Suture Location Impacts Clinical Outcome for Endoscopic Treatment of Gastroesophageal Reflux Disease

Abstract

Purpose: Endoscopic treatments for gastroesophageal reflux disease (GERD) have variable long-term success rates, however the reason for such variability in response rates is unclear. The aim of this study was to determine the effects of location and number of sutures on clinical outcome in patients undergoing endoscopic treatment for GERD. Methods: Patients with persistent GERD symptoms despite medical therapy and undergoing endoscopic anti-reflux treatment with more than one year follow up were included. Endoscopic suturing of the gastroesophageal junction (GEJ) was done using commercially available endoscopic suturing devices. Sutures were placed within 2 cm distal to the squamo-columnar junction in a circumferential fashion. The number of sutures was recorded and the locations of the sutures were documented according to the face clock position at the GEJ. Greater curve sutures were at the 6 o'clock position and lesser curve sutures were at the 12 o'clock position. Complete symptom resolution was defined as absence of heartburn and regurgitation symptoms at the longest available follow up. The association between number of sutures, suture location (combination of lesser and greater curve, or lesser curvature or greater curvature) and symptom resolution was examined using Fisher's exact test. Results: Forty-two patients (26F/16M) with a mean follow up of 20 months were included in the analysis. Thirteen patients (31%) achieved complete symptom resolution. Sixteen patients had placement of three sutures, 24 patients had placement of two sutures, and 2 patients had placement of one suture. The number of sutures did not correlate with clinical outcome. Patients with a combination of greater and lesser curve sutures achieved the best clinical outcome (p = 0.014) during follow up. Conclusions: A combination of greater and lesser curve sutures at the gastroesophageal junction was associated with the best long-term clinical outcome of endoscopic treatment for gastroesophageal reflux disease. Future larger studies will be needed to confirm this finding and to determine the optimal suture placement configuration.