Endoscopic Management of Gastroesophageal Reflux Disease: Revisited

Abstract

Gastroesophageal reflux disease (GERD) is defined by the presence of troublesome symptoms resulting from the reflux of gastric contents. The prevalence of GERD is increasing globally. An incompetent lower esophageal sphincter underlies the pathogenesis of GERD. Proton pump inhibitors (PPIs) form the core of GERD management. However, a substantial number of patients do not respond well to PPIs. The next option is anti-reflux surgery, which is efficacious, but it has its own limitations, such as gas bloating, inability to belch or vomit, and dysphagia. Laparoscopic placement of magnetic augmentation device is emerging as a useful alternative to conventional anti-reflux surgery. However, invasiveness of a surgical procedure remains a concern for the patients. The proportion of PPI non-responders or partial responders who do not wish for anti-reflux surgery defines the 'treatment gap' and needs to be addressed. The last decade has witnessed the fall and rise of many endoscopic devices for GERD. Major endoscopic strategies include radiofrequency ablation and endoscopic fundoplication devices. Current endoscopic devices score high on subjective improvement, but have been unimpressive in objective improvement like esophageal acid exposure. In this review, we discuss the current endoscopic anti-reflux therapies and available evidence for their role in the management of GERD.

Keywords: Catheter ablation; Endoscopy; Fundoplication; Gastroesophageal reflux; Surgery.

Fig. 1.

Currently available endoscopic anti-reflux modalities. Stretta (Mederi Therapeutics), EsophyX (EndoGastric Solutions), MUSE (Medigus), GERDx (G-SURG GmbH).

Fig. 2.

(A) Radiofrequency device (Stretta; Mederi Therapeutics) with a four-needle balloon catheter system. (B) Depiction of Stretta procedure-radiofrequency energy delivered to gastroesophageal junction muscle at multiple sites.

Fig. 3.

(A) Transoral fundoplication device (EsophyX; EndoGastric Solutions) and its components. (B) Retroflexed device in the stomach. (C) Engaging the helical retractor into the tissue. (D) Application of H-shaped polypropylene fasteners (about 20). (E) Creation of full-thickness partial circumference fundoplication.

Fig. 4.

MUSE (Medigus) endoscopic stapling device and its components.

Fig. 5.

(A, B) Full thickness endoscopic plication device (GERDx; G-SURG GmbH). (C) GERDx inside the stomach in retroflexed view. (D) Advancement of ‘Drill helix’ into gastric cardia. (E) Closure of the device arms after gathering tissue and deployment of suture. (F) Reopening of the device arms after plication implant.

Fig. 6.

(A) Submucosal injection of saline with indigo-carmine at gastric cardia. (B) Application of snare over the mucosa with cap-endoscopic mucosal resection technique. (C) Completion of near circumferential (2/3) resection of gastric mucosa. (D) Actively bleeding spurter during mucosectomy procedure. (E) Effective control of bleeding vessel with coagrasper.