Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5554_Библиотеки_им_академика_М_И_Перельмана.pdf
66
Fig. 5.3 Pictures of Stretta
radiofrequency instruments
Fig. 5.4 Pictures of Stretta
radiofrequency instruments
L. Li et al.
67
Fig. 5.5 Pictures of Stretta
radiofrequency instruments
5.2.6 Advantages ofRadiofrequency Therapy
1. Minimally invasive: Minimally invasive treatment without changing the physi-
ological structure.
2. Targeting: Small trauma, needle-like electrodes for precise treatment of reux
etiology (LES relaxation).
3. Safety: The treatment process is safe, patient tolerance is high, and the rate of
bleeding, perforation, dysphagia, and other complications is very low.
4. Effective: For GERD patients who need to take PPI for a long time, 80% of
patients can stop PPI after operation. It is still effective for most refractory
GERD (except patients with hiatal hernia, such as >2cm).
5. Lasting: 10years of curative effect tracking symptoms improved signicantly
and can be repeatedly strengthened after treatment.
Fast: The treatment time is short; the entire operation time lasts only 30–40min.
Simple: The operation is simple and comparable to a painless gastroscope proce-
dure, and can be completed by an outpatient doctor.
Fast recovery: The procedure involves minimal trauma, utilizing precise, local-
ized treatment via a needle electrode, which allows fast recovery.
5.3 Clinical Application ofStretta
Stretta radiofrequency technology in the treatment of gastroesophageal reux was
rst reported in 2001. Currently, tens of thousands of patients worldwide receive
Stretta radiofrequency therapy. Studies have shown that the symptoms of patients
have been signicantly improved, and the efcacy can be maintained for 4–10years,
with fewer complications. Clinical data related to Stretta therapy showed that 93%
of patients were satised with the improvement of symptoms. Gastroesophageal
reux therapy was discontinued in 86% of patients for 4years. Sixty-four percent of
5 Stretta Radiofrequency Treatment
68
patients were able to discontinue the treatment for gastroesophageal reux for
10years. Gastroesophageal reux symptom score and quality of life were improved.
Esophageal acid exposure time was decreased. The endoscopic manifestations of
esophagitis were improved.
Since 2000, a number of studies have conrmed its safety and efcacy, including
1 meta-analysis involving 18 studies and 4 randomized controlled studies. The main
result was signicantly improved subjective reux symptom score after radiofre-
quency treatment, while subgroup analysis of meta-analysis found that objective
measures related to acid reux including DeMeester score and esophageal acid
exposure were also signicantly improved. These results made Stretta the preferred
endoscopic treatment for GERD recommended by the American Association of
Gastroenterological Endoscopic Surgeons in 2013. Recent studies have demon-
strated the long-term effectiveness of Stretta, with signicant improvement in reux
symptom scores and a signicant reduction in PPI dependence 10years after initial
treatment. Currently, there are only two studies comparing Stretta with other treat-
ments, and the results show that although Stretta and Nissen can both achieve symp-
tom relief, Nissen is superior to Stretta in both symptom relief and PPI dependence
reduction. Notably, Stretta, like PPI therapy and gastric fundus folding, did not pro-
duce consistently normal esophageal PH results. To summarize, numerous studies
have demonstrated the safety, efcacy, durability, and repeatability of Stretta radio-
frequency therapy. Importantly, Stretta does not conict with other treatments for
GERD, even after gastric fundus surgery has failed. Stretta is probably the most
cost-effective form of endoscopic GERD treatment. Stretta should be considered as
a viable complement or alternative to traditional GERD therapies.
Triadalopoulos et al. [11] administered Stretta radiofrequency therapy to 47
patients with PPIdependent GERD. Compared with pre-treatment baseline data, the
patients exhibited signicant improvements at 6 months postoperatively in heart-
burn severity grade, GERD symptom score, treatment satisfaction score, SF-36
Mental Component Summary (MCS) score, SF-36 Physical Component Summary
(PCS) score, and esophageal acid exposure time. The corresponding values changed
from the pre-treatment levels (4, 26, 1, 46.2, 41.1, 11.7%) to the post-treatment
levels (1, 7, 4, 55.5, 51.9, 4.8%).
Dughera etal. [12] followed up 69 cases of GERD patients receiving Stretta
radiofrequency treatment for 2years; a total of 56 patients were followed up. The
heartburn score, GERD score, and quality of life of 52 patients were signicantly
improved 24 and 48months after surgery compared with before treatment, and PPI
was completely stopped in 41 cases 48months after treatment.
Leeds etal. [13] pointed out that Stretta radiofrequency therapy could effectively
change GERD symptoms, improve the quality of life, and reduce esophageal acid
exposure. Dysphagia, dysphagia, chest pain, gastroparesis, gastric mucosal injury,
and other adverse reactions are common adverse reactions in Stretta radiofrequency
therapy. Severe adverse reactions are relatively rare.
Liang etal. [14] found in the follow-up of 138 GERD patients 5years after sur-
gery that Stretta could signicantly improve the symptoms of GERD, 42% of the
patients completely stopped PPIs, and no obvious complications occurred.
L. Li et al.
69
A meta-analysis showed that Stretta could signicantly relieve GERD symp-
toms, reduce the time of acid exposure, promote the healing of erosive esophagitis,
and signicantly improve health-related quality of life, and about 51% of patients
stopped PPIs after Stretta surgery [15].
Torquati etal. [16] showed that in the 27-month follow-up of 36 patients after
radiofrequency treatment, 56% of the patients had been discontinuously taking
acid-inhibiting drugs, and the reexamination of esophageal pH values of 20 patients
showed a signicant decrease in acid reux.
A multicentric study of 558 patients showed improvement in symptoms and sat-
isfaction after Stretta radiofrequency therapy compared to drug therapy, while PPI
drug therapy was reduced from two doses per day to as needed. Noar etal. [17]
reported that after treatment of Stretta, patients were followed up for 4years, and
the symptom of heartburn decreased from 3.6 to 1.18, satisfaction increased from
1.4 to 3.8, 25% stopped medication, and the remaining 75% dosage was reduced
from 2 times/day to take medicine as needed.
Meier etal. [18] collected research data from European multicenters, and the
results showed that the GERD-HRQL score decreased from 12.9 before treatment
(the drug group) and 19.2 (the non-drug group) to 6.6 (<0.01) 12months after sur-
gery. Heartburn scores decreased from 2.2 before treatment (drug group) and 3.4
(non-drug group) to 1.3 12months after surgery (<0.05). Only 26.7% of the patients
were satised with the degree of GERD-related symptom control before surgery;
63.3% and 46.7% of the patients were satised 6months and 12months after sur-
gery, respectively. At 12months after treatment, the satisfaction index increased
from 2 to 4 (<0.01).
5.4 Effect
Triadalopoulos et al. [11] administered Stretta radiofrequency therapy to 47
patients with proton pump inhibitor (PPI)-dependent gastroesophageal reux dis-
ease (GERD). Compared with pre-treatment baseline data, the patients exhibited
signicant improvements at 6 months postoperatively in heartburn severity grade,
GERD symptom score, treatment satisfaction score, SF-36 Mental Component
Summary (MCS) score, SF-36 Physical Component Summary (PCS) score, and
esophageal acid exposure time. The corresponding values changed from the pre-
treatment levels (4, 26, 1, 46.2, 41.1, 11.7%) to the post-treatment levels (1, 7, 4,
55.5, 51.9, 4.8%) (Table5.1).
Meier etal. [18] collected research data from European multicenters, and the
results showed that the GERD-HRQL score decreased from 12.9 before treatment
(the drug group) and 19.2 (the non-drug group) to 6.6 (<0.01) 12months after sur-
gery. Heartburn scores decreased from 2.2 before treatment (drug group) and 3.4
(non-drug group) to 1.3 12months after surgery (<0.05). Only 26.7% of the patients
were satised with the degree of GERD-related symptom control before surgery;
63.3% and 46.7% of the patients were satised 6 months and 12months after
5 Stretta Radiofrequency Treatment
70
Table 5.2
Various comparisons before and after Stretta radiofrequency treatment
Stretta was treated for 12months Heartburn score GERD score Satisfaction score
Before the treatment 2.2/3.4 12.9/19.2 2
After treatment 1.3 6.6 4
Table 5.3
Various comparisons before and after Stretta radiofrequency treatment
Stretta was treated
for 4years
Heartburn
score
Satisfaction
score PPI drugs
Before the
treatment
3.6 1.4 All the medicine
After treatment 1.18 3.8 25% drug withdrawal; Reduce 75% dosage
from 2 doses per day to as needed
Table 5.1
Various comparisons before and after Stretta radiofrequency treatment
Stretta was
treated for
6months
Heartburn
score
GERD
score
Satisfaction
score
Mental
SF-36
scale score
Body
SF-36
scale
score
Duration of
esophageal acid
exposure (%)
Before the
treatment
4 26 1 46.2 41.1 11.7
After
treatment
1 7 4 55.5 51.9 4.8
surgery, respectively. Twelve months after treatment, the satisfaction index increased
from 2 to 4 (<0.01) (Table5.2).
Noar etal. [17] reported that after treatment of Stretta, patients were followed up
for 4years, and the symptom of heartburn decreased from 3.6 to 1.18, satisfaction
increased from 1.4 to 3.8, 25% stopped medication, and the remaining 75% dosage
was reduced from 2 times/day to take medicine as needed (Table5.3).
5.5 Compared toOther Treatments
Stretta radiofrequency therapy has been shown to improve GERD symptoms and
patients’ quality of life. Stretta radiofrequency therapy may have better efcacy and
safety compared with the traditional Toupet gastric fundus folding group [19].
At 6months after treatment, DeMeester score in Stretta radiofrequency treat-
ment group was lower than that of Toupet gastric foldout group, and LES pressure
was higher than that of Toupet gastric foldout group. Stretta radiofrequency therapy
may have a more signicant role in lowering DeMeester scoring, and in addition,
Stretta radiofrequency therapy may improve intraesophageal pressure in GERD
patients more than Toupet gastric fundus folding [19]
L. Li et al.
71
References
1. Franciosa M, Triadalopoulos G, Mashimo H.Stretta radiofrequency treatment for GERD: a
safe and effective modality. Gastroenterol Res Pract. 2013;2013:783815.
2. Higuchi K, Fujiwara Y, Okazaki H, etal. Feasibility, safety, and efcacy of the Stretta pro-
cedure in Japanese patients with gastroesophageal reux disease: rst report from Asia. J
Gastroenterol. 2007;42:205–10.
3. Richards WO.Is the Stretta procedure safe and effective for the long-term control of symptoms
in patients with refractory GERD? Nat Clin Pract Gastroenterol Hepatol. 2007;4:654–5.
4. Arts J, Bisschops R, Blondeau K, etal. A double-blind sham-controlled study of the effect of
radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in
GERD.Am J Gastroenterol. 2012;107:222–30.
5. Triadalopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency energy delivery to the
gastroesophageal junction for the treatment of GERD.Gastrointest Endosc. 2001;53:407–15.
6. Tam WC, Schoeman MN, Zhang Q, etal. Delivery of radiofrequency energy to the lower
oesophageal sphincter and gastric cardia inhibits transient lower oesophageal sphincter relax-
ations and gastro-oesophageal reux in patients with reux disease. Gut. 2003;52:479–85.
7. Smith CD. SAGES clinical spotlight review: endoluminal treatments for gastroesophageal
reux disease (GERD). Surg Endosc. 2013;27:2655–7.
8. Qingqing Z, Lian-Zhen Y, Ruihua S. Progress of endoscopic therapy for gastroesophageal
reux disease. Gastroenterology. 2006; Then 1–184.
9. Utley DS, Kim M, Vierra MA, Triadalopoulos G.Augmentation of lower esophageal sphinc-
ter pressure and gastric yield pressure after radiofrequency energy delivery to the gastroesoph-
ageal junction: a porcine model. Gastrointest Endosc. 2000;52:81–6.
10. Corley DA, Katz P, Wo JM, etal. Improvement of gastroesophageal reux symptoms after radio-
frequency energy: a randomized, sham-controlled trial. Gastroenterology. 2003;125:668–76.
11. Triadalopoulos G, DiBaise JK, Nostrant TT, et al. The Stretta procedure for the treat-
ment of GERD: 6 and 12 month follow-up of the U.S. open label trial. Gastrointest Endosc.
2002;55:149–56.
12. Dughera L, Navino M, Cassolino P, etal. Long-term results of radiofrequency energy deliv-
ery for the treatment of GERD: results of a prospective 48-month study. Diagn Ther Endosc.
2011;2011:507157.
13. Leeds S, Reavis K.Endolumenal therapies for gastroesophageal reux disease. Gastrointest
Endosc Clin N Am. 2013;23:41–51.
14. Liang WT, Wang ZG, Wang F, etal. Long-term outcomes of patients with refractory gastro-
esophageal reux disease following a minimally invasive endoscopic procedure: a prospective
observational study. BMC Gastroenterol. 2014;14:178.
15. Fass R, Cahn F, Scotti DJ, Gregory DA.Systematic review and meta-analysis of controlled
and prospective cohort efcacy studies of endoscopic radiofrequency for treatment of gastro-
esophageal reux disease. Surg Endosc. 2017;31:4865–82.
16. Torquati A, Houston HL, Kaiser J, etal. Long-term follow-up study of the Stretta procedure for
the treatment of gastroesophageal reux disease. Surg Endosc. 2004;18:1475–9.
17. Noar MD, Lot-Emran S.Sustained improvement in symptoms of GERD and antisecretory
drug use: 4-year follow-up of the Stretta procedure. Gastrointest Endosc. 2007;65:367–72.
18. Meier PN, Nietzschmann T, Akin I, etal. Improvement of objective GERD parameters after
radiofrequency energy delivery: a European study. Scand J Gastroenterol. 2007;42:911–6.
19. Hu Z, Wang Z, Wu J, etal. A comparative study of radiofrequency therapy and laparoscopic
Nissen fundus folding in the treatment of gastroesophageal reux associated severe asthma.
Stretta. Clinical misdiagnosis and mistreatment. 2013; They– 61.
5 Stretta Radiofrequency Treatment
73© Shanghai Scientic and Technical Publishers 2026
L. Li et al. (eds.), Endoscopic Therapy for Gastroesophageal Reux Disease,
https://doi.org/10.1007/978-981-95-5389-1_6
Chapter 6
Peroral Endoscopic Cardial Constriction
(PECC)
QianYue
6.1 Background
The treatment of GERD mainly includes drugs, endoscopy, and surgical treatment
[1, 2]. Drug therapy mainly refers to the use of proton pump inhibitors, but long-
term oral proton pump inhibitors have obvious side effects [3, 4], and for refractory
GERD, the therapeutic effects of proton pump inhibitors are often limited.
Endoscopic treatment mainly includes abdominal cavity endoscopic fundoplication
and endoscopic minimally invasive treatment. The former is more traumatic [5], and
patient compliance is poor; the latter mainly includes Stretta and ARMS, which
have the characteristics of less trauma, good curative effect, and good safety. Peroral
endoscopic cardial constriction (PECC) was pioneered by Professor En-Qiang
Ling-Hu of the PLA General Hospital in 2013 [6]. This procedure primarily achieves
gastroesophageal junction constriction via ligation and xation, which acts on the
cardia and thereby reduces gastroesophageal reux. Preclinical studies have dem-
onstrated that PECC yields signicant short-term efcacy without causing surgery-
related serious complications. As a novel therapeutic modality for GERD, PECC
features relative simplicity, safety, and minimal invasiveness; consequently, patients
experience rapid postoperative recovery, and their clinical symptoms can be signi-
cantly ameliorated.
Q. Yue (*)
Department of Gastroenterology, The Ninth Medical Center of Chinese PLA General
Hospital, Beijing, China
74
6.2 What Is Peroral Endoscopic Cardial
Constriction (PECC)
6.2.1 Denition
Peroral endoscopic cardial constriction (PECC) is a new method for the treatment
of gastroesophageal reux disease. The operation is similar to ligation of esopha-
geal gastric varices. A single ring ligator installed on the front end of the gastro-
scope is used to ligate portions of the mucosa and mucosal muscle layer above the
cardia. After about 7–14days, the ligation site will shed off and form a scar, and
nally the cardia will be narrowed, thereby reducing reux.
6.2.2 Principle ofOperation
PECC is a new method for the treatment of GERD.Through endoscopic ligation
and xation, the gastroesophageal junction mucosa, submucosa, and part of the
muscularis propria undergo necrosis and fall off to form scars. This process reduces
the diameter of the cardia and increases the esophagus to a certain extent. The pres-
sure of the lower sphincter forms an anti-reux barrier to reduce or prevent the
reux of stomach contents [7]. The surgical method of endoscopic band ligation is
very mature and easy to operate. It has been widely used in the eld of digestive
endoscopy in the treatment of esophageal varicose veins [8] and mucosal resection
of esophageal lesions [9]. It is just a treatment for different lesions. There is a dif-
ference in depth. Generally, owing to mucosal necrosis, the ligation ring will shed
off after 7days. The wound will gradually recover, which will eventually cause the
cardia to constrict and strengthen the anti-reux barrier. At the same time, the vagus
nerve terminal in the mucosa is destroyed, which leads to the inactivation of the
receptor of the vagus nerve and reduces transient lower esophageal sphincter relax-
ation, thereby preventing the occurrence of gastroesophageal reux events.
6.2.3 Indications
1. Typical symptoms of heartburn and acid reux
2. Gastroscopy conrmed reux esophagitis, endoscopic grading above LA
3. 24-h PH monitoring of esophagus showed DeMeester score ≥14.72 points
4. Cardia laxity or hiatal hernia with hernia sac ≤3cm in diameter
5. Medical treatment for more than 2months, with insignicant relief or recurring
symptoms, or unable to tolerate long-term medication
6. Age ≥18years old
Q. Yue
75
6.2.4 Contraindications
1. A history of esophageal or gastric surgery, and the normal physiological anat-
omy has been destroyed
2. Barrett’s esophagus or esophageal cancer
3. Hiatus hernia diameter >3cm
4. Reux esophagitis with esophageal stenosis
5. Non-erosive reux esophagitis
6. Severe dysphagia or esophageal motility disorder
7. Severe cardiopulmonary disease
8. Pregnant and lactating women
6.2.5 Complications
Postoperative complications include the following: choking after eating, pain
behind the sternum, tightening behind the sternum, abdominal distension, and other
discomforts. After 1–2weeks of symptomatic treatment, the above symptoms were
alleviated or disappeared; no complications such as dysphagia, esophageal stenosis,
esophageal perforation, and death occurred [10].
6.3 Endoscopic Procedures
6.3.1 Preoperative Preparation
1. Preoperative blood, urine, stool routine, biochemical, coagulation function, pre-
operative ve examinations
2. Cardiac activity and heart activity function, chest and abdomen imaging exami-
nations such as chest and abdomen CT, pulmonary function test, to evaluate the
general condition of the patient before surgery and cardiopulmonary function
3. Gastroscopy, lower esophageal sphincter pressure test, esophageal dynamic pH
monitoring, etc., to evaluate the lower esophageal sphincter pressure and acid
reux, to determine whether there is hiatal hernia and hernia sac specic size
4. Fasting with water for 6h before the operation, and administering sedation and
anesthesia
6 Peroral Endoscopic Cardial Constriction (PECC)
76
6.3.2 Ligation oftheDentate Line
1. Ligation: Install the ligation device on the front end of the gastroscope, enter the
lower esophagus through the mouth, and aspirate the mucosa and part of the
muscle layer along the lesser curvature side and the greater curvature side below
1cm at the proximal end of the gastroesophageal junction (the rst one is placed
about 1cm above the cardia along the lesser curvature side, and the second fold
is located 1cm above the greater curvature side), release the ligation ring for
ligation.
2. Root xation: Fix both ends of the root of the ligation ring with titanium clips [6]
(Figs.6.1, 6.2, 6.3, and 6.4).
ab
Fig. 6.1 Under the endoscope, the cardia is slack when looking directly at the endoscope and the
reverse endoscope
ab
Fig. 6.2 The single-ring ligature is used to ligate the mucosa and submucosal tissue on the lesser
curvature side of the cardia, and then use a titanium clip to x the proximal root of the ligation ring
Q. Yue