When lifestyle and dietary measures fail, most people think they have to use medication or do a very invasive surgery.
But there is something in the middle of these two choices – the Stretta procedure.
The Stretta procedure is done without cutting you open. Therefore, it is less invasive than typical anti-reflux operations – like Nissen fundoplications.
At the same time, Stretta can be a more effective long-term treatment option than medication. Most pills for reflux do not help LPR patients very well in the long term. Plus, side effects of reflux medication become worse the longer you take them.
I have interviewed Dr. Mark Noar about his experiences with the Stretta therapy. Actually, this was the main reason why I wanted to talk with him in the first place. However, we also ended up discussing the role of the sphincters as well as pH monitoring.
Part #3 – The Stretta procedure compared to operations
So, let’s talk about Stretta. Where does the technology come from?
The technology was invented by a gentleman in California.
I was the first adopter of this technology. I was the one who assisted the company in developing the technique to use the technology to help this work for reflux disease.
And what does the Stretta procedure do?
It grows sphincter muscle.
The device includes special needles. Through those needles, we send radiofrequency energy directly into the sphincter muscle. The needles are very soft, so they do not cause harm to patients.
The device is very elegant in its engineering, because if the needles get too hot during the procedure, the device just turns the specific needle off. It’s engineered to be extremely safe. We keep the temperature between 65 and 85 degrees Celsius, which is the temperature of a cup of coffee. The device uses 5 Watt, the same as an LED light bulb. It is very low energy. There’s no damage created by the device. It is just meant to stimulate the muscle.
What is the difference between the Stretta procedure and a Nissen fundoplication?
They fix different parts of the lower esophageal sphincter.
There is an outer layer of the sphincter. The so-called external sphincter. The fundoplication fixes that one.
Then there is the internal esophageal sphincter, which is a muscle. Stretta strengthens that muscle to fix the internal sphincter.
How does the Stretta therapy work?
Stretta stimulates muscle growth. The muscles of the LES become bigger, thicker, stronger, and longer.
In the end, that increases the sphincter pressure.
We’re trying to increase the sphincter pressure so that it’s strong enough to stop the gastric pressure from creating reflux. The primary cause of reflux is that your sphincter relaxes too often. Post-Stretta, the number of esophageal relaxations goes down significantly in these patients.
Many people, also physicians, misunderstand how Stretta works. They think the Stretta procedure works because it creates scar tissue. Stretta works because the stimulation with energy promotes muscle growth. This has been clearly shown by a study.
That’s very interesting, because if I remember right, on many health information platforms it says that Stretta works because it builds up scar tissue.
This is a common misunderstanding by physicians who assume that because you’re using energy, you’re causing a scar, but you never see scars after a Stretta.
Who would be an ideal candidate to get the Stretta procedure?
The ideal candidate is someone who has demonstrated reflux, whether it be GERD or LPR. They are not responding to the standard measures, and they’re dependent on medication or not responding to medication.
Someone who adopts dietary and lifestyle changes and feels good doesn’t need the Stretta procedure.
Someone who takes medication for a couple of weeks and feels great afterward doesn’t need the procedure.
What is the influence of strengthening the LES on delayed gastric emptying? So meaning people who have food in their stomach for too long after eating.
That is an important question.
40 percent of reflux patients have a slow-emptying stomach, called gastroparesis. That is because their LES opens up all the time. The stomach needs to press the food out into the intestines. But if your LES opens up, the food is pushed into the esophagus instead. Instead of the food going down, it’s going up!
What I found out in my research though: Nissen fundoplication patients who had slow-emptying stomachs associated with reflux went back to normal after Nissen.
That’s fascinating. I think I have the same feeling with my LINX. Like there’s a sense of faster emptying.
If the LINX is working and stopping your reflux, it should have the same beneficial effect, but this has not yet been formally studied. It doesn’t matter what the mechanism is to stop the reflux. If you stop the reflux, your stomach can create pressure and move the food where it belongs: into the intestines. So your emptying will be better.
How can you test how well your stomach is emptying?
You can do an electrogastrogram, which shows the motility of the stomach. In addition, a gastric emptying scan can demonstrate if there is a delay.
After you get an anti-reflux operation, it often goes from abnormal to normal.
Any time you fix the sphincter the stomach works better. It empties better, it contracts better, and it’s healthier.
What other procedures are effective against LPR?
Of all the reflux treatments available today there are only two therapies that have been demonstrated by research to stop LPR. One of them is the Nissen fundoplication with a 360-degree wrap. A partial fundoplication like Toupet with a 270-degree wrap is not as tight, so you’re still refluxing, just less.
The other is the Stretta procedure. Those two procedures are very effective in stopping reflux for patients with LPR. Stretta builds muscles and the fundoplication creates an artificial tightening.
What do you think about the LINX procedure?
The LINX procedure is effective in some patients.
The problem is: Sometimes the body creates scar tissue around the LINX device that hinders it from working correctly.
For the readers who do not know the LINX: it is a magnetic device against reflux. There are several magnetic beads which are strung onto a band. The goal is that those magnetic beads attract each other – putting pressure on the lower esophageal sphincter to keep it shut.
What can go wrong with the LINX?
The band has to be able to open freely. If the body forms scar tissue around the beads in an unlucky way, problems start.
Within the first three weeks after placement, the body will form a tunnel of scar tissue around the LINX device. It’s remarkable how the body reacts to foreign bodies.
There are cases in which the LINX works, and cases in which it doesn’t. It depends on how the scar tissue forms around the device.
If it works, then this means that inside the scar tissue there is an open tunnel in which the LINX can move freely.
When it doesn’t work, the scar tissue may fix the beads in the open position, so it holds your esophagus open all the time, and you have even more reflux than before! In these cases, the device has to be removed.
The contrary can happen too: if it fixes the beads in the closed position you can’t swallow.
There is also another issue with LINX: if you look at the x-ray pictures, you’ll see the first bolus of food goes down, and it sits just above the device. When the next one comes down, it pushes the first one through. It’s kind of like playing croquet. You have to hit the first ball to make the second ball go.
Another issue is pseudoachalasia, which is that the esophagus is becoming dilated above the LINX device and losing its motility. Once you lose the esophageal motility, then you can’t swallow anymore and the LINX device has to be removed.
There’s probably close to 60 pages now on the FDA website of all of these complications that have been coming out over the years.
I personally, don’t like foreign bodies. If you’re going to have someone go in and free up the tissue around your esophagus surgically, you might as well have them fix your hiatal hernia and do a Nissen fundoplication, because it works the best for the longest period of time.
If we look at all the procedures, there are only two techniques that have 10-year data. That’s the Nissen fundoplication and the Stretta procedure, which are very effective upwards of 10 years – the Nissen having a slight advantage over the Stretta procedure.
Can you combine the Stretta and the Nissen fundoplication?
Yes, absolutely. It makes sense if one of the procedures failed.
Both Nissen and Stretta aim at fixing the lower esophageal sphincter. But they each only fix one part of it.
Combining both procedures can be extremely effective and is better than putting someone on medication again.
I recommend doing the Stretta first. It is a much simpler and lower risk procedure compared to a Nissen fundoplication.
What about LINX and Stretta: can you combine them as well?
Yes, you can also have both of those.
Stretta is the first thing people should try after failure of a technique, because if you go back in surgically, it’s often with a higher complication rate.
I have had patients who came because of a failed LINX with the device still inside. Many will respond and be very happy and completely asymptomatic.
End of Part #3 of the interview with Dr. Mark Noar.