R.A.C.P.; Mark N. Schoeman, M.B.B.S., Ph.D., F.R.A.C.P.

    Objectives: Plication of the gastroesophageal junction by endoscopic suturing has been reported to improve symptoms and reduce acid exposure in patients with gastroesophageal reflux disease (GERD). The mechanisms underlying these effects are not well defined. The aims of our study were to determine the impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter (LES) function in patients with GERD.
    Methods: In 15 patients (7 males) with GERD (heartburn, % time esophageal pH < 4 greater than 4%, ± history of erosive esophagitis within 6 months), two plications were performed circumferentially 1 cm below the gastroesophageal junction. Endoscopy and combined postprandial esophageal manometry and pH monitoring were performed before and 6 months after treatment; 24-h ambulatory pH monitoring and symptom assessment were also performed before, and at 6 and 12 months after treatment.
    Results: Six months after treatment, the rate of transient LES relaxations (tLESRs) was decreased by 37% (p< 0.05) and basal LES pressure had increased from 4.3 ± 2.2 mmHg to 6.2 ± 2.1 mmHg (p< 0.05). The rate of postprandial reflux events and acid exposure time were not altered. Endoscopic suturing significantly reduced 24-h esophageal acid exposure from 9.6% (9.0-12.1) to 7.4% (3.9-10.1) at 6 months, due predominantly to a reduction in upright acid exposure. The reduction in total 24-h acid exposure was sustained to 12 months. At repeat endoscopy, only one plication was evident in 6 patients (40%) at 6 months. Seven patients (47%) remained off medications at 6 and 12 months follow-up.
    Conclusions: In patients with GERD, endoscopic suturing of the gastroesophageal junction results in a reduction in the rate of tLESRs, and an increase in basal LES pressure. These changes in LES function result in only a modest reduction in gastroesophageal reflux.


  • #2

    Endoscopic Assessment: Informative article, however it's and old one, the procedure is changed a lot and is no longer performed in the manner it was for this study. As many as six - eight stitches are now done and are placed in a different manner as a result of various studies like the above. Here's another section of same.
    Grade of Esophagitis. At time of entry into the trial, 5 patients had erosive reflux esophagitis (Los Angeles grades A - 4; B - 1), while 10 had no visible erosions (Table 1). Six months after treatment, 10 patients had no macroscopic mucosal breaks and 5 patients had mild erosive reflux esophagitis (LA grade A).

    Durability of Plications. Two plications were created in each patient at entry into the trial. At the 6 months follow-up endoscopy, nine patients were found to have the two plications still in place, but in six only one plication was visible (Table 1).

    Clinical Assessment
    Medication Use. All patients were on regular acid-suppressant therapy before endoscopic suturing (Table 1). Six months after endoscopic suturing, 7 out of 15 patients (47%) were asymptomatic and were off medication. The remaining 8 patients were maintained on a lower level of acid-suppressive therapy than that required pretreatment (3 on standard-dose PPI, 1 on standard-dose H2RA, and 4 on half-dose H2RA).

    At 12 months (Table 1), five of the eight patients who had symptomatic relapse at 6 months remained dependent on acid-suppressant therapy (1 on half-dose H2RA, 4 on standard-dose PPI). Two patients had become asymptomatic and were no longer on medical therapy, while 1 was lost to follow-up at 9 months. Two other patients previously in symptomatic remission at 6 months developed heartburn at 12 months follow-up and are on standard-dose PPI therapy. Overall, 7 of 14 patients were completely asymptomatic and off medication.

    Symptom and Quality of Life Assessment. Symptom severity and quality of life as assessed by both the SF-36v2 scale and the GERD-HRQoL showed significant improvement at 6 months (Table 3). These improvements were sustained to 12 months except for the mental component score of the SF-36v2 questionnaire. In addition, dysphagia scores improved at 6 and 12 months after suturing.

    Relationship between 24-hour esophageal acid exposure, symptoms, and endoscopic grade of esophagitis. At 6 months, five of the seven patients in symptomatic remission had demonstrated a reduction in 24-h esophageal acid exposure time, while esophageal pH did not change in the remaining two patients. At 12 months, all seven patients in symptomatic remission had a reduction in their 24-h esophageal acid exposure time.

    Of the four patients with normal acid exposure at 6 months, all were asymptomatic and off acid-suppressant medication. All four patients had two plications still intact on repeat endoscopy at 6 months. Three patients had no evidence of mucosal erosions and the fourth had LA grade A reflux esophagitis. At 12 months, three patients had normal esophageal acid exposure and were asymptomatic off medication.

    Effect of Number of Plications at 6 Months on 24-H Esophageal Acid Exposure and Clinical Outcomes. As a group, patients with two plications still present at 6 months had a significantly greater reduction in median 24-h acid exposure time, compared with the group of patients with one plication (Table 4). Four patients with two plications had normalized 24-h esophageal acid exposure, while no patient with one plication had achieved this. Esophagitis grade did not differ between the two groups. Five of nine patients (56%) with two plications were in symptomatic remission at 6 months compared with two of six patients (33%) with only one plication.

    No major complications occurred. Minor sore throat occurred in four patients, which resolved within 24 h with simple analgesia (paracetamol 1 g orally every 4 h). None of our patients developed abdominal pain, bleeding, symptoms of sepsis, or required readmission to hospital.


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    Am J Gastroenterol 99(2):195-202, 2004. © 2004 Blackwell Publishing