Endoscopic antireflux options and beyond: which patients, which techniques?

Gastro-oesophageal reflux disease (GORD) is among the most commonly diagnosed gastrointestinal disorders, with a substantial impact on quality of life, mental health, sleep and healthcare costs. Although proton pump inhibitors (PPIs) remain first-line therapy, a sizeable minority of patients are PPI-dependent or PPI-refractory and many wish to avoid lifelong pharmacotherapy without committing to laparoscopic fundoplication. Endoscopic antireflux therapies (EARTs) bridge this therapeutic gap. The currently relevant modalities—transoral incisionless fundoplication (TIF V.2.0) and concomitant TIF with hiatal hernia repair (cTIF), endoscopic full-thickness plication (GERD-X), the mucosal interventions antireflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) and radiofrequency ablation (Stretta)—work through distinct mechanisms but share the goal of reinforcing the gastro-oesophageal junction. The 2025 American Society for Gastrointestinal Endoscopy (ASGE) guideline now formally endorses TIF and cTIF as evidence-based alternatives to chronic medical therapy in selected patients. The first sham-controlled randomised controlled trials of ARMA, published in 2026, have refined our understanding of its niche: ARMA appears effective in reflux-predominant GORD characterised by an acid exposure time (AET) <6% with >80 reflux episodes per 24 hours but provides no benefit over sham in conventional acid-predominant disease. Magnetic sphincter augmentation (LINX) has matured as a minimally invasive surgical alternative. This review synthesises the contemporary evidence using Lyon Consensus V.2.0 phenotyping as the framework for patient selection, discusses training, safety and cost considerations and offers a practical algorithm for choosing among EARTs and identifying patients best referred for surgery.