2007 - STRETTA CLINICAL Stretta: ahead of its time or has its time passed?
C. Daniel Smith
Gastrointestinal Endoscopy, Volume 65, No. 3: 2007, Editorial
SUMMARY: In this issue of GIE, 2 separate studies report long-term (48 months) results in patients undergoing Stretta. These studies carefully examine the symptomatic response of nearly 200 patients with uncomplicated GERD unresponsive to maximum dose proton pump inhibitor (PPI) who underwent the Stretta procedure. In both studies, the majority of patients experienced a significant decrease in GERD symptoms, improved quality of life, and elimination of or significant decrease in the use of PPIs or other antisecretaory medications. Notably, 75% and 90.2% of patients were medication free at 48 months. Reymunde and Santiago were able to perform yearly EGD in their patients: none of the 83 patients had endoscopic evidence of any disease progression, and 31% of those with esophagitis pretreatment experienced healing of their esophagitis. No patient in either study experienced any adverse effects from the procedure. These data add to an already large body of data substantiating the safety and efficacy of Stretta. Put simply, Stretta works, and does so without significant risk of an adverse outcome. Again, these findings beg the question whether these new data finally open the door for the Stretta procedure to become accepted and more widely adopted in the care of the patient with GERD. Regrettably, I suspect the answer will be ‘‘no.’’ The reason for this lies in our fear of the unknown, unfavorable reimbursement, and the disruptive nature of these newer approaches. We are all suspicious of the unknown, and there is much about the Stretta procedure that challenges our common beliefs about GERD and its management. Traditionally, we have managed GERD by eliminating the acid refluxate through antisecretory medicines, or by creating a mechanical barrier with surgery. Surgeons tend to continue to reject the mechanism of action for Stretta, largely because of the lack of any physical evidence that an antireflux valve has been created. There is little, if any, immediate evidence that anything changes with the procedure, and there are no imaging studies or other structural evidence demonstrating how Stretta works. I have heard many surgeons surmise that some sort of denervation or scarring of the gastroesophageal junction must be the result of this procedure. Gastroenterologists are similarly skeptical and frequently offer the idea that the procedure creates a stricture or that altered vagal function will have untoward effects on the rest of the GI tract. Both groups frequently ascribe the results of Stretta as placebo-induced, or resulting from desensitization of the distal esophagus, thereby eliminating heartburn but not arresting the pathologic acid reflux. All these claims abound despite studies confirming not only symptom improvement but also improvement in acid exposure times. Interestingly, we have all seen other less-proven and less-studied techniques wildly embraced because we feel the mechanism of action is understandable and ‘‘makes sense’’ (eg, thousands of intestinal bypasses have been performed to manage weight loss without any established mechanism for how these procedures actually work).