Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.

Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux – 1-year follow-up study

Background and Aim Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) was recently described to reduce post-POEM GER. This single-center study reports medium-term outcomes of POEM+F. Patients and Methods Retrospective analysis of prospectively maintained database of patients undergoing POEM+F. Abstracted data – demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy, follow-up. Follow-up was 3-monthly for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD – wrap integrity and esophagitis, and pH studies. GER was defined according to Lyon consensus. Data was recorded as mean (SD) or median (IQR), P-value < 0.05 was considered statistically significant. Results 25 patients underwent POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F was technically successful in 23/25 (92%). Significant dysphagia improvement was seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p < 0.05). Mean total procedure and fundoplication time (SD) – 115.6 (27.2) and 46.7 (12.4) minutes respectively. Time reduced significantly after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). Intact wrap was seen in 19/23 (82.6%). GER (abnormal EAET) was seen in 2/18 (11.1%); one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.1%). Two (8%) minor delayed adverse events required no intervention. Conclusions POEM+F is safe and reproducible. At 12-months follow-up, incidence of post-POEM+F GER was low and acceptable.

Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication for a patient with achalasia

To treat the patient with Achalasia and prevent the symptoms of gastroesophageal reflux the Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication was done by the current authors. After performing a myotomy the endoloop was fixated to the stomach and was attached to the muscle of the esophagus by using the endoclips. The endoloop was tightened therefore shaping the cuff. This operation has been technically feasible and no immediate or delayed complications occurred.