University of Texas Health Science Center at Houston Houston, TX, United States
Layth Alzubaidy, MD1, Kevin K. Yu, MD, MS1, Tejal Mistry, MD1, Nirav Thosani, MD, MHA2 1University of Texas Health Science Center at Houston, Houston, TX; 2University of Texas Health Science Center, Houston, TX
Introduction: CLEAR evolved from Anti-Reflux MucoSectomy (ARMS) and uses band ligation rather than dissection. We present a case of a patient status post fundoplication with persistent reflux symptoms.
Case Description/Methods: 74 year-old female with past medical history of smoldering myeloma, interstitial lung disease, pulmonary fibrosis, rheumatoid arthritis, osteoporosis, hiatal hernia (Grade IV) status post Toupet fundoplication, and long standing GERD who presents with symptoms of heart burn, nocturnal cough, and regurgitation, despite PPI therapy for years. Screening EGD showed recurrent hiatal hernia with a patulous gastroesophageal sphincter wall. She underwent impedance study with high DeMeester score. Subsequent gastric emptying study was consistent with gastroparesis. CLEAR procedure was performed with five bands placed. The patient reported significant improvement of symptoms and was on a reduced dose of PPI. A follow up screening EGD at four months showed improved hiatal hernia. One year post CLEAR, the patient reported mild return of symptoms, so PPI dose was increased BID. She is currently pending a repeat CLEAR procedure at the time of writing of this case.
Discussion: While ARMS procedure has gained popularity as a minimally invasive endoscopic intervention for refractory GERD, major risks involved with it include bleeding, perforation, and dysphagia [4, 5]. In CLEAR, multiple band ligations at the cardia are deployed without resection, resulting in tissue necrosis to suppress backflow by scar formation [3, 7]. Traditionally, patients with failed endoscopic treatments would resort to surgical intervention and the limited literature on ARMS studies have excluded patients with hiatal hernia > 2 cm [8-10]. Therefore, to our knowledge, this is the first case of CLEAR performed on a patient who had already undergone fundoplication. Although the patient reported return of symptoms of one year after CLEAR was performed, such findings are not uncommon among patients who undergo both surgical and endoscopic procedures for GERD relief, including cases of cardia ligation patients [7, 11]. It remains unclear at this time what the optimal number of bands to be placed initially to reduce symptoms or avoid repeat procedures. Nevertheless, this case demonstrates that CLEAR could be a safe, effective, and well-tolerated ambulatory procedure, especially in patients with who are poor surgical candidates for repeat fundoplication.
Disclosures: Layth Alzubaidy indicated no relevant financial relationships. Kevin Yu indicated no relevant financial relationships. Tejal Mistry indicated no relevant financial relationships. Nirav Thosani indicated no relevant financial relationships.
Layth Alzubaidy, MD1, Kevin K. Yu, MD, MS1, Tejal Mistry, MD1, Nirav Thosani, MD, MHA2. P1766 - Cardia Ligation Endoscopic Anti-Reflux (CLEAR) Procedure in the Treatment of Refractory GERD (With Video), ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.