The goals of
gastro-oesophageal reflux disease (
GERD) treatment are to control symptoms, heal the injured oesophageal mucosa, and prevent complications. Pharmacological
therapy is effective in producing acute symptom relief and mucosal healing, as well as the long-term maintenance of remission.
Proton pump inhibitors are the mainstay of
GERD therapy. However, the need for daily administration, failure to provide complete symptom relief and costs of these agents may limit their use in some patients, prompting a consideration of alternative treatment strategies. Laparoscopic
fundoplication may achieve symptom relief and healing of the oesophagitis in these individuals, but its invasiveness, cost and inherent surgical risks have created an interest in endoscopic
therapies for
GERD, with several emerging during the past few years. These interventions may either be viewed as an alternative
therapy or as '
bridge' therapy, with patients still choosing to be treated with
acid anti-secretory drugs or
fundoplication if the endoscopic procedure fails to provide adequate symptom relief or if symptoms recur. Patient selection is critical for the success of
fundoplication as well as endoscopic procedures, with ideal candidates being those with well-established endoscopically documented
GERD, abnormal pH monitoring, normal oesophageal motility studies, and who have experienced at least partial symptom relief with
proton pump inhibitor therapy.
Hiatal hernia is not a contra-indication to
fundoplication, while endoscopic intervention is best suited for those with a
hiatal hernia of less than 3 cm in length. The long-term efficacy, cost-effectiveness, and impact of endoscopic procedures on extra-oesophageal manifestations of
GERD and risk for
GERD-related complications has not been determined.