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77
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Fig. 6.3 The single-ring ligature is used to ligate the mucosa and submucosal tissue on the greater
curvature of the cardia, and use a titanium clip to x the proximal root of the ligation ring
a
b
Fig. 6.4 The cardia is obviously narrowed under the endoscopy, scars can be seen on the greater
and lesser curvatures of the cardia, and chrysanthemum-like narrowing and anti-reux valve can
be seen on the reverse endoscope
6.3.3 Ligation Above andBelow theDentate Line
1. Enter the gastroscope into the gastric cavity and duodenum, observe whether
there is any disease in the upper digestive tract, and determine the position of the
esophageal dentate line.
2. A ligature is installed at the front end of the gastroscope to enter the esophagus.
First, use an endoscopic suction device to aspirate the mucosal and partial mus-
cular layers located 1 cm below the dentate line on the gastric lesser curvature at
the cardia. The base of the aspirated tissue will retract to form a spherical mass.
Next, deploy the ligating band. Avoid ligating the gastric greater curvature to
6 Peroral Endoscopic Cardial Constriction (PECC)
78
prevent damage to the angle of His. Finally, apply ligation at the site 1 cm above
the dentate line in the esophagus. During the ligation procedure, observe the
morphology of the ligated tissue, monitor the tightness of ligation, and ensure
that the gastroscope can pass through the cardia with mild resistance—this is the
optimal ligation endpoint [10].
6.3.4 Postoperative Treatment
1. After the operation, fasting with water for 24h, giving treatments such as acid
suppression, stomach protection, and uid infusion
2. Oral PPI and gastric mucosal protective drugs for 2weeks
6.3.5 Postoperative Follow-Up
Re-examination of gastroscopy, 24-h PH monitoring of esophagus, esophageal
dynamics examination, Gastro-Esophageal Reux Disease-Health Related Quality
of Life (GERD-HRQL), and Gastro-Esophageal Reux Disease-Questionnaires
(GERD-Q) at 3months, 6months, and 12months after surgery.
6.3.6 Efcacy Evaluation
Through GERD-HRQL, GERD-Q scoring standards, gastroscopy, grading accord-
ing to the Los Angeles grading system [11] (LA grading), 24-h PH monitoring of
the esophagus and esophageal dynamics examination, and comparison of changes
before and after surgery.
6.3.7 Surgical Instruments (Table6.1)
Table 6.1 Surgical instruments
Instrument [10, 12] Company
Olympus GIF-Q260 gastroscope host Olympus company (Japan)
Olympus GIF-Q260J/290gastroscope and graphic system Olympus company (Japan)
Single ring band ligator Fuji company (Japan)
Titanium clip Boston Scientic (USA)
Q. Yue
79
6.3.8 Advantages ofPECC
1. Minimally invasive: Endoscopic cardia ligation treatment without changing the
anatomical structure.
2. Fast recovery: Minimal trauma, and liquid food can be taken 24h after surgery.
This technique can be considered in the day ward [12].
3. Safety: No serious complications such as esophageal perforation or death.
4. Simple operation: Endoscopic ligation treatment technology is mature and easy
to master.
5. Economical: Surgical instruments used in ligation are easy to obtain and rela-
tively inexpensive.
6. Mild Side effects: A small number of patients experience choking after eating,
post-sternal pain, and abdominal distension. However, all symptoms were
relieved after 1–2weeks of symptomatic treatment.
7. Effective: After PECC treatment, the symptoms were signicantly relieved, and
the dose was reduced or the drug was stopped.
6.4 Clinical Application ofPECC
Peroral endoscopic cardial constriction (PECC) has been used in clinical treatment
of GERD since it was rst reported in 2013. This method is minimally invasive,
safe, quick to recover, and has few side effects.
A study [13] used DeMeester, GERD-HRQL, and GERD-Q scores to analyze
the clinical treatment effect of PECC on GERD.The DeMeester, GERD-HRQL,
and GERD-Q scores of patients before treatment were compared with the three
indicators from 3 and 6months after surgery. The difference is statistically signi-
cant, indicating that PECC treatment is effective (Table6.2). The results of the 24-h
pH monitoring of the esophagus showed that, compared with 3months and 6months
after the operation, the PH <4-time percentage, the number of reuxes, and the
duration of long reux were signicantly different in these three indicators
(Table6.2). The patient’s acid reux and heartburn symptoms were signicantly
relieved. After rechecking the gastroscope, the healing of esophagitis improved sig-
nicantly (Table6.3). In this study, no serious treatment-related complications such
as esophageal stenosis and dysphagia occurred. Some patients only had slight pain
under the xiphoid process and behind the sternum after the operation, which was
naturally relieved after 2–3days of acid suppression treatment. Considering that the
ligation xation method causes limited cardiac contraction, which may affect the
efcacy, this study excluded patients with hiatal hernias with a diameter greater
than 3cm.
6 Peroral Endoscopic Cardial Constriction (PECC)
80
Table 6.2 Index changes in patients with gastroesophageal reux disease before and after PECC treatment (Mean±SD)
Time
Number of
cases
GERD-HRQL
score
GERD-Q
score DeMeester score
PH <4
percentage of
time (%) Reux times
Long reux
times
Long reux
duration
Preoperative 27 18.56±6.46 10.7±1.64 107.61±76.74 27.78±24.11 212.93±128.02 13.68±9.76 64.37±91.02
3months after
surgery
27 3.93±3.15 1.26±1.19 26.05±20.47 9.46±11.45 79.05±59.32 3.37±3.57 21.49±45.82
6months after
surgery
27 4.37±3.44 1.59±1.50 27.10±20.83 9.18±10.28 97.24±76.62 3.99±5.50 15.69±29.31
a
The data comes from a clinical a study on the treatment of gastroesophageal reux disease with PECC [13]
Q. Yue
81
Table 6.3
Evaluation of the curative effect of patients after PECC treatment [case (%)]
Time
Number of
cases
Basic
cure
Signicant
relief
Partial
relief
Basically
invalid
3months after
surgery
27 22(81.5) 2(7.4) 2(7.4) 1(3.7)
6months after
surgery
27 21(77.8) 3(11.1) 2(7.4) 1(3.7)
a
The data comes from a clinical study on the treatment of gastroesophageal reux disease with
PECC [13]
Table 6.4
Comparison of symptom scores of patients with gastroesophageal reux disease before
and after PECC treatment (points, median)
Symptom
Preoperative
score
Postoperative
score Z value P value
Acid reux 5 2 −4.851 <0.01
Heartburn 5 2 −5.054 <0.01
Cough 4 2 −4.165 <0.01
Foreign body sensation in pharynx 3 3 −3.322 <0.01
Respite 4 2 −3.564 <0.01
a
The data comes from the observation of the effect of oral endoscopic cardia constriction in the
treatment of extra-esophageal symptoms of gastroesophageal reux disease [10]
Table 6.5
Comparison of clinical efcacy of ARMS and PECC in the treatment of gastroesophageal
reux disease
Surgical
approach
Operation success
rate (%)
Effective rate of symptom
improvement (%)
GERD-Q
score P value
ARMS 100 60 7.35±1.79 0.016
PECC 100 89 6.21±1.03 0.016
In another study [10], a total of 52 patients with refractory GERD received PECC
treatment, the gastrointestinal symptoms improved after surgery, the incidence of
extra-esophageal symptoms [14] also decreased (Table6.4), and the treatment effect
was signicantly higher than the previous Hai-Qing Hu [15] and other reports. This
may be due to the effect of ligating the xed mucosa and part of the muscle layer to
form folds below and above the dentate line. Long ligation of the esophagus will
increase the pressure near the lower esophageal sphincter and the cardia.
A retrospective study [16] compared the clinical efcacy of ARMS and PECC in
the treatment of GERD.Although the success rate of these two procedures is 100%,
the operation time of PECC is signicantly shorter than that of ARMS.During fol-
low- up 2months after the operation, the effective rates of symptom improvement in
the PECC group and the ARMS group were 89% and 60%, respectively. The
GERD-Q score of the PECC group was signicantly lower than that of the ARMS
group (Table6.5). After 1year of follow-up, there was no signicant difference
between the two groups in the symptom improvement rate, GERD-Q score,
DeMeester score, and the percentage of time that PH <4. The conclusion is that the
6 Peroral Endoscopic Cardial Constriction (PECC)
82
long-term clinical efcacy of ARMS and PECC in the treatment of GERD is equiva-
lent, but the short-term efcacy of PECC has advantages.
PECC is a safe, effective, minimally invasive, and economical treatment for
GERD.It can reduce reux and other symptoms related to reux. It can be a new
method for the treatment of GERD, but it still requires multicenter randomized
controlled studies and long-term follow-up to conrm the efcacy of PECC.
References
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disease. Chin Electron J Gastroesopha Reux Dis. 2015;2(3):175–7.
4. Bavishi C, Dupont HL.Systematic review: the use of proton pump inhibitors and increased
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5. Li Y-L, Zhang C, Su F-Z, Wang Z, Li H-L, Du Z, Zhu Z-K, Li S.Curative effect analysis of
laparoscopic esophageal hiatus hernia repair combined with fundoplication combined with
cholecystectomy. China Gastroesopha Reux Electron Mag. 2016;3(004):151–4.
6. Ling-Hu E-Q, Wang Y-f, Wang X-x. A case report of endoscopic cardia constriction for gastro-
esophageal reux disease. Chin J Endosc Surg (Electron Ed). 2013;6(6):64.
7. Hai-Qing H.Basic and clinical research on the treatment of gastroesophageal reux disease by
oral endoscopic cardia constriction. Chinese People’s Liberation Army Medical College; 2017.
8. Sarin SK, Gupta R.Endoscopic ligation plus sclerotherapy: two plus two make only three! ☆.
Gastrointest Endosc. 1999;50(1):129–33.
9. Sun S, Jin Y, Chang G, Wang C, Li X, Wang Z.Endoscopic band ligation without electro-
surgery: a new technique for excision of small upper-GI leiomyoma. Gastrointest Endosc.
2004;60(2):218–22.
10. Zhi-Tong L.Observation of the effect of gastroesophageal reux disease on extraesophageal
symptoms of gastroesophageal reux disease by oral endoscopic cardia constriction. Chin J
Dig. 2019;6(39)
11. Lundell LR.Endoscopic assessment of oesophagitis: clinical and functional correlates and
further validation of the Los Angeles classication. Gut. 1999;45(2):172–80.
12. Li X, Zhang X-B, Hai-Qing H, Li H-K, Wang X-X, Ling-Hu E-Q.Safety of peroral endoscopic
cardial constriction for gastro-esophageal reux. Chin J Dig Endosc. 2017;34(3):194–6.
13. Hu H-Q, Zhang H-J, Jin C-L, Yu X-M. Clinical study on the treatment of gastroesophageal
reux disease with cardia constriction under oral endoscopy. Chin J Dig Endoscop. 2019;8(36)
14. Vakil N, etal. The Montreal denition and classication of gastroesophageal reux disease: a
global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900–20.
15. Hai-Qing H, Ning-Li C, En-Qiang L-H, Hui-Kai L, Ying X, Xiao-Bin Z, Jun-Li Z, Xiao-Xiao
W, Jie A.Clinical research on the treatment of gastroesophageal reux disease by oral endo-
scopic cardia constriction. Chin Electron J Gastrointest Endosc. 2016;2(3)
16. He D-Z, Zheng Y-Y, Wang X-T, Chen Y, Song L-J, Yue L-F.Comparison of the clinical ef-
cacy of antireux mucosal resection and cardia coarctation in the treatment of gastroesopha-
geal reux disease. In: 2019 Chinese Society of Integrated Traditional Chinese and Western
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Q. Yue
83© 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_7
Chapter 7
Evaluation ofEndoscopic Treatment
forGERD
XinHuang
7.1 Esophageal Correlation Scale andRoutine
Dynamic Examination
7.1.1 Symptoms andSigns Scale
Abnormal esophageal motility can cause associated esophageal dyskinesia, and the
main manifestations are acid regurgitation, heartburn, dysphagia, and chest pain,
which can also appear outside digestive tract symptom. Some scales can evaluate
gastroesophageal reux, and the dynamic state of the esophagus can be reected
from the side. Common evaluation scales include gastroesophageal reux disease
questionnaire (GerdQ, Table 7.1) and the reux disease questionnaire (RDQ,
Table7.2). For the GerdQ, a total score greater than 8 is considered positive, with
a sensitivity of 65% and a specicity of 71% [1]. For the RDQ, a total score of
more than 12 is considered positive [2]. The use of both scales will improve diag-
nostic specicity, and one study showed higher sensitivity for single GerdQ than
RDQ [3]. Throat reux disease laryngopharyngeal reux disease (LPRD) is one of
the multisystem manifestations of gastroesophageal reux. The gastric contents
reux to the upper esophageal sphincter, causing local mucosal damage, a disease
characterized by a series of symptoms such as pharyngeal foreign body sensation,
cough, hoarseness, esophageal dyskinesia. Removal function decline is part of the
cause of LPDR.Although some current views suggest that throat reux is present
alone in gastroesophageal reux, but a study suggests this may be due to low laryn-
goscopy [4]. The total score of reux symptom index (RSI, Table7.3) was greater
than 13, and the sensitivity was 82.6% and specicity was 84.6%. For the Reux
X. Huang (*)
Department of Gastroenterology, The Ninth Medical Center of Chinese PLA General
Hospital, Beijing, China
84
Table 7.1
Gastroesophageal reux disease questionnaire, GerdQ
Composition Past 7days 0days 1day 2–3days 4–7days
Positive symptoms
(A)
A1 Heartburn 0 1 2 3
A2 Reux 0 1 2 3
Negative symptoms
(B)
B1 Upper abdominal pain 3 2 1 0
B2 Gross 3 2 1 0
Positive effects (C) C1 Reux, heartburn-induced sleep
disorders
0 1 2 3
C2 Additional medication 0 1 2 3
Note: >8 positive
Table 7.2
Reux disease questionnaire, RDQ
Symptoms Never
<1day
every
week
1day
every
week
2–3days
every week
4–5days
every week
Almost
every day
After the sternum
Heartburn feeling
0 1 2 3 4 5
Chest pain 0 1 2 3 4 5
Sore in the mouth 0 1 2 3 4 5
An uncomfortable sensation
caused by upwelling of
stomach contents
0 1 2 3 4 5
Table 7.3
Reux symptom index, RSI
What symptoms have plagued you in the past month? 0=asymptomatic, 5=severe
1. Hoarseness or dyslexia (voice problems) 0 1 2 3 4 5
2. Keep your voice clear 0 1 2 3 4 5
3. Sputum or runny nose 0 1 2 3 4 5
4. Adverse effects of swallowing food, water or pills
cough after
0 1 2 3 4 5
5. Meal or lying down 0 1 2 3 4 5
6. Breathing or repeated suffocation 0 1 2 3 4 5
7. Annoying cough 0 1 2 3 4 5
8. Throat foreign body sensation 0 1 2 3 4 5
9. Heartburn, chest pain, or stomachache 0 1 2 3 4 5
10. Pain in the throat 0 1 2 3 4 5
11. Dry pharynx 0 1 2 3 4 5
12. Burping, belching 0 1 2 3 4 5
13. Breathing 0 1 2 3 4 5
14. Throat tightness 0 1 2 3 4 5
15. Sneezes 0 1 2 3 4 5
(continued)
X. Huang
85
Table 7.3
(continued)
What symptoms have plagued you in the past month? 0=asymptomatic, 5=severe
16. Itching 0 1 2 3 4 5
17. Abdominal distension 0 1 2 3 4 5
18. Snoring 0 1 2 3 4 5
19. Hold your breath and not lie down 0 1 2 3 4 5
20. Reduced smell 0 1 2 3 4 5
21. Hearing loss 0 1 2 3 4 5
22. Tinnitus 0 1 2 3 4 5
Other 1 0 1 2 3 4 5
Other 2 0 1 2 3 4 5
Other 3 0 1 2 3 4 5
Other 4 0 1 2 3 4 5
Note: >13 positive
Table 7.4
Reux signs score, RFS
Pseudoacoustic band sulcus 0=no Laryngeal edema 0=no
2=exist 1=mild
Laryngeal cavity
disappeared
0=no 2=moderate
2=section 3=severe
4=complete 4=blockages
Erythema/hyperemia 0=no Posterior
hyperplasia
0=no
2=conned to scoop
cartilage
1=mild
4=diffuse 2=moderate
Vocal cord edema 0=no 3=severe
1=mild 4=blockages
2=moderate Granuloma 0=no
3=severe 2=exist
4=blockage Laryngolith adhered 0=no
2=exist
Note: >7 is positive
Signs Score (RFS, Table 7.4), a total score greater than 7 suggests sore throat
reux. One correlation study of 3932 cases suggested that RSI and RFS could be
included in the LPRD study as objective, consistent low-cost, and practical param-
eters [6]. Anxiety is an independent risk factor for symptoms of gastroesophageal
reux disease and laryngopharyngeal reux [7, 8]. The total score of Self-rating
Anxiety Scale (SAS) was more than 50 (Table7.5). A study of chest pain patients
showed higher SAS positive rates associated with gastroesophageal reux [9]. The
above scale does not directly reect esophageal motility, and esophageal
7 Evaluation ofEndoscopic Treatment forGERD
86
Table 7.5
Self-rating anxiety scale, SAS
No or little
time (1)
A small part
of time (2)
Quite a lot
of time (3)
Most or all of
the time (4) Score
1. I feel more nervous or
anxious than usual
2. I feel scared for no reason
3. I am easily upset or
frightened
4. I think I may be going
crazy
5. I think everything is ne
6. My hands and feet trembled
7. I suffer from headache,
neck pain or backache
8. I feel weak or tired
9. I feel calm and easy to sit
quietly
10. I feel my heart beating fast
11. I was troubled by a t of
dizziness
12. I have a faint attack or feel
like I’m going to faint
13. I feel easy breathing in
and out
a
14. The numbness and tingling
of my hands and feet
15. I am distressed by
stomachache and
indigestion
16. I often urinate
17. My hands and feet are
often dry and warm
a
18. My face blushes
19. I fall asleep easily and
sleep well all night
20. I have nightmares
Score
Note: >50 positive
a
Reverse score. A standard score=a rough score multiplied by 1.25
dyskinesia is only one of the causes of its positive manifestations. However, the
evaluation of the above scale can be used as a reference for esophageal dynamic
abnormalities.
1. In the past 1month (4weeks), do you have the following occurrence and the
frequency of the occurrence of symptoms?
2. Review the symptoms of the past 1month (4weeks), from light to heavy score
0–5, your degree of symptoms?
X. Huang