Background

Gastroesophageal Reflux Disease

GERD is a common disorder characterized by heartburn and other symptoms related to reflux of stomach acid into the esophagus. Nearly all individuals experience such symptoms at some point in their lives; a smaller number have chronic symptoms and are at risk for complications of GERD. The prevalence of GERD has been estimated to be 10% to 20% in the Western world, with a lower prevalence in Asia.^1,

Pathophysiology

The pathophysiology of GERD involves excessive exposure to stomach acid, which occurs for several reasons. There can be an incompetent barrier between the esophagus and stomach, either due to dysfunction of the lower esophageal sphincter or incompetence of the diaphragm. Another mechanism is an abnormally slow clearance of stomach acid. In this situation, delayed clearance leads to an increased reservoir of stomach acid and a greater tendency to reflux.

In addition to troubling symptoms, some patients will have a more serious disease, which results in complications such as erosive esophagitis, dysphagia, Barrett esophagus, and esophageal carcinoma. Pulmonary complications may result from aspiration of stomach acid into the lungs and can include asthma, pulmonary fibrosis, and bronchitis, or symptoms of chronic hoarseness, cough, and sore throat.

Treatment

Guidelines on the management of GERD emphasize initial medical management. Weight loss, smoking cessation, head of the bed elevation, and elimination of food triggers are all recommended in recent practice guidelines.^1, Proton pump inhibitors have been shown to be the most effective medical treatment. In a Cochrane systematic review, van Pinxteren et al (2010) reported that proton pump inhibitors demonstrated superiority to H₂-receptor antagonists and prokinetics in both network meta-analyses and direct comparisons.^2,

Surgical Treatment

The most common surgical procedure used for GERD is laparoscopic Nissen fundoplication. Fundoplication involves wrapping a portion of the gastric fundus around the distal esophagus to increase lower esophageal sphincter pressure. If a hiatal hernia is present, the procedure also restores the position of the lower esophageal sphincter to the correct location. Laparoscopic fundoplication was introduced in 1991 and has been rapidly adopted because it avoids complications associated with an open procedure.

Although fundoplication results in a high proportion of patients reporting symptom relief, complications can occur, and sometimes require conversion to an open procedure. Patients who have relief of symptoms of GERD after fundoplication may have dysphagia or gas-bloat syndrome (excessive gastrointestinal gas).

Other Treatment Options

Due in part to the high prevalence of GERD, there has been interest in creating a minimally invasive transesophageal therapeutic alternative to open or laparoscopic fundoplication or chronic medical therapy. This type of procedure may be considered natural orifice transluminal surgery. Three types of procedures have been investigated.

1. Transesophageal endoscopic gastroplasty (gastroplication, transoral incisionless fundoplication) can be performed as an outpatient procedure. During this procedure, the fundus of the stomach is folded and then held in place with staples or fasteners that are deployed by the device. The endoscopic procedure is designed to recreate a valve and barrier to reflux.
2. Radiofrequency energy has been used to produce submucosal thermal lesions at the gastroesophageal junction. (This technique has also been referred to as the Stretta procedure.) Specifically, radiofrequency energy is applied through four electrodes inserted into the esophageal wall at multiple sites both above and below the squamocolumnar junction. The mechanism of action of the thermal lesions is not precisely known but may be related to the ablation of the nerve pathways responsible for sphincter relaxation or may induce a tissue-tightening effect related to heat-induced collagen contraction and fibrosis.
3. Submucosal injection or implantation of a prosthetic or bulking agent to enhance the volume of the lower esophageal sphincter has also been investigated.

The Agency for Healthcare Research and Quality published a systematic review of management strategies for GERD in 2005, which was updated by Ip et al (2011).^3,4, The 2005 comparative effectiveness review evaluated studies on the EndoCinch Suturing System, Stretta, Enteryx, and the NDO Plicator.^3, The 2011 update excluded Enteryx and the NDO Plicator, because they were no longer available in the US, and added the EsophyX procedure (endoscopic fundoplication), which was commercialized after the 2005 review.^4, The 2011 report concluded that, for the 3 available endoscopic procedures (EndoCinch, Stretta, EsophyX), effectiveness remained substantially uncertain for the long-term management of GERD. All procedures have been associated with complications, including dysphagia, infection/fever, and bloating, although bloating and dysphagia are also adverse events of laparoscopic fundoplication.^5, A review of endoscopic treatment of GERD by Hummel and Richards (2015) noted that EndoCinch is no longer manufactured.^6,

Regulatory Status

In 2007, EsophyX® (EndoGastric Solutions) was cleared for marketing by the FDA through the 510(k) process for full-thickness plication. In 2016, EsophyX® Z Device with SerosaFuse Fasteners was cleared for marketing by the FDA through the 510(k) process (K160960) for use in transoral tissue approximation, full-thickness plication, ligation in the gastrointestinal tract, narrowing the gastroesophageal junction, and reduction of hiatal hernias of 2 cm or less in patients with symptomatic chronic GERD.^7,In June 2017, EsophyX2 HD and the third-generation EsophyX Z Devices with SerosaFuse fasteners and accessories were cleared for marketing by the FDA through the 510(k) process (K171307) for expanded indications, including patients who require and respond to pharmacologic therapy and patients with hiatal hernias larger than 2 cm when a laparoscopic hiatal hernia repair reduces a hernia to 2 cm or less.^8, FDA product code: ODE.

The Medigus SRS Endoscopic Stapling System (MUSE, Medigus) was cleared for marketing by the FDA through the 510(k) process in 2012 (K120299) and 2014 (K132151). MUSE is intended for endoscopic placement of surgical staples in the soft tissue of the esophagus and stomach to create anterior partial fundoplication for the treatment of symptomatic chronic GERD in patients who require and respond to pharmacologic therapy. FDA product code: ODE.

In 2000, the CSM Stretta® System was cleared for marketing by the FDA through the 510(k) processfor general use in the electrosurgical coagulation of tissue and was specifically intended for use in the treatment of GERD. Stretta® is currently manufactured by Mederi Therapeutics. FDA product code: GEI.

Durasphere® is a bulking agent approved for the treatment of urinary and fecal incontinence. Use of this product for esophageal reflux would be considered off-label use. The website of Carbon Medical Technologies states that the Durasphere® GR product is “intended to treat problems associated with GERD” but is considered an investigational device in the US.

Related Policies

• Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus (Policy #105 in the Treatment Section)
• Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (Policy #134 in the Surgery Section)

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy

FIDE-SNP Coverage:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: This policy was created in 2001 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through October 7, 2019.

This policy was informed, in part, by a TEC Assessment (2003) of transesophageal endoscopic treatments for gastroesophageal reflux disease (GERD) and an Evidence Street Assessment (2016) on transoral incisionless fundoplication (TIF).^9, This policy addresses procedures currently available for use in the US.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life (QOL), and ability to function - including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, two domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Transoral Incisionless Fundoplication for Symptoms Uncontrolled by Proton Pump Inhibitors

Clinical Context and Test Purpose

The purpose of TIF (e.g., EsophyX) is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with GERD and hiatal hernias of 2 cm or less not controlled by PPIs.

The question addressed in this policy is: Does TIF using the EsophyX2 System improve the net health outcomes in individuals with GERD?

The following PICOs were used to select literature to inform this policy.

Patients

The relevant population of interest are individuals with GERD and a hiatal hernia of 2 cm or less uncontrolled by PPIs.

Interventions

The therapy being considered is TIF2.0 (e.g., EsophyX2).

Comparators

The following practice is currently being used to treat GERD: laparoscopic fundoplication.

Outcomes

The general outcomes of interest are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. Follow-up at three years is of interest to monitor outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

McCarty et al (2018) published a systematic review of RCTs and nonrandomized studies that showed significant improvement in a number of clinical outcomes for patients treated with TIF.^10, For example, 89% of TIF patients discontinued PPI therapy after the procedure, and the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire, Gastroesophageal Reflux Symptom Score, and Reflux Symptom Index measures showed significant improvement. The review had several limitations, including the risk of heterogeneity bias, due to the inclusion of studies of first- and second-generation TIF devices and protocols.

Richter et al (2018) published a network meta-analysis of RCTs comparing TIF or laparoscopic Nissen fundoplication (LNF) with sham or PPIs.^11, The meta-analysis was limited by low-quality studies (one did not report the randomization method, others lacked data on allocation concealment, blinding of outcome assessors, or other aspects of study protocol). It should be noted that a reason behind for scarcity of direct comparisons between TIF and LNF is the discrepancy in populations requiring the respective treatments: consequently, TIF studies included patients with mild esophagitis and small hiatal hernias (<2 cm), while LNF studies included patients with Los Angeles grade A, B, C, or D esophagitis and all sizes of hiatal hernias.

Tables 1 and 2 summarize the characteristics and results of selected systematic reviews.

Table 1. Characteristics of Systematic Reviews

Study	Dates	Trials	Participants	N (Range)	Design	Duration
McCarty et al (2018)10,	2008-2016	32	Patients met standard criteria for the TIF procedurea	1475 (10-124)	5 RCTs, 21 prospective and 6 retrospective studies	NR
Richter et al (2018)11,	NR	7	Patients had GERD, established by endoscopic results indicating erosive esophagitis and/or abnormal ambulatory esophageal pH monitoringb		2 RCTs (TIF vs PPI); 2 RCTs (TIF vs sham); 3 RCTs (LNF vs PPIs)	TIF: 6-12 mo LNF vs PPI: 1-5 y

GERD: gastroesophageal reflux disease; LNF: laparoscopic Nissen fundoplication; NR: not reported; PPI: proton pump inhibitor; RCT: randomized controlled trial; TIF: transoral incisionless fundoplication.

^a Body mass index <35 kg/m²; hiatal hernia size ≤2 cm; grade A, B, or C esophagitis using the Los Angeles classification; no underlying esophageal motility disorder.
^b DeMeester score >14.7 and/or percentage total time at a pH <4 of ≥4.0%.

Study	Complete PPI Cessation	GERD-HRQL Score	GERSS	RSI Score	Other Objective Measures
					Esophageal Acid Exposure (% time with pH <4)
McCarty et al (2018)10,
N	1407 (28 studies)	1236 (25 studies)	NR (6 studies)	NR (8 studies)	722 (15 studies)
% (95% CI)	89 (82 to 95)
MD (95% CI)		17.72 (17.31 to 18.14)	23.78 (22.96 to 24.60)	14.28 (13.56 to 15.01)	3.43 (2.98 to 3.88)
p	<0.001	<0.001	<0.001	<0.001	<0.001
I2 (p)	93.6 (0.00)	94 (<0.001)	98 (<0.001)	95 (<0.001)	86 (<0.001)
Mean follow-up (SD), mo	15.5 (14.6)
		TIF-2 Subgroup			TIF-2 Subgroup
N		997 (15 studies)
MD (95% CI)		17.62 (17.19 to 18.05)			53.18 (49.49 to 56.87)
p		<0.001			<0.001
Richter et al (2018)11,
N		TIF=293 (4 studies) LNF=875 (3 studies)
OR (95% CrI)		TIF vs LNF: 2.08 (0.71 to 6.09)			LNF vs TIF: 0.08 (0.02 to 0.36)
Ranking probability (SUCRA)		TIF=0.96 LNF=0.66 Sham=0.35 PPI=0.042			LNF=0.99 PPI=0.64 TIF=0.32 Sham=0.05

Randomized Controlled Trials

Two RCTs have evaluated TIF using ExophyX2 in patients with troublesome symptoms despite daily PPI therapy (see Table 3). Hunter et al (2015) compared treatment using TIF2.0 plus placebo pills (n=87) with treatment using sham TIF plus PPIs (n=42) in the RESPECT trial.^12, Increases in medication (placebo or PPI depending on treatment group) were allowed at two weeks. At three months, patients with continued troublesome symptoms were declared early treatment failures and failed TIF patients were given PPI and failed sham patients were offered TIF. Trad et al (2015) compared TIF2.0 (n=40) with maximum PPI therapy (n=23) without a sham procedure in the TEMPO trial.^13, The primary outcome in both trials was the elimination of symptoms, measured in slightly different ways (see Table 3).

In both trials, the primary outcome was achieved by a higher percentage of patients treated with TIF than with PPIs (see Table 4). Elimination of symptoms was reported by 62% to 67% of patients treated by TIF compared with 5% of patients treated with maximum PPIs and 45% of patients who had a sham procedure plus PPIs (p=0.023). In TEMPO, the relative risk of achieving the primary outcome was 12.9 (95% confidence interval, 1.9 to 88.9; p<0.001).

Secondary outcomes for the RESPECT trial showed no significant differences between treatments, except for Reflux Disease Questionnaire scores, which showed significant improvement in the TIF group compared with baseline. Physiologic measurements such as the number of reflux episodes, percentage of total time pH less than 4, and DeMeester score (a composite score of acid exposure based on esophageal monitoring) showed statistically significant differences between groups, but these measurements were performed when off PPIs for 7 days and the difference in pH between TIF and continued PPI therapy cannot be determined from this trial.

In TEMPO, self-reported troublesome regurgitation was eliminated in 97% (29/30) of TIF patients who were off PPIs. However, the objective measure of esophageal acid exposure did not differ significantly between groups.

Table 3. Characteristics of Randomized Controlled Trials Comparing TIF With Medical Management in Patients Whose Symptoms Were Not Controlled on PPIs

Study; Trial	TIF/CTL, n	Patient Symptoms or Other Characteristics	Comparator	FU, mo	Principal Clinical Outcome
Hunter et al (2015)12,; RESPECT	87/42	Hiatal hernia≤2 cm Troublesome regurgitationa not controlled on PPI	Sham + PPI	6	Relief of regurgitation without PPI in TIF group vs PPI escalation in control group
Trad et al (2015)13,; TEMPO	40/23	Hiatal hernia≤2 cm Troublesome symptoms not controlled on PPIb	Maximum-dose PPI	6	Elimination of daily symptoms other than heartburn

CTL: control; FU: follow-up; PPI: proton pump inhibitor; TIF: transoral incisionless fundoplication.

^a Troublesome regurgitation was defined as mild symptoms for ≥2 days a week or moderate-to-severe symptoms >1 day a week.

^b Gastroesophageal reflux disease for >1 year and a history of daily PPI use for >6 months.

Trial	Symptomsa	Regurgitation	Heartburn	Reflux	Esophageal pH
	Elimination of Troublesome Regurgitation	Change in RDQ Regurgitation Score	Change in RDQ Heartburn Score	Change in RDQ Heartburn Plus Regurgitation Score
RESPECT (2015)12,
TIF + placebo, % (n/N)	67% (58/87)	-3	-2.1	-2.5
Sham + PPI, % (n/N)	45% (19/42)	-3	-2.2	-2.4
p	0.023	0.072	0.936	0.313
	Elimination of Symptoms Other Than Heartburnb	Change in GERD-HRQL Score	Change in GERD-HRQL Heartburn Score	RSI Score	Percent Time With pH >4
TEMPO (2015)13,
TIF	62%	-21.1	-14	-17.4	54%
Maximum-dose PPI	5%	-7.6	-5.2	-3.0	52%
RR (95% CI)	-12.9 (1.9-88.9)
p	0.001	NR	NR	NR	0.914
Summary
TIF	62%-67%

^a Primary outcome measure.

^b Primary outcome measure a composite of 3 GERD symptom scales: the GERD-HRQL, RSI, and RDQ.

Trad et al (2018) also reported a 5-year follow-up for the TEMPO trial (see Table 5).^15, Data were available for 44 patients, of whom 37 (86%) showed elimination of troublesome regurgitation at 5 years. Twenty (43%) patients were completely off PPIs at the 5-year follow-up, and 31 (70%) patients expressed satisfaction with the procedure, as assessed by the GERD-HRQL scores. While data on pH normalization were available for 24 patients at the 3-year follow-up, at 5 years, 22% (n=5) of these patients could not be assessed for pH normalization.

Table 5. Follow-Up of Patients Treated With EsophyX2 in the TEMPO Trial

Outcome Measure	Baseline	1 Year	2 Years	3 Years	5 Years
Sample size (% of 63)		60 (95%)	55 (87%)	52 (83%)	44 (70%)
Elimination of troublesome regurgitation (RDQ)a		88% (42/48)	90% (41/44)	90% (37/41)	86% (37/43)
Elimination of atypical symptoms (RSI ≤13)a		82% (45/55)	84% (43/51)	88% (42/48)	80% (31/39)
GERD-HRQL score	32.8 (/60)	7.1 (/58)	7.3 (/52)	5.0 (/43)	6.8 (/31)
Esophagitis	55% (33/60)	5% (3/59)	10% (5/50)	12% (5/41)
Cessation of PPI use		78% (47/60)	76% (42/55)	71% (37/52)	46% (20/44)
pH normalizationb		41% (24/59)	37% (18/49)	40% (16/40)

Adapted from Trad et al (2017) and Trad et al (2018).^14,15,
Values are % (n/N) unless otherwise noted.
GERD-HRQL: Gastroesophageal Reflux Disease Health-Related Quality of Life; PPI: proton pump inhibitor; RDQ: Reflux Disease Questionnaire; RSI: Reflux Symptom Index.

^a Primary outcome: elimination of daily troublesome regurgitation and atypical symptoms as measured with the RDQ and RSI. Troublesome symptoms are defined as mild symptoms, occurring ≥2 days a week, or moderate-to-severe symptoms, occurring >1 day a week.
^b Normality was defined as percent of total recorded time pH <4 of ≥5.3%.

Table 6. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Follow-Upe
Hunter et al (2015)12,			2. Not compared to fundoplication 3. Measurement off PPIs group
Trad et al (2015)13,			2. Not compared to fundoplication 3. No sham surgery
Hakansson et al (2015)16,			2. Sham only (no active treatment)
Witteman et al (2015)17,			3. Continued PPI only (no sham surgery)

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
PPI: proton pump inhibitor

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.

^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.

^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.

^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.

^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms

Study	Allocationa	Blindingb	Selective  Reportingc	Data  Completenessd	Powere	Statisticalf
Hunter et al (2015)12,
Trad et al (2015)13,		1, 2. No blinding				1.Within-group analysis only
Hakansson  et al (2015)16,				1. Unequal dropout rates in both treatment groups	1. Power calculations not reported	2. Adjusted for baseline values but not for repeated measures
Witteman et al (2015)17,		1, 2. No blinding		1. Study stopped following unplanned interim analysis	1.Power calculations not reported

^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.

^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.

^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

^d Data Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).

^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.

^f Statistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Two nonrandomized comparative studies have compared TIF with laparoscopic fundoplication in patients whose symptoms were not controlled on PPIs.^18,19,

A nonrandomized study by Toomey et al (2014) compared 20 patients undergoing TIF, 20 patients undergoing Nissen fundoplication, and 20 patients undergoing Toupet fundoplication.^18, Age, body mass index and preoperative DeMeester score were controlled, however, the indications for each procedure differed. Patients with abnormal esophageal motility underwent Toupet fundoplication, and only patients who had a hiatal hernia of 2 cm or less were offered TIF. As a result, only 15% of the TIF group had a hiatal hernia vs 65% and 55% of the 2 fundoplication groups, limiting comparison of both treatments. Adverse events were not reported.

Frazzoni et al (2011) compared 10 patients undergoing TIF with 10 patients undergoing laparoscopic fundoplication with the first-generation EsophyX procedure.^19, The patients selected which treatment they wanted, but the groups were comparable to a baseline. Regarding clinical outcomes assessed at three months, seven patients undergoing TIF reported only partial/no symptom remission vs zero patients undergoing fundoplication. Mild dysphagia was reported by two patients after fundoplication and one patient after TIF. Two patients reported epigastric bloating after fundoplication. Several measures of GERD assessed by manometry and impedance-pH monitoring showed greater improvement in the fundoplication group than in the TIF group. This study reported that TIF with the first-generation EsophyX device is less effective than fundoplication in improving symptoms of GERD.

Tables 8 and 9 summarize the characteristics and results of selected nonrandomized studies.

Table 8. Nonrandomized Study Characteristics

Study	Study Type	Country	Dates	Participants	Treatment	Treatment	Follow-Up
Toomey et al (2014)18,	Case-control	U.S.	2010 - 2013	Patients with GERD undergoing TIF, LNF, or LTF	20 patients underwent TIF	20 patients each had LTF or LNF	NR
Frazzoni et al (2011)19,	Prospective open-label	Italy	2000 - 2008	Patients had heartburn and/or regurgitation despite high-dose PPIs	10 patients chose first-generation EsophyX fundoplication	10 patients chose laparoscopic fundoplication	3 mo

GERD: gastroesophageal reflux disease; LNF: laparoscopic Nissen fundoplication; LTF: laparoscopic Toupet fundoplication; NR: not reported; PPI: proton pump inhibitor; TIF: transoral incisionless fundoplication.

Table 9. Nonrandomized Study Results in Patients Whose Symptoms Were Not Controlled by PPIs

Study	Percent Partial or No Symptom Remission	Normalization Esophageal Acid Exposure Time	Normalization of Distal Refluxes	Normalization of Proximal Refluxes	Mild Dysphagia	Bloating
Frazzoni et al (2011)19,
TIF, %	70	50	20	40	10	0
Fundoplication, %	0	100	90	100	20	20
p	0.003	0.03	0.005	0.011	NR	NR

NR: not reported; PPI: proton pump inhibitor; TIF: transoral incisionless fundoplication.

Section Summary: TIF for Symptoms Uncontrolled by PPIs

Studies Comparing TIF With Continued PPIs

The evidence on TIF in patients whose symptoms are not controlled by PPIs includes two RCTs, one of which followed TIF patients for three years. The highest quality study is the sham-controlled RESPECT trial by Hunter et al (2015). RESPECT found a significantly greater proportion of patients who reported the elimination of troublesome regurgitation compared with sham plus PPIs, however, elimination of regurgitation was achieved in only 67% of patients treated with TIF. Also, other symptom measures did not differ between the TIF and sham-PPI groups. A strong placebo effect of the procedure is suggested by the subjective outcome measures in the sham group, in which 45% of patients whose symptoms were not previously controlled on PPIs reported elimination of troublesome regurgitation. The strong placebo effect suggested by the RESPECT trial raises questions about the validity of the nonblinded TEMPO trial. TEMPO reported significant improvements in subjective measures with TIF compared with maximum PPI treatment, but there was no significant difference in the objective measure of esophageal acid exposure. At a 3-year follow-up, about twice as many patients reported symptom improvement compared with improvement in the objective measure. It is not clear whether the discrepancy is due to a general lack of correlation between pH and symptoms, or to a placebo effect on the subjective assessment. Together, these data would suggest the most appropriate comparator for patients whose symptoms are not controlled on PPIs is laparoscopic fundoplication. However, a 5-year follow-up of the TEMPO trial found sustained cessation of PPI therapy in most patients with data available, as well as the resolution of several types of trouble symptoms. These results may suggest long-term safety and durability of TIF 2.0 as an alternative to LNF.

Studies Comparing TIF With Laparoscopic Fundoplication

Each study comparing TIF with laparoscopic fundoplication has methodologic problems that do not permit conclusions on the comparative efficacy of the two procedures. The Frazzoni et al (2011) nonrandomized study showed that TIF is less effective than a fundoplication. However, this study was conducted with an earlier device. In the Toomey et al (2014) study, patients were assigned to different procedures based on specific baseline characteristics. Two of the studies concluded that TIF and fundoplication were similarly effective based on a lack of statistically significant differences across symptom outcomes. However, because of the small sizes of these samples, the lack of a statistically significant difference in outcomes cannot be interpreted as equivalent outcomes. For these studies, several outcomes favored fundoplication over TIF. The studies did not report adverse events or rates of postoperative symptoms associated with fundoplication (e.g., dysphagia, bloating). Thus, it is not possible to evaluate whether a difference in effectiveness between procedures might be accompanied by a difference in adverse events. Limited data suggest that the first-generation TIF is considerably inferior to laparoscopic fundoplication in patients who have failed PPI therapy, and this treatment is no longer available. Current data are insufficient to determine the risks and benefits of the second-generation TIF procedure compared with laparoscopic fundoplication in patients whose symptoms are not controlled by PPIs.

TIF for Symptoms Controlled by PPIs

Clinical Context and Test Purpose

The purpose of TIF (e.g., EsophyX2) is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with GERD and hiatal hernias of 2 cm or less controlled by PPIs.

The question addressed in this policy is: Does TIF using the EsophyX2 System improve the net health outcomes in individuals with GERD?

The following PICOs were used to select literature to inform this policy.

Patients

The relevant population of interest are individuals with GERD and hiatal hernias of 2 cm or less controlled by PPIs.

Interventions

The therapy being considered is TIF (e.g., EsophyX2).

Comparators

The following therapy is currently being used to treat GERD: PPI therapy.

Outcomes

The general outcomes of interest are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. Follow-up at two, three, and six years is of interest to monitor outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the principles outlined in indication 1.

Randomized Trials

Two published RCTs have evaluated the efficacy of TIF in patients whose symptoms were adequately controlled on PPIs, but who were considering an intervention over lifelong drug dependence (see Table 10). Hakansson et al (2015) compared TIF (n=22) with sham only (n=22).^16, The expected outcome in the sham group was that, without PPIs, GERD symptoms would eventually recur. Witteman et al (2015) compared TIF (n=40) with continued PPI therapy (n=20) without a sham procedure (see Table 10).^17, The objective was to demonstrate that outcomes with TIF were not significantly worse than those with continued PPI therapy.

The primary outcome of the Hakansson et al (2015) trial was treatment failure, defined as the need to resume PPIs. The primary outcome of the Witteman et al (2015) trial was treatment success, defined by an improvement of 50% or more on the GERD-HQRL score.

In Hakansson et al (2015), Kaplan-Meier curves showed a higher rate of treatment failure in the sham group than in the TIF group (p<0.001, time to treatment failure), with significantly more patients in the TIF group in remission at 6 months (59%) compared with the sham without PPI group (18%, p=0.01). In Witteman et al (2015), PPI therapy was stepped up or down as necessary during follow-up. At 6 months, 55% of TIF patients had more than a 50% improvement in subjective GERD symptoms vs 5% of patients on continued PPI therapy (see Table 11). Mean change in GERD symptoms from baseline was consistent with this result (TIF, -14.1; control, -3.1), however, it is uncertain whether the difference between groups was due to a combination of TIF plus PPI, or if the PPI therapy in the control group was at maximum following the step-up protocol.

Secondary outcomes measuring GERD symptoms in the Hakansson et al (2015) trial showed results consistent with more favorable outcomes in the TIF group. However, no statistical between-group analysis was reported for these outcomes. Dysphagia, bloating, and flatulence were reported in twice as many patients undergoing TIF (four, four, and two, respectively) compared with sham (two, two, and one, respectively). These results were reported as not statistically different. However, it is unlikely that the trial was powered to detect differences in these outcomes.

Table 10. Characteristics of Randomized Trials Assessing TIF in Patients Whose Symptoms Were Controlled by PPIs

Study	TIF/CTL, n	Patient Symptoms or Other Characteristics	Comparator	FU, mo	Principal Clinical Outcome
Hakansson et al (2015)16,	22/22	Controlled on PPI, run-in to confirm PPI dependence	Sham only	> 6	Time to resumption of PPI, percent needing PPI at 6 mo
Witteman et al (2015)17,	40/20	Controlled on PPI; those who received TIF had GERD with hiatal hernias ≤2 cm	Continued PPI only	6	Mean GERD symptoms, percent with >50% improvement

CTL: control; FU: follow-up; GERD: gastroesophageal reflux disease; PPI: proton pump inhibitor; TIF: transoral incisionless fundoplication.

Table 11. Results of RCTs Comparing TIF With Nonsurgical Treatment in Patients Whose Symptoms Were Controlled on PPIs

Study	Days to PPI Resumption	Change in PPI Therapy	Change in Symptoms	Change in QOL	Change in Esophagitis	Esophageal pH
		Remission at 6 Months	Median GSRS Score	Median QOLRAD Score		Percent Time pH <4
Hakansson et al (2015)16,
TIF	197	13 (59%)	4	1.5		3.6%
Sham only	107	4 (18%)	1.4	0.4		9.8%
p	0.001	0.01	NR	NR		NR
			Percent >50% Improvement in GERD-HRQL Score	Mean GERD-HRQL Score	Percentage With Esophagitis	Percent Patients With Normalized pHa
Witteman et al (2015)17,
TIF			55%	-14.1	-19%	50%
Continued PPI			5%	-3.1	-20%	63%
p			<0.001	<0.001	>0.05	NR

GERD-HRQL: Gastroesophageal Reflux Disease Health-Related Quality of Life; GSRS: Gastrointestinal Symptom Rating Scale; NR: not reported; PPI: proton pump inhibitor; QOL: quality of life; QOLRAD: Quality of Life in Reflux and Dyspepsia; RCT: randomized controlled trial; TIF: transoral incisionless fundoplication.

^a Defined as <4% for ≤4.2% of recording time.

TIF patients were followed beyond six months, with additional control patients who crossed over to have TIF. Sixty patients eventually underwent TIF. Although GERD symptoms remained improved over baseline (p<0.05), esophageal acid exposure did not differ significantly from baseline. At least occasional use of PPI increased between 6 months and 12 months, from 34% to 61%. Endoscopy findings at 6 months and 12 months showed several findings indicating possible worsening of GERD in terms of esophagitis rating, Hill grade rating of the gastroesophageal valve, and size of a hiatal hernia. Although this RCT met its principal endpoint at 6 months and improvements in GERD symptoms appeared to be maintained for 12 months, long-term reflux control was not achieved, and the trialists concluded that “TIF is no[t an] equivalent alternative for PPIs in GERD treatment, even in this highly selected population.” The trial was originally designed as a dual-center study, but it was terminated following interim analysis showing loss of reflux control.

Observational Studies

Observational case series and prospective cohort studies can provide information on the durability of the TIF procedure. Studies were included if they provided additional information on treatment durability or addressed treatment safety.

A case series and a cohort study have evaluated outcomes to six years after TIF2.0 (see Tables 12 and 13). Both studies were performed in patients with hiatal hernias of 2 cm or less in size whose symptoms were adequately controlled on PPIs but did not want to take medication indefinitely. Stefanidis et al (2017) reported on a retrospective series that about 75% of patients had the elimination of esophagitis and had discontinued PPI use at 5 years, while 62% of the 13 patients with hiatal hernias had a reduction in hernia size at follow-up.^20,

In a prospective cohort by Testoni et al (2015, 2019), 72% of the patients were completely responsive to PPIs at baseline, and 24% were partially responsive.^21,22, Hiatal hernias had recurred by 12 months in 46% of the patients who had hernias at baseline, and at the 24-month follow-up, 20% of TIF2.0 procedures were considered unsuccessful. Nine percent of patients had additional surgery for poor response by two years. The Johnson-DeMeester score was not significantly improved. A poor response to treatment was associated with a hiatal hernia of 2 cm, higher Hill grade, the presence of esophagitis at baseline, and the use of fewer fasteners. About half the patients with a complete response initially resumed PPI use by 6 years and 20% had undergone additional surgery for a poor response, although these findings are limited by the low number of patients at follow-up. The number of fasteners used in this study might also be lower than current procedures.

Table 12. Characteristics of Observational Studies With Long-Term Outcomes in Patients Whose Symptoms Were Controlled by PPIs

Study	Country	Participants	Treatment Delivery	Mean FU, mo
Stefanidis et al (2017)20,	Greece	PPI-controlled, hiatal hernia ≤2 cm	EsophyX2	59
Testoni et al (2015, 2019)21,22,	Prospective study from 1 center in Italy	Daily PPI, esophagitis or abnormal pH, hiatal hernias ≤2 cm	ExophyX2	53

FU: follow-up; PPI: proton pump inhibitor.

Table 13. Long-Term Durability of TIF in Patients Whose Symptoms Were Controlled by PPIs

Outcomes	Mean Baseline	6 Months	1 Year	2 Years	3 Years	6-7 Years	10 Years
Stefanidis et al (2017)20,
Sample size	45					44
GERD-HRQL score off PPI	27					4
PPI discontinuation						72.7%
Elimination of esophagitis	n=33		81.8%			72.7%
Reduction in hiatal hernia	n=13					61.5%
Testoni et al (2015, 2019)21,22,
Sample size	50	49a	49	45b	45	30	14
GERD-HRQL score off PPI (SD)	46 (19)			18 (13)	19 (14 )	10 (7.7)	9.5 (6.1)
GERD-QUAL score off PPI (SD)	114 (20)			71 (24)	80 (21)
Johnson-DeMeester score (SD)	22 (12)	18 (15		19 (20)
PPI discontinuation n(%)		61.2%	51.0%	25/45 (55.6)	24/45 (53.3)	11/30 (36.7)	5/14 (35.7)
Additional surgery for poor response n (%)				4/45 (8.8)	4/45 (8.8)	6/30 (20.0)	2/14 (14.1)

GERD-HRQL: Gastroesophageal Reflux Disease Health-Related Quality of Life; GERD-QUAL: Gastroesophageal Reflux Disease Quality of Life; PPI: proton pump inhibitor; SD: standard deviation; TIF: transoral incisionless fundoplication.

^a Excluding 1 failed procedure due to pneumothorax

^b Excluding 4 patients who underwent Nissen fundoplication for failed procedure.

Huang et al (2017) conducted a systematic review with a meta-analysis of TIF for the treatment of GERD.^23, They included 5 RCTs and 13 prospective observational studies, of which 14 were performed with the TIF2.0 procedure. Efficacy results from the RCTs were combined for patients whose symptoms were controlled by PPIs and for those whose symptoms were not controlled by PPIs, and are not further discussed here. The follow-up to six years in prospective observational studies indicated a decrease in efficacy over time. The reported incidence of severe adverse events, consisting of gastrointestinal perforation and bleeding, was 19 (2.4%) of 781 patients. This included seven perforations, five cases of post-TIF bleeding, four cases of pneumothorax, one case requiring intravenous antibiotics, and one case of severe epigastric pain.

Section Summary: TIF for Symptoms Controlled by PPIs

The evidence on TIF in patients whose symptoms are controlled by PPIs includes two RCTs and observational studies with long-term follow-up. The sham-controlled trial by Hakansson et al (2015) found the time to resume PPI therapy was longer following TIF and the remission rate was higher, indicating that TIF is more effective than no therapy. The nonblinded trial by Witteman et al (2015) found a benefit of TIF compared with continued PPI therapy for subjective measures, but not for the objective measures of pH normalization and esophagitis, raising questions about a possible placebo effect. Extended follow-up of the TIF patients in the Witteman trial found the use of PPI increased over time, while endoscopy showed several findings indicating possible worsening of GERD. The limited evidence beyond two years is consistent with some loss of treatment effectiveness. Increased use of PPIs beyond 2 years occurred in Testoni et al (2015). Adverse events associated with the procedure may be severe. Current evidence is insufficient to determine the effect of this intervention on the net health outcome in patients whose symptoms are adequately controlled by PPIs.

Transesophageal Radiofrequency

Clinical Context and Test Purpose

The purpose of endoscopic radiofrequency energy (e.g., Stretta) is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with GERD.

The question addressed in this policy is: Does the use of endoscopic radiofrequency energy improve the net health outcomes in individuals with GERD?

The following PICOs were used to select literature to inform this policy.

Patients

The relevant population of interest are individuals with GERD.

Interventions

The therapy being considered is endoscopic radiofrequency energy (e.g., Stretta).

Comparators

The following therapies and practices are currently being used to treat GERD: PPI therapy and laparoscopic fundoplication.

Outcomes

The general outcomes of interest are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity.

Study Selection Criteria

Methodologically credible studies were selected using the principles outlined in indication 1.

Systematic Reviews

A meta-analysis of 4 RCTs (total n=165 patients) was published by Lipka et al (2015) (see Table 14).^24, Three trials compared Stretta with sham, and one compared Stretta with PPI therapy (see Table 15). Results of the individual sham-controlled trials were inconsistent, generally supporting some improvement in symptoms, but not in objective measures of esophageal acid exposure. For example, Corley et al (2003) reported improvements in heartburn symptoms, QOL, and general physical QOL in the active treatment group compared with the sham group, but there were no significant differences in medication use or esophageal acid exposure.^25, Aziz et al (2010) found statistically significant improvements in GERD-HRQL scores in all treatment groups.^26, Arts et al (2012) reported that the symptom score and quality-of-life score for bodily pain improved, but no changes were observed in PPI use, esophageal acid exposure, or lower esophageal sphincter pressure after radiofrequency ^27, Pooled results of the meta-analysis showed no significant differences between Stretta and either sham treatment or PPI management for the measured outcomes, including the ability to stop PPI therapy (see Table 16). The overall quality of evidence was considered to be very low with a high-risk of bias, and the meta-analysis was limited by heterogeneity in the included studies, which might have been due to small sample sizes, differences in measures, and differences in follow-up times.

Fass et al (2017) published a meta-analysis of the same 4 RCTs plus 23 prospective cohort studies and 1 registry that evaluated the Stretta procedure for patients with GERD.^28, Pooled results showed clinically significant improvements in subjective outcome measures and a reduction in PPI use from a baseline of 97% of patients to 49% of patients after treatment, but there was a smaller difference from the sham group in the RCTs and high heterogeneity in the cohort studies. For objective outcome measures, erosive esophagitis was not significantly improved using a random-effects model, and there was high heterogeneity in the cohort studies. The time that esophageal acid exposure was less than four was significantly improved in the cohort studies but was not significantly different from sham in the RCTs. The authors are business advisors to Mederi Therapeutics.

Table 14. Meta-Analytic Characteristics of RCTs Assessing TERF

Study	Dates	Trials	Participants	N (Range)	Design	Duration, mo
Fass et al (2017)28,	Inception to May 2016	28	Patients with GERD undergoing endoscopic radiofrequency (Stretta)	2468 (9-558)	Meta-analysis of 4 RCTs, 23 cohort studies, and 1 registry	3-120
Lipka et al (2015)24,	Inception to Feb 2014	4	Patients with physiologic evidence of GERD who were on PPI therapy	165 (22-64)	Meta-analysis of RCTs	6-12

GERD: gastroesophageal reflux disease; PPI: proton pump inhibitor; RCT: randomized controlled trial; TERF: transesophageal radiofrequency.

Table 15. Characteristics of RCTs Assessing TERF

Study	TERF/CTL, n	Patient Symptoms or Other Characteristics	Comparator	FU, mo	Principal Clinical Outcome
Arts et al (2012)27,	11/11	GERD at least partially controlled by PPIs and abnormal pH, hiatal hernia ≤3 cm	Sham with crossover at 3 mo	3	Composite reflux symptom score, esophageal pH, motility, and distensibility
Aziz et al (2010)26,	12/12	GERD controlled by PPIs; patients randomized to single or double TERF or sham	Sham	12	GERD-HRQL score
Coron et al (2008)29,	20/16	GERD symptoms controlled by PPIs and abnormal EAE	Continued PPI	6	Stopping or decreasing PPI use
Corley et al (2003)25,	35/29	Abnormal EAE, symptoms at least partially controlled by PPIs, hiatal hernia ≤2 cm	Sham	6	Heartburn, QOL, PPI use, pH

CTL: control; EAE: esophageal acid exposure; FU: follow-up; GERD: gastroesophageal reflux disease; GERD-HRQL: Gastroesophageal Reflux Disease Health-related Quality of Life; PPI: proton pump inhibitor; QOL: quality of life; RCT: randomized controlled trial; TERF: transesophageal radiofrequency.

Table 16. Meta-Analytic Results

Study	Heartburn	GERD-HRQL Score	Use of PPI Therapy	Acid Exposure Time (pH <4)	Other Objective Outcome Measures
	Heartburn Score				DeMeester score
Fass et al (2017)28,
Patients (studies), n	637 (12)	507 (11)	1795 (23)	364 (11)	407 (8)
Change (95% CI)	-1.53 (-1.97 to -1.09)	RCT: -14.56 (-16.63 to -12.48) Cohort: -14.69 (-16.90 to -12.47)	Baseline: 1743 (97.1%) Post-treatment: 850 (49%) RR: 0.49 (0.40 to 0.60)	-3.01 (-3.72 to -2.30)	-13.79 (-20.01 to -7.58)
p	<0.001	<0.001	<0.001	<0.001	<0.001
I2 (p)	Significant in all subgroups (p<0.001)	RCTs: NS Cohort: 85% (<0.001)	RCTs: NS Cohort: 95% (<0.001)	Not significant in any subgroup	77%
	Ability to Stop PPI Therapy				Mean LES Pressure
Lipka et al (2015)24,
Patients (studies), n	118 (3)	88 (2)		153 (4)	110 (3)
MD (95% CI)	RR=0.87 (0.75 to 1.00)	-5.24 (-12.95 to 2.46)		1.56% (-2.56% to 5.69%)	0.32 mm Hg (-2.66 to 2.02 mm Hg)
p	0.06	0.18		0.46	0.79
I2 (p)	0%	96% (<0.001)		99% (<0.001)	96% (<0.001)
Range of N	24-51	22-64		22-64

CI: confidence interval; GERD-HRQL: Gastroesophageal Reflux Disease Health-related Quality of Life; LES: lower esophageal sphincter; MD: mean difference; PCS: Physical Component Summary; PPI: proton pump inhibitor; RCT: randomized controlled trial; RR; relative risk.

Randomized Controlled Trials

Although not included in the meta-analyses tabulated in Table 14, Kalapala et al (2017) published interim results from a small RCT of 20 patients randomized to PPI plus Stretta or PPI alone, with 3 months of follow-up.^30, While short-term outcomes such as GERD symptoms and cessation of PPIs appeared improved for the Stretta group, the study sample was small and power calculations were not conducted.

Controlled Trials Comparing TERF With Laparoscopic Fundoplication

Liang et al (2015) reported on a prospective comparison of laparoscopic Toupet fundoplication with the Stretta procedure (see Table 17).^31, Of 165 patients treated, 125 (76%) completed the 3-year follow-up (65 fundoplications, 60 Stretta) and were included in the analysis. Although the two groups were comparable in symptoms at baseline, nine patients in the Stretta group had revised treatment and were not included in the final symptom scores. A similar percentage of remaining patients in the two groups achieved complete PPI independence and had similar improvements in belching, hiccup, cough, and asthma. The Stretta procedure was less effective than laparoscopic fundoplication in reducing symptoms of heartburn, regurgitation, and chest pain (see Table 18). Significantly more patients in the Stretta group underwent reoperation, while more patients in the fundoplication group complained of bloating, but this difference was not statistically significant. This study lacked randomization and, along with not reporting the TERF failures, had a high loss to follow-up. Also, while symptom scores were comparable at baseline, the study might have been subject to selection bias related to treatment choice, which affected baseline differences for other variables.

Table 17. Characteristics of Studies Comparing TERF With Laparoscopic Fundoplication

Study	Study Type	Country	Dates	Participants	Treatment 1	Treatment 2	FU, y
Liang et al (2015)31,	Comparative cohort	China	2011	165	TERF	Laparoscopic fundoplication	3

FU: follow-up; TERF: transesophageal radiofrequency.

Table 18. Results Comparing TERF With Laparoscopic Fundoplication

Study	PPI Independence	Improvement in Heartburn Score	Improvement in Regurgitation Score	Improvement in Chest Pain Score	Reoperation	Bloating
Liang et al (2015)31,
TERF	68.3%	2.53	2.41	2.96	11.8%	0%
LF	72.3%	4.05	4.03	5.50	0%	6.2%
p	0.627	0.01	0.004	0.005	0.006	0.120

LF: laparoscopic fundoplication; PPI: proton pump inhibitor; TERF: transesophageal radiofrequency.

Prospective Cohort Studies

Long-term follow-up from case series and cohort studies can inform the durability of TERF. For example, 5- and 10-year follow-ups after TERF were reported in 2014 (see Table 19).^32,33, Elimination of PPI use was similar for both studies at around 42% (see Table 20). Liang et al (2014) reported that symptoms of heartburn, regurgitation, chest pain, cough, and asthma were all decreased compared with baseline. Noar et al (2014) reported symptom improvement in 72% of patients and elimination of dysplasia in 85% of patients, but the interpretation of these findings is limited due to the 34% loss to follow-up in this study.

Table 19. Cohort Study and Case Series Characteristics

Study	Country/Institution	Participants	Follow-Up, y	Loss to Follow-Up
Liang et al (2014)32,	China	152 who failed PPI therapy	5	9%
Noar et al (2014)33,	University of Pittsburgh	149 who failed PPI therapy	10	34% (7% deceased)

PPI: proton pump inhibitor.

Table 20. Cohort Study and Case Series Results at Follow-Up

Study	Elimination of PPI Use	Symptom Improvement	Elimination of Dysplasia	Bloating
Liang et al (2014)32,	42.8%	p<0.001 vs pretreatment		8.7%
Noar et al (2014)33,	41%	72%	85%

PPI: proton pump inhibitor.

Section Summary: TERF (Stretta Procedure)

Four RCTs (n range, 22-64 patients), 3 of which were sham-controlled, reported some improvements in symptoms following treatment with TERF. However, measures of esophageal acid exposure were typically not improved. Also, meta-analyses of these same studies found no significant improvements in outcomes. The findings of improvements in symptoms but not esophageal acid exposure have led to questions about whether TERF is acting by reducing sensation in the esophagus. Although single-arm studies have shown maintenance of symptom relief at five to ten years, the interpretation depends on the efficacy of the procedure in the short term. A nonrandomized comparative study has suggested that symptom relief with TERF is lower than with fundoplication and there is a greater incidence of reoperations. Larger RCTs with longer follow-up are needed to define the risks and benefits of this procedure with greater certainty.

Esophageal Bulking Agents

Clinical Context and Test Purpose

The purpose of esophageal bulking agents is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with GERD.

The question addressed in this policy is: Does the use of esophageal bulking agents improve the net health outcomes in individuals with GERD?

The following PICOs were used to select literature to inform this policy.

Patients

The relevant population of interest are individuals with GERD.

Interventions

The therapy being considered is esophageal bulking agents.

Comparators

The following therapies and practices are currently being used to treat GERD: PPI therapy and laparoscopic fundoplication.

Outcomes

The general outcomes of interest are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. Though not completely standardized, follow-up for GERD symptoms would typically occur in the months to years after starting treatment.

Study Selection Criteria

Methodologically credible studies were selected using the principles outlined in indication 1.

Durasphere

The available evidence for Durasphere consists of a single case series. One open-label pilot study by Ganz et al (2009) assessed 10 GERD patients injected with Durasphere (Carbon Medical Technologies), a bulking agent approved for the treatment of urinary and fecal incontinence, at the gastroesophageal junction.^34, At 12 months, 7 (70%) patients discontinued all antacid medication completely. No erosion, ulceration, or sloughing of the material was noted at any injection site.

Gatekeeper Reflux Repair System

The available evidence for Gatekeeper Reflux Repair System consists of a single RCT reported by Fockens et al (2010).^35, In this industry-funded sham-controlled single-blind, multicenter study randomized 118 patients into Gatekeeper (n=75) or sham (n=43) treatment. An additional 25 patients were treated as lead-ins during the initial training of investigators and included only in the safety analysis. The patients were implanted initially with four Gatekeeper prostheses. At 3 months, 44% of implanted patients received retreatment with up to 4 additional prostheses due to unsatisfactory symptom control. The primary safety endpoint was a reduction in a serious device- and procedure-related adverse events, compared with a surgical procedure composite complication rate of 15%. Four serious adverse events were reported (two perforations, one pulmonary infiltrate related to a perforation, one severe chest pain). The primary efficacy endpoint was a reduction in heartburn symptoms using the GERD-HRQL questionnaire. Planned interim analysis after 143 patients were enrolled found that heartburn symptoms and esophageal acid exposure had improved significantly in both the Gatekeeper and sham groups at 6 months, but there was no significant difference between groups. The trial was terminated early due to a lack of efficacy.

Polymethylmethacrylate Beads

The available evidence for polymethylmethacrylate beads consists of a single case series. A case series by Feretis et al (2001) evaluated on transesophageal submucosal implantation of polymethylmethacrylate beads in 10 patients with GERD who were either refractory to or dependent on PPIs.^36, While a significant decrease in symptom scores was noted at posttreatment follow-up (time not specified), the small number of patients and lack of long-term follow-up precluded scientific analysis. No additional studies have been identified evaluating this treatment option.

Section Summary: Esophageal Bulking Agents

The evidence on the injection of bulking agents includes an RCT terminated early due to a lack of efficacy and case series. High-quality data from large RCTs are needed to compare bulking procedures with both sham controls and with the currently accepted treatments for GERD (i.e., drug therapy, laparoscopic fundoplication). Well-designed trials should use standardized outcome measures to examine both subjective (e.g., GERD-HRQL scores) and objective (e.g., esophageal acid exposure) effects on health outcomes.

Summary of Evidence

For individuals who have GERD and a hiatal hernia of 2 cm or less that is not controlled by PPIs who receive TIF (e.g., EsophyX), the evidence includes two RCTs comparing TIF with PPI therapy, nonrandomized studies comparing TIF with fundoplication, and case series with longer-term follow-up. The relevant outcomes are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. The highest quality RCT (RESPECT) was sham-controlled that compared TIF with PPI therapy while the other RCT (TEMPO) compared TIF with maximum PPI therapy. Both trials found a significant benefit of TIF on the primary outcome measure in about 65% of patients. The sham-controlled trial reported improvement in 45% of the sham-controlled group and no benefit on secondary subjective outcome measures. The nonblinded RCT found significant improvements in subjective measures but no difference in objective outcome measures compared with PPI therapy. Together, these trial results would suggest a strong placebo effect of the surgery and a modest benefit of TIF in patients whose symptoms were not controlled by PPIs. For these patients, the most appropriate comparator would be laparoscopic fundoplication. Studies comparing TIF with fundoplication have limitations that include earlier TIF procedures and unbalanced groups at baseline and are inadequate to determine relative efficacy. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have GERD and a hiatal hernia of 2 cm or less that is controlled by PPIs who receive TIF (e.g., EsophyX), the evidence includes two RCTs and observational studies with longer-term follow-up. The relevant outcomes are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. A sham-controlled trial found that the time to resume PPI therapy was longer following TIF and the remission rate was higher, indicating that TIF is more effective than no therapy. The nonblinded RCT found a benefit of TIF compared with continued PPI therapy for subjective measures, but not for the objective measures of pH normalization and esophagitis. These results raise questions about a possible placebo effect for the procedure. Also, observational studies have indicated a loss of treatment effectiveness over time. Adverse events associated with the procedure (e.g., perforation) may be severe. At present, the available evidence does not support the use of this intervention in patients whose symptoms are adequately controlled by medical therapy. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have GERD who receive endoscopic radiofrequency energy (e.g., Stretta), the evidence includes four small RCTs, a nonrandomized comparative study, and observational studies with longer-term follow-up. The relevant outcomes are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. The RCTs reported some improvements in symptoms and QOL following treatment with radiofrequency energy compared with sham controls. However, objective measures of GERD and a meta-analysis of these studies found no significant improvements in outcomes, raising questions about the mechanism of the symptom relief. Symptom relief is reported to be lower than after fundoplication, and reoperations greater. Larger RCTs with longer follow-up, preferably compared with fundoplication, are needed to define the risks and benefits of this procedure better. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have GERD who receive esophageal bulking agents, the evidence includes an RCT and case series. The relevant outcomes are symptoms, change in disease status, QOL, medication use, and treatment-related morbidity. The RCT for a single product was terminated early due to lack of efficacy, while other products have only case series to support use. High-quality data from large RCTs are needed to compare bulking procedures with both sham controls and with the currently accepted treatments for GERD (i.e., drug therapy, laparoscopic fundoplication). Well-designed trials should use standardized outcome measures to examine whether subjective improvement (e.g., discontinuation of medication therapy, GERD-HRQL scores) is supported by objective improvement (e.g., esophageal acid exposure). The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

2015 Input

In response to requests for clinical input on transesophageal radiofrequency (Stretta) as a treatment of gastroesophageal reflux disease (GERD), input was received from 1 physician specialty society (2 reviewers) and 3 academic medical centers while this policy was under review in 2015. Input was mixed on the treatment of GERD with transesophageal radiofrequency to create submucosal thermal lesions of the gastroesophageal junction (i.e., Stretta). Potential conflicts of interest were noted by two reviewers.

2011 Input

In response to requests for clinical input on transoral incisionless fundoplication (TIF) using EsophyX, input was received from 2 physician specialty societies and 4 academic medical centers while this policy was under review in 2011. Reviewers agreed that TIF differed sufficiently different from laparoscopic Nissen fundoplication to warrant evaluation as a separate procedure. Reviewers considered TIF (i.e., EsophyX) to be investigational for the treatment of GERD.

Practice Guidelines and Position Statements

American Society for Gastrointestinal Endoscopy

The American Society for Gastrointestinal Endoscopy (2015) published guidelines on endoscopic procedures for GERD.^37,In its review of the EsophyX and Stretta procedures, the Society noted some positive findings but discrepancies between subjective and objective outcome measures or a lack of objective outcome measures in reported trials, concluding that these techniques represent “potentially new therapeutic indications for GI endoscopy”, but that prospective trials using objective measures of GERD as the primary endpoint could be useful in defining the clinical role of these procedures.

American College of Gastroenterology

Updated guidelines from the American College of Gastroenterology (2013) indicated the use of current endoscopic therapy or SAGES; (2017) provided a clinical spotlight review on endoluminal treatments for GERD.^38, The SAGES gave a strong recommendation based on moderate-quality evidence that TIF using EsophyX can be performed with an acceptable safety risk in selected patients. The SAGES concluded that EsophyX results in better control of GERD symptoms than proton pump inhibitor (PPI) treatment in the short term (six months), and leads to similar improvements in objective GERD measures compared with PPIs. TIF appears to lose effectiveness during longer-term follow-up and is associated with moderate patient satisfaction scores. SAGES found no comparative, controlled trials between TIF and surgical fundoplication, but preliminary evidence suggested that surgical fundoplication can be used safely after TIF failure.

The SAGES gave a strong recommendation based on moderate-quality evidence that Stretta is safe for adults and significantly improves health-related quality of life score, heartburn scores, the incidence of esophagitis, and esophageal acid exposure in patients with GERD. Stretta was found to decrease PPI use by about 50%, and be more effective than PPIs, but less effective compared to fundoplication. The effectiveness of the procedure decreases over time.

American Society of General Surgeons

The American Society of General Surgeons (2011) issued a position statement on transoral fundoplication stating that “ASGS supports the use of transoral fundoplication by trained General Surgeons for the treatment of symptomatic chronic gastroesophageal reflux disease (GERD) in patients who fail to achieve satisfactory response to a standard dose of Proton Pump Inhibitor (PPI) therapy or for those who wish to avoid the need for a lifetime of medication dependence.”^39,

National Institute for Health and Care Excellence

The NICE (2013) updated its guidance on endoscopic radiofrequency treatment for GERD, concluding: "The evidence on the safety of endoscopic radiofrequency ablation for gastro-esophageal reflux disease is adequate in the short and medium term, but there is uncertainty about longer‑term outcomes. With regard to efficacy, there is evidence of symptomatic relief, but objective evidence on reduction of reflux is inconclusive....."^40, The NICE noted "concern on the part of some specialists about the possibility that symptoms may improve as a result of denervation caused by the procedure; if that were the case then failure to recognize and treat reflux might lead to complications in the long term."

The NICE (2011) issued guidance on endoluminal gastroplication for GERD, concluding that "The evidence on endoluminal gastroplication for gastroesophageal reflux disease raises no major safety concerns. Evidence from a number of RCTs [randomized controlled trials] shows a degree of efficacy in terms of reduced medication requirement in the short term, but changes in other efficacy outcomes are inconsistent, and there is no good evidence of sustained improvement in esophageal pH measurements...."^41,

The NICE (2004) issued guidance on bulking agents for GERD found that "Current evidence on the safety and efficacy of endoscopic injection of bulking agents for gastro-esophageal reflux disease does not appear adequate for this procedure to be used without special arrangements....."^42, The NICE (2016) removed guidance on endoscopic bulking agents/hydrogel implants from guidelines on treatment for "dyspepsia and gastro-esophageal reflux" because the product had been withdrawn by the manufacturer.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this policy are listed in Table 21.

Table 21. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT02366169a	A Worldwide Post-Market Surveillance Registry to Assess the Medigus Ultrasonic Surgical Endostapler (MUSE™) System for the Treatment of GERD	200	Dec 2019
Unpublished
NCT01110811a	A Randomized Controlled Trial Comparing Transoral Incisionless Fundoplication (TIF) Using EsophyX With Sham Procedure for the Treatment of PPI Dependent GERD: the TIF vs Sham Study	60	Dec 2018 (completed)
NCT01682265	Stretta in Reflux Uncontrolled by Intake of Inhibitors of Protons Pump (IPP)-The SIRUP Trial-Multicentric, Randomized, Double-Blind, Prospective Study	62	Nov 2018 (completed)
NCT01118585a	Prospective Outcome Evaluation of Transoral Incisionless Fundoplication (TIF) for the Treatment of Gastroesophageal Reflux Disease (GERD): The TIF Registry Study	278	Dec 2018 (completed)

NCT: national clinical trial.

^a Denotes industry-sponsored or cosponsored trial.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Transendoscopic Therapies for Gastroesophageal Reflux Disease
BESS
Bard Endoscopic Suturing System
EndoCinch
Endoluminal Gastroplication
Endoscopic Gastroesophageal Suturing
Endoscopic Gastroplasty
Endoscopic Submucosal Injection for GERD
Enteryx
Esophyx
Fundoplication, Transoral Incisionless for GERD
Gastroesophageal Reflux Disease Endoscopic Suturing
Gastroplasty, Endoscopic
Gastroplication, Endoluminal
GERD, Transoral Endoscopic Suturing for
PMMA (polymethylmethacrylate)
Polymethylmethacrylate Beads
Stretta System
Transesophageal Radiofrequency for GERD
Transoral Endoscopic Suturing for GERD
Transoral Incisionless Fundoplication for GERD
Plicator System
ESD System
Wilson-Cook ESD System
Gatekeeper System

References:
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3. Ip S, Bonis P, Tatsoni A, et al. Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease (Evidence Report/Technology Assessment No. 1). Rockville, MD: Agency for Healthcare Research and Quality; 2005.

4. Ip S, Chung M, Moorthy D, et al. Management strategies for gastroesophageal reflux disease: An update (Comparative Effectiveness Review No. 29). Rockville, MD: Agency for Healthcare Research and Quality; 2011.

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6. Hummel K, Richards W. Endoscopic treatment of gastroesophageal reflux disease. Surg Clin North Am. Jun 2015;95(3):653-667. PMID 25965137.

7. Food and Drug Administration (FDA). 510(k) Summary: EsophyX (K106960). 2016; https://www.accessdata.fda.gov/cdrh_docs/pdf16/K160960.pdf. Accessed October 29, 2018.

8. Food and Drug Administration (FDA). EsophyX Summary K171307. 2017; https://www.accessdata.fda.gov/cdrh_docs/pdf17/K171307.pdf. Accessed October 29, 2018.

9. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Transesophageal Endoscopic Treatments for Gastroesophageal Reflux Disease. TEC Assessment. 2003;Volume 18:Tab 20. PMID.

10. McCarty TR, Itidiare M, Njei B, et al. Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endoscopy. Jul 2018;50(7):708-725. PMID 29625507.

11. Richter JE, Kumar A, Lipka S, et al. Efficacy of laparoscopic Nissen fundoplication vs transoral incisionless fundoplication or proton pump inhibitors in patients with gastroesophageal reflux disease: a systematic review and network meta-analysis. Gastroenterology. Apr 2018;154(5):1298-1308 e1297. PMID 29305934.

12. Hunter JG, Kahrilas PJ, Bell RC, et al. Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial. Gastroenterology. Feb 2015;148(2):324-333 e325. PMID 25448925.

13. Trad KS, Barnes WE, Simoni G, et al. Transoral incisionless fundoplication effective in eliminating GERD symptoms in partial responders to proton pump inhibitor therapy at 6 months: the TEMPO Randomized Clinical Trial. Surg Innov. Feb 2015;22(1):26-40. PMID 24756976.

14. Trad KS, Fox MA, Simoni G, et al. Transoral fundoplication offers durable symptom control for chronic GERD: 3-year report from the TEMPO randomized trial with a crossover arm. Surg Endosc. Jun 2017;31(6):2498-2508. PMID 27655380.

15. Trad KS, Barnes WE, Prevou ER, et al. The TEMPO Trial at 5 years: transoral fundoplication (TIF 2.0) Is safe, durable, and cost-effective. Surg Innov. Apr 2018;25(2):149-157. PMID 29405886.

16. Hakansson B, Montgomery M, Cadiere GB, et al. Randomised clinical trial: transoral incisionless fundoplication vs. sham intervention to control chronic GERD. Aliment Pharmacol Ther. Dec 2015;42(11-12):1261-1270. PMID 26463242.

17. Witteman BP, Conchillo JM, Rinsma NF, et al. Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease. Am J Gastroenterol. Apr 2015;110(4):531-542. PMID 25823768.

18. Toomey P, Teta A, Patel K, et al. Transoral incisionless fundoplication: is it as safe and efficacious as a Nissen or Toupet fundoplication? Am Surg. Sep 2014;80(9):860-867. PMID 25197871.

19. Frazzoni M, Conigliaro R, Manta R, et al. Reflux parameters as modified by EsophyX or laparoscopic fundoplication in refractory GERD. Aliment Pharmacol Ther. Jul 2011;34(1):67-75. PMID 21539587.

20. Stefanidis G, Viazis N, Kotsikoros N, et al. Long-term benefit of transoral incisionless fundoplication using the esophyx device for the management of gastroesophageal reflux disease responsive to medical therapy. Dis Esophagus. Feb 01 2017;30(3):1-8. PMID 27868281.

21. Testoni PA, Testoni S, Mazzoleni G, et al. Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study. Surg Endosc. Sep 2015;29(9):2770-2780. PMID 25480624.

22. Testoni PA, Testoni S, Distefano G et al. Transoral incisionless fundoplication with EsophyX for gastroesophageal reflux disease: clinical efficacy is maintained up to 10 years. Endosc Int Open, 2019 May 7;7(5). PMID 31058207.

23. Huang X, Chen S, Zhao H, et al. Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Surg Endosc. Mar 2017;31(3):1032-1044. PMID 27495332.

24. Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. Jun 2015;13(6):1058-1067 e1051. PMID 25459556.

25. Corley DA, Katz P, Wo JM, et al. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology. Sep 2003;125(3):668-676. PMID 12949712.

26. Aziz AM, El-Khayat HR, Sadek A, et al. A prospective randomized trial of sham, single-dose Stretta, and double-dose Stretta for the treatment of gastroesophageal reflux disease. Surg Endosc. Apr 2010;24(4):818-825. PMID 19730952.

27. Arts J, Bisschops R, Blondeau K, et al. A double-blind sham-controlled study of the effect of radiofrequency energy on symptoms and distensibility of the gastro-esophageal junction in GERD. Am J Gastroenterol. Feb 2012;107(2):222-230. PMID 22108449.

28. Fass R, Cahn F, Scotti DJ, et al. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc. Dec 2017;31(12):4865-4882. PMID 28233093.

29. Coron E, Sebille V, Cadiot G, et al. Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients. Aliment Pharmacol Ther. Nov 1 2008;28(9):1147-1158. PMID 18616516.

30. Kalapala R, Shah H, Nabi Z, et al. Treatment of gastroesophageal reflux disease using radiofrequency ablation (Stretta procedure): An interim analysis of a randomized trial. Indian J Gastroenterol. Sep 2017;36(5):337-342. PMID 29030802.

31. Liang WT, Yan C, Wang ZG, et al. Early and midterm outcome after laparoscopic fundoplication and a minimally invasive endoscopic procedure in patients with gastroesophageal reflux disease: a prospective observational study. J Laparoendosc Adv Surg Tech A. Aug 2015;25(8):657-661. PMID 26258269.

32. Liang WT, Wang ZG, Wang F, et al. Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study. BMC Gastroenterol. Oct 10 2014;14:178. PMID 25304252.

33. Noar M, Squires P, Noar E, et al. Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later. Surg Endosc. Aug 2014;28(8):2323-2333. PMID 24562599.

34. Ganz RA, Fallon E, Wittchow T, et al. A new injectable agent for the treatment of GERD: results of the Durasphere pilot trial. Gastrointest Endosc. Feb 2009;69(2):318-323. PMID 19185691.

35. Fockens P, Cohen L, Edmundowicz SA, et al. Prospective randomized controlled trial of an injectable esophageal prosthesis versus a sham procedure for endoscopic treatment of gastroesophageal reflux disease. Surg Endosc. Jun 2010;24(6):1387-1397. PMID 20198491.

36. Feretis C, Benakis P, Dimopoulos C, et al. Endoscopic implantation of Plexiglas (PMMA) microspheres for the treatment of GERD. Gastrointest Endosc. Apr 2001;53(4):423-426. PMID 11275880.

37. ASGE Standards of Practice Committee, Muthusamy VR, Lightdale JR, et al. The role of endoscopy in the management of GERD. Gastrointest Endosc. Apr 2015;81(6):1305-1310. PMID 25863867.

38. Society of American Gastrointestinal and Endoscopic Surgeons. Clinical Spotlight Review: Endoluminal Treatments for Gastroesophageal Reflux Disease (GERD). 2017; https://www.sages.org/publications/guidelines/endoluminal-treatments-for-gastroesophageal-reflux-disease-gerd/. Accessed October 17, 2019.

39. American Society of General Surgeons (ASGS). Coverage of Transoral fundoplication. 2011; https://theasgs.org/position-statements/coverage-of-transoral-fundoplication-2/. Accessed October 17, 2019.

40. National Institute for Health and Care Excellence (NICE). Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease [IPG461]. 2013; https://www.nice.org.uk/guidance/ipg461. Accessed October 17, 2019.

41. National Institute for Health and Care Excellence (NICE). Endoluminal gastroplication for gastro-oesophageal reflux disease [IPG404]. 2011; https://www.nice.org.uk/guidance/ipg404. Accessed October 17, 2019.

42. National Institute for Health and Care Excellence (NICE). Endoscopic injection of bulking agents for gastro-oesophageal reflux disease [IPG55]. 2004; https://www.nice.org.uk/guidance/ipg55. Accessed October 17, 2019.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

43201
43210
43212
43236
43257
43266
43499