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15© Shanghai Scientic and Technical Publishers 2026
L. Li et al. (eds.), Endoscopic Therapy for Gastroesophageal Reux Disease,
https://doi.org/10.1007/978-981-95-5389-1_2
Chapter 2
Endoscopic Fundoplication
forGastroesophageal Reux Disease
FengDu
2.1 Background
Proton pump inhibitors (PPIs) are currently the main drugs for treating gastro-
esophageal reux disease (GERD). Due to the limitation of its therapeutic
effect, 17%–32% of patients still have reux symptoms after taking PPIs, some
patients need long-term or even life-long medication, and about 75%–90% of
patients show reux symptoms after withdrawing [1]. Although laparoscopic
fundoplication can relieve recurrent reux symptoms, less than 5% of patients
have received laparoscopic fundoplication due to the massive surgical trauma
and higher surgical indications compared with endoscopy [2]. As a result, about
25%–30% of GERD patients have poor curative effects after taking drugs or
cannot tolerate long-term medication but are unwilling to carry out surgical
treatment. The emergence of gastroesophageal reux endoscopic treatment
technology is lling this gap [3–5].
The concept and method of endoscopic gastroesophageal reux suture
were rst proposed by Swain and Mills in 1986. Then animal experiments pre-
liminarily conrmed the feasibility of endoscopic suture around the gastric car-
dia. Early studies have shown that the treatment increases the length of the
lower esophageal sphincter, but the length and pressure increase of the
F. Du (*)
Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University,
Beijing, China
State Key Laboratory of Digestive Health, Beijing, China
National Clinical Research Center for Digestive Diseases, Beijing, China
16
intra-abdominal segment depends on the method of the suture. In 2001, the rst
clinical case of endoscopic suture for GERD was reported [6, 7]. At present,
there are mainly two kinds of endoscopic suture device components available:
one is Endo Clinch of Bard company, the other is Sew-Right of Wilson Cook
company. Endo Clinch is the only device approved by the FDA for GERD treat-
ment. Endoscopic fundoplication for gastroesophageal reux can be divided
into endoscopic suturing, transoral endoscopic fundoplication (TIF), and endo-
scopic fundoplication (Muse) [2, 5, 8–12]. This chapter focuses on the technol-
ogy, efcacy, and application of gastroesophageal reux endoscopic therapy.
2.2 Method ofEndoscopic Gastric Fundus Suture
Endoscopic fundus suture
2.2.1 Endoscopic Suturing/Transoral Endoluminal
Gasrtroplication (ELGP)
2.2.1.1 Concepts
In 1994, gastroesophageal reux was applied to the human body by gastroscope
suture. After decades of observation and instrument improvement, it was gradually
applied in clinical practice. The endoscopic suture is also known as transoral endo-
scopic gastroplasty (ELGP) or endoscopic gastroplasty, but there is no unied name
[5]. In this method, the suturing device of the Bard company was installed in front
of the end of the gastroscope. Under direct vision, the gastric wall tissue was sutured
around the dentate line to form wrinkles to increase mucosa’s tension around the
cardia and extend the length of the intra-abdominal esophagus, and form folds to
block the reux of gastric contents [9, 11, 13].
2.2.1.2 Indications andContraindications
Indications:
① Abnormal gastric acid reux conrmed by 24h pH monitoring of esophagus.
② The diameter of hiatal hernia was less than 4mm.
③ Obvious gastroesophageal reux symptoms for 3weeks or more.
④ Long-term dependence on antacids.
F. D u
17
Contraindications:
① Patients with coagulation dysfunction, severe cardiopulmonary dysfunction,
obesity, and other systemic diseases.
② Patients with severe esophagitis, esophageal varices, esophageal sclerosis, and
other esophageal diseases or surgical history.
③ Patients with mental disorders, pregnant women, and those under 18years old.
④ Patients with upper gastrointestinal endoscopy contraindication.
2.2.1.3 Surgical Procedure
There are two kinds of gastroesophageal reux endoscopic suture: longitudinal
suture along the small curvature side and circular suture around the cardia. The
longitudinal suture can be selected for esophageal ssure less than 2cm, and circu-
lar suture or combination of two methods can be used for more than 2.5cm. The
distance between needles is about 1.5–2cm, and the distance between the twofolds
is about 1.5cm. The average operation time was about 40–60min. After the opera-
tion, the patients could get a liquid diet 4h after the operation. There was no activity
restriction, and the patients could be discharged in 2days on average. The greatest
advantage of this technique is its ultra-minimally invasive nature: it requires no
external incisions, with suturing performed transorally via the esophagus.
Additionally, intraoperative repair, real-time observation of procedural outcomes,
and suture removal can all be accomplished under endoscopic guidance. It is cur-
rently recognized as the least invasive, most convenient, and safest surgical option
for the treatment of GERD (Fig.2.1).
2.2.1.4 Clinical Application andEfcacy
A double-blind, single center randomized controlled trial was conducted to explore
the therapeutic effect of gastroscopic fundus folding suture in 60 patients with reux
esophagitis. The patients were divided into an observation group, simulation group,
and treatment group. The proportion of drug use reduced by more than 50% after
3 months of treatment was 0%, 25%, and 50%, respectively, in the observation
group, the simulation group, and the treatment group [14]. Compared with the simu-
lation group, the treatment group had a signicant effect on improving the quality
of life and relieving heartburn symptoms. However, there was no signicant differ-
ence between the treatment group and the simulation group in improving esopha-
geal acid exposure. The effective period of treatment lasted from 6 to 12months.
During this period, 29% of the patients received the second treatment. The nal
2 Endoscopic Fundoplication forGastroesophageal Reux Disease
18
a b
cd
ef
Fig. 2.1 Schematic diagram of endoscopic suture
results showed that gastroesophageal reux endoscopic suture treatment for
3months can signicantly improve reux symptoms, reduce the use of acid sup-
pressants, signicantly improve the quality of life, and the treatment effect can be
maintained for 12months. However, the esophagus acid exposure was not signi-
cantly improved, and it was easy to cause complications such as hypoxemia, bleed-
ing, and perforation. A few patients may have abdominal pain, chest pain, and
throat pain.
2.2.2 Transoral Incisionless Fundoplication (TIF)
2.2.2.1 Concept
TIF is an oral fundoplication in the gastric cavity without thoracotomy. The length
of the hiatal hernia can be reduced by reconstructing His angle to remodel the gas-
troesophageal valve. The main surgical instrument is EsophyX equipment [15–17].
F. D u
19
The device comprises a control handle, a tubular reset device, a reverse folding
mold casting device, a spiral traction needle, and a puncture needle located in the
reset device’s side hole. In 2007, the FDA approved the EsophyX device for the
treatment of gastroesophageal reux by endoscopic TIF.
2.2.2.2 Indications andContraindications
Indications:
① Patients with GERD who have an inadequate response to medical therapy or
experience relapse after drug withdrawal, present with symptoms of acid reux
and heartburn lasting for more than 2 months and occurring ≥3–5 times per week,
and are diagnosed with Los Angeles classication Grade A or B reux esophagitis.
② Patients with asthma or chronic pharyngitis in remission stage, hiatal hernia
larger than 2.0cm in diameter, partial lower esophageal stenosis, and gastro-
esophageal reux disease after partial esophagectomy.
Contraindications:
① Symptoms include nasal obstruction, cold, and tracheal stenosis that reduce the
intraoperative respiratory ventilation.
② Patients whose neck is too short, the tongue is too large, or the oropharyngeal
deformity cannot be placed cannula.
③ Patients with hiatal hernias are very large and cannot be reduced.
2.2.2.3 Surgical Procedure
The patient was left lying position according to the standard endoscopy position and
received general anesthesia. The specic steps are as follows:
① First, a routine gastroscopy was performed to observe the existence of esopha-
geal hiatal hernia and the size of the hernia sac from the perspective of ipping
the mirror body.
② The gastroscope was inserted into the stomach via the endoscopic port of the
EsophyX device; the device was fully lubricated before being passed transorally
through the pharynx into the stomach under direct visualization.
③ The body of the mirror was turned over, and the casting device of the anterior
segment was reversed. The gastroesophageal junction was xed with a screw
traction needle under the endoscope. The gastric wall tissue was retracted and
positioned between the repositioner and the mold, allowing reconstruction of the
angle of His and the gastroesophageal valve ap.
④ Tighten the casting device to make the lower segment of the esophagus close to
the gastric fundus. Operate the knob to make the puncture needle and reinforcing
device penetrate through the side hole of the reset device, penetrate the esopha-
geal and gastric wall close to the mold, and release the H-shaped reinforcing
device to form the folding above the EGJ.
2 Endoscopic Fundoplication forGastroesophageal Reux Disease
20
Fig. 2.2 Schematic diagram of TIF operation
⑤ Continue to rotate EsophyX device and mirror body, respectively, puncture and
suture at different angles, and nally form 200–270° fundus fold. At the end of
the procedure, the endoscopic observation was performed to ensure adequate
folding without perforation or bleeding (Figs.2.2 and 2.3).
2.2.2.4 Risk ofTIF Operation
The common adverse reactions of gastroscope suture are nausea during operation,
bleeding at the suture site after the operation, pharyngeal pain, upper abdominal
pain, and burping. A few patients may have dyspnea, hypoxia, massive hemorrhage,
suture tissue tear, and suture perforation. In general, the endoscopic suture is a safe
treatment.
2.2.2.5 Comparison ofClinical Application andCurative Effect
Toomey etal. made a comparative study on the efcacy of TIF and laparoscopic
fundoplication. The results showed that TIF and fundoplication had similar thera-
peutic effects in the treatment of GERD, but TIF had shorter operation time and
fewer complications than fundoplication [18, 19]. Bellrc and other studies found
that the following factors can affect the efcacy of TIF surgery:
F. D u
21
Fig. 2.3 Schematic diagram 2 of TIF operation
① Preoperative endoscopic diagnosis of anti-reux barrier(Hill grade I or II) and
esophageal hiatal hernia.
② The esophageal motility.
③ The number of clamps used.
④ The related scores of reux symptoms after PPI treatment.
2.2.3 Medigus Ultrasonic Surgical Endostapler (MUSE)
2.2.3.1 Concept
MUSE is a new technology approved by the FDA in 2014. Unlike TIF, the MUSE
system is a special device integrated into endoscopy to achieve intraluminal fundus
folding. MUSE system is composed of an endoscope, camera, ultrasonic probe, and
suture device. The operation is easier than that of TIF.By turning the mirror body
2 Endoscopic Fundoplication forGastroesophageal Reux Disease
22
under an endoscope and clamping the mucosal plica with the suturing device, the
serosa tissue suture is completed under ultrasonic probe guidance [1, 20].
2.2.3.2 Indications andContraindications
Indications:
① Medical treatment failure cases.
② Patients who have side effects or are unwilling to use drugs for a long time.
③ Patients with Barrett’s esophagus, stenosis, or severe reux esophagitis
were found.
④ Patients with gastroesophageal reux disease that leads to severe respiratory
diseases.
⑤ Patients with paraesophageal hernia or mixed hiatal hernia.
Contraindications:
① Patients with coagulation dysfunction, severe cardiopulmonary dysfunction,
obesity, or other systemic diseases.
② Patients with severe esophagitis, esophageal sclerosis, esophageal varices, and
other esophageal diseases or surgical history.
③ Patients with mental disorders, pregnant women, and those under 18years old.
④ Patients with upper gastrointestinal endoscopy contraindication.
2.2.3.3 Surgical Procedure
Preoperative Preparation
① Evaluation: Necessary preoperative evaluation must be carried out before oper-
ation. Patients in good condition, no serious underlying diseases or well-
controlled, no uncontrollable coagulation diseases, and patients with good
cardiopulmonary function can be treated with endoscopic fundoplication.
Aspirin and other non- steroidal anti-inammatory drugs were stopped for
1week before the operation.
② Gastrointestinal preparation: All oral intake should be discontinued at 22:00
on the day prior to surgery, and water intake should be prohibited after mid-
night, so as to prevent asphyxia or aspiration pneumonia caused by vomiting
F. D u
23
during anesthesia and the surgical procedure. A glycerin enema should be
administered preoperatively to prevent anal sphincter relaxation induced by
anesthesia, avoid contamination of the surgical eld by fecal matter, and
reduce the risk of postoperative abdominal distension and constipation.
③ Respiratory tract preparation: Smokers are required to stop smoking for 2weeks
before the operation to prevent postoperative pulmonary complications caused
by excessive respiratory secretions, and try to learn abdominal breathing (deep
inspiration, shrunken stomach) and effective expectoration (cough from the
deep). Pay attention to keep warm and prevent respiratory tract infections. Before
treatment, patients with infection usually receive acid suppression treatment for
more than 1 week, intravenous drip of antibiotics, and aerosol inhalation for
more than 3days to control respiratory tract inammation and use methylpred-
nisolone control asthma symptoms if necessary.
④ Blood was prepared 1 day before the operation, and a drug allergy test was
performed.
⑤ Keep a good mood and sleep well before the operation.
⑥ The vital signs were monitored in the morning of the operation day; the gastric
tube was indwelling for gastrointestinal decompression, gastric gas and liquid
were emptied, and the urinary catheter was indwelling.
Surgical Procedure (Performed Under General Anesthesia)
① The stapler entered the stomach through a super tube (inner diameter 17mm/
outer diameter 19.5mm) and bent backward under direct video guidance.
② After a stapling position was determined, the stapler was gently pulled back, and
the stapler was placed in the esophagus about 3cm away from the gastroesopha-
geal junction.
③ Use the knuckle knob to bend the device’s tip, press the fundus of the eye on the
esophagus, and unfold the screw.
④ When the tissue thickness is 1.4–1.6mm, the stapler is activated. Because the
tissue is compressed, it cannot display directly, so an ultrasonic rangender can
automatically display tissue thickness.
⑤ Firing ve 4.8mm surgical screws each time. The screws were retracted to the
top of the device. The stapler was removed and sutured again (Figs.2.4 and 2.5).
2 Endoscopic Fundoplication forGastroesophageal Reux Disease