Is Endoscopic Gastric Fundoplication indicated for a patient with a 2cm sliding hiatus hernia and Los Angeles (LA) grade A reflux esophagitis?

Endoscopic Gastric Fundoplication is NOT Indicated for This Patient

Based on current AGA guidelines, this patient with LA grade A esophagitis and a 2cm hiatus hernia should NOT undergo endoscopic fundoplication at this time. 1, 2, 3

Why This Patient Does Not Meet Criteria

LA Grade A Esophagitis is Insufficient Evidence of GERD

• LA grade A esophagitis is considered "borderline GERD" and can be seen in healthy asymptomatic volunteers—it does not constitute confirmatory evidence of pathologic GERD. 4
• Confirmatory GERD evidence requires either LA grade B or higher esophagitis, OR acid exposure time (AET) ≥6.0% on 2 or more days on prolonged wireless pH monitoring. 4
• This patient has only LA grade A disease, which falls into the "borderline" category requiring optimization of medical therapy first. 4

The 2cm Hiatus Hernia is Within Acceptable Range BUT Requires pH Monitoring Results

• While endoscopic fundoplication candidates should have small (<2cm) hiatal hernias, this patient's 2cm hernia is at the upper limit. 5
• More critically, the Hill grade IV finding indicates a severely incompetent gastroesophageal flap valve, but this anatomic finding alone does not justify proceeding to endoscopic fundoplication without confirming pathologic acid exposure. 4
• The wireless pH capsule was appropriately placed—you must wait for these results before making any decision about anti-reflux procedures. 4

Required Next Steps Before Considering ANY Anti-Reflux Procedure

1. Await pH Monitoring Results

• The wireless pH monitoring results are essential to determine if this patient has true pathologic GERD, borderline GERD, or no GERD. 4
• If AET <4.0% on all days: No GERD—stop PPI therapy and consider functional disorder. 4
• If AET ≥4.0% but <6.0% on most days: Borderline GERD—optimize medical therapy. 4
• If AET ≥6.0% on 2 or more days: Confirmed GERD—consider escalation if medical therapy fails. 4

2. Optimize Medical Therapy First

• A therapeutic trial of 4-8 weeks of optimized PPI therapy (potentially twice daily) with aggressive lifestyle modifications is mandatory before considering any invasive procedure. 3
• This includes weight management, dietary modifications, and elevation of head of bed. 4

3. Additional Testing if Medical Therapy Fails

• High-resolution manometry must be performed to exclude achalasia and confirm normal esophageal peristaltic function before ANY anti-reflux procedure. 2
• Esophageal motility disorders are an absolute contraindication to endoscopic fundoplication. 1, 2

Why Endoscopic Fundoplication Has Limited Evidence

Current AGA Position

• The AGA states there are no definite indications for endoscopic therapy for GERD at this time, as durability and long-term safety remain unresolved. 3
• Endoscopic techniques show modest effects on lower esophageal sphincter pressure and rarely normalize acid exposure. 3
• Most studies enrolled PPI-dependent patients without severe esophagitis or large hernias, limiting applicability. 3

If Surgery Becomes Necessary

• Laparoscopic fundoplication (not endoscopic) is the recommended surgical approach for patients who fail optimized medical therapy. 3, 6
• The Nissen fundoplication remains the gold standard for durable relief of GERD symptoms. 6

Critical Pitfalls to Avoid

• Do not proceed to any anti-reflux procedure without confirming pathologic GERD through objective pH monitoring. 1, 2
• Do not skip the trial of optimized medical therapy—this is mandatory even if pH monitoring confirms GERD. 3
• Do not perform endoscopic fundoplication without first obtaining high-resolution manometry to exclude motility disorders. 2
• The gastric subepithelial lesion requires separate evaluation and is not an indication for fundoplication. 3

Recommended Management Algorithm

1. Review wireless pH monitoring results when available 4
2. If borderline or confirmed GERD: Initiate 4-8 weeks of optimized PPI therapy (twice daily if needed) plus lifestyle modifications 3
3. If symptoms persist after optimized medical therapy: Obtain high-resolution manometry and consider esophagram 2
4. If all criteria met and medical therapy fails: Consider laparoscopic fundoplication (NOT endoscopic) as the evidence-based surgical option 3, 6