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First Experience with Banded Anti-reflux Mucosectomy (ARMS) for GERD: Feasibility, Safety, and Technique (with Video)
Abstract
Background
Anti-reflux mucosectomy (ARMS) is a relatively new endoscopic procedure for gastroesophageal reflux disease (GERD). A hemi-circumferential endoscopic mucosal resection (EMR) is performed around the gastroesophageal junction (GEJ), which then contracts and tightens during healing. The aim of this study was to assess the feasibility and safety of the procedure. A secondary aim was to assess short-term outcomes on PPI use and symptom resolution.
Methods
IRB approval was obtained for retrospective review of a prospectively collected database including patients who underwent ARMS during a 2-year period. To be eligible for the procedure, patients required medically refractory GERD and a hiatal hernia no more than 2 cm. A 270-degree mucosal resection of the gastric cardia was performed in a retroflexed position using a multi-band EMR system. Demographics, preoperative workup, intraoperative factors, additional procedures, and other follow-up were collected by chart review. Voluntary validated surveys assessed symptomatic improvement over time.
Results
There were 19 patients available for review. The procedure was technically completed in all cases. There was one muscle injury due to a deep resection that was repaired by endoscopic suturing. All patients were discharged on the day of the procedure. Early dysphagia was experienced by three patients (16%) which was addressed with endoscopic balloon dilation. GERD symptoms improved in 13 patients (68%) after discontinuing PPI therapy. Three of the six failures went on to have additional anti-reflux surgery. Among patients who did not have additional surgery, quality of life data showed significant symptomatic improvement by 6 months.
Conclusion
In this ARMS case series, the procedure was technically successful in all patients with only one minor complication. Two thirds of patients showed symptomatic improvement and were able to discontinue their PPI. ARMS appears to be a safe procedure that does not hinder future laparoscopic anti-reflux surgery in case of failure. Additional tuning of technique and postoperative management may be able to reduce dysphagia rates and the need for dilation.
... Since the pilot study in 2014, 16 an increasing number of reports have been published. 8,14,15,[17][18][19][20][21][22][23] Moreover, two variants of ARMS have been subsequently reported: antireflux mucosal ablation (ARMA) [24][25][26] and antireflux band ligation (ARBL). [27][28][29] The three procedures not only share the common mechanism of creating artificial ulcers and fibrosis at the GEJ by mucosal intervention but also use preexisting techniques and devices. ...
... Study outcomes, statistical analysis, and risk-of-bias assessment The primary outcome in this systematic review was clinical success, which referred to the proportion of patients who had ⩾50% symptomatic improvement compared with baseline, and it was embraced in many included studies as the primary endpoint. 14,15,[19][20][21]24,29 The secondary outcomes were the changes in the following score: symptom score, AET, and DeMeester score; need for PPI postoperatively; procedure time; endoscopic findings; and adverse events. ...
... After the review process with the predefined selection criteria, 15 studies were considered eligible for the review, 8,14,15,[17][18][19][20][21][22]24,25,[27][28][29][30] (Table 1 and Figure 1): nine used ARMS, 8,14,15,[17][18][19][20][21][22] three used ARMA, 24,25,30 and three used ARBL [27][28][29] as the main procedure. Most studies were designed as single-arm cohort, except for three comparative studies -two with PPI 27,28 and one with antireflux surgery. ...
Background
Endoscopic treatments are increasingly being offered for refractory gastroesophageal reflux disease (GERD). Three procedures have similar concepts and techniques: antireflux mucosectomy (ARMS), antireflux mucosal ablation (ARMA), and antireflux band ligation (ARBL); we have collectively termed them antireflux mucosal intervention (ARMI). Here, we systematically reviewed the clinical outcomes and technical aspects.
Methods
The PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. The primary outcome was the clinical success rate. The secondary outcomes were acid exposure time, DeMeester score, need for proton pump inhibitors (PPIs), endoscopic findings, and adverse events.
Results
Fifteen studies were included. The pooled clinical success rate was 73.8% (95% confidence interval (CI) = 69%–78%) overall, 68.6% (95% CI = 62.2%–74.4%) with ARMS, 86.7% (95% CI = 78.7%–91.9%) with ARMA, and 76.5% (95% CI = 65%–85.1%) with ARBL. ARMI resulted in significantly improved acid exposure time, DeMeester score, and degree of hiatal hernia. Furthermore, 10% of patients had dysphagia requiring endoscopic dilatation after ARMS or ARMA, and ARMS was associated with a 2.2% perforation rate. By contrast, no bleeding, perforation, or severe dysphagia was noted with ARBL. Severe hiatal hernia (Hill grade III) may predict treatment failure with ARMA.
Conclusions
The three ARMI procedures were efficacious and safe for PPI-refractory GERD. ARMA and ARBL may be preferred over ARMS because of fewer adverse events and similar efficacy. Further studies are necessary to determine the optimal technique and patient selection.
... And, PPIs could be discontinued postoperatively in all patients. Subsequently, several studies validated effectiveness and safety of ARMS in treatment of rGERD [17,18]. However, quality evidence and follow-up data are still scarce. ...
... Moreover, overall efficacy of ARMS in this study was similar to reported results in other retrospective and some uncontrolled prospective studies, which demonstrated symptom improvement rates of 68-88% and PPI discontinuation rates of 68% to 100% after 6 months or longer [17][18][19]. The improvement on distal esophageal acid exposure was not as significant as reported in pilot study by Inoue et al. [16] and a slightly higher proportion of normalized distal esophageal acid exposure at 6 months after treatment was accomplished in our study than those treated with TIF or PPI therapy [15]. ...
... Additional advantage of this study is that ARMS was completed on basis of ESD technique in all patients. Both ESD and multi-fragment EMR were applied in initial study by Inoue et al. [16], other two studies used cap-assisted EMR (EMR-C) or EMR with a band ligation device (EMR-L) [17,18]. Moreover, complete excision of expected mucosa using ESD technique can provide intact pathological samples, which cannot be achieved with multi-fragment EMR. ...
Background
Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD.
Methods
This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed.
Results
Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups ( p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups.
Conclusion
Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.
... Contraction of the scared area during the healing period led to the tightening of the cardia opening, resulting in significant improvement of GERD symptoms. [78] The standard endoscopic technique involves a hemi-circumferential mucosectomy of the gastric cardia around the gastroesophageal junction. While the patient is under general anesthesia, the endoscope is advanced into the stomach, and in a retroflexed position, the mucosa is marked by a hot snare and then resected around the gastroesophageal valve for up to 270°, sparing the greater curvature side. ...
... While the patient is under general anesthesia, the endoscope is advanced into the stomach, and in a retroflexed position, the mucosa is marked by a hot snare and then resected around the gastroesophageal valve for up to 270°, sparing the greater curvature side. [78,79] Anti-reflux mucosectomy (ARMS) can also be conducted using a cap-assisted device, resection, and plication (RAP) technique, or by using a band ligation device. ...
... Another retrospective study evaluated the efficacy and safety of ARMS in 19 patients showing symptomatic improvement and PPI treatment discontinuation in 68% of them. [78] Three patients (16%) experienced dysphagia post-procedure, which resolved by endoscopic balloon dilatation. The procedure failed in 16% of the patients; three of those patients required additional anti-reflux surgery. ...
Purpose of review
Endoscopic intervention is one of the therapeutic modalities that are currently available for GERD. Endoscopic treatment for GERD has been recently positioned as an alternative for chronic medical therapy or anti-reflux surgery. Patients who are candidates for these procedures include those with typical symptoms of GERD, low-grade erosive esophagitis (Los Angeles A and B), abnormal esophageal acid exposure if normal endoscopy, small hiatal hernia (< 3 cm), and partial or complete response to PPI treatment. This review will highlight the present and emerging data available about current and new endoscopic therapeutic modalities for GERD.
Recent findings
Presently, there are three endoscopic techniques that are approved for GERD, including the Stretta procedure, transoral incisionless fundoplication (TIF), and Medigus ultrasonic surgical endostapler (MUSE). Overall, all endoscopic techniques for GERD have reported excellent control of GERD-related symptoms, improvement of health-related quality of life, durability, and safety. However, the quality of evidence to support these claims varies greatly from one procedure to the other. Furthermore, there is an important discrepancy between improvement of subjective clinical parameters versus objective clinical parameters. There is a growing interest in positioning the endoscopic techniques in patient’s post-bariatric surgery, after peroral endoscopic myotomy (POEM), and in those who also require hiatal hernia repair. There are several new endoscopic interventions for GERD that are currently under investigation.
Summary
Endoscopic techniques are currently part of our therapeutic armamentarium for GERD. Criticism about their limited effect on objective clinical endpoints has tempered the enthusiasm of patients and physicians alike about their therapeutic value. However, endoscopic therapy for GERD is here to stay as more patients are looking for alternatives to medical and surgical therapy.
... Formally described in 2014, the ARMS procedure involves a hemi-circumferential endoscopic mucosal resection (EMR) of the gastric cardia around the GE junction, causing contraction and scarring with healing, which is thought to tighten the GE junction [7]. Since then, several case series have demonstrated short-term efficacy but few have examined long-term clinical or quality of life (QOL) outcomes in these patients [8][9][10]. In this study, we aim to compare clinical and QOL outcomes of patients who underwent ARMS to patients who underwent laparoscopic Nissen fundoplications (NF), but were potential candidates for ARMS based on clinical criteria. ...
... The anti-reflux mucosectomy (ARMS) technique at our institution has been previously described [8]. Briefly, the procedure is done with the patient in the supine position under general anesthesia. ...
... Recent studies have demonstrated that ARMS is a safe and feasible minimally invasive endoscopic intervention for the management GERD [7][8][9][10]14]. However, none have compared the outcomes of ARMS to the gold standard surgical intervention of laparoscopic Nissen fundoplication (NF). ...
Background
Anti-reflux mucosectomy (ARMS) is a new endoscopic procedure involving a hemi-circumferential endoscopic mucosal resection (EMR) around the gastroesophageal junction. We aim to compare perioperative and quality of life outcomes of patients with reflux who underwent ARMS to a comparable group who underwent laparoscopic Nissen fundoplication (NF).
Methods
A retrospective review of a prospectively maintained quality database was performed. All patients who underwent ARMS (n = 33) were matched with patients who underwent NF (n = 67). Clinical and quality of life (QOL) outcomes were collected preoperatively and up to two years postoperatively, measured by the Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Score. Outcomes were compared using the Wilcoxon rank-sum and Fisher’s exact test.
Results
While 10 patients (30.3%) who underwent ARMS required additional laparoscopic anti-reflux operations, the ARMS group had shorter OR time (p<0.001), less estimated blood loss (p<0.001), shorter hospital stay (p<0.001), less pain at discharge (p = 0.007), earlier narcotic discontinuation (p<0.001), and earlier return to activities of daily living (p<0.001) compared to the NF group. There was no difference in 30-day complication rates, emergency room visits, or readmission rates between the groups. There was no difference between ARMS and NF groups in terms of GERD-HRQL, RSI, or Dysphagia scores at 3 weeks, 6 months, 1 year, or 2 years postoperatively. However, the ARMS group reported less symptoms of gas and bloating postoperatively at all time points (all p<0.05). Both groups reported increased dysphagia at 3 weeks postoperatively (p<0.01) but this did not persist at 6 months, 1 year, or 2 years.
Conclusion
While ARMS had better perioperative outcomes compared to NF, reflux quality of life outcomes were comparable. ARMS can be an effective endoscopic intervention for GERD when performed on appropriately selected patients without limiting future laparoscopic anti-reflux interventions.
... Magnetic sphincter augmentation (MSA) is becoming increasingly utilized due to a shorter operative time, ease of reversibility, and less postoperative gas bloat [1, 2]. One of the least invasive treatment options is the Anti-reflux Mucosectomy (ARMs) which uses endoscopic mucosal resection to tighten the gastroesophageal junction by inducing scaring [3]. ...
... Our institution only offers MSA in those with 80% normal swallows. Anti-reflux mucosectomy was only offered to patients with a hiatal hernia measuring less than or equal to 2 cm [3,13]. Our institution's operative protocols for all four procedures are well described previously [14]. ...
Background
Surgical treatment options of gastroesophageal reflux disease have changed significantly in the last 50 years. Magnetic Sphincter Augmentation (MSA) and Anti-reflux Mucosectomy (ARMs) are gaining traction but there is a paucity of literature comparing these novel options to Toupet fundoplication and gold standard Nissen fundoplication.Methods
This is a retrospective review of a prospectively maintained database, evaluating patients undergoing Nissen, Toupet, MSA, and ARMs. Pre-operative, intra-operative, and post-operative variables including Reflux symptom index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL), and Dysphagia scores were compared between groups.ResultsDuring the study period, 649 patients underwent anti-reflux surgery. Patients who underwent Nissen or Toupet were younger than those undergoing MSA or ARMs (65 ± 12 and 67 ± 14 years vs 56 ± 14 and 56 ± 18 years, P < 0.01). Average operative time for Nissen was 127 ± 40 min which was similar to a Toupet at 122 ± 32 min. These durations were significantly longer than for MSA, averaging 79 ± 29, and ARMs, at a mean 35 ± 3 min (all P < 0.001). Length of stay was significantly different among all four groups with Nissen, Toupet, MSA, and ARMs patients staying a median of 31, 24, 7, and 3 h post operatively, respectively (all P < 0.001). Complications and re-admissions were similarly low among all groups. Despite minor differences in RSI and GERD-HRQL scores at isolated follow-up time points, quality of life scores seems to be similar overall at up to 5 years follow-up. Gas bloat and dysphagia did not differ among groups at any time point.Conclusions
Novel anti-reflux surgery options provide similar GERD-related quality of life compared to traditional full or partial fundoplications with the added benefit of shorter operative time and faster recovery.
... ARMS (11,12): (I) submucosal injection: submucosal injection (glycerol fructose + methylene blue mixture) was performed along the outside of the marking points until the mucosa was fully raised. (II) Endoscopic mucosal resection (EMR): the transparent cap was mounted onto the distal tip of the endoscope, and the snare was inserted into the cap through the sheath. ...
... The SRF procedure involves inserting a radiofrequency catheter into the esophagus, piercing the lower esophageal sphincter and cardiac muscle layer with a radiofrequency therapeutic instrument electrode, and burning the gastroesophageal junction at multiple points on multiple surfaces to increase the pressure at the lower end of the esophagus and reduce tissue compliance to achieve an antireflux effect (20)(21)(22). Compared with endoscopic injection therapy, transoral incisionless fundoplication (TIF), and medial ultrasonic surgical endostapler (MUSE) treatment, ARMS and SRF are simple, do not leave any foreign objects in the body, and complications are less likely (6,12,23). The procedures increase cardiac contraction and lower esophageal sphincter pressure in different ways, thus reducing the occurrence of reflux events. ...
Background:
Currently, antireflux mucosectomy (ARMS) and Stretta radiofrequency (SRF) are the most commonly used minimally invasive antireflux therapies. To date, there have not been any reports comparing ARMS and SRF. Our aim was to compare the clinical efficacies of these two therapeutic methods.
Methods:
We analyzed data from gastroesophageal reflux disease (GERD) patients, including 39 who received ARMS treatment and 30 who received SRF treatment between January 2020 and May 2021. Symptom control, gastroesophageal reflux disease questionnaire (GERDQ) score, gastroesophageal reflux disease health-related quality of life (GERD-HRQL) score, proton pump inhibitor (PPI) withdrawal, and PPI reduction were analyzed and compared.
Results:
After 6 months of follow-up, the results showed that both therapies were effective in improving symptoms and quality of life. No difference was found between the ARMS group and SRF group in GERDQ score, GERD-HRQL score, PPI withdrawal rate, or PPI reduction rate (P>0.05). There was no significant difference in the PPI withdrawal rate between the two therapies among patients with gastroesophageal flap valve (GEFV) grade II and grade III (P>0.05), but the PPI withdrawal rate in the ARMS group was significantly higher than that in the SRF group among patients with GEFV grade IV (P<0.05).
Conclusions:
The clinical efficacies of ARMS and SRF 6 months postoperation were equivalent. The results showed that both ARMS and SRF treatment were acceptable for patients with GEFV grades II and III, while ARMS should be selected for patients with GEFV grade IV.
... Efectos adversos graves (perforación gastrointestinal, neumonía y hemorragia) ocurren en 2,4%. Tampoco hay estudios con un gran número de enfermos [32][33][34][35][36][37] . ...
... Inoue en su primera publicación con 10 pacientes, con seguimiento de 2 meses observó disminución del diámetro cardial, mejoría subjetiva y objetiva. En el último tiempo se han publicado otros trabajos, pero solo uno reporta evaluación objetiva respecto de la pHmetría [34][35][36][37][38][39][40] . ...
ResumenDurante las últimas 2 décadas se han desarrollado una serie de nuevos tratamientos endoscópicos para el tratamiento de la enfermedad por reflujo gastroesofágico. (ERGE) como alternativas al tratamiento médico o funduplicatura quirúrgica. Estos dispositivos incluyen aplicación de tratamiento por radiofrecuencia (Stretta), plicatura endoscópica (EndoCinch, Plicator, Esophyx, MUSE) e inyección o implantación de biomateriales (Enteryx, Gatekeeper, Plexiglas, Duragel). Su objetivo es el alivio de los síntomas creando una barrera anatómica antireflujo. En esta revisión, evaluamos críticamente los resultados reportados, aunque faltan datos a largo plazo superiores a 5 o 7 años. Estos procedimientos reducen el uso de inhibidores de la bomba de protones en cerca del 50%. Evaluaciones subjetivas reportan mejoría de la calidad de vida y satisfacción del paciente. Sin embargo, la evaluación objetiva con endoscopia, manometría, radiología y pHmetría son escasos y si los hay, no muestran cambios significativos. No existe evidencia convincente para adoptar estos métodos como tratamiento definitivo. AbstractDuring the last 2 decades, new endoscopic treatments have been developed for the treatment of gastroesophageal reflux disease. (GERD) as alternatives to medical treatment or surgical fundoplication. These devices include application of radiofrequency treatment (Stretta), endoscopic plication (EndoCinch, Plicator, Esophyx, MUSE) and injection or implantation of biomaterials (Enteryx, Gatekeeper, Plexiglas, Duragel). Its objective is the relief of symptoms by creating an anatomical anti-reflux barrier. In this review, we analyse critically the reported results, although long-term data greater than 5 or 7 years are lacking. These procedures reduce the use of proton pump inhibitors by about 50%. Subjective evaluations report improvement in quality of life and patient satisfaction. However, objective evaluation with endoscopy, manometry, radiology and pHmetry are scarce and if there are, they do not show significant changes. There is no convincing evidence to adopt these methods as definitive treatment.
... Anti-reflux mucosectomy (ARMS) was adopted as an alternative endoscopic method for GERD treatment after incidentally discovered in 2003 when a patient with Barret's esophagus was submitted to endoscopic mucosal resection (EMR) and experienced improvement in GERD symptoms (23). As the mucosectomy area heals and scars, the tissue contracts to augment the natural antireflux valve. ...
... With the scope in a retroflexed position, the mucosa is marked with the snare 240-270º around de gastroesophageal valve. Then the mucosa of the cardia is raised with solutions, and then the tissue is banded and transected with forced coagulation (6,23). ...
... Another endoscopic anti-reflux procedure that can be performed in patients with less than 2cm hiatal hernias is anti-reflux mucosectomy (ARMS). First described in 2003, the ARMS procedure utilizes cap endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) to perform a hemi-circumferential EMR of the gastric cardia around the GE junction, causing contraction and scarring which is thought to tighten the GE junction (16,17). While the true anti-reflux mechanism of ARMS has not been studied, small series with short-term outcomes have reported good reflux control on select patients in the absence of hiatal hernias or very small (<2 cm) hiatal hernias (16). ...
... First described in 2003, the ARMS procedure utilizes cap endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) to perform a hemi-circumferential EMR of the gastric cardia around the GE junction, causing contraction and scarring which is thought to tighten the GE junction (16,17). While the true anti-reflux mechanism of ARMS has not been studied, small series with short-term outcomes have reported good reflux control on select patients in the absence of hiatal hernias or very small (<2 cm) hiatal hernias (16). Another proposed mechanism of reflux control from ARMS is disruption of the neuropathway that contributes to transient lower esophageal sphincter (LES) relaxations. ...
... Compared to that used by Inoue et al. [8], our cardial constriction with band ligation procedure was simpler and easier to operate than ARMS because no mucosectomy area of EGJ was needed. Twenty-eight patients had mild dysphagia after the PECC-b procedure which did not require endoscopic dilation, and disappeared within 1-2 weeks, which was lower than after ARMS, as reported in the literature [8,28]. ...
... Our results not only showed improved better reflux symptoms, but also extra-esophageal symptoms. The reason caused different efficacy might be due to different surgical procedures, which was similar as the effect of ARMS (GERD symptoms improved in 68% patients during a 2-year period) [28]. ...
Background
Gastroesophageal reflux disease (GERD) is a common digestive disease, could cause extra-esophageal symptoms. Peroral endoscopic cardial constriction with band ligation (PECC-b) is a minimally invasive method for the treatment of GERD in recent years. The goals of this study were to evaluate the clinical efficacy of PECC-b to treat gastroesophageal reflux-related symptoms.
Methods
A retrospective study of patients undergoing PECC-b between January 2017 and December 2018 at a single institution was conducted. All patients confirmed GERD by endoscopy, esophageal PH-impedance monitoring, esophageal manometry and symptom questionnaires. The outcome measures included reflux-related scores, patients’ satisfaction and drug independence after 12 months following surgery.
Results
A total of 68 patients, with follow-up of 12 months post surgery, were included in the final analysis. The symptom scores were all significantly decreased as compared with preoperation ( P < 0.05). The esophageal symptom scores showed a better improvement than extra-esophageal symptoms ( P < 0.001). Fifty-three (77.9%) patients achieved complete drug therapy independence and 52 (76.5%) patients were completely or partially satisfied with the symptom relief following surgery.
Conclusions
The PECC-b is a safe, effective and recommended approach for the control of GERD-related symptoms. Further multicenter prospective studies are required to confirm these outcomes.
... 84 Several studies have reported that this technique is safe and feasible; over two-thirds of patients in all studies had improved symptom scores, while some demonstrated improved esophageal acid exposure and decreased PPI use. [85][86][87][88] Despite its effectiveness, ARMS is difficult to standardize because the procedure entirely depends on each endoscopist's skill. Additionally, the appropriate size and depth of mucosa to be resected and the level of resection have yet to be established. ...
Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.
... This initial case series demonstrated the potential anti-reflux effect of ARMS, with a crescentic mucosal resection appearing adequate. Several centers subsequently trialed this technique for safety, feasibility, and efficacy, with similar encouraging results, good safety profile and over two-thirds of patients in all studies improving their symptom scores, as well as some decreasing PPI use and improving esophageal acid exposure [73][74][75][76][77]. ...
Gastroesophageal reflux disease (GERD) has consistently been the most frequently diagnosed gastrointestinal malady in the USA. The mainstay of therapy has traditionally been medical management, including lifestyle and dietary modifications as well as antacid medications. In those patients found to be refractory to medical management or with a contraindication to medications, the next step up has been surgical anti-reflux procedures. Recently, though innovative advancements in therapeutic endoscopy have created numerous options for the endoscopic management of GERD, in this review, we discuss the various endoscopic therapy options, as well as suggested strategies we use to recommend the most appropriate therapy for patients.
... In addition, in their recent study Sumi et al. confirmed the 3-year beneficial effect [25]. In other recent studies, ARMS was also effective, but follow-up was short (a few months) and GERD symptoms were not severe [26][27][28]. In our study, all patients had severe dependent or refractory to PPI treatment GERD and post-ARMS followup lasted up to 24 months. ...
Background:
Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease).
Methods:
Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events.
Results:
Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%.
Conclusions:
In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.
... 92 A subsequent study including 19 patients showed by EMR-L techniques that two-thirds of patients obtained symptomatic improvement and were able to discontinue their PPI. 93 A study comparing ARMS and laparoscopic Nissen fundoplication (NF) in 33 patients showed that ARMS groups had significantly shorter operation time, less estimated blood loss, shorter hospital stay, less pain at discharge, earlier narcotic discontinuation, and earlier return to activities of daily living. 94 GERD-HRQL and dysphagia scores were comparable between ARMS and NF. ...
Gastroesophageal reflux disease (GERD) is a common disease that may cause a huge economic burden. Endoscopy is performed not only to rule out other organic diseases but also to diagnose reflux esophagitis or Barrett's esophagus. Non-erosive GERD (non-erosive reflux disease [NERD]) is called endoscopy-negative GERD; however, GERD-related findings could be obtained through histological assessment, image-enhanced endoscopy, and new endoscopic modalities in patients with NERD. Moreover, endoscopy is useful to stratify the risk for the development of GERD. In addition, endoscopic treatments have been developed. These techniques could significantly improve patients’ quality of life as well as symptoms.
... Endoscopic treatment of GERD is being constantly updated, and anti-reflux mucosectomy (ARMS) has attracted our attention. [3][4][5] The mechanism of both HH-ESD and ARMS is the same. However, the two procedures are different in three respects: (1) The indications are different. ...
... Dysphagia requiring balloon dilatation was reported in three (16%) patients. 40 Maydeo et al. did mucosal resection on 62 patients and followed them for 12 months. There was a significant improvement of the DeMeester score in 72.5% of the patients, while the mean GERD-HRQL score improved from 10.6 to 3.4 in 70.1% of patients. ...
Endoscopic therapies in proton pump inhibitors (PPI) dependant/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal antireflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favourable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independency. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using Esophyx device and GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.
... Three patients (16%) experienced dysphagia which was resolved by endoscopic balloon dilatation. Third (6 of 19) of the procedures failed, and three of the patients underwent additional antireflux surgery [110]. ...
Purpose of review:
Despite the many areas of unmet needs in gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) remain the cornerstone of medical therapy. However, since their introduction, the therapeutic limitations of PPIs in GERD management have been increasingly recognized.
Recent findings:
In this review we discuss the new medical, endoscopic, and surgical therapeutic modalities that have been developed over the last decade. They include the potassium-competitive acid blockers (P-CABs) which provide a rapid onset, prolonged, and profound acid suppression, mucosal protectants which promote the physiological protective barrier of the esophageal mucosa, new prokinetics and neuromodulators. There are growing numbers of novel therapeutic endoscopic techniques that are under investigation or were recently introduced into the market, further expanding our therapeutic armamentarium for GERD. The development of diverse therapeutic modalities for GERD, despite the availability of PPIs, suggests that there are many areas of unmet need in GERD that will continue and drive future exploration for novel therapies.
... Thus, the authors reported ARMS to be a safe procedure and encountered only two patients with stenosis. Furthermore, in a subsequent case series of 19 patients, a technical success rate of 100% was reported by Hedberg et al. 6 Early dysphagia was observed in 3 (16%) patients treated with endoscopic balloon dilation; GERD symptoms improved in 13 (68%) patients after PPI therapy termination. Overall, two-thirds of patients reported symptomatic improvement after PPI therapy termination. ...
Author contributions: Conception and design: YS and HI. Drafting of the article: YS. Critical revision of the article for important intellectual content: HI. Both authors have approved the final draft submitted. Gastroesophageal reflux disease (GERD) is one of the most common and problematic gastrointestinal diseases, and it poses a great challenge to gastroenterologists owing to its high prevalence and demanding management.
... 65 Besides radiofrequency ablation and endoscopic fundoplication, some of the recent studies have evaluated the efficacy of endoscopic band ligation and cap or multiband assisted antireflux mucosectomy for the management of GERD. [66][67][68][69] The basic mechanism of these endoscopic techniques is the tightening of gastric cardia as a result of scarring after band ligation or endoscopic mucosal resection. It should be noted that these techniques need to be standardised and evaluated in randomised trials to conclude their efficacy. ...
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered gastrointestinal diseases in clinical practice. Proton pump inhibitors (PPI) remain the cornerstone of the treatment of GERD. Up to one-third of patients do not respond to optimal doses of PPI and fall into the category of refractory GERD. Moreover, the long-term use of PPI is not risk-free, as previously thought. The pathophysiology of refractory GERD is multifactorial and includes reflux related and unrelated factors. It is therefore paramount to address refractory GERD as per the aetiology of the disease for optimal outcomes. The management options for PPI refractory GERD include optimisation of PPI, lifestyle modifications, and the addition of alginates and histamine-2 receptor blockers. Neuromodulators, such as selective serotonin reuptake inhibitors or tricyclic antidepressants, may be beneficial in those with functional heartburn and reflux hypersensitivity. Laparoscopic antireflux surgeries, including Nissen's fundoplication and magnetic sphincter augmentation, are useful in patients with objective evidence of GERD on pH impedance studies with or without a hiatal hernia. More recently, endoscopic antireflux modalities have emerged as an alternative to surgery in patients with PPI-dependent and PPI-refractory GERD. Long-term data and randomised comparison studies, however, are required before incorporating endoscopic therapies in the management algorithm for refractory GERD.
... Even though EMR and ESD techniques have been popularized and standardized, these techniques are more difficult to perform on the cardia and take longer time even with experienced endoscopists. Recently, Hedberg et al. reported that modified ARMS using multiband EMR method could reduce the procedure time to 40.7 min (range, 17-64 min), with 68% clinical success rate and 15% stricture, which was addressed [14]. Meanwhile, the median procedure time of our method was 28 (23.5-33.8) ...
Background and aims
Currently available endoscopic or minimally invasive antireflux modalities are not widely accepted due to high procedure cost or inconsistent results. Therefore, a simpler and less technically demanding method is required. We evaluated the feasibility and efficacy of new endoscopic antireflux method (the Ripple Procedure) using functional lumen imaging probe (FLIP).
Methods
This 5-week survival study included 10 domestic pigs (control, n = 4; experimental [Ripple], n = 6). The procedure includes the following steps: (i) semicircular marking along the lesser curvature of the cardia; (ii) submucosal injection; and (iii) semicircular mucosal incision along the marking. Endoscopic and FLIP evaluations were performed preoperatively and on postoperative days (PODs) 14 and 35. Technical feasibility was evaluated, and FLIP parameters, including the distensibility index (DI) at the esophagogastric junction (EGJ) and histopathological findings, were compared between groups.
Results
The median procedure time was 28 (23.5–33.8) min. There was no significant difference in dysphagia score and body weight between groups. On POD 35, the Ripple group showed significantly lower EGJ DI at 30 mL [2.0 (1.3–2.5) vs 4.9 (2.7–5.0), P = 0.037]. The EGJ DI was significantly reduced at 30 mL, compared with that at the baseline level [− 59.0% (− 68.8% to − 32.1%) vs 27.8% (− 26.3% to 83.1%), P = 0.033]. Histologic evaluation revealed submucosal granulation tissues near the mucosal incision site, with increased intervening fibrosis between lower esophageal sphincter fibers in the Ripple group.
Conclusion
The EGJ DI significantly decreased after the Ripple Procedure; hence, the procedure appears to be feasible and effective in this porcine model.
... However, a circumferential mucosal resection on the gastric side of the cardia is still technically demanding for many endoscopists. Thus the procedure underwent some modifications: the resection area was reduced and others preferred the multiband ligation-assisted EMR or the Argon Plasma Coagulation for mucosal ablation instead of resection [8]. This procedure seems indicated for patients without hiatal hernia, with a slightly enlarged esophagogastric junction. ...
... 39 Subsequently, Hedberg and colleagues published the outcomes of multiband endoscopic mucosal resection in 19 patients with refractory GERD. 40 The authors performed a 270° mucosal resection of the gastric cardia. The symptoms of GERD improved in 13 patients (68%). ...
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered gastrointestinal diseases in outpatient clinics. Proton pump inhibitors (PPIs) are the cornerstone of the treatment of GERD. However, approximately one-third of patients have suboptimal response to PPIs. The management options in such cases include antireflux surgery or endoscopic antireflux treatments. Antireflux surgery is not popular due to its invasive nature and potential for adverse events. Therefore, minimally invasive endoscopic antireflux therapies are gaining popularity for the management of PPI-dependent and PPI-refractory GERD. These endoscopic therapies include radiofrequency application , endoscopic fundoplication modalities, and mucosal resec-tion techniques. In appropriately selected patients, the response to these endoscopic modalities is encouraging. Unlike surgical fundoplication, endoscopic antireflux therapies are less likely to be associated with complications such as dysphagia and gas-bloat syndrome. On the other hand, antireflux surgery remains the ideal treatment in patients with a large hiatal hernia (laparoscopic Nissen fundoplication), morbid obesity (gastric bypass), and severe reflux esophagitis. Endoscopic treatment modalities bear the potential to narrow the treatment gap between PPIs and antireflux surgery. Long-term follow-up studies and randomized comparison with antireflux surgery are required to provide a clear understanding of the current role of endoscopic modalities in patients with PPI-refractory and PPI-dependent GERD.
There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.
The last decade has seen the rise of multiple novel endoscopic techniques to treat gastroesophageal reflux disease, many of which are efficacious when compared with traditional surgical options and allow relief from long-term dependence on antacid medications. This review will explore the latest endoscopic treatment options for gastroesophageal reflux disease including a description of the technique, review of efficacy and safety, and future directions.
During the last 2 decades, new endoscopic treatments have been developed for the treatment of gastroesophageal reflux disease (GERD) as alternatives to medical treatment or surgical fundoplication. These devices include application of radiofrequency treatment (Stretta), endoscopic plication (EndoCinch, Plicator, Esophyx, MUSE) and injection or implantation of biomaterials (Enteryx, Gatekeeper, Plexiglas, Duragel). Its objective is the relief of symptoms by creating an anatomical anti-reflux barrier. In this review, we consider articles indexed in Pubmed, Medline and Scielo in the last 10 years, reviewing a total of 55 papers, we analyse critically the reported results, although long-term data greater than 5 or 7 years are lacking. These procedures reduce the use of proton pump inhibitors by about 50%. Subjective evaluations report improvement in quality of life and patient satisfaction. However, objective evaluation with endoscopy, manometry, radiology and pHmetry are scarce and if there are, they do not show significant changes. There is no convincing evidence to adopt these methods as definitive treatment. Therefore, laparoscopic fundoplication is the gold standard for the treatment of gastroesophageal reflux disease.
Background:
Anti-reflux mucosectomy (ARMS) is a choice for proton pump inhibitor (PPI)-dependent patients with gastroesophageal reflux disease (GERD). We present an extended anti-reflux mucosectomy, named ligation-assisted anti-reflux mucosectomy (L-ARMS). The aim of this study was to assess the feasibility of the procedure and short-term outcomes on PPI use and symptom resolution.
Methods:
Institutional review board approval was obtained for retrospective review of a prospectively collected database including patients who underwent L-ARMS. L-ARMS includes mucosa ligation and endoscopic mucosectomy without submucosal injection around the squamocolumnar junction. The GERD symptoms, endoscopy, 24-h pH monitoring results, and manometry were collected by chart review. Voluntary validated surveys assessed symptomatic improvement over time.
Results:
There were 69 patients available for review. The procedure was technically completed in all cases with no severe complications, and the average operation time was 33 min. At 6 months after L-ARMS, treatment with PPIs had been halted in 55.1% of the patients, 30.4% of the enrolled patients used PPIs occasionally, and the lower esophageal sphincter (LES) pressure, DeMeester scores, and GERD-health-related quality of life questionnaire (GERD-HRQL) scores showed a significant improvement compared with the baseline measurements (P < 0.001). Forty-five patients complained of mild dysphagia and were relieved in 4 weeks with no specific treatment. Compared to patients without dysphagia, patients complained of dysphagia after surgery had better clinical benefits indicated by GERD-HRQL and DeMeester score.
Conclusions:
As a modified ARMS, L-ARMS is an effective procedure for controlling GERD symptoms, esophageal acid exposure, and LES pressure, which can be safely performed endoscopically in a time-saving and simple manner.
Gastroesophageal reflux disease (GERD) is one of the most common obesity-associated comorbidities. The increasing prevalence of obesity worldwide is expected to cause a concomitant increase in the prevalence of GERD. While laparoscopic Nissen fundoplication (LNF) remains the gold standard for the treatment of GERD, its efficacy in the setting of obesity is limited by a relatively high rate of post-procedural reflux recurrence. Currently, Roux-en-Y gastric bypass (RYGB) is the gold standard treatment for GERD in patients with obesity. However, despite its proven efficacy, it remains underutilized due to its cost, safety concerns, and patient acceptance. During the past 2 decades, endoscopic therapies have emerged as minimally invasive and safe alternatives for the management of GERD. While most studies assessed their outcomes in patients without obesity, recently published case reports offered a potential framework for their use in patients with obesity. In this article, we review the available endoscopic anti-reflux therapies (EART) and endoscopic bariatric therapies (EBT), with emphasis on their potential role in the management of GERD in patients with obesity.
Objective:
There is still no gold standard regarding the optimal circumference of antireflux mucosectomy (ARMS) in patients with treatment-refractory gastroesophageal reflux disease (GERD). The aim of this study is to assess the safety and effectiveness of resection procedures when the circumferences are different.
Patients and methods:
Thirty-two patients with treatment-refractory GERD were allocated into group A (16 cases) and group B (16 cases) by randomization. In group A and group B, a 2/3 and 1/2 circumference, 1.5 cm wide mucosal resection of the gastric cardia was performed. Health-related quality of life (HRQOL), frequency scale for the symptoms of GERD (FSSG), DeMeester scores and acid exposure time (AET) were accessed at baseline and at 24 months after treatment. Physical component summaries (PCS), mental component summaries (MCS), and RE-specific summary (RES) scores were calculated.
Results:
All patients had successful surgical procedures and no bleeding, perforation, or dysphagia occurred. The PCS, MCS, and RES scores of post-ARMS were higher than those of pre-ARMS in groups A and B, and the FSSG, DeMeester scores and AET decreased after ARMS in both groups, with differences that were statistically significant (P<0.05). The changes in PCS, MCS, RES, FSSG, DeMeester scores, and AET were greater in group A than in group B, with significant differences in PCS, MCS, RES, and FSSG scores (P<0.05), but no significant differences in, DeMeester scores and AET (P>0.05).
Conclusion:
ARMS is an effective treatment for treatment-refractory GERD. Moreover, we recommend the 2/3 circumference, 1.5 cm wide mucosal resection of the gastric cardia.
Gastroesophageal reflux disease (GERD) occurs in up to 20% of the population. Effective management of the condition is essential to reduce both symptoms and the risk for dysplastic changes of esophageal mucosa. Although lifestyle and diet modification and proton-pump inhibitors (PPIs) remain the standard of therapy, approximately 30% of patients experience persistent or recurrent symptoms with this therapy, which has been labeled PPI-refractory GERD. Surgical antireflux procedures have long been the standard therapy for PPI-refractory GERD, but drawbacks include cost and surgical morbidity. Endoscopic techniques for GERD management have been developed over the past 20 years including transoral incisionless fundoplication, the Stretta procedure, and antireflux mucosectomy. This article will review the current literature on each of these endoscopic procedures as well as highlight areas where further research is needed to fully understand the best practices for use of these endoscopic techniques for the management of PPI-refractory GERD.
Gastroesophageal reflux disease (GERD) is the most prevalent GI disorder in the United States and results from an incompetent barrier resisting the retrograde movement of gastric content. While medical and surgical therapy have been the mainstay of treatment for GERD, there are currently several Food and Drug Administration–approved devices available for endoscopic treatment of GERD, thus filling in the therapeutic gap between medications and surgery. This chapter reviews the endoscopic anti‐reflux procedures, with special emphasis on the proposed mechanism of action, patient selection, technical considerations, safety and clinical outcomes, and future opportunities. To evaluate the role of endoscopic anti‐reflux procedures, one first has to discern the mechanism of action of each procedure. This is only possible by first understanding the gastroesophageal junction anatomy and physiology as it pertains to GERD and, subsequently, the opportunities for intervention with an endoscopic approach.
The treatment of gastroesophageal reflux disease is multifactorial and includes diet/lifestyle modification, weight loss, endolumenal therapies, magnetic sphincter augmentation, formal surgical fundoplication (Nissen, Toupet, and related procedures), and weight loss surgery (Roux-en-Y gastric bypass). Endolumenal therapies, such as transoral fundoplication and radiofrequency treatment of the lower esophageal sphincter, represent an option for carefully selected patients (with early disease and favorable anatomy) who do not desire formal anti-reflux surgery but desire to stop taking daily anti-acid medications. This chapter provides an overview of the available endolumenal therapies for the treatment of patients with reflux.
Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.
Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.
Laparoscopic sleeve gastrectomy has become the most commonly used bariatric surgery worldwide. However, there are a proportion of patients who present with a refractory GERD after this procedure. In these patients, when surgical conversion to RYGPB is not possible or declined, we propose to describe the results of an endoscopic antireflux mucosectomy band (ARM-b) technique in 6 LSG patients with refractory GERD. The technical feasibility was 100%; 5 out of 6 patients had a clinical response with a reduction of the GERD-HRQL score of > 50%. Two patients had adverse events: one esophageal stricture and one benign bleeding. ARM-b is feasible and potentially effective to treat patients with refractory GERD after LSG.
Purpose of review
There is a growing interest in minimally invasive approaches to the management of gastroesophageal reflux disease (GERD), including endoscopic GERD therapy. This review evaluates available endoscopic therapeutic options utilized in GERD management.
Recent findings
Application of radiofrequency energy at the esophagogastric junction (EGJ) reduces reflux symptoms, but esophageal acid exposure does not necessarily normalize, and esophageal sensation is compromised. Two approaches to the creation of a valve at the EGJ, the Medigus ultrasonic surgical stapler (ultrasound guided stapling of the gastric fundus to the EGJ) and EsophyX (fasteners to create a 270 ° partial fundoplication), improve symptoms and reduce esophageal acid burden, but long-term durability remains unknown. Endoscopic management is widely utilized for GERD complications.
Summary
Selecting the appropriate patient is key for therapeutic success with endoscopic GERD therapy. Patients with minimally disrupted EGJ barrier (< 2 cm hiatus hernia) and intact esophageal peristalsis are optimal candidates.
Main Recommendations
ESGE suggests flexible endoscopic treatment over open surgical treatment as first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size.
Weak recommendation, low quality of evidence, level of agreement 100 %.
ESGE recommends that emerging treatments for Zenker’s diverticulum, such as Zenker’s peroral endoscopic myotomy (Z-POEM) and tunneling, be considered as experimental; these treatments should be offered in a research setting only.
Strong recommendation, low quality of evidence, level of agreement 100 %.
ESGE recommends against the widespread clinical use of transoral incisionless fundoplication (TIF) as an alternative to proton pump inhibitor (PPI) therapy or antireflux surgery in the treatment of gastroesophageal reflux disease (GERD), because of the lack of data on the long-term outcomes, the inferiority of TIF to fundoplication, and its modest efficacy in only highly selected patients. TIF may have a role for patients with mild GERD who are not willing to take PPIs or undergo antireflux surgery.
Strong recommendation, moderate quality of evidence, level of agreement 92.8 %.
ESGE recommends against the use of the Medigus ultrasonic surgical endostapler (MUSE) in clinical practice because of insufficient data showing its effectiveness and safety in patients with GERD. MUSE should be used in clinical trials only.
Strong recommendation, low quality evidence, level of agreement 100 %.
ESGE recommends against the use of antireflux mucosectomy (ARMS) in routine clinical practice in the treatment of GERD because of the lack of data and its potential complications.
Strong recommendation, low quality evidence, level of agreement 100 %.
ESGE recommends endoscopic cecostomy only after conservative management with medical therapies or retrograde lavage has failed.
Strong recommendation, low quality evidence, level of agreement 93.3 %.
ESGE recommends fixing the cecum to the abdominal wall at three points (using T-anchors, a double-needle suturing device, or laparoscopic fixation) to prevent leaks and infectious adverse events, whatever percutaneous endoscopic cecostomy method is used.
Strong recommendation, very low quality evidence, level of agreement 86.7 %.
ESGE recommends considering endoscopic decompression of the colon in patients with Ogilvie’s syndrome that is not improving with conservative treatment.
Strong recommendation, low quality evidence, level of agreement 93.8 %.
ESGE recommends prompt endoscopic decompression if the cecal diameter is > 12 cm and if the Ogilvie’s syndrome exists for a duration of longer than 4 – 6 days.
Strong recommendation, low quality evidence, level of agreement 87.5 %.
Objectives
Some patients with gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI) therapy. Anti‐reflux mucosectomy (ARMS) is a minimally invasive endoscopic procedure for treatment of GERD. In this study, we retrospectively evaluated the outcomes of ARMS performed in patients with PPI‐refractory GERD at our institution.
Methods
A total of 109 patients with PPI‐refractory GERD who underwent ARMS were retrospectively reviewed. Pre‐ and post‐ARMS questionnaire scores, acid exposure time (AET), DeMeester score, proximal extent, and PPI discontinuation rate were compared.
Results
There was a significant improvement in Symptom score (p < 0.01) and 40%–50% of patients were able to discontinue PPI after ARMS. In patients who were followed up for 3 years, sustained improvement in subjective symptoms was observed. AET and DeMeester score significantly improved after ARMS (p < 0.01); however, there was no significant improvement in proximal extent (p = 0.0846).
Conclusions
ARMS is an effective minimally invasive therapy for patients with PPI‐refractory GERD. The therapeutic efficacy is attributable to suppression of acid backflow due to contraction of the scar tissue in cardia.
Backgrounds and Aims
New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT), GERD control in patients without hiatal hernia.
Methods
PPI-refractory GERD patients without hiatal hernia underwent ARAT between January 2016 and October 2019. GERD-HRQL, upper endoscopy, 24-hour pH monitoring and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT.
Results
One hundred eight patients were included (61 male [56.5%]; median age 36.5 years [18-78]). ARAT was performed in all patients. At 36-month evaluation, 84 patients completed protocol. Median ARAT time was 35.5 minutes (22-51), and median circumference ablation was 300°(270°-320°). No major adverse events were found, and 14 out of 108 (12.9%) presented with stenosis that was responsive to balloon dilation in all cases (<5 sessions). At 3-month evaluation, we found a decrease from 18.8 to 2.8 (P=0.001), 42.5 to 9.1 (P=0.001) and 36.5 to 10 (P=0.02), for AET (acid exposure time), DM and GERD-HRQL scores, respectively, and were maintained up to 36 months. Success (AET<4%) was achieved in 89% and 72.2% at 3 and 36 months respectively. Related factors at 36 months were as follows: Pre-ARAT Hill type II (OR, 3.212; 95% CI, 1.431-5.951; P=0.033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P=0.042) and AET<4 at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P=0.021).
Conclusions
ARAT is a feasible, safe, and effective therapy at early- and mid-term for treatment of GERD in patients without sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role.
Background:
We provide a comprehensive report of our institution's experience with the endoluminal functional lumen imaging probe (EndoflipTM) impedance planimetry system, a device that can be utilized intra-operatively to objectively evaluate the distensibility of any sphincter of the gastrointestinal tract. We aim to describe the variety of ways in which the EndoflipTM can be used in a foregut surgeon's practice.
Study design:
This is a retrospective review of a prospectively maintained quality database of all patients in which the functional lumen imaging probe (FLIP) system was utilized between February 2013 and June 2019.
Results:
During the study period, 402 FLIP cases were performed: 226 fundoplications, 94 peroral endoscopic myotomies (POEM), 15 peroral pyloromyotomies, 12 anti-reflux mucosectomies, 11 magnetic sphincter augmentations, 9 laparoscopic Heller myotomies, 8 pre-esophagectomy esophagogastroduodenoscopies (EGD), 4 diagnostic EGDs, 8 endoscopic Zenker's diverticulotomies, 5 post-POEM EGDs, 8 EGDs with dilations and 2 transoral incisional fundoplications.
Conclusion:
Within a foregut surgeon's practice, the FLIP can be used to measure the upper esophageal sphincter, lower esophageal sphincter and pylorus in a variety of clinical scenarios and settings.
Minimally invasive endoscopic antireflux therapies are critical for bridging the gap between medical and surgical treatments for gastroesophageal reflux disease (GERD). Although multiple endoscopic devices have been developed, perhaps some of the most exciting options that are currently evolving are the full-thickness suturing techniques using widely available and low-cost platforms. Full-thickness endoscopic suturing can allow for a highly durable recreation of the anatomic and functional components of a lower esophageal sphincter, which are deficient in patients with GERD. Proper patient selection, endoscopic hiatal hernia evaluation, and standardized suturing methods are necessary to ensure success of endoscopic suturing for antireflux therapy.
Background:
Anti-reflux mucosectomy (ARMS) is a newfangled minimally invasive technique, with successful outcomes for the management of Gastroesophageal Reflux (GER). We present our initial experience (success rate) and safety profile for this procedure.
Methods:
Consecutive patients with daily dependence on Proton Pump Inhibitor (PPI) for GER were prospectively enrolled from September 2016 to August 2019 and underwent ARMS using a Cap assisted endoscopic mucosal resection. Severity was accessed by GERD-Questionnaire. Gastroscopy and 24-h pH-metry was done pre and post procedure. Patient characteristics, PPI requirement, adverse events and follow-up were documented.
Results:
Sixty-two patients [44(71%), male] underwent successful ARMS with a mean age (SD) of 36 (9.9) years. Technical success was achieved in 100 % of patients. Intraoperative bleeding was noted in 62(100 %) patients, endoscopic hemostasis was successfully achieved. At follow up dysphagia was seen in 5(8%) patients which needed a single session of endoscopic dilation. At 2 months, mean (SD) DeMeester score normalized in 45(72.5%) patients from 76.8 (18.3) to 14.3 (6.1) (p<0.001). PPI could be stopped in 43(69.4%) patients. The mean (SD) GERD-Q score reduced from 10.6 (1.9) to 3.4 (1.5) (p<0.001). However, in 12(19.3%) patients low dose of PPIs was continued, while 7 (11.3%) patients continued full dose. 38(61.3%) patients telephonically reported symptomatic improvement and were off PPIs at 12 months.
Conclusions:
ARMS is safe and effective for treatment of GER. The long term outcomes are favorable, response is durable and promising at our center. Appropriate patient selection still remains primal to the overall success of ARMS.
Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.
Background
In our previous case report of circumferential mucosal resection for short-segment Barrett’s esophagus with high-grade dysplasia, symptoms of gastro-esophageal reflux disease (GERD) were significantly improved. This observation suggests that anti-reflux mucosectomy (ARMS) could represent an effective anti-reflux procedure, with the advantage that no artificial devices or prostheses would be left in situ.
Methods
In this pilot study, 10 patients with treatment-refractory GERD received ARMS, 2 of whom circumferential, and the remaining 8 crescentic.
Results
Key symptoms of GERD improved significantly after ARMS. In the DeMeester score, mean heartburn score decreased from 2.7 to 0.3 (P=0.0011), regurgitation score from 2.5 to 0.3 (P=0.0022), and total score from 5.2 to 0.67 (P=0.0011). At endoscopic examination, the flap valve grade decreased from 3.2 to 1.2 (P=0.0152). In 24-h esophageal pH monitoring the fraction of time at pH <4 improved from 29.1% to 3.1% (P=0.1). Fraction time absorbance more than >0.14 of bile reflux was controlled from 52% to 4% (P=0.05). In 2 cases of total circumferential resection, repeat balloon dilation was necessary to control stenosis. In all cases, proton pump inhibitor prescription could be discontinued with no ill effects.
Conclusion
This initial case series demonstrated the potential anti-reflux effect of ARMS, with a crescentic mucosal resection appearing adequate. Further longitudinal study of patients without sliding hiatus hernia will be required to establish ARMS as an effective technique to control GERD in this setting.
Gastroesophageal reflux disease (GERD) contributes to substantial medication use and costs worldwide. Economic evaluations provide insight into the value of healthcare, taking into account cost, quality, and benefits of particular treatments.
Our objectives were to systematically review the existing literature to identify economic evaluations of GERD management strategies, to assess the scientific quality of these reports, and to summarize the economic outcomes of these evaluations.
We identified economic evaluations and cost studies of GERD management strategies by searching PubMed and the UK NHS Economic Evaluation Database via the Cochrane Library. Searching was restricted to articles in English-language journals from July 2003 to July 2013. Cost-identification articles were excluded from the final analysis.
Eighteen articles were included in the final analysis; 61 % of these met all criteria for quality reporting. Overall, proton pump inhibitor (PPI) therapy was preferred (most effective and least costly) as empiric therapy for patients with reflux symptoms, except in patient populations with high Helicobacter pylori prevalence (>40 %). Initial empiric PPI therapy (vs. initial endoscopy stratification or H. pylori testing) is likely the most cost-effective initial strategy for patients with typical GERD symptoms. Surgery may be cost effective in patients with chronic GERD symptoms at time horizons of 3-10 years. Endoscopic anti-reflux procedures were not cost effective based on available data.
Further economic evaluations should adhere to standard reporting measures of cost estimates and outcomes, and should attempt to account for and compare the large heterogeneity of patient phenotypes and treatment effects seen with anti-reflux therapies.
Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence.
Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months.
A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.
Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.Am J Gastroenterol advance online publication, 31 March 2015; doi:10.1038/ajg.2015.28.
Proton pump inhibitors have become the mainstay of medical treatment of acid-related disorders. Long-term use is becoming increasingly common, in some cases without a proper indication. A large number of mainly observational studies on a very wide range of possible associations have been published in the past decade and are critically reviewed in this article and the existing evidence is evaluated and translated into possible clinical consequences. Based on the existing evidence the benefits of PPI treatment seem to outweigh potential risks in the large majority of patients especially if PPI use is based on a relevant indication. The concern for complications should primarily be directed at elderly, malnourished with significant co-morbidity. In this population an increased risk for enteric infections, fractures and nutritional deficiencies might have clinical consequences and should lead to a careful evaluation of the indication for PPI treatment.
This review focuses on the pathophysiology of gastroesophageal reflux disease (GERD) and its implications for treatment. The role of the natural anti-reflux mechanism (lower esophageal sphincter, esophageal peristalsis, diaphragm, and trans-diaphragmatic pressure gradient), mucosal damage, type of refluxate, presence and size of hiatal hernia, Helicobacter pylori infection, and Barrett’s esophagus are reviewed. The conclusions drawn from this review are: (1) the pathophysiology of GERD is multifactorial; (2) because of the pathophysiology of the disease, surgical therapy for GERD is the most appropriate treatment; and (3) the genesis of esophageal adenocarcinoma is associated with GERD.
Endoluminal gastroplication (ELGP) was the first endoscopic therapy for gastroesophageal reflux disease (GERD). Data on the long-term outcomes, including the plication status and data from Asian populations, are limited. The aim of this study was to evaluate the short-term and long-term effectiveness and safety of ELGP for GERD in the Japanese population.
This was an open-label, prospective, multicenter trial of ELGP. Forty-eight patients with GERD were enrolled. The procedure involved placing circumferential plications 1-2 cm below the GE junction using the EndoCinch system. Outcome measurements were improvement of heartburn, medication use, endoscopic Los Angeles grade, durability of plications, 24-h esophageal acid exposure, esophageal manometry, and frequency of adverse events.
During the 24-month follow-up, the rate of complete resolution of heartburn ranged from 54 to 66%, the rate of discontinuation or reduction of PPI/H2RA use ranged from 65 to 76%, and the rate of endoscopic classification to grade O ranged from 66 to 81%. The status with more than one plication remaining was associated with higher rates of improvement of heartburn, PPI/H2RA use, and endoscopic findings as compared with those associated with the loss of all plications. A modest decrease of the esophageal acid exposure level, but no change of the manometric parameters, was observed after ELGP. No serious adverse events were observed.
In this 24-month follow-up study conducted in Japanese subjects, ELGP was found to be effective in about 60% of patients with GERD, and the procedure was safe.
Quantifications of gastro-oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling-clasp fibres at the oesophago-cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth-muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound-manometry assembly was drawn through the human gastro-oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol I, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull-throughs. These were repeated after administering atropine to suppress the cholinergic smooth-muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine-resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth-muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non-oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth-muscle sphincter pressures were measured after lung inflation to approximate FI. The cholinergic smooth-muscle pressure profile in protocol I (FI) matched closely the post-cisatracurium smooth-muscle pressure profile in protocol II, and the atropine-resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine-resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components. The smooth-muscle pressures had well-defined upper and lower peaks. The upper peak overlapped and displaced rigidly with the crural sling, while the distal peak separated from the crus/upper-peak by 1.1 cm between FI and FE. These results suggest the existence of separate upper and lower intrinsic smooth-muscle components. The 'upper LOS' overlaps and displaces with the crural sling consistent with a physiological LOS. The distal smooth-muscle pressure peak defines a 'lower LOS' that likely reflects the gastric sling/clasp muscle fibres at the OCJ. The distinct physiology of these three components may underlie aspects of normal sphincteric function, and complexity of sphincter dysfunction.