981 RESECTION AND PLICATION (RAP): AN ENDOSCOPIC ANTI-REFLUX SOLUTION IN ALTERED ANATOMY

Abstract

In recent years, significant advances have been made in the treatment of gastroesophageal reflux disease (GERD). Options for therapy have expanded in the surgical field, and new endoscopic options have emerged as alternative means of treating GERD in select populations. However, GERD remains a common problem in many polulations that do not quality for these new therapies, either due to severe co-morbidities or altered anatomy. The Resection and Plication (RAP) procedure is a novel endoscopic option for the treatment of medication refractory GERD. The RAP procedure can uniquely be empolyed in patietns unable to undergo surgical or alternate endoscopic anti-reflux therapies due to gastroesophageal junction (GEJ) anatomy that has been altered, for example in patients with prior nissen fundoplication, roux-en-Y gastric bypass, sleeve gastrectomy, or esophagectomy. The RAP procedure involves band endoscopic mucosal resection (EMR) semi-circumferential mucosectomy at the GEJ followed by full-thickness plication (RAP). Endoscopic suturing creats a gastro-gastric plication which serves to tighten the GEJ and decrease the rate of reflux into the esophagus. The following video demonstrates the RAP procedure in 2 patients with altered anatomy. Case 1, 66-year-old female with GERD previously treated with Nissen Fundoplication 10 years ago presents with refractory GERD symptoms. Case 2, 44-year-old female with history of morbid obesity treated with roux-en-Y gastric bypass with initial weight loss, now with significant weight gain and morbid obesity who is presenting with persistent GERD symptoms. 26 patients have undergone the RAP procedure at our institution. The average procedure time is 31 minutes. Ninety percent of were discharged the same day without major complications. Eighteen patients had altered anatomy (5 Fundoplication, 4 Gastric Bypass, 4 Esophagectomy, 2 failed TIF, 2 Endoscopic Sleeve Gastroplasty, 1 Sleeve Gastrectomy). We observed dramatic improvements in Reflux Disease Questionnaire (RDQ) and GERD Health Related Quality of Life (HRQL) questionnaires (RDQ Frequency 80%, RDQ Severity 76%, GERD-HRQL 85%). Sixty percent of patients were able to stop or decrease PPI use at follow-up. The average follow-up period was 6 months. The Resection and Plication (RAP) procedure is a novel endoscopic endoscopic anti-reflux procedure which results in gastro-gastric plications just below the level of the GEJ, thereby reducing the rate of reflux of gastric contents into the esophagus. This provides an effective endoscopic option in patients who otherwise cannot get other surgical or endoscopic therapies, specifically due to prior surgeries. This is a same day procedure and is overall safe, well tolerated and patients report a high degree of satisfaction following therapy.