Endoscopic anti-reflux treatment for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a heterogeneous condition with substantial diagnostic and therapeutic complexities. Endoscopic anti-reflux therapies have emerged as minimally invasive options positioned between pharmacological therapy and surgical fundoplication. However, their optimal role remains incompletely defined. Endoscopic anti-reflux therapies encompass distinct mechanistic categories, including mucosal remodeling-based interventions, neuromodulatory therapy, and endoscopic fundoplication. Among these, transoral incisionless fundoplication has the most clearly defined role in current international guidelines for carefully selected patients with mild-to-moderate GERD, predominant regurgitation, and minimal anatomical disruption. In contrast, radiofrequency-based therapy is generally confined to a limited symptom-oriented role. Anti-reflux mucosal interventions represent an evolving approach with encouraging results from observational studies and meta-analyses; however, their use remains limited by the heterogeneity of techniques and lack of robust randomized evidence. This review provides an evidence-based appraisal of contemporary endoscopic anti-reflux therapies, focusing on the mechanistic rationale, patient selection, clinical outcomes, and guideline positioning. Accurate diagnosis and phenotypic classification are essential. Objective confirmation of pathological reflux, assessment of the esophagogastric junction anatomy, and evaluation of esophageal motility are critical for distinguishing patients who may benefit from endoscopic intervention from those with functional or overlapping esophageal disorders.