Endoscopic therapy for gastroesophageal reflux disease

Abstract

Therapeutic gastrointestinal endoscopy has thrived in areas previously claimed by more invasive surgical procedures. Colonoscopic polypectomy, endoscopic retrograde cholangio-pancreatography with sphincterotomy, and endoscopic therapy for upper gastrointestinal bleeding from peptic ulcer are prime examples. Now we are witnessing a major endoscopic offensive into an arena contested not only by surgery but also by medical pharmacological therapy—gastroesophageal reflux disease (GERD). The stakes are high. Millions of Americans have symptomatic GERD. The market for pharmacological agents both over the counter and by prescription can be calculated in billions of dollars. The success of the proton pump inhibitor class of medications for GERD is one of the great pharmaceutical achievements of the current era, with an outstanding record of efficacy and safety. In a minority of patients in whom proton pump inhibitor therapy is not successful and the cost of drug therapy becomes an economic burden, surgical therapy is an alternative. Laparoscopic fundoplication (with technical variations) has emerged as the clear winner in terms of the surgical management of GERD. There are certainly problems in a small number of patients who are left with uncomfortable postoperative symptoms. Furthermore, there are accumulating data indicating that as years go by, a majority of patients who have surgery resume taking antacid medications. Can endoscopic therapy become another option for GERD patients to medical or surgical therapy? There are at least three types of approaches to endoscopic