Peroral Endoscopic Cardial Constriction with Band Ligation for Gastroesophageal Reflux Disease: A Prospective Pilot Study

Abstract

Background Limited retrospective data suggest peroral endoscopic cardial constriction with band ligation (PECC-b) as a feasible, safe, and effective treatment for GERD. We performed a prospective study to assess the efficacy and safety of PECC-b for the treatment of GERD.

Methods We prospectively recruited proton pump inhibitor (PPI)-dependent GERD patients. Patients with absence of acid reflux on a 24-hour pH study, esophageal motility disorder, and ≥Hill’s grade III hiatus on endoscopy were excluded. The primary endpoint was GERD health-related quality of life (GERD-HRQL) score improvement at 3 months. Secondary end points were decrease in PPI use, esophageal acid exposure time, reflux episodes, and DeMeester score at 3 months. Safety outcomes included serious and overall adverse events.

Results Between July 2023 and June 2025, 130 patients were screened. Of these, 40 patients underwent PECC-b therapy (median age 34 years (IQR: 18–60), 75% male) and were followed up for 3 months. At follow-up, significant improvement in GERD-HRQL scores (22.8 ± 3.2 at baseline to 12 ± 4.7; p < 0.001) was observed. In total, 85% ( n = 34) of the patients achieved complete or partial PPI independence at 3 months. Median acid exposure time decreased from 28.1% (IQR: 18.2–54.5%) to 14.8% (8.0–18.0%) ( p < 0.05), median number of reflux episodes from 81.5 (53.8–126) to 30 (21.8–70.8) ( p < 0.005), and the Demeester score decreased from 103 (51–161) to 52.5(33.5–78.3) ( p < 0.005). Totally, 15 (37%) patients had chest pain postprocedure and required analgesics. There were no serious procedure-related adverse events.

Conclusion PECC-b is a promising, safe, and effective endoscopic treatment for PPI-dependent GERD, offering significant symptomatic relief and improvement in quality of life.

Introduction

Gastroesophageal reflux disease (GERD) is a major functional gastrointestinal disorder with a high incidence and an estimated global prevalence of 8–33%, leading to high healthcare costs and resource utilization. ¹ It is one of the most frequent reasons for outpatient gastroenterology consultation. The symptoms of GERD are often troublesome and lead to disturbed sleep, reduced energy, and anxiety, thus impairing the quality of life. ² Although initial treatment is lifestyle modification, proton pump inhibitors (PPIs) have been the mainstay for the treatment of GERD for many decades. However, up to 40% of patients with GERD continue to experience reflux symptoms despite taking PPIs. ³ Furthermore, studies have reported patterns of prolonged usage of PPI in patients with GERD due to persistent/recurrent symptoms. There is also a rising concern regarding the side effects of long-term PPI usage, including bone fractures, hypomagnesemia, and Clostridium difficile infections, ⁴ although a systematic review and meta-analysis showed that the quality of evidence for these reported side effects is low. ⁵

Antireflux surgery is a therapeutic option for patients with GERD who have unsatisfactory or undesirable responses to medical therapy or are unwilling to consume long-term PPIs. ⁶ Although superior to medical therapy for controlling reflux, antireflux surgeries are invasive and are associated with gas bloat syndrome, dysphagia, and diarrhea, ⁷ requiring redo surgery in up to 15% with recurrence of symptoms in 62% of patients after 11–13 years of surgery. ⁸ There is an established trend toward decreased patient preference for surgical therapies owing to these concerns, and only 5% of patients with refractory GERD actually undergo laparoscopic fundoplication. ⁹ There is thus an unmet need for safe, long-lasting, and minimally invasive therapy for GERD. Since the early 2000s, endoscopic management of GERD has gained traction using approaches like fasteners, transmural sewing, radiofrequency energy, staplers, and mucosectomy ¹⁰ . Endoscopic therapy is beneficial in patients with an intact lower esophageal sphincter (LES) complex (absence of hiatal hernia or small hiatal hernia, Hill Grade 1 or 2). The requirement of expertise, dedicated instruments, and high costs has precluded the establishment of endoscopic therapies as the mainstay for GERD management. Given these shortcomings with the available endoscopic options, the need for an alternative endoscopic therapy that is safe, effective, easy, cheap, and readily available is appealing.

Peroral endoscopic cardial constriction with band ligation (PECC-b) is an economic and easy-to-perform endoscopic technique for patients with GERD. It involves the application of multiple rubber bands at the esophagogastric junction (EGJ) and in the gastric cardia, causing submucosal necrosis and resultant fibrosis that leads to LES augmentation, thus preventing reflux. It is mechanistically similar to anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA), where the gastric cardia tightening is achieved using a combination of endoscopic submucosal dissection or endoscopic mucosal resection and/or ablation. While all the other available endoscopic measures for GERD require general anesthesia, require significant technical expertise, and often need specialized, costly equipment, PECC-b is less time-consuming, requires only readily available instruments (multiband ligator device), does not require any technical expertise or general anesthesia to perform, and has a very small learning curve. Limited data have shown a good efficacy of PECC-b in patients with GERD, with symptomatic improvement in up to 70% of patients. ^{11 12} However, most of the studies are either retrospective or have a small sample size. This study was therefore conducted prospectively to evaluate the efficacy and safety of the PECC-b procedure in patients with PPI-dependent GERD.

Methods

Study Design and Setting

This investigator-initiated, open-label, prospective pilot study was conducted at a tertiary care hospital in India. The protocol was approved by the Institutional Ethics Committee (AIIMS/IEC/2023/4748). All procedures followed the Good Clinical Practice guidelines and the Declaration of Helsinki.

Screening and Eligibility Criteria

Between July 2023 and June 2025, consecutive adult patients (age ≥18 to 75 years) who presented with persistent GERD symptoms (heartburn, regurgitation) and were consuming daily oral PPI to control the same for at least 6 months were included for assessment.

PPI was stopped for two weeks, following which an esophagogastroduodenoscopy (EGD), a 24-hour esophageal pH monitoring, and high-resolution esophageal manometry (HRM) were done for all screened patients. A 24-hour esophageal pH monitoring was done using standard protocols. The pH-impedance catheter was positioned transnasally under manometric guidance, with the distal esophageal pH sensor placed 5 cm above the upper border of the LES, as per established recommendations. During EGD, photographic evidence of a normal esophagus, stomach, and duodenum was documented, and the EGJ was assessed using retroflexion.

Patients were considered for inclusion if they met the standardized objective criteria for GERD on 24-hour pH monitoring, defined as an acid exposure time (AET) >6%, a total number of reflux episodes >80, or an abnormal DeMeester score > 14.7 , with LES pressure >15 mm Hg on esophageal manometry, gastroesophageal flap valve grade I–III (Hill’s classification), and no hiatus hernia or small (<2 cm) hiatal hernia on endoscopy.

Patients with prior esophageal or gastric surgery, known coagulation disorder, connective tissue or autoimmune disorders, evidence of esophageal stricture, esophageal peristaltic abnormality as defined by the Chicago Classification, LES pressure <5 mm Hg with ineffective esophageal motility, para-esophageal hernia, and large hiatus hernia (>2 cm) were excluded. Patients with other concurrent medical conditions that would preclude compliance or confound study outcomes (e.g., concurrent malignancies including HCC, history of unstable angina, myocardial infarction or congestive heart failure, uncontrolled asthma or diabetes, significant hormonal conditions, uncontrolled seizure disorders, severe psychiatric disorders, active tuberculosis under current treatment, etc.) were also excluded.

All patients were enrolled after written informed consent. GERD-Health Related Quality of Life (GERD-HRQL) assessment was done using the GERD-HRQL ( Supplementary Table 1) validated questionnaire to assess the impact of GERD-specific symptoms on the quality of life of patients at baseline. ¹³

Interventions

Endoscopic Procedure

The endoscopic procedure was performed by an experienced endoscopist (AA, CLB). Both the endoscopists had experience of performing more than 5000 endoscopies independently per year. The procedure used similar principles as in esophageal varices band ligation. All patients were kept nil per oral (NPO) at least 6 h before the procedure. The procedure was carried out under conscious sedation using a flexible endoscope (Olympus gastroscope GIF-HQ190) in left lateral decubitus position.

Procedure Details

Video 1 A video describing the per oral endoscopic cardial constriction with band ligation (PECC-b) procedure.

Download video file ^{(62.4MB, mp4)}

A band ligation device (6 Shooter Universal Saeed Multi-Band Ligator from Cook) was fitted on the endoscope. The mucosa of the gastric cardia was captured in a retroflexed position in a straight row using three bands at the level of the EGJ toward the lesser curvature of the stomach. Just beneath the previously applied bands, another row of three bands was applied to capture the mucosa, and thus two rows of ligation rings were formed in the direction of the stomach’s lesser curvature to constrict the cardia ( Fig. 1 ). The greater curvature was spared to prevent harm to the angle of HIS. Then another multiband ligation device was used in forward viewing position to capture the mucosa at the level of the EGJ in the direction of the esophageal side of the lumen. The number of ligation rings depended on the circumference of the cardia and, as per the endoscopist’s discretion. The total length of the cardial constriction was about 5 cm. The overall procedure is provided as a supplementary video ( Supplementary Video ).

Fig. 1.

Technical details of the PECC-b procedure. ( A ) Retroflexed view of GE junction; ( B ) After 1st row of band application; ( C ) After 2nd row of band application; ( D ) After esophageal band application.

Monitoring and Follow-Up

Patients were monitored for 6 hrs after the procedure for any adverse effects related to the procedure, such as dysphagia, abdominal distension, hematemesis, or perforation. Intravenous analgesics were given in case of pain. Patients were prescribed two weeks of oral PPI and sucralfate at discharge. After two weeks, patients were advised to stop taking PPI regularly and use it only if symptoms of GERD are present and note the number of days of PPI usage per week. Occasional PPI use postprocedure was defined as the need for PPI once or twice a week. No response was defined as a requirement of PPI more than twice per week for symptom control. Follow-up visits were scheduled at one and 3 months from the procedure.

Follow-up assessments included an EGD at 1 month to document mucosal healing and evaluate for stricture formation, followed by repeat EGD and 24-hour pH monitoring at 3 months to assess for esophagitis, stricture, and reflux parameters. GERD-HRQL was also assessed at 3 months. Adverse events, if any, were recorded.

Outcome Measures

The primary outcome was the improvement in the quality of life using the GERD-HRQL validated questionnaire at 3 months after the procedure.

Secondary outcomes included improvement in GERD symptom scores, resolution of esophagitis on endoscopy, changes in DeMeester score, and AET on 24-h pH study, and drug independence at 3 months. Safety outcomes included serious adverse events and overall adverse events.

Definitions

The standardized baseline diagnosis and objective assessment of GERD were uniformly evaluated across all clinical endpoints on the basis of clinical symptoms paired with 24-hour pH monitoring parameters, requiring an AET >6%, a total number of reflux episodes >80, or an abnormal DeMeester score > 14.7. GERD-related quality of life was evaluated with the GERD-HRQL validated questionnaire, which is a set of nine questions scored on a six-point Likert scaling system, ranging from 0 to 5. The symptom score is then calculated as the sum of the frequency and severity ratings for each outcome measure.

Statistical Analysis

There are a few retrospective studies that have assessed the role of PECC-b on improvement in the GERD health-related quality of life following the procedure. There was a very small case series of 13 patients by Hu et al., which prospectively assessed the role of PECC-b for GERD. The analysis included all patients who underwent the procedure. We expressed baseline/follow-up continuous data as mean with standard deviations or median and interquartile range, depending on the normality of the underlying data distribution. Nominal/ordinal data were presented as proportions with a 95% confidence interval. The Wilcoxon test or the t test, if applicable, was used to compare preoperative and postoperative status. A p < 0.05 was considered statistically significant. Computed p -values were adjusted for multiple comparisons. All data was entered in Microsoft Excel version 16.62 and were analyzed using RStudio Version 2024.09.1 + 394. Besides base packages in R, tidyverse, readxl, ggradar, tableone, emmeans, and lme4 packages were also used.

Results

Baseline Characteristics

Between July 2023 and June 2025, 130 patients with typical GERD symptoms of heartburn and regurgitation were screened for inclusion. Of these, 40 patients (median age 34 (IQR: 18–60) years, 75% male) underwent PECC-b therapy and were included for analysis. Heartburn was present in all patients, regurgitation was seen in 35/40 (88%), and chest pain in 12/40 (30%) of patients. All the patients were on PPI, and the median duration of PPI usage was 12 (IQR:10–14) months at the time of enrolment. Baseline characteristics are summarized in Table 1 . There were no protocol deviations, and all patients completed a 3-month follow-up ( Fig. 2 ).

Table 1. Demographic and clinical characteristics of the patients who underwent PECC-b procedure ( n = 40).

Characteristics	Value
Male gender, n (%)	30 (75%)
Mean age (in years) ±SD	36 ± 10
Symptoms
Heartburn, n (%)	40 (100%)
Regurgitation, n (%)	35 (88%)
Symptom duration
>1 year, n (%)	35 (87.5%)
<1 years, n (%)	5 (12.5%)
Hill’s grade of GE flapn (%)
Hills grade 1	32 (80%)
Hills grade 2	8 (20%)
Hills grade 3	0
Hills grade 4	0
Esophagitis*n (%)
No erosive reflux esophagitis	34 (85%)
A	0
B	5 (12.5%)
C	1 (2.5%)
D	0
24 h pH study
% Total acid exposure time, median (IQR)	28.1 (18.2–54.5)
Number of reflux episodes, median (IQR)	81.5 (53.8–126)
DeMeester score, median (IQR)	103 (53–161)
Mean GERD-HRQL score ±SD	22.8 ± 3.2
Mean LES pressure at esophageal manometry ±SD	7.2 ± 2

* Esophagitis-as per Los Angeles Classification. ²²

Abbreviations : GERD-HRQL -Gastroesophageal reflux disease health-related quality of life; GE- Gastroesophageal; LES- Lower esophageal sphincter; SD: standard deviation.

Fig. 2.

Flow of patients in the study.

Intra and Postoperative Outcomes

All patients underwent PECC-b therapy successfully. The mean duration of the PECC-b procedure from the point of gastroscope insertion to withdrawal was 11 ± $3\mathrm{mi}$ n. Maximum number of bands used during the procedure were 10 while at least 8 bands were used in all patients who underwent the procedure. The number of ligation rings depended on the circumference of the cardia and, as per the endoscopist’s discretion. All patients who underwent the PECC-b procedure developed chest pain, and 15 (37%) patients required IV analgesics postprocedure. Three patients required a short duration (one day) of oral analgesics at discharge. Liquid diet was resumed 6 h after the procedure. None of the patients developed procedure-related dysphagia or bleeding.

Primary Outcome

On follow-up at 3 months, there was a significant improvement in GERD-HRQL scores (22.8 ± 3.2 at baseline to 12 ± 4.8; p < 0.001). About 50% (20/40) of the patients achieved 50% or more improvement in the GERD-HRQL score at 3 months post-intervention ( Table 2 , Fig. 3 ).

Table 2. Results of GERD health-related quality of life and 24-h esophageal pH monitoring in patients with GERD before and after 3 months of PECC-b procedure ( n = 40).

Characteristics	Before PECC-b	After 3 months	p Value *
GERD-HRQL score, mean ± SD	22.8±3.2	12±4.8	<0.0001
Regurgitation symptom score, median (IQR)	7.5 (5.8–8)	3 (2–5)	0.0004
Heartburn symptom score, median (IQR)	15 (12–16)	8 (4–9)	0.0002
%Total AET (%), median (IQR)	28.1 (18.2–54.5)	14.8 (8.0–18.0)	<0.0001
Total number of reflux episodes, median (IQR)	81.5 (53.8–126)	30 (21.8–70.8)	<0.0001
DeMeester score, median (IQR)	103 (51–161)	52.5 (33.5–78.3)	<0.0001
AET upright (%), median (IQR)	33.9 (16.5–59.8)	12.5 (9.9–20.5)	0.0004
AET recumbent (%), median (IQR)	23.4 (11.8–52.5)	12.0 (8.0–18.0)	<0.0001
Episodes Over 5 min, median (IQR)	8 (4–14)	5 (3–7)	<0.0001
Longest reflux episode (min), median (IQR)	125 (45–233)	87 (45–125)	<0.0001

*Paired t test/Wilcoxan test; p < 0.05 is significant.

Abbreviations: AET -Acid exposure time; GERD-HRQL -Gastroesophageal reflux disease health-related quality of life; IQR -Interquartile range.

Fig. 3.

Change in GERD health-related quality of life before and 3 months after the PECC-b procedure.

Secondary Outcomes

Improvement in Esophagitis

Endoscopic evaluation at 3 months showed complete resolution of esophagitis in all patients who had esophagitis at baseline ( n = 6). There was no symptomatic dysphagia or endoscopic evidence of luminal narrowing at the gastroesophageal junction on EGD.

Changes in 24 h pH Parameters

Significant improvement was observed in all 24-h pH parameters post procedure after 3 months, including a reduction in the esophageal acid exposure in standing [33.9% (16.5–59.8%) to 12.5% (9.9–20.5%); p < 0.005] and recumbent position [23.4% (11.8–52.5%) to 12.0% (8.0–18.0%); p < 0.005], and total AET [28.1% (18.2–54.5%) to 14.8% (10.4–18.6%); p < 0.005]. There was a significant improvement in median DeMeester score [103 (51–161) to 52.5 (33.5–78.3); p < 0.005]. There was significant improvement in other individual parameters of Demeester score – total number of reflux episodes [81.5 (53.8–126) to 30 (21.8–70.8); p < 0.005], episodes more than 5 min, [7.9 (4.3–14) to 5 (3–7); p < 0.005], longest episode[125 (45–233) to 87 (45–125); p < 0.005] ( Table 2 , Fig. 4 ).

Fig. 4.

Change in DeMeester score and its components on 24-h pH study before and 3 months after the procedure. ( A ) DeMeester score; ( B ) Acid exposure time upright; ( C ) Acid exposure time supine; ( D ) Total acid exposure time; ( E ) long reflux.

Clinical Improvement

At 3 months, there was an improvement in individual symptom score of heartburn [median heartburn score 15 (11–19) before to 8 (5–13) after; p < 0.005] and regurgitation [median regurgitation score 6 (3–9) before to 3 (1–5) after; p < 0.005].

PPI Use

At the 3-month follow-up, 57.5% (23/40) of patients were completely off PPI. In all, 27.5% (11/40) of the patients were partially responsive and needed PPIs occasionally (up to twice per week), and 15% (6/40) of patients had no response (requiring PPI more than twice per week) and were using PPI at the end of 3 months post therapy.

Adverse Events

Overall, chest pain was the most common reported symptom immediately after the procedure; 37% (15/40) of the patients received a single dose of IV analgesics in the postprocedure observational period, and 7% (3/40) of the patients were prescribed oral analgesics at discharge for one day. No patient required post-procedure medical consultation for pain management. None of the patients developed dysphagia or bleeding after the procedure. At the end of the 3-month follow-up, there were no serious adverse events related to the procedure.

Discussion

In this prospective study, we have shown that the PECC-b procedure has a significant symptomatic improvement with a reduction in GERD-HRQL scores in a select subgroup of patients with GERD on long-term PPI. Up to 50% of the patients had 50% or more reduction of GERD-HRQL scores with significant improvement of heartburn and regurgitation symptom scores. More than 50% patients were off PPI at 3 months of follow-up. These clinical results corroborated with the findings on the 24-hour pH study, thus providing objective evidence of a reduction in GERD. Furthermore, the procedure time was very short, and while the procedure was generally safe, it was associated with short-lasting postprocedural pain; however, none of the patients required postprocedure monitoring for more than 4 h, and there were no long-term adverse events on follow-up visits, thus confirming the safety of the procedure. Although there was no serious morbidity, this high rate of postprocedural pain highlights an important clinical finding necessitating perioperative pain management protocols.

In patients who have a largely intact crural sphincter (i.e., absence or a very limited hiatal hernia, Hill Grade 1 or 2), the potential for an endoluminal approach for restoring the LES exists. The mechanism of PECC-b is attributed to the application of multiple rubber bands at the EGJ, leading to submucosal necrosis and subsequent fibrosis. This process augments the LES pressure, thereby preventing reflux of gastric contents. The underlying mechanism is similar to anti-reflux mucosal interventions (ARMIs) in which mucosal resection or ablation is done at the cardia, ¹⁴ leading to scarring and tightening of the gastroesophageal reflux valve. However, ARMI is a technically more challenging procedure than PECC-b and is currently limited by the availability of expertise. A recent meta-analysis evaluating ARMI by Garg et al. showed an overall 97.7% technical success rate with 17.2% adverse events, most common being bleeding (5%), followed by perforation, muscle injury, and aspiration pneumonia. About 11.4% of the patients had dysphagia secondary to EGJ stricture requiring dilatation with ARMI. ¹⁵ Further, ARMI requires intubation and general anesthesia, and the median procedure duration is 40–50 min. In contrast, PECC-b is performed using a multiband ligator, a readily available and cost-effective tool, under conscious sedation, and has similar results with no serious adverse events. Our PECC-b cohort had a mean procedure duration of 11 ± 3 min while achieving 100% technical success rates. In addition, considering variceal banding as a routine procedure done by most gastroenterologists, we presume that PECC-b has a short learning curve, and performing initial three to five procedures under supervision is sufficient to gain adequate expertise. Postprocedural esophageal spasm and mucosal ischemia translated into acute chest pain in majority of the patients across the cohort, which remains a key clinical consideration. None of the patients had bleeding, perforation, or aspiration pneumonitis after PECC-b, suggesting a good safety profile of the procedure. All patients could resume a soft diet 6 h after the procedure, with resumption of normal diet 48 h after the procedure. There were no significant adverse events at the end of 3 months of follow-up.

Currently, multiple endoscopic therapeutic modalities exist for the management of GERD, each using a different mechanism of action: a transoral incisionless fundoplication device (EsophyX, EndoGastric Solutions, Redmond, WA), ¹⁶ a radiofrequency energy delivery system (Stretta, Mederi Therapeutics, Inc., Greenwich, CT), ¹⁷ the Ultrasonic Surgical Endostapler device (MUSE, Medigus, Omer, Israel), ¹⁸ and GERDx (G-SURG GmbH, Seeon-Seebruck, Germany). ¹⁹ All of these modalities require specialized equipment, technical expertise, and have cost-related implications. A meta-analysis by Fass et al. showed PPI independence was achieved in up to 51% of patients after Stretta procedure, with a significant decrease in erosive esophagitis and esophageal acid exposure ²⁰ . Similarly, a recent meta-analysis by Niu et al. for endoscopic full-thickness plication systems showed significant improvement in GERD-HRQL and PPI independence in up to 60% of patients. ²¹ These results are comparable to the PECC-B therapy, circumventing the need for additional equipment and cost implications, while maintaining similar results. While long-term data on the effectiveness of PECC-b are required, the procedure is very simple and can be repeated in case of recurrence of the symptoms. Moreover, PECC-b may be considered an initial endoscopic therapeutic option for GERD, as it does not significantly alter the anatomy of the gastroesophageal junction. Consequently, additional endoscopic or surgical interventions can be pursued in the event of treatment failure.

The strengths of our study are the prospective study design with the use of objective indicators for evaluation, such as validated GERD-HRQL scores, 24-hour pH study, and manometry, which enhances the reliability and validity of the findings. The prospective study design ensured that all patients had a complete evaluation before and after the procedure and underwent the standard procedure without any variations. However, the findings of the study should be interpreted while considering the limitations of our study; first and foremost being the single-group, nonrandomized design being a major limitation, with the inherent biases associated with such a study design. Secondly, the number of patients in our study is relatively small, with a short duration of follow-up. A long-term follow-up is required to establish safety, long-term efficacy, patient satisfaction rates, and cost-effectiveness of the procedure. Thirdly, a potential placebo effect cannot be ruled out, as 15% of the patients did not have any improvement in symptoms and were using PPIs at the end of 3 months. Furthermore, postprocedural high-resolution manometry was not performed; therefore, mechanistic conclusions regarding LES augmentation through fibrosis cannot be clearly established. Finally, studies have shown that up to 40% of patients with symptomatic GERD on PPIs have a nonacidic reflux. In our study, PPIs were stopped for 2 weeks before pH testing to remove this confounder. It would be interesting to do impedance studies and assess whether PECC-b improves nonacidic reflux as well. Initial screening and enrolment of patients were done on historical details. However, in a routine clinical setting, most patients with PPI-dependent GERD would not undergo objective testing for the same, and we believe that our study results are generalizable to routine care. The current data only support short-term feasibility and short-term symptomatic improvement in a highly selected population, but not durable efficacy.

In conclusion, this pilot study suggests that PECC-b is a promising and safe endoscopic treatment for selected patients with PPI-dependent GERD, demonstrating short-term improvements in symptom relief and quality of life. Its simplicity, cost-effectiveness, and minimal adverse event profile make it an appealing alternative to more invasive procedures. Further large-scale, multicenter, randomized controlled trials with longer follow-up periods are warranted to confirm these findings and establish PECC-b’s role in the broader GERD treatment landscape.

Declaration of Generative AI Use

The authors confirm that no Generative AI was used in the preparation of this manuscript.

Data availability Statement

Data underlying this article will be shared on reasonable request to the corresponding author.

Informed Consent

Written informed consent has been taken from the patient for the publication of the case details.