PERFORMING THE STRETTA PROCEDURE: New Minimally Invasive Treatment of Chronic Heartburn

The Center for Minimally Invasive Surgery is pleased to announce the introduction of a new minimally invasive technique for the treatment of chronic heartburn, that is, gastroesophageal reflux disease (GERD). Called the Stretta procedure, this newly developed outpatient endoscopic procedure takes about one hour to perform, and provides considerable benefits to patients.

Stony Brook University Hospital is the only health facility in Suffolk County that offers the Stretta procedure, the use of which further demonstrates our commitment to providing truly state-of-the-art patient care.

             

Arif Ahmad, MBBS (photo at left), assistant professor of surgery and director of the Center for Minimally Invasive Surgery, and Louis T. Merriam, MD (photo at right), assistant professor of surgery, have acquired the training necessary to perform the procedure. With special expertise in minimally invasive "videoscopic" surgery, they both have a long-standing interest and proficiency in the surgical correction of GERD.

Describing the procedure's benefits, Dr. Ahmad says: "No hospital stay is required and typically patients may return to normal activities the following day. Moreover, most patients are able to discontinue acid-reducing GERD medications in a month."

The procedure itself is performed with a flexible, disposable catheter connected to a radiofrequency (RF) generator. With the patient under conscious sedation, the surgeon delivers controlled RF energy to the lower esophageal sphincter (LES) muscle and gastric cardia to create thermal lesions. As the lesions heal, the barrier function of the LES is enhanced, reducing the frequency of reflux events.

Early clinical studies appearing in the medical literature demonstrate that the Stretta procedure is a promising new treatment of GERD, which affects 1 in 14 adults in the United States today.

For consultations/appointments with Dr. Ahmad and Dr. Merriam, please call the Center for Minimally Invasive Surgery at 631-444-4545.

FROM THE MEDICAL LITERATURE . . . Initial Experience with the Stretta Procedure for the Treatment of Gastroesophageal Reflux Disease Background: The Stretta device (Curon Medical, Sunnyvale, CA) is a balloon-tipped four-needle catheter that delivers radiofrequency (RF) energy to the smooth muscle of the gastroesophageal junction. It can be used for the endoscopic treatment of gastroesophageal reflux disease (GERD).     Step 1: The physician places the catheter through the mouth and into the valve between the stomach and esophagus. The electrodes are placed into the tissue and radiofrequency energy is delivered to create well-defined areas of coagulation around the electrodes. Water delivered through ports in the catheter irrigates the surface mucosa during treatment. The device monitors temperature readings to assure safety and precise control during treatment. Step 2: The physician repeats this sequence along the length of the gastroesophageal junction. Step 3: Over the next few weeks, the coagulated tissue resorbs and shrinks, increasing resistance to reflux. Patients and methods: Data prospectively collected on the first 25 consecutive patients undergoing the Stretta procedure at Vanderbilt University Medical Center between August 2000 and March 2001 are reported. Patient evaluation included esophageal manometry, ambulatory 24-hour pH testing, a standard GERD-specific quality-of-life survey (QOLRAD), a general quality-of-life survey (SF12), and endoscopy. Stretta surgery was performed following a standardized protocol. Thermocouple-controlled RF energy was delivered to the lower esophageal sphincter (LES) after endoscopic location of the z-line. Patients were followed up 3 months after endoscopic treatment. Results are presented as mean ± SEM. Results: Prior to treatment, patients had a mean DeMeester score of 31.0 ± 11.4, an LES pressure of 24 ± 2 mm Hg, and normal esophageal peristalsis. Of the 25 outpatient procedures, 19 were done under conscious sedation and 6 under general anesthesia. There was a small learning curve (76 ± 8 min for the first three procedures; 50 ± 2 min for the subsequent 22). The mild to moderate pain during the first 24 postoperative hours was controlled with over-the-counter medication. Two complications were noted: one patient presented with ulcerative esophagitis and gastroparesis 10 days after the Stretta treatment, and one patient developed pancreatitis on postoperative day 27, which was probably unrelated to the Stretta procedure. Eight of the thirteen patients (62%) available for 3-month follow-up were off all antisecretory medication. The other five patients were still taking medications but had been able to reduce the amount considerably. The average daily dose of proton pump inhibitors was 43.0 ± 5.0 mg/preoperatively and 6.4 ± 2.2 mg/3 months postoperatively (P < 0.001). Other classes of GERD treatment such as metoclopramide had been completely abandoned. In all patients, QOLRAD scores improved (3.5 ± 0.4 to 5.5 ± 0.5; P < 0.001) as did SF12 physical (23.7 ± 3.0 to 31.0 ± 3.4; P < 0.008) and mental (40.5 ± 2.9 to 47.7 ± 3.2, P < 0.017) scores. All patients would undergo a Stretta procedure again except one 78-year-old man with progressive Alzheimer's disease. Conclusions: The Stretta procedure is a promising new modality in the management of GERD. It can be safely performed in one short session with gastroesophageal endoscopy under conscious sedation in an outpatient setting. It improves GERD symptoms and quality-of-life scores in patients at 3 months and eliminates or significantly reduces the need for antisecretory drugs. ~~~~~~~~~~~~~~~~ Richards WO, Scholz S, Khaitan L, Sharp KW, Holzman MD. Initial experience with the Stretta procedure for the treatment of gastroesophageal reflux disease. Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A. 2001 Oct;11:267-73.