Endoscopic versus surgical anti-reflux procedures for GERD

Endoscopic and surgical anti-reflux procedures are both effective treatment options for managing gastroesophageal reflux disease (GERD), but they differ significantly in terms of efficacy, safety, and patient suitability. Below is a detailed comparison based on the findings from the systematic review and network meta-analysis:

### 1. **Efficacy**

• Both endoscopic and surgical interventions are more effective than continued proton pump inhibitor (PPI) therapy alone for controlling GERD symptoms and reducing the need for PPI use.
• **Surgical Procedures**:
• **Laparoscopic Nissen Fundoplication (LNF)**: Demonstrated the highest overall efficacy for reflux control and medication discontinuation (SUCRA = 0.84). It is considered the gold standard for GERD surgery.
• **Laparoscopic Toupet Fundoplication (LTF)**: Ranked second in efficacy (SUCRA = 0.71). It is a partial fundoplication that may have fewer side effects compared to LNF.
• **Anterior Partial Fundoplication (APF)**: Ranked third in efficacy (SUCRA = 0.70), offering a less invasive surgical option with good outcomes.
• **Endoscopic Procedures**:
• **Transoral Incisionless Fundoplication (TIF)**: While not as effective as surgical options for overall reflux control, TIF excelled in symptom relief, particularly for reducing heartburn (SUCRA = 0.87) and bloating (SUCRA = 0.86).

### 2. **Safety**

• Surgical and endoscopic procedures generally have comparable safety profiles to continued PPI therapy.
• **Surgical Procedures**:
• LNF, while highly effective, is associated with a higher risk of postoperative complications such as dysphagia and gas-related symptoms.
• **Endoscopic Procedures**:
• TIF has the lowest rate of adverse effects among all evaluated procedures, making it a safer and less invasive alternative for patients who prioritize minimal side effects.

### 3. **Suitability**

• **Surgical Procedures**:
• Best suited for patients with severe GERD symptoms, significant anatomical abnormalities (e.g., large hiatal hernia), or those who require the strongest reflux control and long-term independence from medication.
• However, patients must be aware of the potential for higher postoperative complications, particularly with LNF.
• **Endoscopic Procedures**:
• Ideal for patients who prefer a minimally invasive approach with fewer risks and are primarily seeking symptom relief (e.g., heartburn and bloating) rather than complete reflux control.
• TIF, in particular, is a promising option for patients who are not candidates for surgery or who prioritize safety and quicker recovery.

### 4. **Patient Priorities**

• Patients who prioritize long-term reflux control and independence from PPIs are better suited for surgical treatments like LNF.
• Patients who prioritize safety, minimal invasiveness, and symptom relief without significant recovery time may prefer endoscopic treatments like TIF.

### Conclusion:

Both endoscopic and surgical anti-reflux procedures are effective for GERD management, but the choice of treatment depends on individual patient needs, priorities, and risk tolerance. LNF provides the strongest reflux control and medication independence but carries a higher risk of complications. TIF, on the other hand, offers a safer, less invasive alternative with excellent symptom relief and minimal side effects, making it a promising option for selected patients. Consulting with a healthcare provider is essential to determine the most suitable approach based on the severity of GERD, anatomical considerations, and personal preferences.