Interventional procedure overview of endoluminal gastroplication for gastro-oesophageal reflux disease

Indications and current treatment

Gastro-oesophageal reflux disease (GORD) is a common condition caused by failure of the sphincter mechanism at the lower end of the oesophagus. Symptoms of GORD can be broadly grouped into those directly related to reflux episodes, such as heartburn, regurgitation and chest pain and nausea, and those symptoms caused by complications of reflux disease, including problems swallowing (dysphagia) and respiratory symptoms. Repeat episodes of GORD can damage the lining of the oesophagus and lead to oesophageal ulceration, oesophageal stricture, and Barrett's oesophagus.

NICE's clinical guideline on the investigation and management of gastro-oesophageal reflux disease and dyspepsia in adults makes recommendations for treatment The standard treatments for symptomatic GORD are lifestyle modification and drug therapy. Drug therapy includes acid-lowering agents such as H₂ receptor antagonists and proton pump inhibitors (PPIs). People with reflux symptoms that do not respond to medical treatment or develop intolerance to medication may have anti-reflux surgery. Surgical or laparoscopic fundoplication surgery may be used, and minimally invasive treatments such as endoscopic radiofrequency ablation or endoscopic injection of bulking agents are available.

What the procedure involves

Different devices have been used for this procedure and exact details of the technique vary. The procedure is usually done with the patient under general anaesthesia. An endoscopic fastening device is inserted through the mouth and into the stomach, along with an endoscope for constant visualisation. The device is used to attach the fundus to the anterior and left lateral wall of the distal oesophagus slightly above the oesophagogastric junction. With 1 of the devices, polypropylene fasteners are delivered through apposed layers of oesophageal and fundus tissue to anchor the repair. About 20 fasteners are implanted during the procedure to create a full thickness, partial circumference, gastro-oesophageal fundoplication. The aim is to recreate a valve and form a barrier to reflux.

Endoluminal gastroplication for gastro-oesophageal reflux disease aims to reduce the morbidity associated with open or laparoscopic fundoplication.

Outcome measures

The Gastro-oesophageal Reflux Disease-Health Related Quality of Life (GORD-HRQL) is used to measure patient symptoms and impacts on daily life. Questions are scored 0 to 5 with higher scores indicating greater severity. Overall scores are obtained by summing the scores for each individual question; scores range from 0 to 50 or 0 to 75 depending on whether questions related to regurgitation are included.

The Gastro-oesophageal Reflux Symptom Score (GERSS) is used to assess the severity (scored 0 to 3 with 3 being the most severe) and frequency (scored 0 to 4 with 4 being daily) of heartburn, regurgitation, abdominal distension, dysphagia, and cough. To calculate total symptom scores, severity and frequency are multiplied for each symptom and are then summed, with overall scores ranging from 0 to 60.

The Reflux Symptom Index (RSI) is used to assess the severity of reflux and consists of 9 items each scored 0 to 5 (with 5 being the most severe).

The Reflux Disease Questionnaire (RDQ) is a 12-item self-reported questionnaire used to measuring the frequency and severity of upper gastrointestinal symptoms (heartburn, regurgitation, and epigastric pain) over a week; scores range from 0 to 5 for each item (with 5 being the most severe).

The DeMeester score is a 6-point global measure of acid exposure (defined as an oesophageal pH drop below 4) and ranges from 0 to 100, with a DeMeester score of greater than 14.72 indicating reflux.