Is Endoscopic Gastric Fundoplication indicated for a patient with incompetent cardia, small hiatus hernia, bile reflux gastritis, moderate fluid, gastroparesis, and reflux esophagitis grade LA B, with a 2 cm hiatus hernia?

Endoscopic Gastric Fundoplication for GERD with Hiatal Hernia and Gastroparesis

Endoscopic Gastric Fundoplication is indicated for this patient with reflux esophagitis LA grade B, incompetent cardia, 2 cm hiatal hernia, bile reflux gastritis, and gastroparesis, as surgical intervention is recommended for complicated hiatal hernias with significant reflux symptoms that affect quality of life.

Assessment of Patient's Clinical Presentation

The patient presents with multiple significant findings:

• Incompetent cardia (lower esophageal sphincter dysfunction)
• Small hiatal hernia (2 cm)
• Bile reflux gastritis
• Moderate amount of fluid
• Gastroparesis
• Reflux esophagitis LA grade B (moderate erosive disease)

These findings collectively represent a complicated case of gastroesophageal reflux disease (GERD) with structural abnormalities that contribute to persistent symptoms and tissue damage.

Rationale for Endoscopic Gastric Fundoplication

Evidence Supporting Intervention:

1. Severity of Esophagitis:

   • LA grade B esophagitis is considered moderate erosive disease and represents objective evidence of GERD 1
   • Follow-up endoscopy is recommended after PPI therapy for severe esophagitis to ensure healing 1

2. Structural Abnormalities:

   • Both hiatal hernia and incompetent LES are independent predictors of abnormal esophageal acid exposure 2
   • The altered geometry of the cardia imposed by a hiatal hernia facilitates reflux by compromising LES function 2

3. Complicated GERD Presentation:

   • Surgery is recommended in complicated non-traumatic diaphragmatic hernia (Strong recommendation based on moderate-quality evidence) 1
   • In stable patients with complicated non-traumatic diaphragmatic hernia, a minimally invasive approach is suggested 1

4. Bile Reflux and Gastroparesis:

   • Bile reflux gastritis represents a more severe form of reflux disease that may be refractory to medical management 3
   • The combination of gastroparesis with GERD creates a challenging clinical scenario that often requires intervention beyond medical therapy

Treatment Algorithm

Step 1: Confirm Failure of Medical Management

• Ensure patient has undergone an adequate trial of twice-daily PPI therapy for 4-8 weeks 1
• Document persistent symptoms and endoscopic findings despite optimal medical therapy

Step 2: Evaluate for Surgical Candidacy

• Confirm the presence of objective GERD (already done via endoscopy showing LA grade B esophagitis)
• Consider pH monitoring if there is any doubt about the diagnosis 1
• Assess for comorbidities that might affect surgical outcomes

Step 3: Choose Appropriate Intervention

• For this patient with moderate esophagitis, hiatal hernia, bile reflux, and gastroparesis:
  • Endoscopic Gastric Fundoplication is appropriate as a minimally invasive approach 1
  • Alternative: Laparoscopic fundoplication (Nissen or Toupet) if endoscopic approach is not feasible

Step 4: Post-Procedure Management

• Follow-up endoscopy 2-3 months after procedure to assess healing
• Consider maintenance PPI therapy if complete resolution is not achieved
• Address gastroparesis with prokinetic agents as needed

Important Considerations and Caveats

1. Gastroparesis Management:

   • Gastroparesis may complicate GERD management and should be addressed concurrently
   • Consider prokinetic therapy and dietary modifications
   • Gastropexy may be beneficial in addition to fundoplication 1

2. Bile Reflux:

   • Standard fundoplication may not completely address bile reflux
   • In severe cases refractory to endoscopic fundoplication, a Roux-en-Y diversion might be considered 3

3. Procedure Selection:

   • Nissen fundoplication has been the most common technique, but Toupet fundoplication may have a lower recurrence rate 1
   • The endoscopic approach offers lower morbidity (5-6%) compared to open approaches (17-18%) 1

4. Potential Complications:

   • Post-procedure dysphagia
   • Recurrent reflux symptoms (11-62.9% complication rate reported) 1
   • Gas-bloat syndrome

Conclusion

The combination of incompetent cardia, hiatal hernia, bile reflux gastritis, gastroparesis, and LA grade B esophagitis represents a complex GERD presentation that warrants intervention beyond medical management. Endoscopic Gastric Fundoplication offers a minimally invasive approach with lower morbidity than open surgical approaches and is appropriate for this patient's clinical scenario.