Endoscopic gastric plication for the treatment of GERD and underlying class I obesity

Obesity and GERD are both common diseases in the United States. Compared to those with a normal body mass index (BMI), patients with obesity have a higher rate of acid reflux, with an odds ratio of 1.5. This is thought to be due to an increase in intragastric pressure, transient relaxations of the lower esophageal sphincter, and a decrease in lower esophageal sphincter pressure.

For a specific group of patients with GERD and underlying class I obesity, there is no ideal surgical treatment option. Sleeve gastrectomy can cause worsening of acid reflux and is not approved for a BMI <35. Gastric bypass is effective at treating reflux. However, many patients refuse because of perceived invasiveness. Additionally, Nissen fundoplication has been shown to be associated with worse outcomes when BMI is >30. Therefore, there is a clinical need for an effective minimally invasive alternative.

Our patient is a 72-year-old woman with a history of class I obesity and GERD with a history of erosive esophagitis. She was referred by our surgical colleague for endoscopic treatment options for acid reflux and obesity. Her BMI is 34. Despite being on maximal-dose proton pump inhibitors twice daily, she continues to have breakthrough reflux symptoms several times per day.

A diagnostic endoscopy was performed. On retroflexion, a Hill grade 3 hiatus was visualized. Additionally, real-time esophageal function testing was performed, which revealed a gastroesophageal (GE) junction distensibility index of 7 with a high-pressure zone length of 1.5 cm. The decision was then made to pursue an endoscopic gastric plication procedure to treat both acid reflux and obesity in a single session.

The procedure uses an endoscopic plication device that has Food and Drug Administration approval for general endoscopic tissue apposition. The device consists of a large-channel disposable endoscope with 4 working channels and an attachment for a laparoscopic insufflator. One of the channels is designed for passage of a 4.9-mm endoscope. Other parts of the device include a helix for grasping tissue, a tissue approximation instrument, and a catheter-based hollow needle that allows passage of tissue anchors for plication.

Our plan was to perform the antireflux portion of the procedure first because it needs to be in a retroflexion position. The goal is to achieve lengthening and tightening of the intra-abdominal lower esophageal sphincter by creating a 270-degree valve of approximately 3 cm in length. Subsequently, the scope is unretroflexed to perform the bariatric component of the procedure. For this step, plications are placed in the gastric body, sparing the fundus. Specifically, as shown in the bottom right, a belt and suspenders plication pattern is used, with the blue lines representing belt plications that reduce the width of the stomach and green lines representing the suspender plications that reduce the gastric length.

First, we retroflex the device to assess the cardia. As labeled here, the greater curvature is located at the 7 o’clock position and the anterior side is at the 5 o’clock position. The first plication is placed at the anterior aspect of the greater curvature. The helix is used to acquire tissue at the GE junction prior to pulling it into the tissue approximation device. A needle is passed through the tissue, and a tissue anchor is advanced through the needle. The needle is then pulled back and the second tissue anchor is released. These 2 anchors are then pulled together, plicating the tissue. The suture is then cut and released. The next plication is performed adjacent to the first plication along the anterior side of the greater curvature. Of note, this type of plication allows serosa-to-serosa apposition as opposed to suturing, which induces mucosa apposition and is typically considered less durable. Shown is the appearance after 6 plications placed along the anterior and greater curvature aspects of the cardia. Following this, more plications are placed on the posterior side and finally on the anterior aspect of the lesser curvature.

Shown is the final appearance of the newly created gastroesophageal junction valve, which spans an approximately 270-degree circumference around the cardia. This pattern is designed to substantially elongate the abdominal esophagus.

After the antireflux component of the procedure, the device is unretroflexed in preparation for the bariatric component of the procedure.

The first set of plications are placed perpendicular to the length of the stomach to narrow the distal gastric body. As shown, the approximation device is oriented along the width of the stomach. Once the tissue is acquired, the needle is passed through the tissue before release of the first tissue anchor. The helix is removed. The second tissue anchor is dropped before tissue cinching. The suture is then cut. After distal belt plications, a reduction in the width of the stomach is noted. Next, plications are placed parallel to the length of the stomach. This portion of the procedure is intended to shorten the length of the gastric body and reinforce the antireflux portion of the procedure by further pulling the GE junction distally. Shown is the appearance at the end of the first row of suspenders.

The next set of plications is placed along the posterior aspect of the stomach. It is important to pull the entire device back to create space between the instrument and gastric wall. This maneuver allows the tissue to be pulled up until it reaches the top of the approximation instrument to ensure a large full-thickness bite. Because each arm of the approximation device is 33 mm long, each tissue bite is approximately 6 to 7 cm. After suspender plications, the stomach has become shorter. Finally, the approximation device is rotated back 90 degrees so that it lines up along the width of the stomach. Plications are then placed at the proximal gastric body to further reduce the stomach width.

At the end of the procedure, a significant reduction in gastric volume is noted. In this case, the GE junction was pulled down by approximately 4 cm and the gastric body was shortened by 12 cm. Real-time esophageal function testing showed that the distensibility index decreased from 7 to 3 and the high-pressure zone was lengthened by approximately 2 to 3 cm.

At 6 months, the patient went from having daily breakthrough reflux symptoms on maximal-dose proton pump inhibitors to being symptom-free off all antireflux medications. From a weight loss standpoint, she experienced a 15.8% total weight loss with a 5-point decrease in BMI.

In conclusion, patients with GERD and class I obesity do not qualify for sleeve gastrectomy and have inadequate long-term outcomes with Nissen fundoplication. This video demonstrates the use of endoscopic gastric plication to elongate the intra-abdominal esophagus and create a GE flap valve for antireflux treatment and to reduce gastric length and width to induce weight loss. Single-session endoscopic gastric plication therefore may be considered for this patient population and appears feasible, safe, and effective.