What is the role of endoscopic fundoplication in treating gastroesophageal reflux disease (GERD)?

Role of Endoscopic Fundoplication in GERD Treatment

Transoral incisionless fundoplication (TIF) is an effective endoscopic option for carefully selected patients with proven gastroesophageal reflux disease (GERD) who have failed medical management but are not suitable candidates for surgical intervention. 1

Patient Selection Criteria

• Endoscopic fundoplication should only be considered in patients with:

  • Confirmed diagnosis of pathologic GERD through objective testing 1
  • Small or no hiatal hernia (<2 cm) 2, 3
  • Normal esophageal peristaltic function 1, 4
  • Absence of achalasia or other esophageal motility disorders 1

• Ideal candidates include:

  • Patients with PPI-refractory symptoms despite optimized medical therapy 2
  • Patients unwilling or unable to take long-term PPI therapy 2, 5
  • Patients who are poor candidates for surgical fundoplication 6
  • Patients with regurgitation-predominant GERD 1

Diagnostic Workup Before Considering Endoscopic Fundoplication

• Complete endoscopic evaluation to assess for:

  • Erosive esophagitis (graded by Los Angeles classification) 1
  • Diaphragmatic hiatus (Hill grade of flap valve) 1
  • Axial hiatal hernia length 1
  • Barrett's esophagus 1

• Ambulatory reflux monitoring:

  • Prolonged wireless pH monitoring off PPI therapy (96-hour preferred) to confirm GERD diagnosis 1
  • 24-hour pH-impedance monitoring on PPI for patients with persistent symptoms despite therapy 1

• High-resolution manometry to:

  • Exclude achalasia 1
  • Assess esophageal peristaltic function 1, 4

Efficacy and Outcomes

• Endoscopic fundoplication (TIF) has demonstrated:

  • Improvement in GERD symptoms and quality of life 6, 2
  • Partial reduction in PPI dependency 2, 3
  • Value in patients with regurgitation-predominant GERD 1
  • Recent data showing efficacy when combined with laparoscopic hiatal hernia repair in patients with minor crural defects 1

• However, important limitations include:

  • Less complete normalization of acid exposure compared to surgical fundoplication 1
  • Limited long-term durability data beyond 1-2 years 1
  • Variable efficacy depending on patient selection 2

Comparison with Other Treatment Options

• Endoscopic fundoplication bridges the gap between:

  • Medical therapy (PPIs) which does not address the underlying pathophysiology 6
  • Surgical options (laparoscopic fundoplication, magnetic sphincter augmentation) which are more invasive but potentially more effective long-term 1, 4

• For obese patients with GERD:

  • Roux-en-Y gastric bypass is more effective as a primary anti-reflux intervention 1
  • Sleeve gastrectomy should be avoided as it may worsen GERD 1

Procedural Considerations

• The TIF procedure:
  • Performed under general anesthesia 3
  • Requires both a surgeon operating the device and an endoscopist operating the gastroscope 3
  • Creates a 270-300° fundoplication approximately 3-4 cm in length 3
  • Is less invasive than surgical fundoplication with fewer side effects like dysphagia and gas bloating 6, 4

Safety and Complications

• Potential complications include:
  • Gastric mucosal tears and bleeding 3
  • Less severe than complications associated with surgical fundoplication 6
  • Lower risk of post-procedure dysphagia compared to surgical approaches 4

Follow-up Recommendations

• Patients should be monitored for:
  • Symptom resolution and quality of life improvement 2, 3
  • Need for continued PPI therapy 2
  • Potential need for more definitive surgical intervention if symptoms recur 5

Key Pitfalls to Avoid

• Performing endoscopic fundoplication without objective confirmation of GERD 1
• Selecting patients with large hiatal hernias (>2 cm) 2, 3
• Expecting complete normalization of acid exposure in all patients 1
• Using the procedure in patients with esophageal motility disorders 1
• Proceeding without thorough preoperative assessment including endoscopy, pH monitoring, and manometry 1