Is endoscopic gastric fundoplication indicated for a patient with reflux esophagitis, incompetent cardia, small sliding hiatus hernia, chronic gastritis, and a gastric subepithelial lesion?

Endoscopic Gastric Fundoplication for Reflux Esophagitis with Hiatus Hernia

Endoscopic gastric fundoplication is not indicated for this patient with reflux esophagitis LA grade A, 2cm hiatus hernia, chronic gastritis, and gastric subepithelial lesion. 1

Current Evidence on Endoscopic Fundoplication

• According to the American Gastroenterological Association (AGA), there are no definite indications for endoscopic therapy for GERD at this time, as the durability and long-term safety of these techniques remain unresolved 1
• Endoscopic fundoplication techniques (including suture plication of proximal fundic folds) have shown modest effects on lower esophageal sphincter pressure and 24-hour acid exposure measures, with normalization of acid exposure being the exception rather than the rule 1
• Most studies of endoscopic therapy have enrolled primarily PPI-dependent patients without severe esophagitis or large hiatus hernias, limiting their applicability to more complex cases 1

Appropriate Management for This Patient

Diagnostic Considerations

• A correct diagnosis of GERD is mandatory before intensifying medical therapy or planning any surgical intervention 1
• MII-pH monitoring over 24 hours is the best available tool for confirming GERD diagnosis, which has already been performed in this patient 1
• Endoscopy has already identified LA grade A esophagitis, 2cm hiatus hernia, chronic gastritis, and a gastric subepithelial lesion 1

Recommended Treatment Approach

• Medical therapy should be the first-line treatment for this patient with mild reflux esophagitis (LA grade A) and small hiatus hernia (2cm) 1
• A therapeutic trial of 4-8 weeks of twice-daily proton pump inhibitor (PPI) therapy is indicated before considering any surgical intervention 1
• Only if symptoms persist despite optimized medical therapy should surgical options be considered 1

Surgical Considerations if Medical Therapy Fails

• For patients with persistent symptoms despite medical therapy, laparoscopic fundoplication is the recommended surgical approach rather than endoscopic techniques 1
• The laparoscopic approach has been demonstrated to be feasible, safe, and effective, with lower morbidity (5-6%) compared to open approaches (17-18%) 1, 2
• The choice between total or partial fundoplication should be based on surgeon expertise and patient factors 1

Specific Concerns in This Patient

• The presence of a small (2cm) hiatus hernia is not a contraindication to medical management, as most small hernias respond well to medical therapy 2, 3
• The gastric subepithelial lesion requires separate evaluation and management, and is not an indication for endoscopic fundoplication 1
• Endoscopic fundoplication has shown limited success in patients with hiatal hernias, with better results typically seen in patients with no hernia or very small (<2cm) hernias 4

Common Pitfalls to Avoid

• Proceeding directly to endoscopic or surgical intervention without an adequate trial of medical therapy is not recommended for mild GERD 1
• Endoscopic fundoplication techniques have shown high sham response rates in clinical trials, highlighting the need for careful patient selection 1
• For hiatal hernias >2cm, standard laparoscopic repair is preferred over endoscopic techniques if surgical intervention becomes necessary 2, 5
• Overlooking the gastric subepithelial lesion, which requires separate evaluation and may influence management decisions 1

Conclusion Based on Evidence

• This patient with LA grade A esophagitis and a 2cm hiatus hernia should first undergo optimized medical therapy with lifestyle modifications and PPI therapy 1
• Endoscopic gastric fundoplication is not currently recommended as a first-line treatment for this patient based on AGA guidelines 1
• If medical therapy fails after 4-8 weeks of optimized treatment, laparoscopic fundoplication would be the preferred surgical approach rather than endoscopic techniques 1