Endotherapy and surgery for GERD.
Endotherapy and surgery for GERD.
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GERD 的内科治疗和手术。
DOI：
10.1097/mcg.0b013e3180322d96
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发表时间：
2007
影响因子：
2.9
通讯作者：
Triadafilopoulos,George
中科院分区：
文献类型：
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作者：
Triadafilopoulos,George
今天，有几种方式来治疗胃食管反流病（GERD）（药物，内镜治疗，手术），这些治疗可以单独使用，或串联使用，或与其他治疗组合使用，旨在“正常化”患者的GERD相关的生活质量，如果可能的话，食管酸暴露。一些治疗方式尚未达到几个中间终点或临床显著结局，并且没有一种单一方式是完美的。这些中间终点的统计学显著改善已在“一些”但不是所有研究中显示。虽然食管炎的愈合可以通过药物或手术治疗来完成，但内镜治疗的数据不足，因为大多数接受内镜治疗的患者既往接受过质子泵抑制剂（PPI）试验，因此食管炎愈合。有效预防并发症，如食管腺癌，仍然是所有模式的挑战。每日1次或2次PPI治疗后GERD相关生活质量未恢复正常的患者应进行功能性食管评价（pH检测和食管动力研究），并应由内镜医师和外科医生进行评价。应根据内镜治疗和手术的标准、当地内镜和手术专业知识的可用性以及患者的偏好决定如何进行。这种多模态治疗模式在许多方面类似于冠状动脉疾病的长期管理，其中药物治疗、血管成形术和旁路手术经常串联或组合使用。旨在使GERD相关生活质量正常化的多模式治疗是当今的一种选择，并且应该可用于所有需要治疗的患者。GERD内镜治疗的目标人群目前包括PPI依赖性GERD患者，这些患者患有小的（< 2 cm长）或无滑动性食管裂孔疝，并且没有严重的食管炎或Barrett食管。到目前为止，只有Stretta和NDO plicator在假对照试验中进行了研究。并发症登记表明，这些技术相对安全，但有严重的发病率，包括罕见的死亡率报告（有关内镜治疗相关并发症的持续更新，请参见：http：//www. FDA. gov/cdrh/maude。html）。所有这些都可以在门诊进行，在静脉镇静和局部咽部麻醉下进行。未来的比较研究，包括预先确定的具有临床意义的终点、有效的结局指标、长期随访和完整的并发症登记，将最终确定内镜手术在GERD患者中的确切作用。
Today, there are several modalities to treat gastroesophageal reflux disease (GERD)(medications, endoscopic therapies, surgery) and such therapies can be used either singly, or in tandem, or in combination with the others, aiming at “normalization” of the patient's GERD-related quality of life and, if possible, esophageal acid exposure. Several intermediate end points or clinically significant outcomes have not been reached by some therapeutic modalities and no single modality is or can be perfect. Statistically significant improvements in these intermediate end points have been shown in “some” but not all studies. Although healing of esophagitis can be accomplished with either medical or surgical therapy, there is inadequate data with endotherapies, because most patients treated with endotherapies have had prior trials of proton pump inhibitors (PPIs) and hence healed their esophagitis. Effective prevention of complications, such as esophageal adenocarcinoma, remains challenging for all modalities. Patients who have not normalized their GERD-related quality of life with once or twice daily PPI therapy should undergo functional esophageal evaluation with pH testing and esophageal motility study and they should be evaluated by both an endoscopist and a surgeon. The decision on how to proceed should be made on the basis of the criteria for endotherapy and surgery, availability of local endoscopic and surgical expertise and patients' preference. Such multimodality therapy model is in many ways similar to the long-term management of coronary artery disease where pharmacotherapy, angioplasty, and bypass surgery are frequently used in tandem or in combination. Multimodality therapy aiming at normalization of GERD-related quality of life is an option today, and should be available to all patients in need of therapy. The target population for GERD endotherapy currently consists of PPI-dependent GERD patients, who have a small (< 2-cm-long) or no sliding hiatal hernia, and without severe esophagitis or Barrett esophagus. Thus far, only Stretta and the NDO plicator have been studied in sham-controlled trials. Registries of complications suggest that these techniques are relatively safe, but serious morbidity, including rare mortality have been reported (for a continuous update on complications related to endoscopic therapies see: http://www. fda. gov/cdrh/maude. html). All can be performed on an outpatient basis, under intravenous sedation and local pharyngeal anesthesia. Future comparative studies with predetermined clinically significant end points, validated outcome measures, prolonged follow-up, and complete complication registries will eventually determine the precise role of endoscopic procedures for the patients with GERD.