We read with great interest the article by Schiefke and colleagues (Gut 2005;54:752–8) on the long term failure of endoscopic gastroplication (Endocinch). The authors reported more than 80% of patients had lost at least one suture and only 17% had all sutures in situ after 18 months (clip device). Loss of plications has been reported both with knot¹ as well as clip devices (Gut 2005;54:752–8) used for anchoring sutures but seems to be more with the later. Further studies are needed to confirm above. However, a previous study did not find a significant difference between the mean tensile failure force (tissue tear out and suture disruption) for the knot compared with the clip device anchoring technique.² The depth of a suture seems to be an important factor in the durability of a suture. With the present size of a suction chamber in a sewing capsule after an appropriate suction an average depth of a suture would be 2.86±0.91 mm.³ This enable placement of most of the sutures in the submucosal layer of the stomach and some sutures may enter the muscular wall. Hence increasing the size of the suction chamber may increase the depth of suture, which may improve the durability of sutures.

The procedure has been followed up for 1–4 years in other published series. At one year of follow up, the marked improvement in gastro-oesophageal reflux disease (GORD) symptoms, quality of life, and reduced requirements for proton pump inhibitors (PPIs) using the Endocinch technique is associated with some continuing oesophageal acid reflux.^1,4 Those patients who did not revert to PPIs at 12 months had a significantly lower degree of acid reflux at three months than those who went back on PPIs. The reason why some patients went back on PPIs is unclear but it may relate to the higher DeMeester score in this group pre-procedure.¹ Two years post-procedure follow up (n = 33) from the US multicentre study revealed a sustained significant improvement in symptom score and regurgitation. Twenty five per cent were completely off antisecretory medication and 26% were requiring less than or equal to half of their initial PPI/H₂ blockers.⁵ In the paediatric group at 33 months post-procedure, 82% maintained their symptomatic improvement and remained off all antireflux medications.⁶ Most patients with good improvement maintain their improvement at 2–4 years.⁷ A non-randomised comparison study between Endocinch and the gold standard laparoscopic Nissen fundoplication (LNF) revealed significant reduction in symptom and regurgitation score, requirement for antisecretory medications, and improved quality of life in both groups. However, physiological control of acid reflux was significantly better in the LNF group at the expense of a higher incidence of post-procedure dysphagia and difficulty in vomiting and belching.⁸

Better outcome shown by Thomson and colleagues⁶ in respect of symptom improvement and oesophageal pH control was probably due to better sedation which may have provided a relaxed and safe environment for taking deeper stitches. Also, they took three as compared with two plications in all other Endocinch studies. Hence further studies are necessary to determine what modifications to this technique are required in order to produce the maximum clinical benefit and to prevent complications associated with GORD. At this stage in its development it is important that medical practitioners using Endocinch should enter their results into formal trials to assess and improve its efficacy and durability. Nevertheless, the Endocinch technique has added a new and exciting era which has the potential to improve the quality of life of patients with GORD.