SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).

Auyang, Carter, Rauth, and Fanelli, along with the members of the SAGES Guidelines Committee, have produced a comprehensive, clear review of available medical literature on the topic of endoluminal treatments for gastroesophageal reflux disease (GERD). This represents an objective, fair, and credible assessment of a diverse body of literature covering a complex and thorny topic. The conclusions and recommendations are invaluable to the physician and surgeon caring for patients with GERD, helping guide not only their advice to patients, but also their own understanding of these offerings and where they fit in today’s treatment of the patient with GERD. I’d like to expand on two carefully chosen words out of the preceding paragraph, complex and thorny, and challenge us to consider better ways to assess new technology so as to achieve an earlier understanding of whether novel technology has a role in our care of patients. First, this clinical spotlight review (CSR) tackles a complex clinical condition and its treatment, GERD. Although GERD as a disease is complex, its basic definition is not: it is simply abnormal reflux of gastric content into the esophagus due to an ineffective lower esophageal sphincter (LES)—a fairly clear definition of a mechanical defect. Yet it has taken decades for us to develop and understand a series of diagnostics to accurately diagnose GERD. Even after decades of study, there remain challenging diagnostic situations, such as how to diagnose clinically significant laryngopharyngeal reflux or how to identify and quantitate clinically significant nonacid reflux. With this, innovation around diagnostics for GERD continues. Many recent introductions provide new insights and ultimately will result in better care for GERD patients (e.g., impedance pH and high-resolution manometry). In contrast, our therapeutic options have changed little in the past decades: acid suppression with proton pump inhibitors and H2 blockers, or a half-century-old operation to augment the ineffective LES, the esophagogastric fundoplication (Nissen or Toupet fundoplication). Although the basis for acid suppression with medication has been well understood and accepted, the mechanism of action of the fundoplication—and more importantly translating a mechanism of action into a standardized technique to achieve consistent and good results—has remained elusive. Hence, achieving a true augmentation of the ineffective LES remains complex. With this as a backdrop, the development and advancement of endoluminal therapies has introduced a whole new level of complexity and confusion to GERD management, largely based on new hypothetical mechanisms of action added to an already poorly understood mechanism for how fundoplication works. For example, when considering these endoluminal therapies, how exactly does delivering radiofrequency energy to the LES alter LES function to control GERD, or can any totally endoluminal technique dependent on tissue fixation really create a durable plication or effect a true fundoplication? Ideally, when assessing new technology, data associated with the development of these new devices will help answer some of these questions. This is where this topic gets thorny. As is true with many new surgical techniques introduced during the past 10–20 years, endoluminal treatments for GERD are oriented around new devices, and with this, these interventions are largely industry driven in their development and introduction into clinical practice. Industry’s interest and development of new devices are essential to our ability to develop and implement new C. D. Smith (&) Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA e-mail: smith.c.daniel@mayo.edu