A simple endoscopic full-thickness plication procedure for the treatment of gastroesophageal reflux disease

Endoscopic full-thickness plication (EFTP) of the cardia or fundus has been shown to have efficacy in treating patients with gastroesophageal reflux disease (GERD) [1] [2]. However, EFTP requires proprietary equipment that may not be available in many countries. Herein, we describe a novel method of EFTP using an endoloop and metal clips, which we termed endoclip and loop cardioplication (ECLC).

A 33-year-old man presented with a 3-year history of heartburn and acid reflux that had worsened over the preceding year especially at night, despite treatment with a proton pump inhibitor (PPI). He attended our center for endoscopic treatment and provided informed signed consent to undergo ECLC. Gastroscopy demonstrated reflux esophagitis (Los Angeles classification grade C) and a hiatus hernia with loosening of the lower esophageal sphincter ([Fig. 1 a, b]). ECLC was performed with the patient under general anesthesia; a single-channel gastroscope equipped with a transparent cap was used for the procedure ([Video 1]). An electrocautery dual knife was used to mark the lesser curvature and posterior aspect of the cardia (approximately one quarter of the total circumference) at the diaphragm level of the hiatal hernia. After submucosal injection, the marked mucosa and submucosa were deeply incised to expose the smooth muscle fibers. The incised mucosa was observed to contract naturally in the direction of the cardia ([Fig. 1 c]). Next, a metal clip mounted with an endoloop was applied to the margin of the exposed smooth muscle layer. The endoloop was delivered from outside the scope rather than through the working channel. Four more clips were applied to anchor the endoloop to the smooth muscle, one on the same margin as the first clip, one between the first two clips, and two on the exposed smooth muscle layer of the opposite margin ([Fig. 1 d]). The endoloop was then tightened, resulting in approximation of the exposed smooth muscle margins, which in turn led to tight closure of the gastroesophageal junction (GEJ) around the scope ([Fig. 1 e]). Additional clips were placed to fully close the exposed smooth muscle. After the procedure, the patient fasted overnight and was given intravenous PPI therapy. He resumed a liquid diet and was discharged the following day.

Fig. 1 Endoscopic images of the endoloop-assisted cardioplication procedure and follow-up findings. a Initial findings of reflux esophagitis (Los Angeles classification grade C). b Wide lumen at the gastroesophageal junction. c Incision of the mucosa and submucosa to expose the underlying smooth muscle fibers. The smooth muscle fibers needed to be slightly injured to facilitate merging of the smooth muscle tissue during healing. d The endoloop was anchored to the smooth muscle with metal clips. e Approximation of the exposed smooth muscle by tightening of the endoloop. f Resolution of reflux esophagitis at 3 weeks after the procedure. g The metal clips and endoloop had fallen off, with only a tiny mucosal defect observed. h Retroflexed view demonstrating the narrower gastroesophageal junction.

Video 1 A simple method of endoscopic full-thickness plication using metal clips and an endoloop for the treatment of gastroesophageal reflux disease.

At a routine follow-up visit 3 weeks later, the patient reported being symptom-free at night and the cessation of medications. Endoscopic examination revealed significant alleviation of reflux esophagitis ([Fig. 1 f]) and the GEJ fitted closely around the scope. The metal clips and endoloop were gone and the mucosal defect was covered with normal mucosa, with only a tiny defect observed that was expected to fully heal ([Fig. 1 g, h]).

In conclusion, ECLC represents a simple, low-cost, adjustable method of suture- and staple-free EFTP for the treatment of GERD.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Nabi Z, Reddy DN. Update on endoscopic approaches for the management of gastroesophageal reflux disease. Gastroenterol Hepatol (NY) 2019; 15: 369-376
• 2 Kalapala R, Karyampudi A, Nabi Z. et al. Endoscopic full-thickness plication for the treatment of PPI-dependent GERD: Results from a randomised, sham controlled trial. Gut 2022; 71: 686-694

Publication History

Article published online:
16 February 2023