What are the indications for Endoscopic Gastric Fundoplication 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 response to PPI therapy but are not suitable or willing for surgical fundoplication, particularly those with small hiatal hernias and high-volume reflux episodes. 1

Patient Selection Criteria

Proper patient selection is critical for successful outcomes with endoscopic gastric fundoplication. The following criteria should be met:

Required Criteria

• Confirmed diagnosis of GERD with objective evidence (pathologic acid exposure on pH monitoring)
• PPI-dependent or PPI-refractory symptoms
• Small hiatal hernia (<2 cm)
• Absence of severe esophagitis (Los Angeles grade C or D)
• Normal esophageal motility (exclusion of achalasia)

Contraindications

• Large hiatal hernia (>2 cm)
• Severe erosive esophagitis
• Barrett's esophagus (especially long-segment ≥3 cm)
• Esophageal motility disorders
• Failed previous anti-reflux surgery

Diagnostic Evaluation Before Procedure

Before considering endoscopic fundoplication, patients must undergo comprehensive testing:

1. Upper endoscopy - To assess for erosive esophagitis, hiatal hernia size, and Barrett's esophagus 1
2. Ambulatory pH monitoring - Preferably prolonged wireless pH monitoring off PPI to confirm pathologic GERD 1
3. Esophageal manometry - To exclude achalasia and assess esophageal peristaltic function 1
4. Gastric emptying study - If delayed gastric emptying is suspected 1

Available Endoscopic Techniques

Several endoscopic techniques are available:

1. Transoral incisionless fundoplication (TIF) - Using devices like EsophyX to create a 270-300° fundoplication 2
2. Radiofrequency ablation (Stretta) - May be considered for PPI-refractory GERD and patients with reflux hypersensitivity 3
3. Endoscopic plication - Using devices like GERD-X to approximate tissue at the gastroesophageal junction 1, 3
4. Mucosal resection/ablation techniques - Including anti-reflux mucosectomy and anti-reflux mucosal ablation (emerging techniques) 3

Clinical Scenarios Where Endoscopic Fundoplication Is Appropriate

Endoscopic fundoplication should be considered in the following scenarios:

1. PPI-dependent patients who wish to avoid lifelong medication but are not suitable candidates for surgery 3
2. Patients with regurgitation-predominant GERD that persists despite PPI therapy 1
3. Patients with proven GERD who have inadequate response to optimized PPI therapy but are not willing to undergo surgical fundoplication 1, 4
4. Patients with reflux hypersensitivity who may benefit from procedures like Stretta 3

Important Caveats and Limitations

• Current evidence for endoscopic techniques is limited in terms of long-term outcomes
• The durability of these procedures beyond 1-2 years remains unclear 1
• Normalization of acid exposure is the exception rather than the rule for all endoscopic techniques 1
• These procedures are less invasive than antireflux surgery but their long-term efficacy is not fully established 5

Realistic Expectations

Patients should be counseled on realistic expectations:

• Symptom improvement and quality of life enhancement are common outcomes
• Reduction in PPI dependence is likely, but complete PPI independence is not guaranteed
• The procedure may need to be repeated or converted to surgical fundoplication if symptoms recur

Conclusion

While endoscopic gastric fundoplication offers a less invasive alternative to surgical fundoplication for selected GERD patients, it requires careful patient selection and thorough diagnostic evaluation. The 2022 AGA clinical practice update supports transoral incisionless fundoplication as an effective endoscopic option for carefully selected patients with proven GERD 1, particularly those with small hiatal hernias and without severe esophagitis or large hiatal hernias.