A novel endoscopic approach for the treatment of hiatal hernia combined with refractory gastroesophageal reflux disease

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Abstract
Hiatal hernia (HH) is an important cause of refractory gastroesophageal reflux disease (GERD) [1]. Repair of hiatal hernias primarily relies on surgical intervention, with a lack of robust options for endoscopic treatments [2]. Here, we report a case in which a hiatal hernia combined with refractory GERD was successfully treated by gastric fundal and esophageal mucosal ligation combined with titanium clips (GEML-C). A 69-year-old woman came to our hospital with a 20-year history of refractory GERD. Despite being on twice-daily proton pump inhibitor (PPI) therapy, she continued to experience symptoms, primarily acid reflux. The gastroscopic report suggested grade C erosive esophagitis and presence of a hiatal hernia ([Fig. 1] a, b). Esophageal manometry confirmed a grade III hiatal hernia ([Fig. 2]). The patient opted for GEML-C after the discussion of the options. A therapeutic endoscope was used throughout the whole process. With use of the inverted mirror condition, ligatures were placed with a multiring ligator (MBL-U-10; Cook Medical, USA) in a direction that was parallel to the angle of His. Six ligature rings were placed on the fundal side of the hernia sac ([Fig. 3] a). Two ligation rings were placed in the lower esophagus on the sides of the greater and lesser curvatures, and two large titanium clips (ROCC-D-26-195; MT, China) were placed at the base of the ligations ([Fig. 3] b). The lack of active resection in GEML-C is speculated to increase its safety profile, with a reduced risk of bleeding and perforation. In addition by ligating both the stomach and esophagus at the same time, it plays a better role in repairing the hernia sac and improving antireflux ([Video 1]). The patient was discharged 1 day after the procedure. By 2 weeks later, she had reduced her dosage of PPI from twice daily to twice a week. After 3 months of follow-up, her clinical symptoms, gastroscopy, and esophageal manometry results all showed significant improvement ([Fig. 4] and [Fig. 5]; [Table 1]). This case suggests that this new type of minimally invasive endoscopic interventional therapy may be safer and faster for the treatment of hiatal hernia combined with refractory GERD. Endoscopy_UCTN_Code_TTT_1AO_2AJ Article published online: 03 June 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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