Endoscopic suturing with muscular after fundus mucoresection for refractory gastroesophageal reflux disease：a new anti-reflux technique

A 63-year-old male with a 20-year history of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) presented with persistent heartburn and regurgitation (GERD-HRQL score 29). High-resolution manometry showed a hypotensive lower esophageal sphincter (LES), and 24-hour pH-impedance monitoring confirmed pathological reflux (DeMeester score: 83.18). The patient underwent endoscopic suturing with muscular after fundus mucoresection (ESFM), a novel hybrid procedure combining endoscopic mucosal resection with fundoplication principles ( Fig. 1 ). Following an 8-hour preoperative fasting period, the gastric cardia was endoscopically exposed. Key steps included are as follows: mucosal marking at the gastric cardia (1.5 cm × 2 cm area); submucosal injection and circumferential endoscopic mucosal resection; nylon loop placement with clip-anchored muscular plication; and creation of an anti-reflux valve via suture tightening ( Video 1 ). Postoperative recovery was uneventful with a 3-day hospitalization. At 3-month follow-up, the patient reported complete resolution of reflux symptoms without dysphagia (GERD-HRQL 7). Repeat endoscopy demonstrated a well-healed plication fold.

Fig. 1.

Endoscopic suturing with muscular after fundus mucoresection (ESFM) procedure for PPI-refractory GERD. a Preoperative view showing a patulous cardia. b Mucosal resection at the gastric fundus. c Suturing with muscular layer plication. d Postoperative appearance demonstrating successful luminal narrowing.

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Endoscopic suturing with muscular after fundus mucoresection (ESFM).

Video 1

The ESFM procedure effectively addresses GERD pathophysiology by creating a mechanical barrier through combined mucosal resection and muscular plication while narrowing the lumen at the esophagogastric junction, avoiding the morbidity associated with traditional surgical interventions ^{1 2} . This case demonstrates ESFM as a promising minimally invasive alternative for PPI-refractory GERD, successfully merging the safety profile of endoscopic resection with the functional efficacy of fundoplication ³ . Further studies are necessary to validate the long-term clinical outcomes of this innovative technique.

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