Stretta Procedure for GERD & LPR: Does It Work?

Stretta is a minimally-invasive procedure that delivers a series of radiofrequency bursts to the gastroesophageal junction (GEJ) to enhance both tone and integrity of the LES via induction of fibrosis and/or hypertrophy.

It is thought that enhancement of LES tone and integrity can improve certain chronic reflux conditions such as: GERD (gastroesophageal reflux disease) and NERD (non-erosive reflux disease).

Stretta was approved by the U.S. FDA in 2000 and was originally produced and marketed by Curon Medical, Inc. – a company that filed for bankruptcy in 2006.

Mederi Therapeutics, Inc. acquired Curon’s assets in 2008 and Stretta became commercially available again in 2010 (after being off the market for several years).

Nevertheless, many still question whether Stretta is legitimately effective, safe, and durable (in terms of duration of effect).

Table of Contents

How does Stretta procedure work?

In a nutshell: Stretta delivers a series of radiofrequency (RF) energy bursts to specific locations in the gastroesophageal junction (GEJ) whereafter the LES & gastroesophageal junction musculature undergo hypertrophic remodeling which prevents and/or minimizes future reflux events.

Mechanisms of Stretta’s antireflux effect

Stretta seems to induce “thickening” of the LES which ultimately results in fewer transient lower esophageal sphincter relaxations (TLESRs) and fewer total reflux events. (R)

  • Increased LES pressure: Stretta is thought to increase LES pressure.
  • Decreased TLESRs: Stretta is thought to decrease TLESRs (transient lower esophageal sphincter relaxations).
  • Decreased tissue compliance: Stretta is thought to decrease tissue compliance.
  • Decreased acid exposure: Stretta is thought to reduce overall acid exposure (due to improved LES tone) within the upper GI tract.

Stretta procedure (specifics) (R)

  1. Endoscopy: Patients are anesthetized/sedated (e.g. midazolam, fentanyl, meperidine, propofol, etc.) and undergo an upper GI endoscopy wherein the endoscopist measures the distance from the incisors to the squamo-columnar junction (Z-line).
  2. Positioning device: The endoscope is then removed and a balloon-tipped 4-channel radiofrequency (RF) catheter (the Stretta device) is passed through the mouth and positioned 1 cm above the Z-line according to the distance measured in endoscopy.
  3. RF admin: The 4 needle electrodes on the Stretta device are then extended to a specified length of 5.5 mm and RF administration to the LES and gastric cardia ensues.
  4. Needle electrodes: Each needle electrode delivers pure sine-wave RF energy for 60 seconds to reach target temperature of 85 Celsius. (Each needle tip has an inbuilt thermocouple that auto-adjusts power output to a desired target temperature within the muscle layer.)
  5. Rotations: Other treatment locations are created by rotating and adjusting the linear position of the catheter to create rings over a span of 2 cm above and below the cardia.
  6. Removal: The Stretta RF catheter is then removed and endoscopy repeated.
  7. Complete: Stretta RF energy is administered to ~56 specific locations over an estimated time of ~35-60 minutes.

Stretta procedure research

Included below are summaries of studies and/or papers that’ve discussed the effect of Stretta for the treatment of reflux conditions.

Systematic reviews & meta-analyses

The highest quality evidence to determine the efficacy, safety, and durability of Stretta in the treatment of GERD is derived from quality systematic reviews and meta-analyses – so this was my primary focus.

2021: Efficacy of different endoscopic treatments in patients with GERD (R)

Xie et al.

  • Aim: Evaluate the efficacies of various endoscopic interventions for the treatment of GERD.
  • Methods: Examine data from RCTs that compare the efficacy of Stretta to sham/PPI for GERD.
  • Stretta studies: A total of 13 articles reporting 10 RCTs were included in this network meta-analysis – encompassing 516 patients (312 procedure recipients vs. 204 control recipients). 5 RCTs specifically examined the effect of Stretta – encompassing 173 patients.

Stretta studies

  • Kalapala (2017): 20 patients (Stretta vs. PPI) – 3-month follow-up
  • Arts (2012): 22 patients (Stretta vs. Sham + PPI) – 6-month follow-up
  • Aziz (2010): 24 patients (Stretta vs. Sham + PPI) – 12-month follow-up
  • Coron (2008): 43 patients (Stretta vs. PPI) – 12-month follow-up
  • Corley (2003): 64 patients (Stretta vs. Sham + PPI) – 12-month follow-up

What were the results?

Health-related QoL (HRQL)

  • 2 RCTs reported significant improvements in HRQL from Stretta.
  • Stretta was significantly better than PPIs for improving HRQL – and about equal to TIF procedure.
  • SUCRA values: TIF (92.1%), Stretta (57.9%), PPI (0%) – quality of evidence was low due to limitations.

Heartburn scores

  • 4 RCTs examined improvement in heartburn scores from baseline to follow-up.
  • Stretta and TIF procedures were more effective than PPI for improving heartburn.
  • SUCRA values: TIF (98.5%), Stretta (50.2%), PPI (1.2%)

LES pressure

  • Stretta is less effective for increasing LES pressure than TIF.
  • TIF was significantly better than PPIs at increasing LES pressure.
  • SUCRA values: TIF (99.4%), Stretta (48.8%), PPI (1.7%)

Esophageal acid exposure

  • Improvement in % time pH <4.0 from baseline to follow-up endpoint were reported in 3 RCTs using Stretta.
  • Improvement of esophageal acid exposure from PPIs was superior to TIF.
  • SUCRA values: Stretta (89.1%), PPI (60.3%), TIF (0.6%)

Esophagitis severity

  • 4 RCTs involving Stretta reported downgrade in severity or healing of esophagitis.
  • Stretta was less effective than TIF but the difference wasn’t significant.
  • SUCRA values: TIF (77%), Stretta (57.3%), PPI (15.7%)

PPI use

  • 4 RCTs with Stretta reported the rate of patients achieving symptom relief and dose reduction or discontinuation of PPIs.
  • SUCRA values: TIF (92.1%), Stretta (56.5%), PPI (1.4%)

What can we conclude?

Stretta appears able to: improve HRQL, heartburn scores, LES pressure, esophageal acid exposure, esophagitis severity, and PPI use – between 3-12 months follow-up post-procedure.

The evidence to support the findings ranges from “moderate” to “very low” quality.

Limitations: Assessment of long-term efficacy N/A; short-term follow-ups (12 months or less); few total studies; small sample sizes of studies; heterogeneity.

2017: Systematic review & meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of GERD (R)

Fass et al.: “The Stretta procedure significantly improves subjective and objective clinical endpoints, except LES basal pressure, and therefore should be considered as a viable alternative in managing GERD.”

  • Aim: Determine the effectiveness of Stretta in GERD patients using a systematic review and meta-analysis of controlled and cohort studies.
  • Methods: Evaluated randomized controlled trials (RCTs) and cohort studies in which the Stretta procedure was used for the treatment of GERD. Generalized inverse weighting was used for outcomes. Results calculated by fixed effects and random effects model.
  • Included studies: 28 total (4 RCTs, 23 cohort studies, 1 registry) – across 2,468 Stretta recipients. The mean follow-up time for the 28 studies was 25.4 months.

What were the results?  

Pooled results indicate that Stretta significantly improved: (A) health-related quality of life scores (~14.6 points) and (B) pooled heartburn standardized scores (~1.53 points).

After Stretta treatment, only 49% of patients using PPIs at baseline required PPIs at follow-up.

Stretta treatment decreased rates of erosive esophagitis (~24%) and decreased esophageal acid exposure by an average of ~3 points.

Lower esophageal sphincter (LES) pressure increased post-Stretta therapy by ~1.73 mmHg (although this wasn’t statistically significant).

Limitations: Pooled analysis of RCTs + cohort studies (diluting the quality with cohort studies); lack of contemporaneous control groups in most studies; small sample sizes in RCTs.

Randomized controlled trials (RCTs)

Below are some RCTs that were not included in the above systematic reviews/meta-analyses either as a result of newness or studying a different condition than GERD (e.g. NERD).

2020: Stretta vs. PPIs for NERD (R)

He et al. (2020): “The Stretta procedure was safe and effective in the short term for the management of NERD. The Stretta procedure resulted in higher LES pressure and achieved better improvement of symptom control and PPI cessation than did the PPI in the short term.”

  • Sample: 28 patients (Stretta group) vs. 21 patients (PPI group) – all diagnosed with NERD (non-erosive reflux disease)
    • Stretta group: Received Stretta procedure with the Stretta system by 1 skilled endoscopist in an operation room. Patients took 40 mg omeprazole for 14 days post-procedure to promote mucosal healing. A liquid/soft food diet was required for 2 weeks after surgery – followed by a regular diet thereafter.
    • PPI group: Received the same PPI dose they had previously used to control symptoms. If symptoms were well-controlled – PPI dosing was reduced by 1 step. If symptoms worsened – PPI dosing was increased by 1 step.
  • Measures: Symptom control, QoL (quality-of-life), LES pressure, 24-hour pH, PPI use, satisfaction rate, complications – at baseline and 6 months (follow-up)

What were the results?

  • Both groups (Stretta & PPI) exhibited significant improvements in symptom severity and quality-of-life from baseline to 6-month follow-up examination.
  • Symptom score improvement was significantly greater in the Stretta group than the PPI group (Stretta = 6.3 vs. PPI = 8.5, P = 0.03).
  • LES pressure significantly increased in the Stretta group vs. the PPI group (Stretta = 14.2 mm Hg vs. PPI = 10 mm Hg, P < 0.01).
  • Both interventions improved 24-hour pH parameters including number of acid episodes, acid exposure time, and DeMeester score – with no significant differences between groups.
  • Complete PPI discontinuation rate was significantly higher in Stretta recipients (~82%) vs. PPI users (52%) (P = 0.03) – as was overall satisfaction rate (Stretta = ~89% vs. PPI = ~57%) (P = 0.02).

What can we learn here?

Stretta appears significantly more effective than PPI therapy for the treatment of NERD (non-erosive reflux disease) over a 6-month period.

The superiority of Stretta relative to PPI therapy is evidenced by significantly: higher NERD symptom improvement; increased LES pressure; greater PPI discontinuation rate; and higher patient satisfaction rate.

Limitations: Single-center, uncontrolled, nonrandomized, small sample, loss of participants in follow-up (4 in Stretta & 2 in PPI group), limited follow-up term (6 months), NERD-only (NERD patients less likely to respond to PPIs than GERD), PPI dosing/adherence (may have been suboptimal), between group differences (age, BMI, duration of NERD, etc.).

What does the research suggest re: efficacy of Stretta for reflux conditions?

There is low-to-moderate quality evidence suggesting that Stretta is safe and effective for the treatment of GERD among a specific subset of GERD patients that meet eligibility requirements for the procedure.

GERD

Two systematic reviews and meta-analyses of Stretta studies indicate that the procedure is safe and effective for the treatment of GERD.

  • Xie et al. (2021): Analysis of 5 RCTs revealed improved HRQL, heartburn scores, LES pressure, esophageal acid exposure, esophagitis severity, and PPI use – between 3-12 months post-Stretta. (Evidence quality = moderate to very low)
  • Fass et al. (2017): Analysis of 28 studies (4 RCTs, 23 cohort, 1 registry) revealed improvements in HRQL, heartburn scores, PPI use, erosive esophagitis, and esophageal acid exposure.

NERD

A randomized controlled trial published in 2020 suggests that Stretta may be safe and effective for the treatment of NERD (non-erosive reflux disease).

  • He et al. (2020): A small RCT found that Stretta was safe and effective in the short-term management of NERD – and induced higher LES pressure, better symptom control, and greater PPI discontinuation in the short-term (6-month follow-up).

LPR

At this time there is no evidence to support the use of Stretta for the isolated treatment of LPR. In the research I discovered that involved patients with both GERD and LPR – some relief was attained, however, patients with isolated LPR did not appear to benefit.

Is Stretta a durable procedure over the long-term? (Durability of effect)

Multiple studies suggest that Stretta provides a lasting (i.e. durable) therapeutic effect for patients with refractory GERD.

2017: 15+ years after Stretta antireflux endoscopy procedure (R)

Alvaro & Nilda: “Stretta is a safe and long lasting endoscopic therapy for GERD with results remaining over 15 years, especially in this sub group of selected patients with partial response to PPIs or good response to PPIs.”

  • Methods: Evaluate 35 patients who were partial or good responders to PPIs that underwent Stretta procedure between 2000-2001 for GERD – 15+ years after Stretta.
  • Measures: Quality of life; heartburn & regurgitation; upper endoscopy; 48-hour Bravo pH (subset of patients)

What were the results? (15+ years later)

  • QOL: 3.9 (15 years) vs. 2.4 (baseline)
  • GERD symptoms: 1.1 (15 years) vs. 2.7 (baseline)
  • Daily PPI use: none (15 years) vs. all patients (baseline)
  • Acid reducer use: 10 patients: H2 blockers (6) & PPIs (2) (15 years) vs. all patients (baseline)
  • Bravo 48-hour pH: 4.5 DeMeester score (15 years)

Limitations: Small sample (35 patients); single center; no motility data; biased patient selection (?); ultra-specific subgroup; potential lifestyle modifications/GERD interventions used; questionnaire data.

2014: Long-term maintenance effect of RF energy delivery for refractory GERD (R)

Noar et al.: “In this single-group evaluation of 217 patients before and after Stretta, GERD-HRQL scores, satisfaction, and PPI use significantly improved and results were immediate and durable at 10 years.”

  • Methods: Prospectively analyzed 217 patients with medically-refractory GERD before and after Stretta (10-years later).
  • Measures: GERD-HRQL; PPI use; treatment satisfaction; complications

What were the results? (10 years later)

  • 72% of Stretta recipients achieved normalization of GERD-HRQL.
  • 64% of Stretta recipients achieved a 50% or greater reduction in PPI use.
  • 41% of Stretta recipients were able to discontinue PPIs entirely.
  • 54% of Stretta recipients reported at least 60% or greater increase in satisfaction.

Limitations: Single center; no objective pH analyses; no motility data; biased patient selection (?); no control group (GERD symptoms may spontaneously improve over a long-term); potential lifestyle modifications and/or other GERD treatments used; questionnaire data.

Advantages of Stretta procedure (Possibilities)

  • Non-surgical: Stretta is a non-surgical procedure for the treatment of reflux conditions. It involves administration of radiofrequency energy bursts to modify the thickness of the GEJ/LES.
  • No anatomical changes: Stretta is the only antireflux procedure capable of treating reflux without rearranging or significantly altering structures within the gastrointestinal tract.
  • Outpatient: Stretta can be done in an outpatient setting such that most people won’t need to stay overnight in the hospital.
  • Minimally invasive: Stretta is considered minimally invasive in that its analogous to getting an endoscopy. No portions of the stomach or GI tract are cut open and rearranged.
  • Fast procedure: Stretta reportedly takes an average of ~35 minutes to complete.
  • Quick recovery: Most people take about 2 weeks (on average) to recover from Stretta – such that they can resume eating a normal diet.
  • No post-surgery lifestyle changes: Many procedures such as Nissen fundoplication require lifelong lifestyle modifications (e.g. no lifting heavy weights, etc.). Stretta requires zero major changes in lifestyle.
  • Effective: Evidence suggests that Stretta generally provides significant therapeutic effect in the treatment of GERD.
  • Safe: Because Stretta is minimally-invasive and “non-surgical” – it is arguably the single safest antireflux procedure available.
  • Alternative to PPIs: Many people cannot tolerate PPIs and/or are concerned with long-term effects of PPI therapy (Read: PPIs & C. diff; PPIs & Cognitive impairment; PPIs & kidney disease). For these individuals, Stretta may be a viable alternative.
  • Alternative to other surgeries: Some individuals are hesitant to get “invasive” endoscopic surgery for reflux conditions and/or may not qualify for other procedures. In these cases, Stretta is a strong alternative option.
  • Durable effect: A study that followed patients with “refractory GERD” for 10-years post-Stretta found that the procedure provides a lasting/durable therapeutic effect.
  • Cost: Stretta is thought to be cheaper than many other surgeries for GERD including Nissen fundoplication and TIF.
  • Low risk of complications: Stretta is associated with low risk of post-surgical complications due to its non-invasiveness.

Disadvantages of Stretta procedure

  • Expensive: Although Stretta is cheaper than many other surgeries, it’s still relatively expensive. Patients will require pre-surgical workup (e.g. endoscopy) and the surgery itself costs ~$10,000 – and probably won’t be covered by insurance.
  • Ineffective: While many individuals derive significant benefit from Stretta for reflux – some individuals who’ve had the procedure claim that it provided zero symptom relief. Therefore, even if a patient is seemingly a “good fit” for the procedure – it isn’t guaranteed to be effective.
  • Complications: Complications associated with Stretta are usually transient (i.e. short-lived) such that they fade within days or weeks of the procedure. Nonetheless, some serious complications have occurred including: esophageal perforation and 2 deaths (due to aspiration pneumonia). (R)
  • New-onset GI symptoms: Occasionally some individuals will report new-onset GI symptoms post-Stretta procedure such as difficulty swallowing, inability to burp, gastritis, and bloating. Although most post-procedure symptoms are transient – some may be long-lasting and/or permanent in select individuals.
  • Worsening of GI symptoms: Some patients have anecdotally reported a worsening of GI symptoms after Stretta – such that either reflux worsens relative to pre-procedure baseline or different symptoms emerge that are worse than the symptoms at baseline.
  • Limited duration of effect: Some patients have anecdotally reported responding well to Stretta followed by eventual “failure” such that symptoms revert back to pre-Stretta baseline.
  • Multiple procedures (?): Some Stretta practitioners may encourage patients to undergo multiple Stretta procedures for full GERD relief. There is some evidence to support non-statistically significant improvement with a second Stretta procedure, however,
  • Not for everyone: Certain individuals may be ineligible for Stretta on the basis that it’s unlikely to work and/or unsafe for their particular circumstances. For example: A patient with certain anatomical features (e.g. large hiatal hernia over 2 cm) will not be eligible for Stretta. Patients with undiagnosed functional esophageal disorders are unlikely to benefit.
  • Suboptimal evidence basis: Some might argue that evidence to support the use of Stretta for the treatment of GERD is suboptimal given the numerous limitations associated with various trials including: small sample sizes; limited follow-up duration; lack of RCTs; etc.

Stretta procedure side effects & complications

Included below is a list of potential side effects and/or complications associated with Stretta.

Keep in mind that rates and severities of side effects and/or complications are largely contingent upon: (1) the specific patient and (2) performance quality of the procedure.

Complication rates associated with Stretta are extremely low relative to other endoscopic procedures for GERD – and most are minor and transient.

Over 15,000 Stretta procedures have been performed worldwide without major complications. (R)

A study of 118 patients reported 10 complications (9%) none of which required medical intervention, including: fever (2 patients); superficial mucosal injury (3 patients); chest pain (2 patients); transient dysphagia (1 patient); sedation-related hypotension (1 patient); analgesia allergy (1 patient). (R)

Side effects

  • Bleeding: This is generally transient and subsides quickly post-procedure.
  • Bloating: Some individuals may experience increased bloating after Stretta.
  • Chest pain: Chest pain is listed as a transient reaction following Stretta.
  • Difficulty burping: Some patients may struggle to “burp” or “belch” after Stretta.
  • Dysphagia: Certain people report difficulty swallowing (requiring more time to move food/liquid from the mouth to the stomach).
  • Epigastric pain or discomfort: Pain or discomfort below the ribs in the part of the abdomen that sits below the rib cage (i.e. epigastrium).
  • Esophageal mucosa laceration: A tear in the esophageal mucosa that causes bleeding and pain.
  • Fever: Select individuals will experience fever after Stretta – but it generally fades quickly.
  • Pharyngitis: Inflammation of the pharynx may occur in some patients after Stretta – and this may cause some throat pain/soreness.
  • Nausea & vomiting: Certain individuals may feel nauseous and/or end up vomiting after the procedure but this isn’t common.

Serious complications

  • 3 patients experienced esophageal perforation from Stretta – which were attributable to suboptimal patient selection and/or operational mistakes.
  • 2 deaths have been attributable to aspiration pneumonia following Stretta.

Stretta procedure anecdotes (Reddit & Facebook & YouTube)

Keep in mind that some of the positive anecdotes may be fake/marketing tactics in effort to entice more people with reflux conditions to consider and/or get Stretta.

 

On the other hand, non-responders/negative responders may be more likely to vent about experiences online relative to responders (who may not bother with GERD forums because they’re recovered).

Anecdote #1: Stretta made things far worse for me – had multiple pH studies and followed the procedure all of which demonstrated lower pH in oropharynx correlating with decrease in QoL.

Anecdote #2: Stretta was a waste of $5K for me unfortunately. On paper it resored my motility and looked like sphincter pressures increased but I was still refluxing. (Individual had a 2cm hiatal hernia).

Anecdote #3: Had Stretta done in 2019 and it did absolutely nothing for me – made no difference in reflux. (Individual had a 2.3 cm hiatal hernia).

Anecdote #4: My symptoms decreased a bit after Stretta and I was able to decrease my dose of pantoprazole from 60 mg/day to 10 mg/day – so I guess it’s having some beneficial effect.

Anecdote #5: Had Stretta in 2016 for LPR and went back to work the day after. It was painful for about a week but then improved. It worked well for me for about 2 years, but then its therapeutic effect wore off.

Anecdote #6: I would say that I’m 95% healed from LPR after 14 months post-Stretta procedure. The recovery was slow and consistent and I was pregnant a few months after having the procedure. I was able to stop all antireflux medication and remove the incline from my bed.

Anecdote #7: Had Stretta 1 month ago and noticed an immediate improvement in LPR symptoms. I even ate chocolate every day and would lay down right after and there were zero symptoms. Am off all PPIs. (3-year update: Zero PPIs & still improved).

Anecdote #8: Had Stretta done 15 months ago and it has had zero significant effect. (Individual has hiatal hernia, weak/small LES, and esophageal dysmotility).

Frequently asked questions (FAQs): Stretta procedure

How long does it take for Stretta to work?

Stretta is thought to provide a rapid-onset therapeutic antireflux effect – such that many patients report improved symptoms within 1-2 weeks post-procedure.

That said, endoscopists who perform the Stretta state that maximum symptom improvement generally occurs ~3-6+ months post-procedure.

Are there any restrictions after Stretta procedure?

Most patients will be recommended to eat soft/liquid, low-acid foods for a period of 2+ weeks after Stretta to promote proper healing of the RF-stimulated gastroesophageal mucosa.

It may also be necessary to rest for 1-2 weeks to promote proper recovery post-surgery. That said, unlike other procedures (e.g. fundoplication) which carry lifetime restrictions (e.g. no heavy lifting, no overeating, etc.) – Stretta does not.

How long does Stretta procedure take?

One scientific report estimated that the Stretta procedure takes ~35 minutes. However, other sources state that the entire process takes about 1 hour (60 minutes) to complete.

This is a much quicker procedure than other antireflux surgeries which can take hours and require overnight stays in the hospital.

How much does Stretta procedure cost?

According to MDSave – a website that estimates the prices of medical procedures, Stretta costs an average of $10,581 as of 2022.

That said, the cost of Stretta will vary depending on location and the specific endoscopist performing the procedure – some skilled endoscopists may charge more due to reputation in the reflux community.

Is Stretta covered by insurance?

It depends. In some cases, Stretta may be fully or partially covered by insurance, but this depends on: (1) where you live (i.e. country, city, etc.), (2) your specific insurance policy, and (3) whether the provider performing Stretta accepts your specific insurance.

Assuming you meet preexisting requirements set by your insurance provider to have Stretta covered – then chances are good that it’ll be at least partially covered by the insurer.

How does Stretta compare to other antireflux interventions?

Stretta is generally considered lower risk and less invasive than other antireflux surgeries among individuals that meet eligibility requirements.

Some evidence suggests that TIF (transoral incisionless fundoplication) should be as effective as Stretta – and possibly more effective in some cases, however, it may have higher rates of complications due to rearranging structures in the gastroesophageal junction (GEJ).

In terms of basic PPI therapy coupled with lifestyle modifications (e.g. weight loss for GERD), preliminary evidence from randomized controlled trials (RCTs) and meta-analyses/reviews of those RCTs indicates that Stretta is more effective.

How does Stretta compare to standard PPI therapy?

In patients for whom Stretta is a “good fit” (i.e. those that meet eligibility requirements) – there is evidence to suggest that Stretta is more effective than standard PPI therapy for the treatment of GERD over a short-term (up to 12 months).

Long-term studies in small cohorts indicate that the antireflux effect of Stretta is durable such that most patients no longer need to take daily PPIs.

Does Stretta work for LPR?

Many patients diagnosed with “LPR” do not actually have LPR – it is likely overdiagnosed and often misdiagnosed.

Assuming the LPR is confirmed via both: (A) objective examinations: laryngeal examination (e.g. flexible laryngoscopy); endoscopy; 24-hour pH monitoring; etc. AND (B) subjective symptom scores – then surgeries can be considered.

Patients with GERD + LPR appear to derive benefit from Stretta – likely because it effectively targets GERD symptoms.

However, there is zero strong evidence to support undergoing Stretta procedure for LPR as an isolated diagnosis – this would be a risky choice.

If it is somehow deemed that suboptimal LES tone may be causing one’s LPR – then it’s theoretically possible Stretta might improve LPR symptoms.

Who is eligible for Stretta procedure? (Good candidates)

According to The Society of American Gastrointestinal & Endoscopic Surgeons, the following characteristics are necessary for Stretta: (R)

  • 18+ years of age
  • GERD diagnosis: Heartburn and/or regurgitation (6+ months)
  • PPI responders (complete or partial)
  • Declined laparoscopic fundoplication
  • Non-pregnant
  • Inability to tolerate PPIs
  • Desire to stop PPIs

Who should NOT get Stretta procedure?

  • Hiatal hernia: Certain individuals believe that anyone with a hiatal hernia should NOT get Stretta.
  • Large hiatal hernia: Standard medical guidelines suggest that anyone with a hiatal hernia 2 cm or larger is ineligible for Stretta.
  • Sliding hiatal hernia: Some individuals have what’s known as a “sliding hiatal hernia” (which is occasionally difficult to detect). If a sliding hiatal hernia is discovered, Stretta may not be a good fit.
  • Extremely low LES pressure: If lower esophageal sphincter pressure is less than 5 mmHg – Stretta is thought to be a poor fit.
  • Negative pH/impedance studies: Individuals with negative pH/impedance studies (objectively demonstrating acid reflux) should not receive Stretta.
  • No symptom correlation with acid events: If reflux symptoms do not correlate with acid events – alternative diagnoses should be considered and Stretta should be avoided.
  • Functional esophageal disorders: Individuals with functional esophageal disorders should be treated with psychoplastogens and lifestyle modifications – not an invasive procedure.
  • Pregnant women: Pregnancy is contraindicated with Stretta.
  • Patients without GERD: There’s no evidence that Stretta is effective for conditions other than GERD – as it hasn’t been extensively researched for things like LPR & NERD.
  • Poor surgical classification: Patients with poor surgical classification should not be considered for Stretta.
  • Under age 18: Nobody under the age of 18 can receive Stretta.
  • Achalasia or incomplete LES relaxation: This is a disorder wherein food/liquid struggles to efficiently pass from the esophagus to the stomach.
  • PPI non-responders: Individuals who derive zero benefit from PPIs cannot be considered for Stretta.
  • PPI complete responders: Should not necessarily pursue Stretta unless there are either concerns or tolerability issues associated with long-term PPI therapy.

Drew’s thoughts on Stretta for reflux conditions…

The primary reason I researched Stretta for reflux is because I’ve been suffering with LPR (laryngopharyngeal reflux) for the past 7+ months – and it’s been nothing short of nightmarish.

Twice-daily PPIs (esomeprazole 20 mg, b.i.d.) combined with small meals, head-of-bed elevation, weight loss (~25 lbs.), low acid diet, alkaline water, and certain supplements – seems to have helped… with the biggest symptom relief [subjectively] attributable to PPIs.

In any regard, I stumbled upon Dr. Mark Noar and it seemed like Stretta was an ideal procedure for reflux conditions: low-risk of complications/adverse events, fast recovery time, outpatient, minimally-invasive, non-surgical, fairly low cost, etc.

The quality-of-evidence to support the efficacy of Stretta over PPIs and/or sham procedures is “low-to-moderate” quality – meaning it’s far from ideal.

The durability of effect seems strong in specific cohorts (based on 10+ and 15+ year follow-up studies, respectively) – but the quality of evidence supporting a durable effect is low due to serious limitations.

Overall, Stretta is a fairly low-risk procedure for objectively-confirmed (e.g. with 24-hour pH monitoring) chronic GERD that’s fully or partially responsive to PPIs – in patients without hiatal hernia.

If Stretta ends up being ineffective, there don’t seem to be any serious adverse consequences for most people (other than loss of time and $).

There’s no evidence that Stretta is effective for standalone/isolated LPR – such that it probably shouldn’t be recommended for LPR patients until all evidence-based interventions have been trialed without sufficient symptom relief.

Have you considered or tried the Stretta procedure?

  • What was your diagnosis (pre-Stretta)?
  • How much did you pay for Stretta? (Was any of this cost covered by insurance?)
  • Did Stretta provide any significant symptom relief? (None vs. modest vs. moderate vs. 100% cured)
  • Did you meet proper eligibility requirements to receive Stretta?
  • If you benefitted from Stretta: (1) How long did it take to notice symptom improvement? (2) Which symptoms improved the most?
  • Who performed your Stretta procedure?
  • Did you have a hiatal hernia (if so, what size)?
  • Would you recommend Stretta based on your experience?
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