State of evidence and future perspectives in minimally invasive management of gastroesophageal reflux disease (GERD)

Abstract

The future of minimally invasive treatment of gastroesophageal reflux disease (GERD) will be realized through collaborative precision medicine more than any foreseeable new technology. Multidisciplinary foregut societies are fostering the collaboration and expertise needed to provide a personalized treatment of GERD. Patient-centric therapy will consider combination therapies' clinical successes. Taking a patient uncontrolled on medication to controlled via a combination of medicine and a procedure will replace the historical mutual exclusivity of acidsuppressive medication or surgery as a treatment for GERD. Research directed at precision medicine will focus on subgroup analysis rather than randomized controlled trials. Recognition of the crural diaphragm as a reflux barrier which fails in GERD patients regardless of the presence of an axial hernia has resulted from modalities such as 3-D high-resolution impedance manometry, endoscopic ultrasound, functional luminal impedance planimetry. More precise patient selection for purely endoscopic therapies will be possible.The concept of hernia reduction will be replaced by calibration of the crural repair to restore its sphincteric function. Partnering a surgically calibrated hernia repair partnered with interventional gastrointestinal endoscopic reinforcement of the lower esophageal sphincter will foster physician alliances and offer patient-centric alternatives to traditional fundoplication. As such, laparoscopic Nissen Fundoplication will lose its historical primacy and be relegated to the most severe GERD. Magnetic sphincter augmentation (LINX®), varing degrees of partial fundoplication, and endoluminal therapies with or without hiatal hernia repair will become the mainstay of GERD AntiReflux Procedures. Radio Frequency modulation (Stretta®) may be an alternative to neuromodulators in treating the acid-sensitive esophagus. The nascent era of endoscopic robotics will improve precision, reproducibility and revive natural orifice transluminal endoscopic surgery.