Digestive Diseases Center, Showa University Koto Toyosu Hospital

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POEF (Per-Oral Endoscopic Fundoplication)

A brand-new endoscopic treatment for GERD
For PPI refractory GERD patients



  • Per-oral endoscopic fundoplication (POEF) is a novel less-invasive endoscopic treatment for PPI refractory GERD patients.
  • The idea of POEF was created from Dor fundoplication, which creates a partial fundoplication on the gastric cardia. Ideally, the shape of the cardia is similarly designed to that of Dor fundoplication. We aim to identify POEF as “endoscopic Dor fundoplication”.
  • POEF is an offshoot of POEM, and it is the world’s first pure-NOTES fundoplication.
  • Natural orifice transluminal endoscopic surgery (NOTES) is a novel procedure within minimal access surgery in which the operator accesses the peritoneal cavity via a luminal organ and performs diagnostic or therapeutic procedures.
  • POEF, as the name states, is per-oral access and only needs gastrointestinal endoscopy.

The image shows the list of procedures that can be performed in our center. The order in line represents the “intensity” of the treatment, not “efficacy”. Of these, POEF has the weakest anti-reflux effect.
We would like to emphasize that “the strongest treatment” is not always “the best treatment” for each patient. If we carry out the strongest fundoplication, like Nissen, for a patient whose peristalsis of the esophagus is weakened due to chronic inflammation, dysphagia may occur after the procedure. Therefore, we perform esophageal motility test (upper endoscopy, esophagogram, esophageal manometry) and esophageal 24hour pH testing in all cases and evaluate the cause of their symptoms.
Based on the result of these tests, we will be able to suggest the best treatment for you.


  • Patients who do not respond to medications for GERD.
  • Patients who would prefer to avoid taking long-term medications for GERD
  • Presence of esophageal or extra-esophageal complications of GERD
  • Weakened or lack of esophageal peristalsis


Illustration: Dr. Kaori Ohwada 

Fig. A:An illustration of POEF procedure. We use two endoscopes. One is in the peritoneal cavity which is used mainly for operation. The second endoscope is in gastric retroflex view to confirm the morphological change of the cardia and to assist the main scope.
Fig.B:An illustration of the result after POEF. Ideally, the shape of the cardia is similarly designed to that of Dor fundoplication.

POEF procedure by endoscopic suturing.
Submucosal endoscope is advanced through the peritoneum into the abdominal cavity.
Distal anchoring at the anterior gastric wall (A) in the abdominal cavity. By pulling back the scope and the device (B), suture is tightened up and partial wrap is created at the gastric cardia (C).

The morphological change at gastric cardia. Before (A) and after fundoplication (B). The cardia is covered again by the created floppy partial wrap.

Reflux esophagitis has improved 2 months after POEF (B) compared with pre-POEF (A).


  • 1. Inoue H, Ueno A, Shimamura Y, et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019; 51(2): 161-4.
  • 3.Toshimori A, Inoue H, Shimamura Y, et al. POEF- Per-Oral Endoscopic Fundoplication -A brand new intervention for GERD-;Video GIE (in press)