What are the indications for Endoscopic Gastric Fundoplication (EGF) in patients with Gastroesophageal Reflux Disease (GERD)?

Indications for Endoscopic Gastric Fundoplication in GERD

Endoscopic gastric fundoplication is indicated for carefully selected patients with proven GERD who have inadequate symptom control despite optimized lifestyle and pharmacotherapy, particularly those with regurgitation-predominant symptoms and without large hiatal hernias. 1

Patient Selection Criteria

Appropriate Candidates:

• Patients with confirmed pathologic GERD through objective testing
• Patients with inadequate symptom control despite optimized medical therapy
• Patients with small hiatal hernias (<2 cm)
• Patients with regurgitation-predominant GERD symptoms
• Patients seeking an alternative to long-term PPI therapy or laparoscopic surgery

Pre-Procedure Assessment Requirements:

• Confirmatory evidence of pathologic GERD through:
  • 24-hour pH-impedance monitoring (gold standard)
  • Upper GI endoscopy to rule out complications and assess anatomy
  • Barium swallow to identify anatomical abnormalities
  • Assessment of esophageal peristaltic function
  • Exclusion of achalasia

Contraindications:

• Large hiatal hernias (>2 cm)
• Severe esophagitis
• Barrett's esophagus
• Esophageal motility disorders
• Failed previous anti-reflux surgery
• Obesity (better suited for Roux-en-Y gastric bypass)

Clinical Decision Algorithm

1. Confirm GERD diagnosis through objective testing (MII-pH monitoring is the best available diagnostic tool) 1
2. Optimize medical therapy (lifestyle modifications, PPI therapy)
3. Assess symptom response:
   • If adequate response → continue medical management
   • If inadequate response → proceed to additional testing
4. Additional testing:
   • Endoscopy to rule out complications
   • Barium swallow to assess anatomy
   • Manometry to assess esophageal function
   • 24-hour pH-impedance monitoring on PPI to determine mechanism of persistent symptoms
5. Evaluate for endoscopic fundoplication:
   • Confirm small or no hiatal hernia
   • Verify normal esophageal motility
   • Rule out other causes of symptoms (functional disorders, rumination)
6. Proceed with endoscopic fundoplication if appropriate criteria are met

Effectiveness and Outcomes

Transoral incisionless fundoplication (TIF) has demonstrated effectiveness in:

• Improving GERD-related quality of life scores
• Reducing PPI dependence in approximately 63% of patients
• Controlling heartburn symptoms in carefully selected patients 2

However, it's important to note that:

• Many patients continue to require some PPI therapy
• Long-term durability beyond 1-2 years remains unclear
• Normalization of acid exposure is the exception rather than the rule 1

Comparison to Other Anti-Reflux Procedures

• Laparoscopic fundoplication: More invasive but highly effective with 80% success rate at 20-year follow-up; preferred for patients with larger hiatal hernias 3
• Magnetic sphincter augmentation: Effective surgical option, often combined with crural repair for hiatal hernias 1
• Roux-en-Y gastric bypass: Effective primary anti-reflux intervention for obese patients 1

Potential Pitfalls and Caveats

• Careful patient selection is critical for successful outcomes
• Sham-controlled trials show significant placebo effect in endoscopic GERD procedures
• Short-term and long-term safety issues remain incompletely resolved
• The presence of even a small hiatal hernia may reduce effectiveness 2
• Patients should understand that this is not a definitive cure and some may still require medication

Endoscopic gastric fundoplication represents a middle-ground approach between medical therapy and more invasive surgical options, offering an alternative for appropriately selected patients with documented GERD who have failed optimized medical management.