Targeted Endoscopic Therapies for Gastro-Esophageal Reflux Disease (GERD): A Narrative Review

Transoral endoscopic therapies in gastro-esophageal reflux disease (GERD) are increasingly performed in patients who do not respond to medical therapy or are not suitable for or willing to undergo long-term PPI therapy or surgery. Currently available effective techniques include reconstruction of the gastro-esophageal valve by transoral incisionless fundoplication (TIF) and tightening of the gastro-esophageal junction through scarring, obtained by mucosal resection or ablation. TIF may be accomplished by an EsophyX 2.0/Z, MUSE, or GERD-X device. An iatrogenic stricture of the cardia may be obtained using a procedure called anti-reflux mucosectomy (ARMS), which includes several technical variants, or through mucosal ablation (ARMA). TIF using EsophyX 2.0 has strong evidence of efficacy in patients with small hiatal hernias, irrespective of hernia reducibility, who experience high-volume reflux episodes and troublesome regurgitation despite PPI therapy. MUSE can be performed only in the presence of a spontaneously reducing hiatal hernia and is probably more effective than EsophyX in maintaining the reduced hernia over time. However, MUSE is no longer available in Western countries. GERD-X shows promising results but needs further confirmation of its efficacy over the long term. ARMS and ARMA are not indicated in the presence of hiatal hernias but have shown promising results in the short term and are less expensive than TIF. Appropriate patient selection and the possibility of proposing a tailored approach to different types of patients and clinical/anatomical conditions result in favorable outcomes in most GERD patients, especially considering their quality of life and independence from PPIs. In the last several years, transoral endoscopic therapies have been proposed, along with concomitant laparoscopic repair for large hiatal hernias (cTIF), for GERD occurring after esophageal peroral endoscopic myotomy (E-POEM), in obese patients before or after bariatric surgery, and in patients with Barrett's esophagus.