Are incisionless fundoplication procedures a safer alternative to the laparoscopic nissen for the treatment of chronic gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a complex disease that can be characterized by a broad spectrum of clinical symptoms. It is the most common upper gastrointestinal disorder in the western civilization with an increasing prevalence and incidence in the last two decades. It has been estimated that 15–25% of adults experience gastroesophageal reflux symptoms at least weekly, and 5–12% suffer these symptoms on a daily basis. The primary barrier to reflux is the esophagogastric junction which consists of the intrinsic lower esophageal sphincter (LES), extrinsic compression of the LES by the crus, intraabdominal position of the sphincter, integrity of phrenoesophageal ligament, and maintenance of the angle of His. Although not completely understood, dysfunction or abnormalities in any of these components introduce the propensity for increased reflux. Due to complex etiology of GERD, the care and treatment ranges as wide as the spectrum of the disorder itself. Therapeutic modalities include lifestyle modification, medications, and ultimately surgical intervention. The initial and most conservative treatment of GERD is to advise lifestyle changes such as weight loss, avoiding foods that decrease LES pressure, avoiding lying down directly after eating, and raising the head of the bed while sleeping. Although there is definitive data that exist regarding the role of obesity and smoking in promoting GERD clinical manifestations, there is no evidence showing that dietary modifications improve symptoms. Despite the insufficient evidence to support an association between dietary behavior and GERD, some dietary interventions continue to be recommended as firstline therapy. Although modern drug therapy is very effective in the long-term management of GERD, antireflux surgery seems to be more cost effective than medical therapy and safer regarding long-term effects of acid suppression and development of adenocarcinoma of the esophagus in patients with severe forms of the disease. Since its conception in 1956, the Nissen fundoplication has been the surgical treatment of choice for GERD. As surgical techniques evolved into the laparoscopic era, the laparoscopic Nissen fundoplication has evolved into the gold standard in antireflux surgery with excellent control outcomes. Dallemagne et al. reported that 90% patients had symptom control 10 years after surgery, and less than 10% of patients had to resume medication again. Hence, the Nissen fundoplication procedure has been the “gold standard” unto which other procedures have been compared to. As the surgical world continues to push towards less invasive techniques, endoscopic interventions have evolved in treating GERD. Currently, there exists several endoscopic options from suturing (i.e., Bard® EndoCinchTM, theWilsonCook Endoscopic Suturing Device, the NDO PlicatorTM, and EsophyX®) to endoscopic injections or implantations(i.e., Enteryx®, the GatekeeperTM Reflux Repair System, and Plexiglas®), all which bulk up the LES by injecting biopolymers into the muscularis layer of the esophagus. Although these techniques are relatively new, there are groups that promote their cosmetic appeal and their effectiveness all without surgical necessity. As the treatment K. Ben-David : J. Carreras : J. Lopes Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA