Endoscopic suturing with muscular after fundus mucoresection for refractory gastroesophageal reflux disease：a new anti-reflux technique

A 63-year-old male with a 20-year history of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) presented with persistent heartburn and regurgitation (GERD-HRQL score 29). High-resolution manometry showed a hypotensive lower esophageal sphincter (LES), and 24-hour pH-impedance monitoring confirmed pathological reflux (DeMeester score: 83.18). The patient underwent endoscopic suturing with muscular after fundus mucoresection (ESFM), a novel hybrid procedure combining endoscopic mucosal resection with fundoplication principles ([Fig. 1]). Following an 8-hour preoperative fasting period, the gastric cardia was endoscopically exposed. Key steps included are as follows: mucosal marking at the gastric cardia (1.5 cm × 2 cm area); submucosal injection and circumferential endoscopic mucosal resection; nylon loop placement with clip-anchored muscular plication; and creation of an anti-reflux valve via suture tightening ([Video 1]). Postoperative recovery was uneventful with a 3-day hospitalization. At 3-month follow-up, the patient reported complete resolution of reflux symptoms without dysphagia (GERD-HRQL 7). Repeat endoscopy demonstrated a well-healed plication fold.