This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations Assessment, Development, and Evaluation framework and serves as an update to the 2014 ASGE guideline on the role of endoscopy in the management of GERD. This updated guideline addresses the indications for endoscopy in patients with GERD as well as in the emerging population of patients who develop GERD after sleeve gastrectomy or peroral endoscopic myotomy. It also discusses how to endoscopically evaluate gastroesophageal junctional integrity in a comprehensive and uniform manner. Importantly, this guideline also discusses management strategies for GERD including the role of lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy (including transoral incisionless fundoplication [TIF], radiofrequency energy, and combined hiatal hernia repair and TIF [cTIF]) in the management of GERD. The ASGE suggests upper endoscopy for the evaluation of GERD in patients with alarm symptoms, with multiple risk factors for Barrett's esophagus, and with a history of sleeve gastrectomy. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings with attention to gastroesophageal junction landmarks and integrity in patients who undergo upper endoscopy to improve care. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration possible while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernias (≤2 cm) and Hill grade I or II who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to chronic medical management. In patients with persistent GERD with large hiatal hernias (> 2cm) and Hill grade III or IV, the ASGE suggests either cTIF or surgical therapy based on multidisciplinary review. This document summarizes the methods, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and serves as an update to the prior ASGE guideline on the role of endoscopy in the management of GERD (2014). The updated guideline addresses the indications for endoscopy in patients with GERD, including patients who have undergone sleeve gastrectomy (SG) and peroral endoscopic myotomy (POEM). It also discusses endoscopic evaluation of gastroesophageal junctional integrity comprehensively and uniformly. Important, this guideline discusses management strategies for GERD including lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy including transoral incisionless fundoplication (TIF), radiofrequency energy, and TIF combined with hiatal hernia repair (cTIF). The ASGE recommends upper endoscopy for the evaluation of GERD in patients with alarm symptoms. The ASGE suggests upper endoscopy for symptomatic patients with a history of SG and POEM. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings and gastroesophageal junction landmarks and integrity to improve patient care and outcomes. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernia (≤2 cm) and Hill grade I or II flap valve who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to long-term medical management. In patients with confirmed GERD with a large hiatal hernia (>2 cm) and Hill grade 3 or 4 flap valve, the ASGE suggests evaluation for combined endoscopic-surgical TIF (cTIF) in a multidisciplinary review. This document clearly outlines the methodology, analysis, and decision used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Endoscopic antireflux therapy is widely used in clinical practice. Peroral endoscopic cardial constriction (PECC), antireflux mucosal intervention (ARMI), and radiofrequency ablation (RF) possess analogous antireflux mechanisms. This comprehensive systematic review and meta-analysis aimed to evaluate and compare the safety and effectiveness of antireflux therapy during endoscopic cardia peripheral tissue scar formation (ECSF) procedures. We comprehensively searched the Web of Science, PubMed, Embase, China National Knowledge Infrastructure, and Wan-Fang databases for articles published from January 1990 to January 2024. Network meta-analysis (NMA) was used to assess the outcomes, with outcome metrics including the Gastroesophageal Reflux Questionnaire (GERD-Q) score, proton pump inhibitor discontinuation rate, pH <4.2 percent acid reflux time (AET), lower esophageal pressure (LES pressure), DeMeester score, adverse events, and patient satisfaction. Twenty studies involving 1219 patients were included. PECC was significantly superior to RF in lowering the patients' postoperative GERD-Q scores(MD = -2.34, 95% confidence interval (CI): [-3.02, -1.66]), augmentation of LES pressures(MD = 3.22, 95% CI: [1.21, 5.23]), and having a lower incidence of serious adverse events. ARMI was preferable to PECC (MD = -2.87, 95% CI [-4.23, -1.51])and RF (MD = -1.12, 95% CI [-1.79, -0.54]) in reducing the AET percentage, but was not as effective as PECC in lowering GERD-Q scores(MD = -1.50, 95% CI [-2.47, -0.53]). The incidence of adverse effects was less than 10% for all interventions, with most of them mildly self-resolving. Each ECSF procedure resulted in a favorable outcome in patients with GERD. Considering the safety and efficacy of treatment, PECC was the most favorable choice among ECSF procedures.

Correcting a gut sphincter malfunction is a difficult problem. Because each sphincter has two opposite functions, that of closure and opening, repairing one there is a risk of damaging the other. Indeed, widening a narrow sphincter, such as lower esophageal sphincter (LES) and anal sphincter, may cause gastroesophageal reflux and fecal incontinence, respectively, whereas narrowing a wide sphincter, may cause a difficult transit. All the corrective treatments for difficult or retrograde transit concerning LES and anal sphincter with their unwanted consequences have been analyzed and discussed. To overcome the drawbacks of sphincter surgical repairs, researchers have devised devices capable of closing and opening the gut lumen, named artificial sphincters (ASs). Their function is based on various mechanisms, e.g., hydraulic, magnetic, mechanical etc, operating through many complicated components, such as plastic cuffs, balloons, micropumps, micromotors, connecting tubes and wires, electromechanical clamps, rechargeable batteries, magnetic devices, elastic bands, etc. Unfortunately, these structures may facilitate the onset of infections and induce a local fibrotic reaction, which may cause device malfunctioning, whereas the compression of the gut wall to occlude the lumen may give rise to ischemia with erosions and other lesions. Some ASs are already being used in clinical practice, despite their considerable limits, while others are still at the research stage. In view of the adverse events of the ASs mentioned above, we considered applying bioengineering methods to analyze and resolve biomechanical and biological interaction problems with the aim to conceive and build efficient and safe biomimetic ASs.

Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.

There are no direct comparisons across different endoscopic therapies for gastroesophageal reflux disease (GERD). This study aimed to evaluate the relative effects of different endoscopic therapies in GERD.

Five databases were searched until August 2023 for randomized controlled trials (RCTs) that compared the efficacy of endoscopic band ligation (EBL), Stretta, endoscopic fundoplication (transoral incisionless fundoplication [TIF], endoscopic full-thickness plication [EFTP], and EndoCinch plication procedure [EndoCinch, CR BARD, Billerica, Mass., USA]), or proton pump inhibitors (PPIs)/sham procedure for GERD. Bayesian network meta-analysis was performed.

A total of 19 trials comprising 1181 patients were included. EBL (mean difference [MD], -7.75; 95% credible interval [CrI], -13.90 to -1.44), Stretta (MD, -9.86; 95% CrI, -19.05 to -0.58), and TIF (MD, -12.58; 95% CrI, -20.23 to -4.91) all significantly improved patients' health-related quality of life score with equivalent efficacy compared with PPIs. TIF and EBL achieved equivalent efficacy in reducing PPIs utility (risk ratio [RR], 0.66; 95% CrI, 0.40-1.05) and both were significantly superior to other endoscopic interventions (Stretta, EFTP, and EndoCinch). Besides, EBL and TIF also could significantly decrease the esophagitis incidence compared with PPIs (EBL [RR, 0.34; 95% CrI, 0.22-0.48] and TIF [RR, 0.38; 95% CrI, 0.15-0.88]). In terms of lower esophageal sphincter (LES) pressure, only TIF could significantly increase the LES pressure (MD, 6.53; 95% CrI, 3.65-9.40) to PPIs. In contrast, TIF was inferior to PPIs in decreasing esophageal acid exposure (MD, 2.57; 95% CrI, 0.77-4.36).

Combining the evidence, EBL and TIF may have comparable efficacy and both might be superior to Stretta, EFTP, or EndoCinch in GERD treatment.

Endoscopic treatment is increasingly used for refractory gastroesophageal reflux disease (rGERD). Unlike the mechanism of conventional surgical fundoplication, gastroesophageal junction ligation, anti-reflux mucosal intervention, and radiofrequency ablation have extremely similar anti-reflux mechanisms; hence, we collectively refer to them as endoscopic cardia peripheral tissue scar formation (ECSF). We conducted a systematic review and meta-analysis to assess the safety and efficacy of ECSF in treating rGERD.

We performed a comprehensive search of several databases, including PubMed, Embase, Medline, China Knowledge Network, and Wanfang, to ensure a systematic approach for data collection between January 2011 and July 2023. Forest plots were used to summarize and combine the GERD-health-related quality of life (HRQL), gastroesophageal reflux questionnaire score, and DeMeester scores, acid exposure time, lower esophageal sphincter pressure, esophagitis, proton pump inhibitors use, and patient satisfaction.

This study comprised 37 studies, including 1732 patients. After ECSF, significant improvement in gastroesophageal reflux disease health-related quality of life score (mean difference [MD] = 18.27 95% CI: 14.81-21.74), gastroesophageal reflux questionnaire score (MD = 4.85 95% CI: 3.96-5.75), DeMeester score (MD = 42.34, 95% CI: 31.37-53.30), acid exposure time (MD = 7.98, 95% CI: 6.03-9.92), and lower esophageal sphincter pressure was observed (MD = -5.01, 95% CI: -8.39 to 1.62). The incidence of serious adverse effects after ECSF was 1.1% (95% CI: 0.9%-1.2%), and postoperatively, 67.4% (95% CI: 66.4%-68.2%) of patients could discontinue proton pump inhibitor-like drugs, and the treatment outcome was observed to be satisfactory in over 80% of the patients. Subgroup analyses of the various procedures showed that all 3 types improved several objective or subjective patient indicators.

Based on the current meta-analysis, we conclude that rGERD can be safely and effectively treated with ECSF as an endoscopic procedure.

In general, gastroesophageal reflux disease (GERD) is diagnosed clinically based on typical symptoms and/or response to proton pump inhibitor treatment. Upper gastrointestinal endoscopy is reserved for patients presenting with alarm symptoms, such as dysphagia, odynophagia, significant weight loss, gastrointestinal bleeding, or anorexia; those who meet the criteria for Barrett's esophagus screening; those who report a lack or partial response to proton pump inhibitor treatment; and those with prior endoscopic or surgical anti-reflux interventions. Newer endoscopic techniques are primarily used to increase diagnostic yield and provide an alternative to medical or surgical treatment for GERD. The available endoscopic modalities for the diagnosis of GERD include conventional endoscopy with white-light imaging, high-resolution and high-magnification endoscopy, chromoendoscopy, image-enhanced endoscopy (narrow-band imaging, I- SCAN, flexible spectral imaging color enhancement, blue laser imaging, and linked color imaging), and confocal laser endomicroscopy. Endoscopic techniques for treating GERD include esophageal radiofrequency energy delivery/Stretta procedure, transoral incisionless fundoplication, and endoscopic full-thickness plication. Other novel techniques include anti-reflux mucosectomy, peroral endoscopic cardiac constriction, endoscopic submucosal dissection, and endoscopic band ligation. Currently, many of the new endoscopic techniques are not widely available, and their use is limited to centers of excellence.

The 3rd edition of the evidence-based clinical practice guidelines for gastroesophageal reflux disease (GERD) 2021 from the Japanese Society of Gastroenterology states that the treatment strategy for potassium-competitive acid blocker (PCAB)-refractory GERD remains unclear. Furthermore, even if GERD improves with the administration of an acid secretion inhibitor, it is feared that GERD may flare up after discontinuation of the drug, resulting in some cases in which patients are forced to take vonoprazan semipermanently (the so-called PCAB-dependent cases). From a global perspective, PCAB is not yet used in all countries and regions, and measures that can be taken now for cases in which a conventional proton pump inhibitor (PPI) is inadequately effective need to be devised.

Endoscopic treatment for GERD may be effective in cases where conventional proton pump inhibitors are ineffective; however, there are insufficient long-term studies to corroborate this, and its cost effectiveness is unknown. Other treatment options for PCAB or PPI-refractory GERD include surgical procedures (Nissen and Toupet operations), which have a longer history than endoscopic treatment for GERD. However, their long-term results are not as good as those of acid secretion inhibitors, and they are not cost effective. Endoscopic treatment for GERD may fill gaps in inadequate surgical treatment. In April 2022, endoscopic anti-reflux mucosal resections (ARMS [anti-reflux mucosectomy] and ESD-G [endoscopic submucosal dissection for GERD]) were approved for reimbursement, making endoscopic treatment of GERD possible throughout Japan.

It is important to identify the background factors in cases in which endoscopic treatments are effective.

The last decade has seen the rise of multiple novel endoscopic techniques to treat gastroesophageal reflux disease, many of which are efficacious when compared with traditional surgical options and allow relief from long-term dependence on antacid medications. This review will explore the latest endoscopic treatment options for gastroesophageal reflux disease including a description of the technique, review of efficacy and safety, and future directions.

To explore the effect of endoscopy in the treatment of gastric mucosal microtumors.

A total of 229 patients with gastric mucosal microtumors were treated in our hospital from January 2016 to December 2021. All patients were divided into three groups group A, group B, and group C. Group A was treated with a transparent cap combined with circle-assisted endoscopic resection, group B with ligator combined with circle-assisted endoscopic resection, and group C with endoscopic mucosal tumor resection. The effects of the three groups were observed.

There were 47 patients in group A, 17 males, and 30 females, aged 36-69 years, with an average age of 55.6 ± 9.2 years. There were 54 patients in group B, 18 males, and 36 females, aged 38-72 years, with an average age of 57.6 ± 7.7 years. There were 128 patients in group C, 29 males, and 99 females, aged 33-78 years, with an average age of 55.6 ± 8.4 years. There is no significant difference in age and sex between group A, group B, and group C (P > 0.05). The incidence of postoperative complications in group B (66.7%) was significantly higher than that in group A (57.4%) and group C (53.9%) (all P < 0.05). The incidence of postoperative complications in group A (57.4%) was higher than that in group C (53.9%), and the difference was statistically significant (P < 0.05).

Endoscopic mucosal resection and ligation combined with circle-assisted endoscopic resection are effective and safe in the treatment of gastric mucosal microtumors, but it needs to be combined with targeted nursing measures. The transparent cap combined with ring-assisted endoscopic resection has a significant effect on the treatment of gastric mucosal micromasses, reducing operative complications.

Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti-reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy and anti-reflux mucosal ablation have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.

Endoscopic treatments are increasingly being offered for refractory gastroesophageal reflux disease (GERD). Three procedures have similar concepts and techniques: antireflux mucosectomy (ARMS), antireflux mucosal ablation (ARMA), and antireflux band ligation (ARBL); we have collectively termed them antireflux mucosal intervention (ARMI). Here, we systematically reviewed the clinical outcomes and technical aspects.

The PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. The primary outcome was the clinical success rate. The secondary outcomes were acid exposure time, DeMeester score, need for proton pump inhibitors (PPIs), endoscopic findings, and adverse events.

Fifteen studies were included. The pooled clinical success rate was 73.8% (95% confidence interval (CI) = 69%-78%) overall, 68.6% (95% CI = 62.2%-74.4%) with ARMS, 86.7% (95% CI = 78.7%-91.9%) with ARMA, and 76.5% (95% CI = 65%-85.1%) with ARBL. ARMI resulted in significantly improved acid exposure time, DeMeester score, and degree of hiatal hernia. Furthermore, 10% of patients had dysphagia requiring endoscopic dilatation after ARMS or ARMA, and ARMS was associated with a 2.2% perforation rate. By contrast, no bleeding, perforation, or severe dysphagia was noted with ARBL. Severe hiatal hernia (Hill grade III) may predict treatment failure with ARMA.

The three ARMI procedures were efficacious and safe for PPI-refractory GERD. ARMA and ARBL may be preferred over ARMS because of fewer adverse events and similar efficacy. Further studies are necessary to determine the optimal technique and patient selection.

Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide. A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects. Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication. The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia. Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials. Band-assisted ligation techniques, anti-reflux mucosectomy, anti-reflux mucosal ablation, and new plication devices have yielded promising results in recent noncontrolled studies. Nonetheless, the role of endoscopic procedures remains controversial due to limited long-term and comparative data, and no consensus exists in current clinical guidelines. This review provides an updated summary focused on the patient selection, technical details, clinical success, and safety of current and future endoscopic anti-reflux techniques.

Gastroesophageal reflux disease (GERD) is one of the most common chronic conditions affecting adults. A substantial proportion of patients continue to have symptoms despite medical therapy, and there has been increased demand for minimally invasive GERD therapy. We will examine currently available techniques and outcomes data on endoscopic approaches to the treatment of GERD.

In the last 2 years, research has given rise to more robust understanding of not only the pathophysiology of GERD but also how to better manage the various phenotypes. We are learning the ideal patient to benefit from endoscopic GERD therapy. In this review, we describe the four major endoluminal techniques for treating GERD and summarize current data.

Endoscopic therapies are well positioned to fill the 'therapy gap' between medical therapy and more invasive surgical procedures.

New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia.

Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT.

One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021).

ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Despite the many areas of unmet needs in gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) remain the cornerstone of medical therapy. However, since their introduction, the therapeutic limitations of PPIs in GERD management have been increasingly recognized.

In this review we discuss the new medical, endoscopic, and surgical therapeutic modalities that have been developed over the last decade. They include the potassium-competitive acid blockers (P-CABs) which provide a rapid onset, prolonged, and profound acid suppression, mucosal protectants which promote the physiological protective barrier of the esophageal mucosa, new prokinetics and neuromodulators. There are growing numbers of novel therapeutic endoscopic techniques that are under investigation or were recently introduced into the market, further expanding our therapeutic armamentarium for GERD. The development of diverse therapeutic modalities for GERD, despite the availability of PPIs, suggests that there are many areas of unmet need in GERD that will continue and drive future exploration for novel therapies.