Endoscopic treatment of GERD: is there still a chance?

esophageal disorder, affecting more than 20% of the population worldwide. GERD symptoms vary from simple heartburn and epigastric pain to more complex clinical situations, with a combination of other various extra-esophageal symptoms that include hoarseness, odynophagia, chronic cough, pharyngitis and laryngitis, asthma, disrupted sleep, chronic bronchitis and pneumonia. Current medical and surgical therapies are adequate treatments for the vast majority of patients with GERD. Proton pump inhibitors (PPI), in particular, are very effective for treatment of typical esophageal symptoms, induce healing of esophagitis, and they prevent recurrences. Nevertheless, in some patients, symptoms are refractory to standard medical therapy. Furthermore, some concerns about possible longterm effects of therapy with PPI now are emerging, and some patients refuse the idea of a lifetime commitment to medical therapy. Laparoscopic Nissen fundoplication is the most common antireflux surgical operation. At shortand mid-term, surgery offers excellent control of symptoms. In contrast, surgery remain a moderately invasive treatment for medical disorders, and carries a certain risk of immediate and long-term complications. Furthermore, the antireflux wrap may be insufficient to control symptoms after more than 5 years, and patients may need to resume medical therapy. At the beginning of the current century, a variety of endoscopic antireflux procedures were ideated, developed and put on the market, to respond to the emerging clinical needs imposed by non-response to PPI therapy of patients with GERD or their reluctance to accept lifelong therapy or surgery. In truth, despite initial enthusiasm for and very promising results with preliminary clinical trials, many of these procedures were quickly abandoned because of serious security warnings, or manifested inefficacy. A common inexorable destiny united the procedures that consisted in the injection or deployment of inert bulking agents at the level of the esophagogastric junction (Enterix, Boston Scientific, United States and Gatekeeper, Medtronic, United States) and those that permitted creation of superficial plications of tissue at the level of the esophagogastric junction (EndoCinch – CR Bard Inc, United States and the Endoscopic Suturing Device – ESD, Wilson-Cook Medical, United States). Only three of the endoscopic antireflux procedures developed almost 20 years ago are still available today: the Strettaprocedure (Restech Corporation, Houston, Texas, United States), the NDO Full-Thickness Plicator (that in truth has been acquired by a new company, re-engineered, and proposed in an, almost completely, new guise – the GERDXTM – G-SURG GmbH, Seeon-Seebruck, Germany), and the Esophyx Transoral Incisionless Fundoplication (EndoGastric Solutions, Redmond, Washington, United States). The first one has a peculiar mechanism of action, actually in large part not completely clarified, and includes delivery of radiofrequency energy at different levels into the LES, by using a special balloon – basket assembly with four retractable needle electrodes arranged radially around the balloon. The latter two devices permit full-thickness plication, with a serosa-to-serosa apposition of tissue, and thus offer more reliable and durable sutures. In addition to these, in more recent years, two other new procedures have become popular: the MUSEsystem (Medigus Ultrasound Surgical Endostapler, Medigus, Omer, Israel) and the ARMS Procedure (Antireflux Mucosectomy): two new kids-on-the-block to reinforce the endoscopic transoral armamentarium against GERD. Endoscopic treatment of GERD: is there still a chance?