Background and Rationale:
Gastroesophageal reflux disease is affecting 1 in 3 US adults with half experiencing daily symptoms. Per recent data, more than 50% continue to experience daily symptoms despite taking medical therapy and not eligible for surgery. In that small fraction of patients who are eligible for surgery, more than 70% resume taking a medicine for their reflux disease. GERD is common among the US veterans and currently there is a lack of minimally invasive endoscopic therapies for management of GERD. This study will investigate performance of minimally invasive, endoscopic therapy using antireflux mucosal ablation (hybrid argon plasma coagulation) that has been used in other areas of GI tract with efficacy and safety for management of chronic GERD among the US veterans.
Objective:
The aim of this study is to assess the safety and effectiveness of antireflux mucosal ablation or ARAT (intervention group) in patients with chronic gastroesophageal reflux disease (GERD) symptoms (typical symptoms of GERD, i.e. heartburn or acid reflux/regurgitation at least twice a week) for the last 6 months and objective evidence of reflux disease (positive ambulatory pH study off PPI for 5-7 days) compared to sham procedure (control group).
Patients with chronic GERD symptoms (at least 1 typical symptom of GERD, i.e. heartburn or acid reflux/regurgitation at least twice a week) for last 6 months and
Objective evidence of reflux disease (positive ambulatory pH study)
Patients prescribed standard dose of PPI for symptoms of GERD
Able to undergo upper endoscopy as evidenced by completion of pre-endoscopy standard of care checklist.
Patients unable to or unwilling to participate or consent
Age <18 years or >80 years
Allergic or intolerant to PPI medications
Large hiatal hernia > 3 cm and Hill grade IV
Parallel
Anti reflux endoscopic theraphy
Deviceo the intervention arm, the area of cardia, along greater curvature will be cleaned first followed by demarcation of a 1-1.5 cm area of non-ablation zone with two vertical lines by use of Pulsed APC using the H-APC catheter for marking and to prevent excess ablation . After this, the area of cardia, on either side will be injected in sequence using a combination of methylene blue and normal saline using the H-APC catheter jet system using between Effect 30 and Effect 70 on the ErbeJet 2 to raise the mucosa and create a submucosal cushion . Once adequate submucosal cushion is created, the mucosa starting below the z-line and up to 3 cm below will be treated by Pulsed APC 50W-80W using the H-APC catheter till golden-brown discoloration of the ablated tissue20 The area of cardia below the Z-line will be treated in a 270-320-degree fashion. Once adequate ablation is achieved and no deeper tissue injury or bleeding is ensured, the procedure will be terminated.
Endoscopy
Other interventionPatients randomized to the control arm, will undergo a sham intervention. This will include performing upper endoscopy with procedural sedation followed by markings of landmarks as described. This will be followed by gastroscope retroflexion in the gastric cardia with at least 15 minute of examination time spent in retroflexion to reciprocate the H-APC intervention. No H-APC or submucosal injection or other intervention will be performed during the upper endoscopy with sham intervention. All Patients will also continue their PPI daily for 4 weeks.
AREA
To determine if procedure can decrease Gastroesophageal reflux scores (RDQ) 50% compared to sham intervention at 3, 6 and 12 months
Anti reflux ablation theraphy
To determine if ARAT can achieve 50% reduction in DeMeester score compared to sham intervention at 3 and 12 months
AREA
To determine if ARAT can achieve PPI dose reduction or discontinuation in 25% of subjects after 3 months compared to sham intervention
Anti reflux ablation theraphy
To determine if intervention can reduce esophageal acid exposure time \<4% (using wireless ambulatory 24-hr pH monitoring) in 50% subjects compared to sham intervention at 3 and 12 months
Reflux disease
To evaluate the safety profile of ARAT therapy by recording major (GI bleeding, perforation, hospitalization, esophageal stricture) and minor complications (chest pain, fever, dysphagia)
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