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Invited Critique
January 19, 2009

Endoluminal Full-Thickness Plication and Radiofrequency Treatments for GERD—Invited Critique

Arch Surg. 2009;144(1):24. doi:10.1001/archsurg.144.1.24

Gastroesophageal reflux disease is one of the most commonly encountered gastrointestinal disorders. Medical therapy for GERD is limited by long-term costs and effectiveness, while antireflux surgery is limited by its inherent morbidity. A durable and effective procedure that focuses on disease control (and not symptom control alone), and that can be accomplished on an outpatient basis without surgery, is needed. For the past 10 years, there has been an intense interest in developing and defining such a procedure. Numerous endoluminal GERD treatments have come and gone during this time. Some devices have been withdrawn from the market owing to safety concerns, and others have fallen out of favor because of a lack of long-term effectiveness. In fact, at the time of this writing, a device for delivering endoscopic radiofrequency treatment for GERD such as the one employed in this trial is not commercially available. Jeansonne and colleagues have nicely demonstrated and compared the short-term symptomatic outcomes of 2 different endoscopic GERD treatment modalities. Both procedures resulted in GERD symptom improvement and demonstrated an excellent safety profile. What this study and others fail to definitively demonstrate is the kind of consistent symptom improvement and durability of therapy related to laparoscopic fundoplication in the hands of an experienced surgeon. In this era of limited health care dollars, especially considering the prevalence of severe GERD in our society, we have a responsibility to ensure that these endoluminal therapies effect durable and consistent results on par with our time-tested treatments. In my opinion, we still have a long way to go before a clear alternative to laparoscopic antireflux surgery emerges for those with medically refractory GERD symptoms.

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