Clinical Scorecard: Integrating Transoral Incisionless Fundoplication with Endoscopic Sleeve Gastroplasty (F-ESG): A Novel Endoscopic Strategy for Managing Obesity-Related Gastroesophageal Reflux Disease

At a Glance

Key Highlights

• F-ESG integrates Transoral Incisionless Fundoplication (TIF) and Endoscopic Sleeve Gastroplasty (ESG) in a single endoscopic session to address both GERD and obesity.
• TIF reconstructs the gastroesophageal junction with a 270° partial fundoplication to augment the anti-reflux barrier; ESG restricts gastric volume via full-thickness sutures creating a sleeve-like stomach.
• The combined procedure is minimally invasive, preserves anatomy, and aims to overcome limitations of pharmacological and surgical treatments for obesity-related GERD.

Guideline-Based Recommendations

Diagnosis

• Confirm pathologic acid reflux with 48-hour pH monitoring (DeMeester score > 14.7).
• Exclude large hiatal hernia (> 2 cm) and esophageal motility disorders via endoscopy and barium esophagram.
• Assess GERD symptoms despite proton pump inhibitor therapy.

Management

• Perform F-ESG with TIF first to restore the anti-reflux barrier followed by ESG to reduce gastric volume in the same endoscopic session.
• Continue PPI therapy for 6 weeks post-procedure with subsequent tapering.
• Implement a staged post-bariatric diet progression and provide nutritional counseling with low-calorie diet and moderate physical activity.

Monitoring & Follow-up

• Evaluate weight, BMI, and percent total weight loss at baseline, 6 months, and 12 months.
• Assess GERD symptoms using validated questionnaires (GERD HRQL and Reflux Symptom Index).
• Repeat 48-hour pH monitoring off PPI therapy to objectively assess reflux control.
• Monitor PPI medication use and dosage post-procedure.

Risks

• Contraindications include previous gastric or esophageal surgery, Barrett’s esophagus, esophageal motility disorders, pregnancy, LA Grade C-D esophagitis, and esophagogastric lesions.
• Potential procedural risks are minimized by performing TIF prior to ESG to maintain fundic anatomy and optimize valve formation.

Patient & Prescribing Data

Adults with obesity (BMI 30–40 kg/m²) and documented GERD refractory to PPI therapy without large hiatal hernia or significant esophageal pathology.

F-ESG offers a minimally invasive alternative combining anti-reflux and weight loss mechanisms, potentially reducing reliance on long-term PPI therapy and avoiding complications associated with bariatric surgery.

Clinical Best Practices

• Perform TIF before ESG in the same session to preserve fundic mobility and optimize anti-reflux valve formation.
• Use validated symptom and objective reflux assessments pre- and post-procedure to monitor efficacy.
• Adhere to strict inclusion and exclusion criteria to select appropriate candidates for F-ESG.
• Provide comprehensive post-procedure dietary guidance and lifestyle counseling to support weight loss and symptom improvement.
• Ensure procedures are performed by endoscopists experienced in both TIF and ESG techniques under general anesthesia.

References

• Obesity and GERD prevalence and pathophysiology
• Comparative GERD rates after bariatric surgery
• Endoscopic bariatric therapies overview
• TIF efficacy for GERD management
• ESG efficacy for weight loss