Endoscopic fundoplication ‘should be considered’ for medication refractory GERD
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CHARLOTTE, N.C. — Endoscopic fundoplication demonstrated comparable efficacy to its surgical counterpart in the treatment of patients with medication refractory GERD, according to a presentation at the ACG Annual Scientific Meeting.
“Endoscopic procedures for medication refractory GERD have been available for a couple of decades now, but there have not been any studies comparing them to the surgical procedures,” Ravi Teja Pasam, MBBS, MPH, of Lahey Hospital & Medical Center in Burlington, Massachusetts, told Healio. “This prompted us to perform this network meta-analysis, which would indirectly provide some answers.”
Pasam and colleagues included 31 randomized controlled trials with 4,371 patients in their analysis. Lower esophageal sphincter pressure (LESP), esophagitis, cessation of use of proton pump inhibitors and percentage of time with a pH less than 4 on a 24-hour esophageal pH monitoring at follow-up of 1 year or less were identified as outcomes of interest.
Compared with PPI, endoscopic fundoplication (EF) and surgical fundoplication (SF) were associated with significantly higher LESP. Further, researchers found no significant difference between EF and Nissen fundoplication (mean difference [MD] = 0.23; 95% CI, –7.01 to 7.48), anterior fundoplication (MD = 1.76; 95% CI, –5.75 to 9.16) or Toupet fundoplication (MD = 2.4; 95% CI, –4.94 to 9.75). Radiofrequency energy delivered via the Stretta (Mederi Therapeutics) endoscopic procedure was inferior to Nissen (MD = –9; 95% CI, –14.55 to –3.45), Toupet (MD = –6.83; 95% CI, –12.5 to –1.55) and anterior (MD = –7.5; 95% CI, –13.35 to –1.71) fundoplications.
Researchers also reported EF was significantly better than Nissen fundoplication in regard to the percentage of time with a pH less than 4 (MD = 4.72; 95% CI, 0.71-8.73). There was not, however, a significant difference between EF and Toupet fundoplication (MD = 3.62; 95% CI, –1.9 to 9.14) or anterior fundoplication (MD = –0.16; 95% CI, –6.29 to 5.96) regarding this metric. None of the procedures were deemed significantly different from the PPI group.
Further, PPI usage cessation was significantly higher for endoscopic procedures and the laparoscopic magnetic sphincter augmentation LINX (Ethicon) procedure compared with the PPI group, although when compared with one another, none of these procedures had significant differences.
“We found that the outcomes with endoscopic fundoplication were comparable to the surgical fundoplication procedures in terms of GERD-health related quality of life score, esophagitis, PPI usage and lower esophageal sphincter pressure at a follow-up period of 1 year or less,” Pasam said. “On the other hand, radiofrequency energy delivery was found to be inferior to all types of surgical fundoplications in terms of lower esophageal sphincter pressure.”
Future studies considering clinical outcomes, cost-effectiveness and length of hospital stay when comparing EF with SF will help determine when EF should be used, he added.
“Endoscopic fundoplication should be considered in patients who have medication refractory GERD and either do not want to undergo a surgical procedure or are not a good surgical candidate,” Pasam said.
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Pasam RT, et al. Abstract S1069: Endoscopic vs Surgical Procedures for Gastroesophageal Reflux Disease. Presented at: ACG Annual Scientific Meeting; Oct. 21-26, 2022; Charlotte, N.C. (hybrid meeting).
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