Triadafilopoulos George
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305-5187, USA.
J Clin Gastroenterol. 2007 Jul;41 Suppl 2:S87-96. doi: 10.1097/MCG.0b013e3180322d96.
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.
如今，有多种治疗胃食管反流病（GERD）的方法（药物治疗、内镜治疗、手术治疗），这些治疗方法可以单独使用、联合使用或与其他方法结合使用，旨在使患者与GERD相关的生活质量“正常化”，并尽可能使食管酸暴露正常化。一些治疗方法尚未达到几个中间终点或具有临床意义的结果，而且没有一种方法是完美的，也不可能完美。在“一些”但并非所有研究中，这些中间终点都有统计学上的显著改善。虽然食管炎的愈合可以通过药物治疗或手术治疗实现，但关于内镜治疗的数据不足，因为大多数接受内镜治疗的患者之前都曾试用过质子泵抑制剂（PPI），因此已经治愈了食管炎。对所有治疗方法来说，有效预防并发症，如食管腺癌，仍然具有挑战性。对于每日服用一次或两次PPI治疗后GERD相关生活质量仍未恢复正常的患者，应通过pH测试和食管动力研究进行功能性食管评估，并且应由内镜医师和外科医生进行评估。应根据内镜治疗和手术的标准、当地内镜和外科专业知识的可及性以及患者的偏好来决定如何进行治疗。这种多模式治疗模式在很多方面类似于冠状动脉疾病的长期管理，在冠状动脉疾病管理中经常联合或结合使用药物治疗、血管成形术和搭桥手术。旨在使GERD相关生活质量正常化的多模式治疗是目前的一种选择，应该提供给所有需要治疗的患者。目前GERD内镜治疗的目标人群包括依赖PPI的GERD患者，这些患者有小的（<2厘米长）或没有滑动性食管裂孔疝，且没有严重食管炎或巴雷特食管。到目前为止，只有Stretta和NDO套扎器在假手术对照试验中得到了研究。并发症登记表明这些技术相对安全，但也有严重并发症的报道，包括罕见的死亡（有关内镜治疗相关并发症的持续更新，请见：http://www.fda.gov/cdrh/maude.html）。所有这些治疗都可以在门诊进行，采用静脉镇静和局部咽部麻醉。未来具有预定临床显著终点、经过验证的结果测量、延长随访时间和完整并发症登记的比较研究最终将确定内镜手术在GERD患者中的精确作用。
