Clinical Report: Combined Transoral Incisionless Fundoplication and Endoscopic Sleeve Gastroplasty for Obesity-Related GERD

Overview

This pilot study evaluates the feasibility, safety, and 12-month outcomes of a novel combined endoscopic procedure—Fundoplication-ESG (F-ESG)—integrating Transoral Incisionless Fundoplication (TIF) and Endoscopic Sleeve Gastroplasty (ESG) to simultaneously address obesity and gastroesophageal reflux disease (GERD). The combined approach demonstrated technical success with promising improvements in reflux symptoms and weight loss, offering a minimally invasive alternative to conventional therapies.

Background

Obesity and GERD are closely linked conditions, with obesity increasing intra-abdominal pressure and disrupting the anti-reflux barrier, thereby exacerbating GERD. Traditional treatments such as proton pump inhibitors provide incomplete symptom control, and bariatric surgeries like sleeve gastrectomy may worsen GERD symptoms. Endoscopic therapies such as ESG for weight loss and TIF for reflux management have emerged as less invasive options. The F-ESG procedure combines these two techniques in a single session to target both conditions simultaneously while preserving gastric anatomy and function.

Data Highlights

Key Findings

• The F-ESG procedure was technically feasible and safe, with no major adverse events reported.
• Significant weight loss was achieved, with mean % total weight loss of 14.1% at 12 months post-procedure.
• GERD symptoms improved markedly, as evidenced by reductions in GERD-HRQL and RSI scores at 6 and 12 months.
• Objective acid reflux parameters improved, with mean DeMeester scores decreasing below pathological thresholds at follow-up.
• PPI medication use was substantially reduced, with only 20% of patients requiring PPIs at 12 months.
• The sequential approach of performing TIF prior to ESG preserved fundic anatomy and facilitated effective valve creation without impairing endoscopic maneuverability.

Clinical Implications

The combined F-ESG procedure offers a minimally invasive, organ-preserving strategy to simultaneously address obesity and GERD, overcoming limitations of pharmacologic and surgical treatments. This approach may reduce reliance on PPIs and avoid GERD exacerbation associated with some bariatric surgeries, providing an effective therapeutic option for patients with obesity-related reflux disease. Careful patient selection and procedural sequencing are critical to optimize outcomes.

Conclusion

Integrating TIF with ESG in a single endoscopic session is a feasible and safe approach that yields significant improvements in both weight and reflux control at 12 months. F-ESG represents a promising novel strategy for managing the complex interplay of obesity and GERD.

References

1. EndoGastric Solutions/ Apollo Endosurgery/ 2023 -- Integrating Transoral Incisionless Fundoplication with Endoscopic Sleeve Gastroplasty (F-ESG): A Novel Endoscopic Strategy for Managing Obesity-Related Gastroesophageal Reflux Disease