Is Endoscopic Gastric Fundoplication indicated for a patient with eosinophilic esophagitis, small rings in the mid esophagus, diffuse erythema, a 2 cm type 2 hiatal hernia, and mild duodenitis with erosions?

Endoscopic Gastric Fundoplication is NOT Indicated for This Patient

Endoscopic fundoplication is contraindicated in this clinical scenario due to the presence of eosinophilic esophagitis (EoE), and the primary focus should be on medical management of the EoE with topical corticosteroids or PPI therapy, followed by treatment of the hiatal hernia only if reflux symptoms persist after achieving histologic remission of the EoE. 1

Why Endoscopic Fundoplication is Inappropriate

Eosinophilic Esophagitis is a Contraindication

• Performance of fundoplication for PPI-responsive EoE is not currently recommended because of the potential anti-inflammatory properties of PPIs, the theoretical concern for retention of offending food antigens in the esophagus, and worsening dysmotility due to a tight gastroesophageal junction 1

• The small rings in the mid-esophagus with white patches are classic endoscopic features of EoE (rings and exudates on the EREFS scoring system), which requires anti-inflammatory treatment rather than mechanical intervention 1

• EoE patients have underlying esophageal inflammation and potential dysmotility that would be worsened by creating a tight gastroesophageal junction through fundoplication 1

The Hiatal Hernia Size is Problematic

• The 2 cm hiatal hernia is at the upper limit for endoscopic fundoplication candidacy, as endoscopic fundoplication seems to be best suited for patients with small hiatal hernias (<2 cm) 2

• Studies of endoscopic fundoplication specifically excluded patients with hiatal hernias larger than 2-3 cm, and your patient is at this threshold 2, 3

• The Hill Type 2 classification indicates the gastroesophageal flap valve is present but transiently opens and closes with respiration, suggesting some degree of anatomic disruption that may not be adequately addressed by endoscopic techniques 1

Correct Management Algorithm

Step 1: Confirm and Treat the Eosinophilic Esophagitis

• Await biopsy results from the mid-esophagus to confirm EoE (diagnosis requires ≥15 eosinophils per high-power field) 1

• Note that biopsies should have been obtained from both distal and proximal esophagus (at least 6 specimens total) for optimal diagnostic yield, not just the mid-esophagus 1

• Initiate topical corticosteroids as first-line therapy (budesonide or fluticasone administered via metered-dose inhaler with lips sealed around device, then no eating, drinking, or rinsing for 30 minutes) 4

• Alternatively, start high-dose PPI therapy (twice-daily dosing) for 6-8 weeks, as this achieves histologic remission in many EoE patients 1, 5

Step 2: Reassess After Achieving Histologic Remission

• Repeat endoscopy with biopsies after 8-12 weeks of treatment to document histologic response 4

• If symptoms recur while on treatment, endoscopy should be repeated for assessment and to obtain further histology 4

• Only after achieving histologic remission of EoE should you consider whether the hiatal hernia and reflux symptoms warrant surgical intervention 1

Step 3: Consider Surgical Fundoplication Only If Appropriate

• If reflux symptoms persist despite EoE treatment and the patient has objective evidence of pathologic reflux (via impedance-pH monitoring), laparoscopic fundoplication is the standard surgical treatment, NOT endoscopic fundoplication 6

• Laparoscopic fundoplication is highly effective with an 80% success rate at 20-year follow-up, whereas endoscopic techniques have limited long-term data and higher failure rates 1, 6

• The 2006 AGA position statement noted that endoscopic antireflux techniques showed only modest effects on LES pressure and acid exposure, with normalization of acid exposure being "the exception rather than the rule" 1

Additional Management Considerations

Address the Gastric and Duodenal Findings

• The diffuse gastric erythema requires biopsy evaluation for H. pylori (5 specimens from greater and lesser curve of body, incisura, and greater and lesser curve of antrum) 1

• The mild duodenitis with erosions should be treated with PPI therapy, which will also address any reflux component and potentially treat the EoE 5

Common Pitfalls to Avoid

• Do not perform any fundoplication procedure until the EoE is adequately treated and in histologic remission 1

• Do not assume the reflux symptoms are solely due to the hiatal hernia when EoE is present, as EoE itself causes heartburn and regurgitation symptoms 1

• Avoid endoscopic fundoplication even if the patient requests a "less invasive" option, as the limited durability and higher failure rates (approximately 25% dissatisfaction rate vs. 4% with laparoscopic approach) make it inappropriate 7

• Several endoscopic antireflux devices have been voluntarily withdrawn from the market due to serious adverse events, highlighting the uncertain safety profile of these techniques 1