Gastroenterology: endoscopic treatment for gastro-oesophageal reflux

By Cristiano Antonino On Jul 24, 2022

Gastro-oesophageal reflux is the rising up of acid juices from the stomach to the oesophagus, due to a malfunction of the lower oesophageal sphincter, i.e. the lower valve of the oesophagus

It is an extremely common condition that is often disabling, so much so that in some cases even surgery is considered.

Due to its invasiveness, however, many prefer, where practicable, an alternative route, which is endoscopic surgery.

The endoscopic procedure with an Esophyx® device

In recent years, endoscopic techniques have been developed for patients with documented pathological gastro-oesophageal reflux who

cannot take medication or want to reduce/eliminate it;
do not want to or cannot undergo surgery.

These include the procedure technically known as transoral fundoplication with an Esophyx® device, i.e. the folding, without cutting, of the stomach floor with a special disposable device that is introduced through the mouth.

Gastro-oesophageal reflux: from Nissen to Esophyx®

The technique in question follows the same principles as the Nissen surgical method, named after its inventor, which involves folding the gastric fundus, i.e. the uppermost section of the stomach, around the oesophagus, surrounding it and creating a new valve to prevent the gastric material from rising.

The Esophyx® device, passed through an endoscope from the oral cavity to the stomach, allows without cutting:

folding of the gastric fundus below the malfunctioning oesophageal sphincter;
stitching of the gastric fundus (with polyethylene stitches) around the malfunctioning oesophageal sphincter;
creation of a new valve of approximately 270° circumference.

The advantages of transoral fundoplication with the Esophyx® device can be summarised as follows

absence of incisions, as the fold is obtained from inside the stomach instead of from the outside, as is the case with traditional surgery;
short duration of the operation, which takes about 45 minutes;
discharge generally the following day.

The data of the procedure

Follow-up data up to 10 years after the procedure document that it is still effective, with approx:

50% of patients no longer taking proton pump inhibitors;
35% taking them occasionally or in reduced doses;
15% who had no benefit or relapsed.

The long-term results are comparable to those of surgery, but without the complications and side effects that can occur with it.

Finally, the procedure is repeatable and, should the need arise, does not preclude future recourse to the surgical procedure.

In what cases of gastro-oesophageal reflux is this type of procedure indicated

Transoral fundoplication with the Esophyx® device is indicated in:

patients with Gastroesophageal Reflux Disease with esophagitis (ERD) that can be detected and clinically assessed endoscopically;
patients with NERD – Gastroesophageal Reflux Disease without oesophagitis, documented by means of functional tests, such as 24-hour oesophageal pH-impedancometry or 48-hour pH-metry with the Bravo system.

It is partially indicated, however, in cases of hypersensitive oesophagus, i.e. characterised by excessive sensitivity to reflux, both acidic and non-acidic, even under normal conditions.

Gastro-oesophageal reflux, when is the procedure not indicated?

In some cases, the endoscopic procedure with the Esophyx® device is not indicated, especially when one is suffering from

functional heartburn (burning sensation), i.e. when there is symptomatology attributable to it, but the reflux is not pathological;
hiatal hernia larger than 2.5 cm.
gastric conditions that make manoeuvring with the device impossible

The gastroenterologist’s duties

The professional has the duty to

select only patients suitable for the procedure, identified by means of the appropriate diagnostics;
provide the patient with realistic expectations and success rates, informing him/her of all possible contraindications, which are present, after all, in any type of medical activity.

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