David P. Lee, MD

David P. Lee, MD,
Methodist Digestive Institute,
Methodist Dallas Medical Center

Evidence suggests that numerous advances in the endoscopic management of GERD have enabled this approach to be viable for larger subgroups of patients with the condition in recent years. With an expanding pool of treatment candidates and several endoscopic management options, careful patient selection is essential to ensure patients are matched to the most appropriate treatment, according to David P. Lee, MD, and Kenneth J. Chang, MD. For a paper published in Digestive Diseases and Sciences, they outline strategies clinicians can use to identify the most appropriate endoscopic procedure for their patients.

“Endoscopic treatments for GERD are now considered appropriate for those patients early in the GERD spectrum, as well as those with altered anatomy where standard laparoscopic surgical approaches are limited,” write Drs. Lee and Chang.

Kenneth J. Chang, MD

Kenneth J. Chang, MD,
Professor and Chief,
Division of Gastroenterology,
Executive Director,
H.H. Chao Comprehensive Digestive Disease Center,
School of Medicine,
University of California Irvine

They note that “a variety of endoscopic options have emerged to bridge the gap between medical and surgical management of GERD.” This is an important development, particularly as an increasing number of risks have been associated with proton pump inhibitors (PPIs), which remain the mainstay of GERD therapy; surgical procedures like Nissen fundoplication have been associated with several uncomfortable adverse effects (AEs), including gas and bloating.

Drs. Lee and Chang explain that three endoscopic devices are currently approved by the FDA to treat GERD:

Stretta system, which received approval in 2000 and uses radiofrequency energy to improve reflux symptoms.

-Esophyx-Z, which received approval in 2007 and facilitates transoral incisionless fundoplication (TIF).

-OverStitch, which received approval in 2008 and is intended for endoscopic placement of suture(s) and approximation of soft tissue.


Radiofrequency Energy Treatment

Stretta is indicated for patients who are not candidates for medical therapy or who have concerns about the long-term AEs associated with PPIs and do not qualify for or do not wish to undergo surgery. The approach is contraindicated in patients younger than 18, pregnant women, poor surgical candidates, and patients with a hiatal hernia greater than 2 cm, demonstrated achalasia or incomplete lower esophageal sphincter (LES) relaxation in response to swallowing, an American Society of Anesthesiology (ASA) IV classification, or without a GERD diagnosis.

Drs. Lee and Chang note that patients with normal gastrointestinal anatomy are the most ideally suited for the Stretta procedure. “These patients have normal LES tone, no hiatal hernia, and a closed diaphragmatic hiatus (Hill Grade I),” they explain, noting that this finding is referred to as dynamic failure, as no anatomical defects are obvious and the main mechanism of GERD in these patients is attributed to inappropriate transient lower esophageal sphincter relaxation. Success of the procedure is most likely in patients who have shown response to antisecretory pharmacologic therapy.



Drs. Lee and Chang note that patients being considered for TIF “must have a clear indication for an anti-reflux procedure.” Once candidacy is established, clinicians must determine whether their patient is best served with TIF alone or whether a concomitant laparoscopic hernia repair (cTIF) is warranted. “There are three components of the anti-reflux anatomy to assess: (1) whether there is a hiatal hernia that needs to be reduced, (2) whether the right crura, which acts like a sling or noose around the [gastroesophageal junction (GEJ)], needs to be tightened, and (3) whether the LES needs to have a valve reconstruction,” they write.

The authors explain that hiatal hernia can be assessed via an esophagram or upper endoscopy, but they caution that either modality can miss sliding hernias. To assess the axial width of the crural opening, they recommend using the Hill classification in retroflex view, adding that a full 60 seconds should be spent in retroflexion with active insufflation to improve accuracy, as in their experience, inaccurate assessment of Hill grade is the most common reason for TIF failure.

“A Hill grade 1 or 2 is acceptable for TIF alone,” they write. “However, if the hiatus is open more than 2 cm (or diameter of 2 scopes, i.e., Hill 3), or there is an axial hernia length of more than 2 cm (Hill 4), the patient will most likely need a crural repair, which can be completed at the same time as the TIF procedure (cTIF).” For Hill 2 and 4, cTIF is performed.


Endoscopic Suturing

A variety of endoscopic suturing techniques have been explored in the literature, some showing greater benefit than others. Among those showing the greatest promise, Drs. Lee and Chang include mucosal ablation and suturing of the esophagogastric junction (MASE) and resection and plication (RAP).

MASE is a technique the pair developed that consists of applying argon plasma coagulation to gastric mucosa below the GEJ to improve tissue apposition before suturing. Thereafter, three sutures are placed along the lesser curvature of the cardia directly below the esophagogastric junction to prevent stomach contents from refluxing into the esophagus.

“The MASE procedure represents a novel endoscopic treatment for GERD which may be particularly useful in managing complex patients with GERD, including those with altered anatomy who may not be candidates for surgical or endoscopic fundoplication,” they write.

RAP replaces the mucosal ablation used in MASE with mucosal resection, pairing a semi-circumferential mucosectomy with full-thickness plication of the LES and cardia; however, Drs. Lee and Chang have also performed a variation of this technique, with the resection and plications performed more posterior and toward the lesser curve, with some patients also receiving a second reinforcing suture.

“We mainly consider performing the RAP procedure in GERD patients with altered anatomy where options for other anti-reflux surgeries or procedures are limited,” they added. “In patients where mucosal resection is not feasible (prior resection, ablation, scarring), we will consider the MASE technique.”