Background:

A 56-year old woman presented with disabling reflux dyspeptic symptoms with episodes of nausea, vomiting, sore throat, retrosternal pain, heartburn, and early morning taste of blood in the saliva. Patient gave a history of food and acid regurgitation with diurnal as well as nocturnal symptoms affecting quality of life and sleep. Her heartburn scores were 4/5 pre- and post-prandial and 5/5 nocturnal (with 5 being the worst). LPR symptoms included sore throat with some vocal irritation. She had a few hospital admissions with above symptoms and chest pain, where she had multiple investigations including scans, oesophageal pH studies, manometry studies, barium swallow and endoscopy studies together with ENT assessments. Endoscopy revealed lax junction, with erosive oesophagitis, visibly refluxing gastric contents and without hiatus hernia as on HRM. DeMeester score was within normal range alongside symptom index (SI) of 69% on pH studies. Oesophageal biopsies showed inflammatory changes without eosinophilic oesophagitis. She was treated with various PPI’s, antacids, analgesia including Zomorph with minimal effect. Her quality of life was substantially affected, including significant depression.

Patient’s Testimony:

“Since the middle of 2012 I had experienced severe prolonged bouts of acid reflux that controlled my life. The long-term effects caused considerable pain and inflammation of the oesophagus and stomach. I was even hospitalised on one occasion because I was unable to keep any food down for a week due to the inflammation. I also experienced waking up with a metallic taste in my mouth. I was on high doses of anti-reflux and pain medications, including morphine and co-codamol. The health issues I was experiencing interfered with my work, social and home life, I even needed to take considerable time off work due to the ongoing pain I suffered at times. My husband and I were finding no grace with the mainstream medical profession as I was outside the box. I came across Prof. Viswanath in Nuffield Hospital, Stockton-on-Tees, who spoke of an endoscopic radio-frequency (Stretta) therapy available for reflux problems. Shortly after visiting Prof. Vis, I went ahead with it and I have not looked back. I found the procedure non-invasive and I had a relatively quick recovery, returning to work after one week. There was some pain and discomfort at first. I was on a liquid diet for six weeks and then soft food for a while, but every step was worth it. It has been four months since the Stretta procedure, I do occasionally use an anti-reflux liquid but otherwise I am off all other forms of anti-reflux medication and pain killers. I do consider what I eat and drink but my quality of life has improved 99% and I would recommend anyone experiencing what I suffered to consider the Stretta procedure. I found Prof. Vis and all the staff at Nuffield very amicable and helpful. The hospital was very comfortable which also made me feel at ease and not so nervous. I am now looking forward to my relatively reflux – and pain – free future. Thank you Prof. Viswanath for listening and assisting me with this health issue that has improved my life and future.”

Treatment and follow up:

Patient was seen and counseled, underwent endoscopic assessment to find lax gastrooesophageal (GO) junction (Grade 2 Hill’s endoscopic grading), without hiatus hernia along with erosive oesophagitis. Following on, she was initially counseled with pictures, videos, and leaflets about Stretta Therapy. She underwent Stretta Therapy as a day case under general anesthesia (patient wishes), although in our practice 80% are done under sedation. At endoscopy, GO junction was located at 37.5cm. At 6 levels, RF energy was delivered, so as to administer 56 thermal lesions at the lower oesophageal sphincter (LES) zone. 6 months following Stretta therapy, she is off pain killers including morphine and PPI’s, and claims all her reflux symptoms have improved considerably. This has led to a large improvement to her quality of life.

Discussion

Gastrooesophageal reflux disease (GORD) with classical symptoms alongside good symptom association probability (SAP) and symptom sensitivity (SI) usually responds well to medical and/or interventional endoscopic or laparoscopic therapy. GERD/GORD patients who fail to respond to medical treatment and those who do not wish to remain on long-term medication are offered alternate therapy, including surgery. However, patients such as this case, in which the presentation is convoluted with some classical and LPR symptoms along with severe nausea, vomiting and/or chest pains, are difficult to adjudicate for surgery. Surgery is invasive and associated morbidities such as dysphagia & gas bloat could affect patients adversely. This particular patient was assessed by gastroenterologists, ENT surgeons and Upper GI surgeons, who advised against surgery (with which I also agreed). She had a normal DeMeester score, underscoring weakly acidic reflux with a positive symptom index; however no impedance test was done in the referring hospital. Patient was extremely keen to be considered for an intervention, including surgery, if recommended. A measure of all reports and assessments was taken prior to recommending Stretta. Any such patients require all diagnostic assessments with thorough counseling. Bearing on her wishes, consent, counseling and suitability, endoscopic radiofrequency (RF) anti-reflux Stretta Therapy was carried out as a day case with an excellent outcome. A thorough assessment with unconcealed and meticulous counseling is essential prior to offering Stretta, especially in GORD patients presenting with a combination of classical reflux with LPR and some nonconforming symptoms.

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Professor Viswanath YKS is a senior Consultant Surgeon specializing in upper GI and advanced laparoscopic & endoscopic surgery at James Cook University Hospital. He holds a visiting chair at Teesside University and is the programme director for MCh postgraduate surgical specialities. With the Universities of Teeside and Durham, Prof Viswanath has supervised PhD, MSc MCh and MPhil students. A recognised national trainer for advanced laparoscopic surgery, he contributes via the ALSGBI council by running live courses. These include TAPP hernia and Stretta training courses for which he established the National ‘Endo RF Anti-reflux’ Therapy (Stretta) Centre in the UK. Prof Viswanath’s research interests are mainly focused in Upper Gastro-intestinal (Oesophago-Gastric) cancer including Barrett’s metaplasia, with particular interests in ‘Cancer Immunology and molecular biology’ in OG cancer. He remains active in research, having presented more than 200 abstracts in national & international meetings, and publishing both clinical and scientific papers.