The target of therapies: pathophysiology of gastroesophageal reflux disease

Recognition of the importance of anatomical and mechanical factors in the pathogenesis of GERD has led to attempts that modify these mechanisms by endoluminal therapies. Although these alterations of EGJ anatomy and function appear minor at first glance, one must be cautious not to upset the delicate balance maintained by this complex anatomic zone. Performing a procedure that effects retrograde flow will inevitably also affect antegrade flow to some degree. The challenge will be to find a middle ground whereby GERD symptoms are not exchanged for symptoms such as dysphagia and gas bloat. With respect to endoluminal therapies, the authors are at an early stage of development and much more work is needed to define the relevant mechanical variables that need to be modified and to define the patient populations most appropriate for these interventions.